Behavioural addictions and Behavioural addictions and suicidesuicide

an under-estimated relationship?an under-estimated relationship?

Sean Sullivan PhDSean Sullivan PhDAbacus Counselling & Training Abacus Counselling & Training

Services LtdServices Ltd

What is an ‘addiction’What is an ‘addiction’ A lay term that hasn’t been fully accepted A lay term that hasn’t been fully accepted

by many mainstream health professionalsby many mainstream health professionals Originally referred to chemical dependenceOriginally referred to chemical dependence Generally included Generally included preoccupationpreoccupation with the with the

addictive substance (funding, obtaining, addictive substance (funding, obtaining, reflecting)reflecting)

Also development of a Also development of a tolerancetolerance (more (more required to attain desired effect), negative required to attain desired effect), negative withdrawalwithdrawal effects when reduce/stop effects when reduce/stop

Includes Includes persistence despite negative persistence despite negative outcomesoutcomes arising from the use of the arising from the use of the substancesubstance

An open category An open category

Examples of behavioural addictions are:Examples of behavioural addictions are: Problem gambling at its more extreme Problem gambling at its more extreme

end (Pathological Gambling Disorder)end (Pathological Gambling Disorder) Pornography addiction, particularly via Pornography addiction, particularly via

the Internetthe Internet Compulsive spending/buyingCompulsive spending/buying Sexual addictionSexual addiction Internet addictionInternet addiction ‘‘Video’ game addiction Video’ game addiction

Can ‘addiction’ be expanded to a Can ‘addiction’ be expanded to a behaviour?behaviour?

Often a reluctance to allow this term to be Often a reluctance to allow this term to be extended beyond its ‘substance extended beyond its ‘substance dependence’ basedependence’ base

Reasons appear varied and not well Reasons appear varied and not well argued. They include:argued. They include: Lack of biological adaptation markers for Lack of biological adaptation markers for

behavioural ‘addiction’behavioural ‘addiction’ No independent proof of lack of control – may No independent proof of lack of control – may

choose not to moderate their behaviourchoose not to moderate their behaviour Weakens the acceptability or importance of the Weakens the acceptability or importance of the

term ‘addiction’ –where will it end (Internet term ‘addiction’ –where will it end (Internet ‘addiction’, pornography ‘addiction’ and even ‘addiction’, pornography ‘addiction’ and even chocolate (?) or coffee ‘addiction’) chocolate (?) or coffee ‘addiction’)

Why include behaviours in Why include behaviours in ‘addictions’ ‘addictions’

The only differences may be the The only differences may be the absence of an external chemical absence of an external chemical introduced into person’s system and introduced into person’s system and less acute withdrawal effects–less acute withdrawal effects–insufficient reasons in themselvesinsufficient reasons in themselves Preoccupation similarPreoccupation similar Tolerance occursTolerance occurs Some withdrawal – irritability, anxietySome withdrawal – irritability, anxiety Persistence despite negative outcomes can be Persistence despite negative outcomes can be

very highvery high But need for some definition to avoid ‘devaluing’ But need for some definition to avoid ‘devaluing’

the term, even when chemicals involved (eg the term, even when chemicals involved (eg coffee, chocolate, and behaviours, movie coffee, chocolate, and behaviours, movie ‘addictions’)‘addictions’)

Why include behaviours in Why include behaviours in ‘addictions’ ‘addictions’ (contin)(contin)

As the new kid on the block, behavioural As the new kid on the block, behavioural addictions must overcome many barriers addictions must overcome many barriers that prevent them being taken seriously:that prevent them being taken seriously: Behavioural addictions are often seen as habits, Behavioural addictions are often seen as habits,

that the absence of a drug means that there is that the absence of a drug means that there is greater control retained to resist (the drug is to greater control retained to resist (the drug is to blame)blame)

Those affected are often perceived as weaker, at-Those affected are often perceived as weaker, at-risk, and unlike the general population risk, and unlike the general population

They are often regarded as less important, less They are often regarded as less important, less problematic, and less life-threatening –often a problematic, and less life-threatening –often a hierarchy of addictions even by those affectedhierarchy of addictions even by those affected

A range of impacts similar to all A range of impacts similar to all addictionsaddictions

As with chemical/drug addictions there is As with chemical/drug addictions there is often more severe outcomes with different often more severe outcomes with different behavioural addictions eg illegal drugs (P, behavioural addictions eg illegal drugs (P, cocaine etc) can have additional cocaine etc) can have additional consequences to legal drugs eg alcoholconsequences to legal drugs eg alcohol

However, greater accessibility for legal However, greater accessibility for legal drugs can have its own problems, as can drugs can have its own problems, as can their widespread social use (I can control their widespread social use (I can control my use of alcohol, so why can’t they?)my use of alcohol, so why can’t they?)

Some behavioural addictions can have Some behavioural addictions can have widespread consequences, and result in widespread consequences, and result in harm for many othersharm for many others

Two examples in more detailTwo examples in more detail

Internet pornography addictionInternet pornography addiction Not a recognised mainstream mental Not a recognised mainstream mental

health disorderhealth disorder Unknown prevalence but probably Unknown prevalence but probably

widespread (can’t survey for it) and widespread (can’t survey for it) and largely maleslargely males

Often perceived as leading to paedophilia Often perceived as leading to paedophilia or risk to others through self-gratificationor risk to others through self-gratification

General negative perception, especially if General negative perception, especially if work with children (regardless of whether work with children (regardless of whether their focus is adults) their focus is adults)

Typical development processTypical development process Viewing pornography is commonplace, Viewing pornography is commonplace,

especially with males, so what is different?especially with males, so what is different? Extent and consequences place those with Extent and consequences place those with

this addiction at high risk (objectionable this addiction at high risk (objectionable images subject to DIA surveillance and images subject to DIA surveillance and prosecution)prosecution)

Typical development is casual accessing of Typical development is casual accessing of pornography that increases to substantial pornography that increases to substantial preoccupation and at a time when preoccupation and at a time when increased likelihood of disclosureincreased likelihood of disclosure

Time spent and extent of the explicitness Time spent and extent of the explicitness of the pornography increases (tolerance)of the pornography increases (tolerance)

CrisisCrisis

Shame and attempts to hide the behaviour Shame and attempts to hide the behaviour increases, but impulsiveness also increasesincreases, but impulsiveness also increases

Behaviour increases at both work and home Behaviour increases at both work and home (late evening) – discovery common at home(late evening) – discovery common at home

Crisis common – discovery at work, or even Crisis common – discovery at work, or even identification by DIAidentification by DIA

Commonly, contrary to employment policy Commonly, contrary to employment policy and termination of that employment commonand termination of that employment common

Reluctance to seek help by males (often Reluctance to seek help by males (often distressed female partner initiates counsellingdistressed female partner initiates counselling

ProcessProcess Marital stressMarital stress Shame and guiltShame and guilt Attempts to stop often unsuccessful due to Attempts to stop often unsuccessful due to

high accessibility of the Internet at work, at high accessibility of the Internet at work, at Internet cafes, and homeInternet cafes, and home

Powerful process – unlike graphic magazines, Powerful process – unlike graphic magazines, images can be changed immediately, more images can be changed immediately, more explicit images always available, prompts can explicit images always available, prompts can invite viewing even when legitimate Internet invite viewing even when legitimate Internet useuse

Powerful reinforcement particularly for males– Powerful reinforcement particularly for males– sexual gratification with a number of ‘partners’ sexual gratification with a number of ‘partners’ who are perfect through digital enhancementwho are perfect through digital enhancement

Perception of total control and no possible Perception of total control and no possible rejectionrejection

ConsequencesConsequences For many, real relationships become less For many, real relationships become less

desirable (less than perfect, lack of control, desirable (less than perfect, lack of control, possible rejection)possible rejection)

Boredom equates to tolerance, greater Boredom equates to tolerance, greater explicitness required, higher riskexplicitness required, higher risk

As with addictions, preoccupation leads to As with addictions, preoccupation leads to decreased effectiveness and sociability, and decreased effectiveness and sociability, and isolationisolation

Accessing images increases, and becomes Accessing images increases, and becomes the preferred status to avoid negative realitythe preferred status to avoid negative reality

As stress increases, accessing images As stress increases, accessing images becomes a way to self medicate, and with becomes a way to self medicate, and with more graphic images, possible more graphic images, possible consequences increases stress consequences increases stress

ConsequencesConsequences For many, the damage to their social For many, the damage to their social

support, loss of employment, loss of the support, loss of employment, loss of the stress relief provided by the behaviour, and stress relief provided by the behaviour, and ambivalence around common relapses, ambivalence around common relapses, often leads to depression and anxietyoften leads to depression and anxiety

Depression and anxiety may not be overt Depression and anxiety may not be overt as these emotions are often suppressed by as these emotions are often suppressed by dissociation with malesdissociation with males

Many of these people were already Many of these people were already depressed and/or anxious and the depressed and/or anxious and the dissociation provided by pornography on dissociation provided by pornography on the Internet relieved the constant stress the Internet relieved the constant stress without conscious awarenesswithout conscious awareness

Additional issues Additional issues Unlike chemical/drug addiction, where Unlike chemical/drug addiction, where

once stopped there is often a rapid once stopped there is often a rapid improvement in health, behavioural improvement in health, behavioural addictions often result in increased addictions often result in increased depressiondepression

Reason may be that the problems still Reason may be that the problems still exist (disclosure of unacceptable exist (disclosure of unacceptable behaviour, loss of employment, loss of behaviour, loss of employment, loss of trust where symptoms of recovery unclear) trust where symptoms of recovery unclear) while use of the behaviour to escape these while use of the behaviour to escape these dysphoric consequences is lostdysphoric consequences is lost

Social repugnance can lead to other ways Social repugnance can lead to other ways to avoid this new reality or may lead to to avoid this new reality or may lead to suicidal ideationsuicidal ideation

An exampleAn example

A second behavioural addictionA second behavioural addiction

Pathological or compulsive gamblingPathological or compulsive gambling More known about this addictionMore known about this addiction Is recognised by mainstream health providersIs recognised by mainstream health providers Negative consequences may be one of the highest Negative consequences may be one of the highest

for both chemical and behavioural addictions for both chemical and behavioural addictions Affects individuals and on average 7 family Affects individuals and on average 7 family

members or othersmembers or others Process is similar in many cases to other addictions Process is similar in many cases to other addictions

(gradual adaptation from reward, tolerance, (gradual adaptation from reward, tolerance, preoccupation, persistence preoccupation, persistence

Added factor of an inbuilt solution and no satiationAdded factor of an inbuilt solution and no satiation

Additional factorsAdditional factors

Gambling, especially electronic modes Gambling, especially electronic modes which have high addictiveness, are which have high addictiveness, are becoming more accessible, and have becoming more accessible, and have high current accessibility in NZhigh current accessibility in NZ

Currently, males and females have Currently, males and females have similar risk similar risk

High co-occurrence of other problems High co-occurrence of other problems that often, but not always, develop as the that often, but not always, develop as the gambling becomes more problematicgambling becomes more problematic

These additional issues include These additional issues include depression, anxiety, alcohol abuse, depression, anxiety, alcohol abuse, family and work dysfunction, poverty, family and work dysfunction, poverty, criminal activity to sustain addiction, and criminal activity to sustain addiction, and suicidal ideationsuicidal ideation

Factors that enhance self harmFactors that enhance self harm As with pornography addiction, although As with pornography addiction, although

gambling is widespread, excessive gambling gambling is widespread, excessive gambling is viewed as indulgent, untrustworthy, trying is viewed as indulgent, untrustworthy, trying to take the easy way to riches, stupid, and to take the easy way to riches, stupid, and because associated crime common, the because associated crime common, the individual is viewed as inherently badindividual is viewed as inherently bad

Relapses are common (cued by advertising, Relapses are common (cued by advertising, pressure from creditors, dissociation that pressure from creditors, dissociation that leads to ‘casual’ gambling opportunities)leads to ‘casual’ gambling opportunities)

Continued lack of trust from others due to Continued lack of trust from others due to lack of symptoms of recoverylack of symptoms of recovery

Guilt, shame, relapses entrench depression Guilt, shame, relapses entrench depression and anxiety, with addiction impulsivenessand anxiety, with addiction impulsiveness

A perceived solutionA perceived solution Many problem gamblers choose suicide Many problem gamblers choose suicide

as an impulsive solution as an impulsive solution Many will prepare for it over time, others Many will prepare for it over time, others

respond impulsivelyrespond impulsively Most do not attempt suicide to draw Most do not attempt suicide to draw

attention to their circumstancesattention to their circumstances An estimate is that 20% of those An estimate is that 20% of those

diagnosed with Pathological Gambling diagnosed with Pathological Gambling Disorder will attempt suicideDisorder will attempt suicide

A recent study of those admitted to A recent study of those admitted to hospital after a suicide attempt found hospital after a suicide attempt found that 17% were positive on a problem that 17% were positive on a problem gambling screen (2%-3% in the general gambling screen (2%-3% in the general populationpopulation

Males and behavioural addictionsMales and behavioural addictions

Because of the lack of prevalence data for Because of the lack of prevalence data for these, for many we can only look to these, for many we can only look to presentation ratespresentation rates Few seek help for pornography addiction, but Few seek help for pornography addiction, but

those that do are invariably malesthose that do are invariably males Half of those that seek help for gambling are Half of those that seek help for gambling are

males, largely because gambling machines are males, largely because gambling machines are the major contributor for problems (75%-85%) the major contributor for problems (75%-85%) and perhaps more than half of players are and perhaps more than half of players are female. More than 90% of sports and track female. More than 90% of sports and track betting clients are male and view their behaviour betting clients are male and view their behaviour as skillful (an ego component). as skillful (an ego component).

Many male clients present as defensive, and with Many male clients present as defensive, and with cognitive rather than emotional perspectives cognitive rather than emotional perspectives

Factors in addressing problem Factors in addressing problem gambling addiction in malesgambling addiction in males

Thoughts around suicide are often common-Thoughts around suicide are often common-place but sometimes discounted as unlikelyplace but sometimes discounted as unlikely When raised, reasons are often given why they When raised, reasons are often given why they

wouldn’t (‘I couldn’t do that to my children’) but wouldn’t (‘I couldn’t do that to my children’) but this can change quickly (‘My children would be this can change quickly (‘My children would be better off without me’)better off without me’)

Levels of anxiety and depression are poorly self-Levels of anxiety and depression are poorly self-monitored and emotions often suppressed monitored and emotions often suppressed (response often to partner’s overt emotion to the (response often to partner’s overt emotion to the addiction)addiction)

However, addressing this with males in a cognitive However, addressing this with males in a cognitive approach without emotion can assist to raise approach without emotion can assist to raise awareness of this possibility, discuss consequencesawareness of this possibility, discuss consequences

An approachAn approach Often ‘normalise’ these ideations in order to Often ‘normalise’ these ideations in order to

avoid barriers of shame/being unable to avoid barriers of shame/being unable to cope and to identify extent of risk cope and to identify extent of risk (thoughts-planning-past attempts)(thoughts-planning-past attempts)

Often use of Motivational Interviewing can Often use of Motivational Interviewing can assist by the counselor emotionally ‘sitting assist by the counselor emotionally ‘sitting on the fence’ but with empathy, resolving on the fence’ but with empathy, resolving ambivalence, motivating self-statements of ambivalence, motivating self-statements of ability to resolve issues ability to resolve issues

Because of the possible impulsive decision Because of the possible impulsive decision of suicide may occur at any time in the of suicide may occur at any time in the future (continued stress, greater future (continued stress, greater depression) this topic is often raised early in depression) this topic is often raised early in counselling some behavioural addictions, counselling some behavioural addictions, especially problem gamblingespecially problem gambling

Some important questionsSome important questions

Is this approach successful?Is this approach successful? Does the raising of the topic of suicide put Does the raising of the topic of suicide put

the idea in the head of a stressed person?the idea in the head of a stressed person? Is this cognitive approach always the best Is this cognitive approach always the best

approach – are all males the same?approach – are all males the same? Is reaching a ‘contract’ with a client not to Is reaching a ‘contract’ with a client not to

attempt suicide ( or at least without first attempt suicide ( or at least without first accessing help) effective?accessing help) effective?

SummarySummary Some behavioural addictions, particularly gambling, Some behavioural addictions, particularly gambling,

may have higher risk for suicide than chemical may have higher risk for suicide than chemical addictions –sudden condemnation on disclosure, addictions –sudden condemnation on disclosure, criminal prosecution, financial loss (Durkheim’s criminal prosecution, financial loss (Durkheim’s egoistic/loss of social connections, and anomie/loss egoistic/loss of social connections, and anomie/loss normal life)normal life)

Less understanding by society, greater willingness Less understanding by society, greater willingness to attribute weakness/indulgence, less overt to attribute weakness/indulgence, less overt symptoms result in less willingness to trust, greater symptoms result in less willingness to trust, greater isolation, less support, greater co-occurring isolation, less support, greater co-occurring addictions and dysphoriaaddictions and dysphoria

Late help-seekingLate help-seeking Those counselling these clients should be aware of Those counselling these clients should be aware of

greater risk for self-harm and be prepared to greater risk for self-harm and be prepared to address it proactivelyaddress it proactively

endend