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Chapter 3 Process Addictions

Laura J. Veach Wake Forest School of Medicine Jennifer L. Rogers Wake Forest University Regina R. Moro Barry University E. J. Essic Professional Counselor James W. McMullen University of North Carolina at Charlotte

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Addiction may be further defined in terms of ingestive or process addictions. Chemical dependence is classified as an ingestive addiction due to the taking in of mood-altering chemicals, like alcohol or other drugs (AOD), whereas process addictions encompass behavior patterns (for example, gambling or sexual addictions) or processes that produce euphoria without the use of mood-altering AOD. Addiction specialists rarely debate that addiction is a biopsychosocial disease, but many continue to challenge the nature of addiction with questions about substance versus process addictions.

The term process addiction—an addiction to a behavior, process, or action—is still contentiously debated. It was not until the 1970s and 1980s that the addiction field began to formally discuss the idea that a behavior could be diagnosed as an addictive disorder. Sussman and Sussman (2011) provide a review of addiction research studies since 1948 to ascertain key elements in understanding addiction, whether substance or process, and highlight the following: “[W]hen contemplating addiction, one often thinks of it in terms of a process” (p. 70). Hagedorn and Juhnke (2005) cite a need for a universal definition of an addictive disorder to “[create a] common clinical language, a legitimization of the disorder for the purposes of third-party reimbursement, and a step toward a standardized treatment protocol” (p. 194). Past research on addiction focused on the presence of physical dependence to the substance or behavior as demonstrated by tolerance and withdrawal, but current research claims physical dependence is no longer necessary to diagnose an addiction to a substance or behavior (Hagedorn & Juhnke, 2005). In fact, the older Diagnostic Statistical Manual (4th ed.,

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text rev.; DSM-IV-TR) explicitly states that “neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of Substance Dependence” (American Psychiatric Association [APA], 2000, p. 194). In addition, newer research using sophisticated brain imaging techniques continues to add compelling evidence that the brain reward and inhibitory systems of process addicts resemble brains of ingestive addicts (Ahmed, Guillem, & Vandaele, 2013; Clark & Limbrick-Oldfield, 2013). Yet researchers and experts continue to debate whether a behavior can be diagnosed under the same criteria as a substance use disorder.

A number of addiction specialists, including the International Association of Addictions and Offender Counselors Committee on Process Addictions, advocated that the newly published Diagnostic and Statistical Manual (DSM-5; APA, 2013) include diagnostic categories of addictive disorders containing subtypes for gambling, sex, spending, work, exercise, Internet, and eating (Hagedorn, 2009). However, gambling was the only disorder included in the revised section on addictive disorders in the newly released DSM-5 (APA, 2013). At present there remains a lack of agreement regarding common terminology throughout the multidisciplinary field of addictions counseling, especially language pertaining to process addiction (Kranzler & Li, 2008; Petry & O’Brien, 2013; Sussman & Sussman, 2011).

According to addiction specialists, the importance of screening and assessment in the treatment of process addiction is paramount. Additional assessment information is reviewed in later chapters, but it is important to stress the

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following as we begin our examination of process addictions: (1) that understanding the addictive elements in compulsive and obsessive patterns with addictive elements and the associated negative consequences is critical; and (2) that assessing the loss of the ability to abstain from harmful processes, or behaviors, is often thought of as one of the hallmarks of addiction, including tolerance and withdrawal patterns, if any. Further, it is critical for the counselor to distinguish a process addiction from other types of behavior that may lead to negative consequences, for example, displaying undesirable social behavior. A person struggling with an addiction, whether it be process or substance, is engaging in behaviors marked by obsession, compulsion, and significant life (career, relationship, health) impairment. Someone engaged in violating a social taboo, such as discussing sexual practices in social settings or eating certain foods, may experience awkward silences and social regrets, but this is not addiction. If, however, an individual experiences euphoria while compulsively and obsessively discussing sexual practices in social settings, even after an ongoing pattern of adverse consequences related to this behavior (for example, arguments with spouse/partner or disciplinary action by an employer), then the counselor would be advised to evaluate further for an addictive pattern. Marked impairment of functioning, accompanied by a continuance of the behavior despite serious adverse consequences, are part of the inherent nature of addiction, thereby separating these patterns from being mere social habits or taboos. Addiction is a complex diagnosis, leading to clinically significant impairment. Process addictions warrant further discussion.

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The debate continues as to whether behavioral addictions should be classified as an addictive disorder. As a result, the concept of what we classify and diagnose as an addiction is still evolving. Whether we are speaking of a process or substance addiction, addictions interfere with people’s ability to truly know themselves, their spirituality, and the world around them (Schaef, 1990). In this chapter we will discuss five of the most prominent and researched process addictions to date: sex, gambling, working, compulsive buying, and food.

It is important to note that frequently, addiction to one substance or process is accompanied or replaced by addiction to another substance or process (e.g., a female with an eating disorder is also struggling with substance abuse or dependence; a male recovering from a sexual addiction develops a gambling addiction). Comorbidity, or multiple addictions occurring at once, is quite common whether a person is suffering from a substance or a process addiction (National Association of Anorexia Nervosa and Associated Disorders [ANAD], 2014; Fassel & Schaef, 1989; Grilo, Sinha, & O’Malley, 2002; Hagedorn, 2009; Hagedorn & Juhnke, 2005; Mitchell et al., 2001). As Schaef (1990) aptly points out, “the addiction changes behavior, distorts reality and fosters self-centeredness . . . [and] no one has only one addiction. As addicts begin recovering from their primary addiction and achieve some sobriety, other addictions emerge” (p. 18).

The prevalence of process addictions is not clearly known since currently there is a lack of agreement as to what

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precise criteria can be used to define the various types of process addictions. Some believe that process addictions are rampant in our society. As an example of possible prevalence, Hagedorn (2009) extrapolated from various data and reported that each sexual addiction treatment center in operation would need to serve 1.08 million persons struggling with sexual addiction; for gambling addiction, there is one treatment facility for every 250,000 individuals suffering; and for those struggling with Internet addiction, one treatment facility exists per 2.9 million clients. Similar to substance addiction, warning signs of process addiction can include a greater sense of isolation, less social interaction, less attention to personal hygiene, increased legal difficulties, changes in eating and sleeping patterns, increased irritability, and wariness of changing compulsive behavior (Zamora, 2003).

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Sexual Addiction Experts in the field of addiction did not really start talking about sex addiction until the early 1980s, when Patrick Carnes introduced the idea that sexual behavior, rather than a drug, could be addicting (Schneider, 2004). The prevalence of sexual addiction is estimated, conservatively, at 3% of U.S. adults (Sussman, Lisha, & Griffiths, 2011). An estimated 20– 25% of sexual addicts are women (Carnes, 2011). Additionally, a range of 20–40% of sex addicts are thought to be struggling with another addiction, such as alcoholism (Sussman et al., 2011). The incidence of sexual addiction is on the rise because of increased affordability, easy access to sexual materials, and anonymity of the Internet (Hagedorn & Juhnke, 2005). Love, or relationship, addiction pertains to different behaviors and often may involve the spouse or partner of addicts, but is not focused primarily on compulsive sexual behaviors and thus is excluded from this section on sexual addiction. More information can be found in materials related to codependency (Co-Dependents Anonymous, Inc., 2010; S-Anon International Family Groups, 2013).

There are varying definitions of sexual addiction. Sexaholics Anonymous, Inc. (SA) defines a sexaholic as someone who is addicted to lust. The sexaholic can no longer determine what is right or wrong, has lost control, lost the power of choice, and is not free to stop sexual behavior despite adverse consequences, such as threats of job or family loss (Sexaholics Anonymous, Inc., 2010). Common characteristics of male and female sexaholics include marked isolation, prevalent guilt, marked depression, and a deep feeling of emptiness. Typical behaviors of a sexaholic include compulsively fantasizing about sexual desires; remaining in harmful codependent relationships; engaging in compulsive masturbation; obsessive and compulsive use of pornography, including on the Internet;

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repeatedly engaging in promiscuous sexual relationships; conducting adulterous affairs; and compulsively pursuing exhibitionism or sexually abusive relationships, regardless of legal, career, or family consequences (Sexaholics Anonymous, Inc., 2010).

According to Bailey and Case with the American Association for Marriage and Family Therapy (AAMFT), sex addicts experience unhealthy abuse of sex in a downward compulsive cycle (2014). For some it may begin with masturbation, pornography, or a relationship, but progresses in an obsessive and compulsive pattern to increasingly dangerous behaviors and greater risks. Cybersex, another term often referenced when discussing sex addiction, involves “Internet-related sexually oriented chat rooms, message boards, and pornography” (Long, Burnett, & Thomas, 2006, p. 218). Long et al. (2006) further identify pornography and telephone sex with dependence patterns.

Denial is the undertone of all addictions. Sexual addiction can be the primary, secondary, or simultaneous disorder along with other substance or process addictions such as chemical dependency, eating disorders, work addiction, compulsive buying, or compulsive gambling. Additionally, sexual addiction often coexists with other psychiatric issues such as depression, anxiety, personality disorder, relationship issues, or bipolar disorder (Seegers, 2003). For example, increased buying, spending, and sexual behaviors often accelerate during manic episodes but do not warrant a diagnosis of sex addiction. Conversely, in some cases, without adequate knowledge about addiction, a client may be misdiagnosed with bipolar disorder when the primary focus of clinical attention is a process addiction. Differential diagnoses add complications since sex addiction can resemble other disorders, for example, a manic or hypomanic episode with hypersexual behaviors. It is recommended that counselors evaluate carefully and obtain adequate psychosocial history before making a final diagnosis. There are few empirical studies regarding the comorbidity of

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sexual addiction and another psychiatric disorder or addiction (Miller, 2005; Sussman et al., 2011). Zapf, Greiner, and Carroll (2008) found that relational anxiety and avoidance behaviors were more prevalent in sexually addicted men in their recent study, noting “sexually addicted men are nearly 50% less likely to relate to their partners in a secure manner than nonaddicted men . . .” (p. 169). More research is needed to investigate sexually impulsive and out of control behaviors (Bancroft & Vukadinovic, 2004; Sussman et al., 2011).

Parkinson’s Disease and Impulse

Control Parkinson’s disease is a disorder of the central nervous system. It is a degenerative condition that usually impairs a person’s speech, motor skills, and other functions. Persons suffering from Parkinson’s disease may experience tremors, joint stiffness, and a decline in the executive functioning of the brain. A relationship between Parkinson’s disease and impulse control disorders is currently being examined by researchers (Ceravolo, Frosini, Rossi, & Bonuccelli, 2010). Dopamine receptor agonists, a type of drug used to treat Parkinson’s, is associated with compulsive gambling, sex, eating, and shopping. Changes in medication doses usually result in improvement in these behaviors.

As of now there are no diagnostic criteria or classifications for sexual addiction (American Psychiatric Association, 2013) in the new edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). Considerable review occurred in the revision of the current DSM-5; however, “subcategories as ‘sex addiction,’ ‘exercise addiction,’ or ‘shopping addiction,’ are not included because at this time there is insufficient peer- reviewed evidence to establish the diagnostic criteria and course

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descriptions needed to identify these behaviors as mental disorders” (Clark & Limbrick-Oldfield, 2013, p. 481). There are, however, DSM-5 diagnoses (and DSM-5 estimated prevalence) for sexual disorders, also known as paraphilic disorders, that can involve compulsivity, obsessions, and harm to others such as voyeurism (concerning perhaps 12% of males and 4% of females), pedophilia (estimated to involve 3–5% of men and a smaller number of women), sexual sadism (estimated range of perhaps 2–30% of individuals), sexual masochism (involving an unknown number of people), and exhibitionism (affecting possibly 2–4% of men) (APA, 2013). Screening for sex addiction is an important step for the counselor; first, the counselor’s reluctance and discomfort regarding explicit sexual information, if present, can cause difficulty in developing the necessary nonjudgmental relationship (Zmuda, 2014). A briefer screening tool, PATHOS, developed by Patrick Carnes and associates, utilizes six items and may be an important way for both the counselor and the client to begin to assess for sexual addiction (Zmuda, 2014). Often treatment for sexual addictions involves many treatment approaches used for substance addictions, such as cognitive behavioral therapy; however, additional biological approaches, such as hormonal therapy involving antiandrogens or certain libido-inhibiting antidepressants, may also be used (Long et al., 2006).

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Case Study

Kevin’s Alcoholic Anonymous sponsor has insisted he come talk with you about his “sex addiction.” He reports being highly sexed and sleeping with several women in the program “just as any other healthy male might.” Upon deeper exploration, he reports having slept with over 500 women in the last 2 years and that when he is not able to have regular and frequent sexual contact, he gets depressed and really wants to drink. He is proud of his sexual prowess and feels that his behavior is to be envied rather than a source of concern. He says that he thinks sex is a much healthier outlet than drinking, and that it is fun, not an addiction.

Discuss whether Kevin’s behaviors seem addictive and why. What red flags do you see? Discuss how he may fit on the addiction spectrum. Conceptually, what is happening? What theories/methods might you employ in his treatment? What leads you to differentiate Kevin’s behavior as addictive rather than in the normal range of healthy sexual behavior?

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Gambling Addiction Gambling continues to rise with the increase in casinos, lotteries, and Internet gambling sites (Buck & Amos, 2000; Suissa, 2007). There is evidence that gambling can be traced back thousands of years, with Egyptian evidence of shell games dating from 2,500 �.�. (Suissa, 2007).

To reflect new research that demonstrates similarities between the reward systems activated by both substance-abuse disorders and behaviors related to gambling, as shown in Figure 3.1 , the DSM-5 made substantial changes and now designates gambling as a disorder under the Non- Substance-Related Disorders section of Substance-Related and Addictive Disorders (APA, 2013)—the first of the process addictions to be so designated. A gambling disorder diagnosis requires that an individual show four or more of the nine gambling behaviors that are persistent and problematic in a 12-month period. Some of the descriptors for a person with a gambling disorder indicate that the person “needs to gamble with increasing amounts of money in order to achieve the desired excitement; lies to conceal the extent of involvement with gambling; and relies on others to provide money to relieve desperate financial situations” (APA, 2013, p. 585). Gamblers do not ingest a substance to experience their “high,” and yet researchers have found that disordered gambling is related to neuroadaptation, or tolerance, and withdrawal symptoms (Shaffer & Kidman, 2003). In a study that looked at Internet gambling behavior (McBride & Derevensky, 2009), 23% of participants (N=563) that included males between the ages of 18 and

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Figure 3.1 Gambling Disorder: New Diagnostic Changes

DSM-IV-TR (2000) DSM-5 (2013)

Classified as an impulse control disorder

Classified as a nonsubstance related disorder

No levels; only specified between pathological gambling vs. social and professional gambling

Severity in 3 levels: mild, moderate, & severe

To be diagnosed, needed to meet 5 of the criteria (over unspecified amount of time)

To be diagnosed, need to meet 4 or more of the criteria in a 12-month period

Diagnostic Criteria A, defined as persistent and recurrent “maladaptive” gambling behavior

Diagnostic Criteria A, defined as persistent and recurrent “problematic” gambling behavior leading to clinically significant impairment or distress

Diagnostic Criteria A has 10 parts

Diagnostic Criteria A has 9 parts: removed #8 of DSM-IV; “Committed illegal acts such as forgery, fraud, theft, or embezzlement to finance gambling”

over 65 identified as problem gamblers. Problem gamblers were more likely to exhibit behaviors such as consuming alcohol or drugs while gambling on the Internet. Men evidence more gambling-related problems and comorbidities, although research indicates the trends show an increasing number of women involved in gambling (Rainone, Marel, Gallati, & Gargon, 2007), and the relationship between trauma and female

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gambling further complicates treatment (Nixon, Evans, Kalischuk, Solowoniuk, McCallum, & Hagen, 2013). For the women interviewed in this qualitative study, trauma that was experienced in life played a significant role in their entrance into the world of gambling (Nixon et al., 2013).

According to the DSM-5, the lifetime prevalence rate of adult disordered gambling ranges from 0.4% to 1% (APA, 2013) and a 12-month incidence of 0.2–0.3%, yet a review of 83 addiction studies by Sussman and colleagues (2011) calculated a 12-month gambling addiction prevalence of 2%. The prevalence rate is higher for youth and middle-aged individuals than the older population (APA, 2013).

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Internet Gaming Disorder There is debate in the field as to whether compulsive online gaming will eventually be acknowledged as a process addiction. Researchers suggest that appropriate diagnostic criteria for the disorder may be similar to those used to identify pathological gambling (Young, 2009). Currently, the DSM-5 includes Internet Gaming Disorder as a condition for further study and offers proposed diagnostic criteria that involve many of the addictive criteria, but does not endorse a diagnosis at this time. However, it does note the following: “Internet gaming has been reportedly defined as an ‘addiction’ by the Chinese government, and a treatment system has been set up” (APA, 2013, p. 796). For example, the overuse of Massively Multiplayer Online Role Playing Games (MMORPGs) is growing worldwide, especially among college students, and researchers are exploring means by which to both operationalize the phenomenon and predict problematic use (Hsu, Wen, & Wu, 2009). This growing area of addictions research will perhaps stretch conceptualizations of addictions in the 21st century.

Source: Hsu, S., Wen, M., & Wu, M. (2009). Exploring user experiences as predictors of MMORPG addiction.

Computers & Education, 53 (3), 990–999. doi:10.1016/j.compedu.2009.05.016

Source: Young, K. (2009). Internet addiction: Diagnosis and treatment considerations. Journal of Contemporary

Psychotherapy, 39 (4), 241–246. doi:10.1007/s10879-009-9120-x

Gambling involves an aspect of risk to get something greater in return, such as the euphoria often referenced by recovering gamblers (APA, 2013). Signs of gambling addiction can include “secretiveness and excessive time with phone calls and Internet access, unaccounted time away from work or home, unexplained preoccupation, increased debt and worry over finances, extravagant expenditures, and increased alcohol, drug consumption or both” (Buck & Amos, 2000, p. 5). Other disorders, such as substance use,

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depressive, anxiety, and personality disorders are often present in comorbidity with gambling disorders, which is to be taken into consideration during treatment (APA, 2013). The National Council on Problem Gambling (NCPG, 2014) has reported costs up to $7 billion related to gambling when factoring in bankruptcies, job loss, and criminal justice actions. Early intervention and treatment is urged by NCPG. Other national data is lacking, but an involved household survey in New York yielded important trends concerning the need for intervention and treatment. One finding indicated 67% of adults within the state had engaged in one or more gambling activities within the past year, and of those, approximately 5% reported problem gambling symptoms that could benefit from addiction counseling services (Rainone, Marel, Gallati, & Gargon, 2007). As knowledge about the prevalence of gambling addiction improves, more is also known about cultural considerations. Further, some helping professionals in the United States are recognizing gambling addiction as a hidden problem within Asian-American communities. One study found gambling problems at rates far greater in Asian-American clients than in the general population (Fong & Tsuang, 2007). A recent report suggests Asian Americans may choose gambling as a leisure activity, but more problematic within the community are those affected by gambling addiction (Forng & Tsuang, 2007). Literature and outreach videos have been prepared with a specific focus on Mandarin, Cantonese, and Vietnamese communities in the United States, to separate moderate gambling social activity from serious problem gambling (Massachusetts Council on Compulsive Gambling, National Problem Gambling Awareness Week, 2009).

Other helpful approaches advocate adaption of a harm reduction model with an emphasis on self-empowerment (Suissa, 2007) and avoiding a model of individual pathology that claims individuals are vulnerable for life (Suissa, 2011). The number of Gamblers Anonymous (GA) meetings has increased since their beginnings in 1957 (Suissa, 2007). Gambling

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addictions continue to create significant financial, family, and legal problems, and continued research is needed. Counselors benefit from specialized counseling training and may want to investigate national certification in this area as outlined by the National Council on Problem Gambling (NCPG, 2014).

Case Study 1

Marilyn reports that the major difficulty in her marriage is due to Du Nguyen’s constant gambling. Family savings are gone, and the couple is 3 months behind on mortgage payments. Du Nguyen, embarrassed for seeking counseling, says that he has tried stopping because he is worried about his marriage. He says he wants to quit and feels shameful and guilty, but when faced with an opportunity to bet on sports or horses, his impulses overcome his reason. He has tried a number of unsuccessful strategies to control himself, and he wants help in order to save his marriage. He says he wants to understand his urges and be able to control them.

How can you help this couple understand the addiction process? What resources can you draw on to help them? What modalities might you use in working with them? How will you approach Du Nguyen’s desire to “control” his gambling addiction? Would you diagnose with the new DSM-5?

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Case Study 2

Jonathan is a computer analyst struggling at work focusing on his daily tasks. He reports that rather than focusing on his job, he consistently signs on to his favorite gambling website throughout the workday as well as when he gets home. When his supervisor asks him about the projects he is working on, he lies and states that issues arose in the project that resulted in it taking more time than usual. Jonathan turned down a promotion 6 months ago that would have made him the head of a team within the company. He says that this promotion would have cut into his ability to shift his focus between gambling online and his work.

What criteria are present for gambling disorder to be identified? How would you begin to work with Jonathan as his counselor? What options for treatment would you consider?

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Technology Addiction Technology addiction (TA), a new term encompassing technological use comprehensively, is an advancing phenomenon that continues to affect society through individuals’ heavy reliance on euphoria- producing technological devices. Easy access offered by constant advances in technology and instant gratification may trigger addictive behaviors among vulnerable individuals. With the development of a specific technology (e.g., cell phones), more drivers are becoming distracted while driving as they are texting and talking on their phones. Research conducted by the Centers for Disease Control and Prevention ([CDC], 2011) found that 31% of adult drivers aged 18–64 had been reading or sending text or email messages while driving within 30 days of the CDC survey. The annual statistics continue to show rising trends of distracted driving related to technology. These findings indicate a need for more research to be conducted to investigate the addictive tendencies of technology.

Within the limits of current literature, there is a notable gap in the current definition and understanding of this phenomenon as the use of a device defines technology addiction rather than the addictive tendencies of the pleasure-seeking behavior for each specific subset, such as smartphone or Internet addiction. To better understand technology addiction, it is important to examine its biological, psychological, and sociological components. In other words, utilization of the biopsychosocial model may help us gain a better awareness of the addictive properties of technology. Acosta (2013) conducted a study to examine at-risk technology users and gain an in-depth understanding of those individuals’ lived experiences. The results of the study suggest that participants identify both positive and negative effects of their technology use.

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After assessing participants’ responses with the help of the biopsychosocial model, there were several themes that were described to influence participants’ experiences with technology. Participants report being influenced by a cultural need to utilize technology, both externally (e.g., work) and internally (e.g., personal need). In other words, individuals experience pressures from their external world as well as their own internal world to use euphoria- producing technologies.

Additionally, several factors that motivate use of technology were discovered. One of the factors is the need for social connections and interpersonal relationships. Furthermore, the participants identified enmeshment of the functionality of technology, which means the device itself is not the object of the use; rather, it is the seeking behavior such as searching the Internet, which can be accessed from multiple devices. Convenience and awareness of personal benefits were also identified as factors that motivate use of technology. On the other hand, negative consequences that were the results of technology use such as utilizing technology for longer than intended, disruptions in interpersonal relationships, and having physical problems due to their use such as eye strain were also reported to influence participants’ experiences with technology (Acosta, 2013).

The results of the study indicate that individuals who use technological devices may be vulnerable to risks associated with technology use. To assist the client with further investigation of the potential technology use hazards, the professional counselor might benefit from conducting a brief screening during therapy session with the help of TECH (Acosta, Lainas & Veach, 2013). If clients respond “yes” to at least one of the questions on the TECH screening instrument, it indicates a positive finding and counselors can start a discussion with the client about that person’s patterns of

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technology use and factors that contribute and affect his or her behaviors related to technology. To date, “reSTART” is the only treatment center that exists in the United States that specializes in technology addiction treatment. Additionally, counselors and clients might find the following websites informative and helpful for exploration and better understanding of technology use and its risks: www.netaddictionrecovery.com, www.congressoftechnologyaddiction.org, and www.netaddictionanon.org

Source: Acosta, K. M., Lainas, H., & Veach, L. J. (2013). An emerging trend: Becoming aware of technology addiction.

NC Perspectives, 8, 5–11.

Source: Acosta, K. M. (2013). Understanding at-risk technology users: A phenomenological approach [Doctoral

dissertation]. Retrieved from ProQuest Digital Dissertations.

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Work Addiction While the term workaholism is commonly used, there is no recognized diagnosis in current diagnostic manuals such as the DSM-5 (American Psychiatric Association, 2013). There is little data available on the actual prevalence of workaholism, but Sussman (2013) notes as many as one- third of workers, or about 18% of the population, may self-identify as workaholics; however, 10% may be a more conservative estimate. Additionally, the oftentimes secretive nature of the addiction, as well as the societal acceptance and even reward of workaholism, limits the availability of accurate data. According to Bonebright, Clay, and Ankenmann (2000), Oates first coined the term workaholism more than 25 years ago, and since then many researchers define workaholism differently. Seybold and Salamone (1994) describe workaholism as an excessive commitment to work that results in the neglect of important aspects of life. “In the narrowest sense, workaholism is an addiction to action; but the action takes many forms . . . the type of action may vary, but the process is the same: You leave yourself ” (Fassel, 1990, p. 4). Chamberlain and Zhang (2009) describe work addiction as a dependence on work despite adverse consequences, with their research focusing on areas of increased somatic complaints, psychological symptoms, and poor self-acceptance. Recent research adds complications from perfectionism, which is often tied closely to workaholism (Stoeber, Davis, & Townley, 2013). Sussman (2013) points out that the number of hours worked weekly may be one important indicator of workaholism if the hours worked exceeds 50 hours per week.

The primary characteristics of workaholics include “multiple addictions, denial, self-esteem problems, external referenting, inability to relax, and obsessiveness” (Fassel, 1990, p. 27), as well as out-of-control behavior

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and an escape from personal issues or relationship intimacy (Buck & Amos, 2000; Sussman, 2013). These characteristics can be the result of a need to control one’s life, an overly competitive drive to succeed, being raised by a workaholic parent or role model, and low self-esteem or self- image (Buck & Amos, 2000). In Figure 3.2 , the stages of work addiction are examined utilizing a biopsychosocial approach depicting the progressive nature of addiction.

Workaholics do things in excess. They keep a frenetic pace and do not feel satisfied with themselves unless they are always doing something. As a result, workaholics tend to have more than one addiction, perhaps as many as 20% (Sussman et al., 2011). Often they smoke, drink, or do drugs as a way to cope with stress. They may have strict eating and exercise regimes in order to have enough energy to sustain such a fast-paced lifestyle. These efforts to cope help hide what is truly going on and prolong the individual’s denial (Fassel & Schaef, 1989). Family, friends, and coworkers are thought to also experience negative effects of workaholism (Bonebright et al., 2000; Chamberlain & Zhang, 2009).

Operationalizing “Workaholism” New research conducted in Japan and the Netherlands assessed the validity of new scales to measure two aspects of work addiction: working excessively hard and working compulsively. Workaholics who worked excessively hard and compulsively showed a high risk of burnout. While more research in this area is needed, the hypothesized two-factor construct fit the data in both countries and may prove a valuable means by which to better understand this process addiction.

Source: Schaufeli, W. B., Shimazu, A., & Taris, T. W. (2009). Being driven to work excessively hard: The evaluation of a

two-factor measure of workaholism in the Netherlands and Japan. Cross-Cultural Research, 43 (4), 320–348.

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Figure 3.2 Stages of Work Addiction, Biopsychosocial Model (L. J. Veach)

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Work Addiction Stages

Symptoms Organizational Response

Early Stage

Time span: 5–8 years on average

Bio: Stress-related symptoms first noticed: frequent headaches, generalized anxiety (especially pertaining to work), digestive problems, minimal sleep problems, or mild irritability.

Psycho: Increased hours thinking about or being at work, seeking additional projects/assignments, greater emphasis being placed on external recognition, decreased ability to self-validate (e.g., “I did a good job, I can stop now and continue this tomorrow”), increased self-criticism (e.g., “I should do more, spend more time at the office; I’m afraid I’m not working hard enough; It’s got to be done better”).

Social: Late arrival at home or social events due to increased work activity; increasing work at home or at social events via cell phone, texting, or Internet communication; increasing heated discussions with partner about time spent on work.

Promotions, recognition from peers & management, increased pay, bonuses, increased workload/assignments, favorable job reviews & evaluations.

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Middle Stage

Time span: 8– 12 years on average

Bio: Increased stress-related symptoms; sleep disorders— insomnia/hypersomnia; pronounced weight loss/gain, or weight fluctuations; increased use of medications for sleep, anxiety, depression, increased use of mood- altering chemicals or processes (e.g. extramarital affairs, sexual promiscuity, gambling) to achieve pleasure or relaxation due to frequent tension and increased difficulty relaxing.

Psycho: Increasing hours spent on work (both on and off site); perfectionism increasing; decreased tolerance of mistakes (self or colleagues); preoccupation with work products, projects, or outcomes.

Social: Less leisure pursuits and/or decreased time spent in established leisure outlets, greater identity associated with workplace, title, or role; work–family conflicts experienced, minimal marital/partner separation may occur; intermittent experiences of significant job dissatisfaction leading to geographic escape from “this demanding job” to new locations.

Promotions, greater responsibilities assigned, management opportunities, possible relocation, increased travel, increased recognition and community service encouraged; job changes, seeking advancement, which may be due to varying productivity or employer/supervisee conflicts.

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Late Stage

Time span: 10– 15 years on average

Bio: Stress-related physical complications such as cardiac events, e.g., heart attack or stroke, brought on by poor physical care with inability to successfully manage intense stress; probable activation of co-occurring addiction to mood- altering chemicals or processes (pathological gambler, alcoholism, or food addict).

Psycho: Working continually or “bingeing” resulting in sustained work activity with reduced accomplishment; less productivity but more time spent on work; greater job dissatisfaction; increased agitation; workplace conflicts increasing; complaints by co- workers/supervisees; poor risk- taking with job assignments.

Social: Minimal leisure activity; increased strife with work–family conflicts, impending divorce or estranged, poor communication with family/loved ones, withdrawn from family and social events.

Varied: Possible advancement due to long history of products OR demotions, reduction in force (RIF), job termination; mandatory supervisory referral to Executive Coach or Employee Assistance Program Counselor.

A compounding problem of workaholism is that our fast-paced, performance-driven society readily supports, encourages, and rewards it

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(Fassel, 1990). In fact, many people are self-proclaimed workaholics. A common myth about workaholics is that since they work longer hours they are more productive; research, however, indicates otherwise (Bonebright et al., 2000; Fassel & Schaef, 1989). Workaholics tend to be less productive than the more relaxed worker who keeps regular hours. The workaholism– perfectionism connection is highlighted by research findings that show “workaholism is mainly driven by personal aspects of perfectionism rather than social aspects” (Stoeber et al., 2013, p. 737). The irony is that the workaholic’s perfectionist tendencies and inability to delegate tasks to others can reduce efficiency and flexibility and decrease progress in the workplace (Bonebright et al., 2000). Numerous studies suggest that there is a relationship between workaholism and many difficulties (Brady, Vodanovich, & Rotunda, 2008; Bonebright et al., 2000; Chamberlain & Zhang, 2009; Sussman, 2013). Although it is difficult to pinpoint accurate numbers, the estimated cost of stress-related issues to companies is $150 million per year. These costs include workers’ compensation for stress, burnout, hiring and retraining new employees, and legal fees when companies get sued by employees for stress-related illnesses (Fassel & Schaef, 1989). Sussman (2013) highlights several studies, of the few conducted, that illustrate negative workaholism consequences, such as driving sleep deprived or driving while working using mobile devices.

Bonebright et al. (2000) claim there are three “causal explanations” for why individuals choose to dedicate so many hours to their work. First, they truly find enjoyment and satisfaction in their work. Second, they have an uncontrollable desire to work, even if they do not enjoy the task. Third, they receive a euphoric high from accumulating the rewards of their hard work. Eventually, their desire to receive these accolades, the workaholic’s euphoria, interferes with their health, relationships, family, and other activities, which is indicative of the addictive cycle.

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Research supports that workaholics compared to nonworkaholics have greater anxiety, stress, anger, and depression. Likewise, workaholics perceive themselves as having more job stress, perfectionism, anxiety, health complaints, and less willingness to delegate job responsibilities to others (Robinson, 1998). In their recent work, Chamberlain and Zhang (2009) reported significant findings—namely, that workaholism negatively affects physical health, psychological well-being, and self-acceptance. These researchers also noted that adult children of workaholics were predominantly self-described workaholics, suggesting the parent’s work addiction is often mirrored in their children. It is of particular concern with the reported low self-acceptance patterns of workaholics that “this nonaccepting attitude toward oneself could transfer to being overly critical and demanding of others” (Chamberlain & Zhang, 2009, p. 167). Brady et al. (2008) added empirical knowledge with an extensive study examining workaholism and work–family conflict, job satisfaction, and leisure among university faculty and staff in one sample along with employees in various community work settings in a different sample. These researchers noted that in both samples: first, high workaholism scores were significant predictors of heightened work–family conflict; next, higher drive scores, or ambition-driven behaviors, led to lower job satisfaction findings, particularly in the university employees; and finally, less enjoyment of leisure was significantly found in workaholics (Brady et al., 2008). Lastly, studies indicate that an individual’s work addiction, as is true with other addictions, has a severe impact on others, producing marital conflict, dysfunction within the family, and strained social relationships (Brady et al., 2008; Robinson, 1998). Children of workaholics may be prone to developing workaholic tendencies of poor self-acceptance, increased physical complaints, or full-blown workaholism as a result of being raised in a workaholic family environment (Chamberlain & Zhang, 2009; Robinson, 1998). Treatment considerations may need to stress family counseling, self-talk, and reviewing with clients their individual reinforcement patterns, as outlined by Chamberlain and Zhang (2009).

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More research is needed in the area of diagnosing and effectively treating work addiction, as well as closer examination of the stages of work addiction in order to assess whether, as with other addictions, the adverse consequences of workaholism are progressive. Brief screening of behaviors described by Sussman (2013) such as frequent hurrying and rushing, overcontrolling, perfectionism, work bingeing, work-related exhaustion, hyperfocus on work leading to poor concentration and recall, compulsive checking on work, and poor self-care can assist the counselor with earlier exploration of possible workaholic patterns and interventions. Treatment approaches may include those based on other addiction treatment approaches including 12-step support groups, such as Workaholics Anonymous begun in 1983 (Sussman, 2013). Many researchers also emphasize the need to examine extensive data, the cost of workaholism to organizations, especially when higher incidences of hypercritical, inefficient, negative, and overcontrolling behaviors or increased complaints by supervisees occur (Brady et al., 2008; Sussman, 2013; Vodanovich & Piotrowski, 2006).

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Case Study

Bryant, a married 48-year-old African-American male, is an associate professor at a midsized university. Recently, he has been experiencing marital discord and his only child, a 15-year-old son, has been experiencing pronounced anxiety accompanied by panic attacks at school. Bryant has recently been considering the offer of a promotion into university administration as an Associate Provost. He has an active research agenda, has published numerous textbooks and publications, and his professional service has received outstanding reviews in his field. He knows he is spending less and less time with his family and on leisure activities, and had a negative encounter with a colleague where he lost his temper, but believes he deserves this next step up since he has worked so hard. He wonders if he should pursue this prestigious offer and seeks career counseling with you, his Employee Assistance Program Counselor. What particular areas would you address? How would you begin to explore workaholism?

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Compulsive Buying The incidence of compulsive buying is estimated at 6% of the U.S population (Sussman et al., 2011). Since most of the data on compulsive buyers come from self-selected samples, it is difficult to know the true prevalence of this disorder. Compulsive shopping, uncontrolled buying, addictive buying, addictive consumption, shopaholism, and spendaholism are all names for compulsive buying (Lee & Mysyk, 2004). Compulsive buying (CB) has been described as a condition caused by chronic failures at self-regulation that becomes self-reinforcing over time, as persons move through antecedent, internal/external trigger, buying, and postpurchase phases (Kellet, 2009; Williams & Grisham, 2012). In its literature, Debtors Anonymous (2014) describes debt aptly for those suffering from compulsive buying, a process addiction, and equates debt with alcohol, food, or gambling for alcoholics, anorexics, and gamblers, respectively. Sometimes referred to as oniomania, a term used first in 1915, it is often comorbid with substance use, eating and impulse control disorders, and mood disorders (Filomensky et al., 2012). In clinical samples, women make up the majority of subjects, yet experts report a 1:1 male-to-female ratio (Filomensky et al., 2012).

Compulsive buying has been defined as consistent, repetitive purchasing that becomes the first response to negative or stressful life events or feelings. Compulsive buyers try to fill the meaninglessness, unhappiness, and void in their lives by purchasing items to relieve these negative feelings. Compulsive buying takes a toll on the individual, family, and society, and it can lead to “overspending, indebtedness, and bankruptcy” (Lee & Mysyk, 2004, p. 1710).

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Recent studies note that impulsive behaviors predominate in compulsive buying and, as such, CB might be diagnosed as an impulse control disorder (Filomensky et al., 2012; Williams & Grisham, 2012). In addition, “kleptomania may be associated with compulsive buying” (APA, 2013, p. 479). Findings in a comprehensive study by Filomensky and colleagues (2012) substantiated that CB participants consistently showed impulsivity and acquiring behaviors on several measures, but minimal hoarding, bipolar, or obsessive-compulsive disorder-related behaviors. Psychosocial, cognitive behavioral, and pharmacotherapy (Filomensky et al., 2012; Kellet, 2009) treatment modalities have been suggested by the literature. In addition, twelve-step groups, such as Debtors Anonymous (2014), offer steps to regain financial health and recovery. Lee and Mysyk (2004) examine the larger social context of what it means to be a compulsive buyer in today’s society. They point out that it is important to keep in mind, when examining and diagnosing a compulsive buyer, that we live in a consumer-driven society fueled by powerful messages urging buyers to spend. These messages tell us that buying things will enhance our self- esteem, make us happy, and increase social status. Strategies such as teaching individuals how to resist powerful marketing messages and examine the social forces at work may be useful. Lee and Mysyk (2004) do not rationalize the behavior of compulsive buyers, but do point out that the social forces behind purchasing in our society, including the media, the state of the economy, and easy access to credit, can also fuel the compulsive buyer. It is important to continue to gather data regarding prevalence and patterns associated with compulsive buying in order to better understand this process addiction.

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Case Study

Gina is a recovering alcoholic whose husband died last year. She has struggled with depression and has withdrawn from most normal activities, including meetings. She began watching and ordering from one of the shopping networks a few months ago. Over the last 2 months her daughter has become increasingly concerned and brought her in for counseling because Gina has spent almost $10,000 on items she does not use or need. Sometimes, Gina admits, she may not even want the item, but feels good when she orders from her “family at the shopping network.” She is angry at being confronted and says that it is her money and her choice. Considering information about process addictions and spending, and Gina’s circumstances, do you consider this behavior problematic? Addictive? Discuss what you think may be happening with Gina, the danger signals you see, and how you would approach counseling with her.

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Food Addiction and Disordered Eating Some addiction experts claim that—similar to alcohol or drugs—food can be addictive (Ahmed et al., 2013; Avena, Rada, & Hoebel, 2008; Clark & Saules, 2013; Gearhardt, White, Masheb, & Grilo, 2013; Gearhardt, Corbin, & Brownell, 2009b; Gearhardt, Corbin, & Brownell, 2009a; Gold, Graham, Cocores, & Nixon, 2009; Sheppard, 1993; Sinha & Jastrehoff, 2013; von Deneen, Gold, & Liu, 2009), while others continue to debate the issue (APA, 2013; von Ranson, McGue, & Iacono, 2003). Experts who claim that eating disorders (including anorexia, bulimia, and binge eating) are addictions argue that individuals suffering with these disorders often share common traits with those addicted to alcohol or drugs, such as obsession, compulsion, denial, tolerance, withdrawal symptoms, and cravings (Ahmed et al., 2013; Clark & Saules, 2013; Gearhardt et al., 2013; Sheppard, 1993). Researchers are exploring the possible addictive qualities of certain types of foods, including foods with high fat and/or sugar content (Ahmed et al., 2013; Gold et al., 2009). For example, sugar releases opioids and dopamines in the brain, causing neurochemical changes and suggesting possible addictive qualities (Avena et al., 2008). The roles of hormones and genes that may be related to whether a person is likely to develop addictive eating patterns are also being investigated (von Deneen et al., 2009). Gold et al. (2009) assert that our nation’s obesity epidemic alone suggests that certain foods may promote a loss of control and continued use despite negative consequences, which are among the diagnostic criterion for substance abuse and dependence. The existence of 12-step recovery programs for disordered eating, modeled after Alcoholics Anonymous’s Twelve Steps and Traditions, perhaps indicates growing support among both the population and professionals for the treatment of

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eating disorders as addictions (von Ranson et al., 2003). Such programs include Overeaters Anonymous, Inc., Food Addicts in Recovery Anonymous, Anorexics Anonymous, and Bulimics Anonymous.

The debate about whether eating disorders are addictions continues as researchers learn more about the causes and best treatment for eating disorders and food addiction. There is still a great deal to learn about the causes of eating disorders. What is known is that eating disorders are complex, involving long-term psychological, behavioral, emotional, interpersonal, familial, biological, spiritual, and social factors (ANAD, 2014; National Eating Disorders Association [NEDA], 2014). In fact, although people with eating disorders are preoccupied with food, appearance, and weight, they also often struggle with issues of control, acceptance, and self-esteem. Regardless of the potential causes of eating disorders, they can create a self-perpetuating cycle of physical and emotional abuse that requires professional help.

Anorexia nervosa is typified by compulsive self-starvation and excessive weight loss. Some of the symptoms can include refusal to maintain a normal body weight for height, body type, age, and activity level; intense fear of weight gain; loss of menstrual periods; continuing to feel “fat” despite extreme weight loss; and extreme obsessive concern with body weight and shape (NEDA, 2014). ANAD (2014) states that symptoms of anorexia nervosa include weighing 15% below what is expected for age and height. An individual with anorexia nervosa may have a low tolerance for change and new situations, may fear growing up and taking charge of his or her own life, and be overly dependent on parents and family. Dieting may represent avoidance of and ineffective attempts at coping with the demands of new stages of life (ANAD, 2014).

Bulimia nervosa is typified by a compulsive cycle of binge eating and then purging. An individual with bulimia eats a large amount of food in a short

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period of time and then gets rid of the food and calories through vomiting, laxative abuse, or excessive exercise. Some of the symptoms of bulimia include repeated cycles of bingeing and purging, frequent dieting, extreme concern with body weight and shape, and feeling out of control during a binge, as well as eating beyond the point of fullness. Impulse control can be a problem for those with bulimia and lack of control may also extend to risky behaviors such as shoplifting, sexual adventurousness, and alcohol and other drug abuse (ANAD, 2014).

Binge eating disorder is a recognized disorder in the new diagnostic manual (APA, 2013) and is differentiated from bulimia nervosa in that there are episodes of uncontrollable, impulsive bingeing but there is no purging. An individual with binge eating disorder engages in random fasting and diets and feels extreme shame and self-hatred after bingeing. Individuals with binge eating disorder tend to eat rapidly and secretly, and be depressed and obese. Other eating disorders include a combination of symptoms from anorexia, bulimia, purging, night eating, and binge eating disorders and the symptoms, if severe enough, can be considered a clinical disorder (APA, 2013).

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Case Study

Maggie is an 18-year-old college freshman. During high school, she was an honor roll student and athlete, participating on the soccer and swim teams. Maggie is very driven to succeed at college, and is feeling the strains of being in a new place with high academic standards. She began to gravitate to comforting favorite foods in the cafeteria, such as pizza, French fries, and soft serve ice cream. She soon began to notice that her clothes were getting tight. Maggie became very scared of gaining the “freshman fifteen” and started working out and eating more healthfully. After she lost the few pounds she had gained, however, she decided she could stand to lose a few more. She began getting up at 6 �.�. to fit in a long gym workout before class, and began to make rules about which foods in the cafeteria she was allowed to eat. Maggie comes to see you at the university counseling center because she is “stressed” and “anxious.” During your assessment, you notice that she is very thin, and you learn that she has lost 20 pounds since she began what she describes as “just eating better and working out to be healthier.”

What are the most important concerns to focus on first as her counselor? How would you begin to explore your concerns about her eating patterns, or would you? What levels of care might you consider: outpatient, intensive outpatient, and/or residential? Explain. How would you discuss the addictive nature of her eating patterns? Or, would you mention addiction?

According to the DSM-5, the lifetime prevalence rate of anorexia nervosa among females is 0.4% and one-tenth of that for men (APA, 2013). In the last 20 years the occurrence of anorexia nervosa has increased. The 12- month prevalence of bulimia nervosa among women is 1–1.53% and the prevalence for men is roughly one-tenth of that of females (APA, 2013). According to ANAD (2014), 1% of female adolescents suffer from anorexia nervosa and 1.1–4.2% of women suffer from bulimia nervosa during their

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life. Other estimates highlight that 5–15% of individuals suffering from anorexia and bulimia are male (ANAD, 2014). NEDA (2014) reports roughly 30 million are struggling with eating disorders. Because physicians are not required to report eating disorders to a health agency, and because the nature of the disorder is secretive, we only have estimates of how many people in this country are affected by eating disorders (ANAD, 2014; NEDA, 2014).

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Summary and Some Final Notations In summary, “to recognize the underlying addictive process is to acknowledge that society itself operates addictively; its institutions perpetuate the addictive process. It does not merely encourage addictions; it regards them as normal” (Schaef, 1990, p. 18). This chapter provides counselors with comprehensive introductory information about process addictions. It is imperative that counselors continue their education about the new scientific discoveries as well as the intricate and complex issues surrounding addiction.

MyCounselingLab

Visit the MyCounselingLab site for Foundations of Addictions Counseling, Third Edition to enhance your understanding of concepts. You'll have the opportunity to practice your skills through video- and case-based exercises. You will find sets of questions to help you prepare for your certification exam with Licensure Quizzes. There is also a Video Library that provides taped counseling sessions, ethical scenarios, and interviews with helpers and clients.

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Useful Websites The following websites provide additional information relating to the chapter topics:

Anorexia Nervosa and Related Disorders, Inc.

www.anad.org/

Anorexics and Bulimics Anonymous

www.aba12steps.org

CoDependents Anonymous

www.codependents.org

Debtors Anonymous

debtorsanonymous.org/

Food Addicts in Recovery Anonymous

www.foodaddicts.org

Gamblers Anonymous

www.GamblersAnonymous.org

Gambling, National Council on Problem Gambling

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www.ncpgambling.org

National Eating Disorders Association

www.nationaleatingdisorders.org

Overeaters Anonymous

www.oa.org

S-Anon (for family and friends of sexually addicted people)

www.sanon.org

Sex Addicts Anonymous

www.saa-recovery.org

Sexaholics Anonymous

www.sa.org

Sex and Love Addicts Anonymous

www.slaafws.org

Stopping Over Shopping

www.shopaholicnomore.com/

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