Six steps for addressing behavioral addictions in clinical work

By Amanda Giordano

October 2021

The first time I worked with a client who said he was addicted to internet pornography, I had no idea how to respond. I quickly tried to recall material from my master’s-level addictions course, but we had discussed only substance use disorders. I hadn’t learned anything about how to address addictive behaviors. Thankfully, one of my professors was a certified sex addiction therapist and supervised me as I worked with this client through internship.

Since then, I have dedicated myself to learning about behavioral addictions and conducting research in this area. In the process of writing a clinical reference book on the topic, I interviewed dozens of clinicians who specialize in behavioral addictions, as well as members of many 12-step programs, to learn more about the realities of behavioral addictions. What I heard from almost every clinician I interviewed is that they had to seek out their own training related to behavioral addictions. Whether through conference presentations, webinars, books or online training programs, they initially taught themselves how to address addictive behaviors because the topic was not covered in their counselor training programs. As a counselor educator, I fully understand that we cannot cover all important topics in depth in a two- or three-year training program, but it seemed as though the clinicians with whom I spoke would have benefited from at least an introduction to behavioral addictions during their graduate training. 

Since becoming a counselor educator, I have been intentional about infusing content related to behavioral addictions into my courses (e.g., human development, addictions counseling, clinical supervision). I also developed an elective solely dedicated to behavioral addictions. I frequently receive emails from former students that say something along the following lines: 

“Thank you for teaching me about internet gaming addiction. I am working with my first high school student with this type of addiction.”

“I am using the resources you mentioned in class about sex addiction because I have several clients who have lost control over their sexual activity.”

“When my client mentioned gambling, I wasn’t afraid to ask more about it because I had a framework for understanding behavioral addictions.”

An issue for all counselors

I monitor published statistics on the prevalence of behavioral addictions, but more than that, I hear firsthand from former students how frequently clients with addictive behaviors present to counseling. Therefore, my goal in writing this article is to present six steps that all counselors can take to better address behavioral addictions. Whether working in a school, college counseling center, community mental health agency, private practice, hospital, couple and family counseling practice, or another setting, we must be able to recognize and respond effectively to behavioral addictions.

1) We need to have a solid conceptualization of behavioral addictions

Researchers have proposed that addiction is one disorder with a variety of expressions — some that take the form of substance misuse and others that take the form of compulsive engagement in rewarding behaviors. Thus, much of what we know about chemical addiction is relevant to behavioral addictions. For example, both drugs of abuse and hedonic behaviors activate reward circuitry in the brain — specifically, the mesolimbic dopaminergic pathway. 

Although more neuroscience research is needed, it is proposed that highly rewarding behaviors (e.g., sex, gaming, gambling) trigger the release of neurotransmitters implicated in reward (e.g., dopamine, opioids). The activation of reward circuitry can cause pleasurable feelings and provide an escape from negative feelings, both of which serve to reinforce the behavior and increase the likelihood of repeating the activity in the future. For individuals with specific vulnerabilities (e.g., genetic predispositions, histories of adverse childhood experiences, mental health conditions, social learning related to specific behaviors as coping mechanisms), a rewarding behavior can become the primary means of regulating their emotions. Thus, it is the unique interaction between a vulnerable individual and the specific nature of the rewarding behavior that increases the risk of behavioral addictions.

Additionally, the chronic activation of one’s reward circuitry via compulsive engagement in rewarding behaviors may lead to neuroadaptations, or changes in the brain as a result of experience. The chronic overstimulation of the reward system due to behavioral addictions may cause the brain to adapt by decreasing the natural production of dopamine, decreasing the number of dopamine receptors or decreasing the number of dopamine transporters. This downregulation of the dopamine system can lessen an individual’s baseline experience of reward (e.g., at baseline, the individual may feel dysphoric), thereby triggering cravings for addictive behaviors to enhance one’s mood. In this way, the addictive behavior becomes part of a cycle of feeling dysphoric at baseline and then seeking engagement in the addictive behavior to induce positive feelings or ward off withdrawal. 

An understanding of behavioral addictions as a means of regulating emotions with potential neurobiological antecedents and consequences can help us cultivate accurate empathy for our clients and develop effective treatment plans.

2) We need to recognize behavioral addictions in our clinical work

There is a lot of shame around addiction in general and behavioral addictions specifically. Many clients may present with other issues (e.g., depression, anxiety, suicidal ideation, relational conflict, low self-esteem) rather than disclose an addiction to sex, gaming, gambling, food, shopping or another behavior. Therefore, it is imperative that counselors consistently ask clients about their engagement in potentially addictive behaviors in a nonevaluative way. For example, when a client discloses difficulty in their lives, a counselor might ask, “I am curious how you cope with these challenges. Some people turn to alcohol, some people escape through sex or pornography, and some people engage in internet gaming to feel better. How do you deal with your negative feelings?” 

Also, including items on one’s intake form related to addictive behaviors can normalize the experience for clients and invite them to disclose early in the course of treatment. As with chemical addiction, it is impossible to recognize a behavioral addiction simply by looking at a client — behavioral addictions occur among clients of all ages, racial and ethnic groups, genders, religious/spiritual affiliations, sexual orientations and socioeconomic statuses. Therefore, counselors need to be intentional and assess for behavioral addictions with all clients. 

Furthermore, it is important for counselors to accurately distinguish between high involvement in a behavior and a behavioral addiction. Definitions of addiction, diagnostic criteria and published research reveal “Four C’s” that can help counselors identify behavioral addictions: 

• If the behavior is compulsive. 
• If the individual has lost control over their behavior.
• If the behavior continues despite negative consequences.
• If the individual experiences cravings or mental preoccupation with the behavior when not engaging. 

A client who is very enthusiastic about a behavior or highly involved (e.g., a professional gamer) will not demonstrate the Four C’s of addiction (e.g., they can limit or control their engagement, they do not experience negative consequences). However, if the Four C’s are present, it should alert counselors to engage in further assessment for a behavioral addiction. There are many assessment instruments for behavioral addictions, including the Internet Gaming Disorder Scale, the Bergen Social Media Addiction Scale, the Sexual Addiction Screening Test-Revised and the South Oaks Gambling Screen.

3) We need to embrace our responsibility to address behavioral addictions

It is likely that counselors in all settings will encounter clients with behavioral addictions, and we should be prepared and willing to address these addictions. Rather than assuming this type of clinical work requires a brand-new set of skills, counselors need only to add to their previously established clinical skill set to address behavioral addictions. For instance, when working with clients with behavioral addictions, counselors will still rely on their basic counseling skills such as empathy, reflective listening, unconditional positive regard, immediacy, genuineness, open questions, multicultural competence and an understanding of theory. These elements are still necessary for developing rapport, setting goals and engaging in effective interventions with clients with behavioral addictions. 

In addition to these foundational skills, counselors should become informed about the specific nature of the addictive behavior (e.g., gambling, gaming, exercise, cybersex), including relevant neuroscience. This can also be helpful when providing psychoeducation to clients and their families. Counselors can gain addiction-specific knowledge through self-study, webinars, conference presentations, attendance at open 12-step meetings, consultation with seasoned professionals and pursuit of certification or relevant credentials. 

Along with gaining addiction-specific knowledge, counselors should apply interventions that have proved to be helpful with behavioral addictions (i.e., those that are evidence based). There is a wealth of research that outlines helpful strategies for working with behavioral addictions (e.g., group interventions, motivational interviewing, dialectical behavior therapy, cognitive behavior therapy, couples counseling interventions, mindfulness-based interventions). Several published studies and manuals exist to help inform and guide counselors who are working with a specific behavioral addiction for the first time. 

All counselors can become more equipped to address behavioral addictions by adding addiction-specific knowledge and evidence-based interventions to their clinical repertoire. There certainly will be times when a referral is in the best interest of the client (e.g., to a residential treatment facility for sex addiction or an intensive outpatient program for gaming addiction), but many times the best (or only) available option will be for counselors themselves to treat clients who have behavioral addictions. In these instances, counselors are encouraged to consult with other clinicians who have experience working with the specific behavioral addiction or to seek supervision. Rather than abdicating the responsibility of addressing behavioral addictions, all counselors should be willing to meet the needs of these clients.

4) We need to understand what abstinence entails for behavioral addictions

Abstinence as it relates to substance use disorders is fairly obvious — stop using drugs of abuse. Abstinence from behavioral addictions is less clear, however. Are clients expected to abstain from sex? Stop shopping? Never use the internet? No, abstinence in relation to behavioral addictions entails identifying and refraining from the out-of-control, compulsive behaviors that lead to negative consequences. 

Twelve-step programs use a variety of tools, such as the three circles technique or the development of bottom lines, middle lines and top lines, to aid in defining abstinence for clients with behavioral addictions. In both techniques, individuals and their sponsors engage in honest evaluation and identify all compulsive, harmful and out-of-control behaviors from which they will abstain (e.g., betting on fantasy sports, engaging in cybersex activities, binge eating when they are not hungry, checking social media while driving, playing or watching internet games). These activities are listed in the innermost of three concentric circles or constitute one’s bottom lines. Next, individuals and their sponsors identify behaviors that are warning signs, triggers or precipitating behaviors to those listed in the inner circle or bottom lines. These activities are then written in the middle circle or serve as one’s middle lines. Finally, behaviors that are encouraged, aspirational, align with the individual’s personal goals and values, and increase wellness are identified and listed in the outer circle or make up the top lines. 

In the realm of behavioral addictions, abstinence is defined by refraining from inner-circle activities or bottom lines. When a middle-circle or middle-line activity takes place, it is not considered a relapse, but rather serves as a warning sign that the individual is nearing the inner-circle (or bottom-line) activities and needs to take action (e.g., call a sponsor, go to a 12-step meeting, use a predetermined coping strategy). Thus, the process of recovery among those with behavioral addictions includes abstaining from inner-circle/bottom-line activities, minimizing middle-circle/middle-line activities and increasing outer-circle/top-line activities.

5) We need to be familiar with the 12-step programs in our area

Twelve-step programs can be extremely valuable (and affordable) resources for our clients with behavioral addictions. The number of 12-step groups dedicated to behavioral addictions (e.g., Computer Gaming Addicts Anonymous, Internet and Technology Addicts Anonymous, Sex Addicts Anonymous, Sexaholics Anonymous, Gamblers Anonymous, Overeaters Anonymous, Food Addicts in Recovery Anonymous, Workaholics Anonymous, Debtors Anonymous, Celebrate Recovery) further confirms their prevalence in society. 

Prior to referring clients to a 12-step program, counselors should be familiar with the programs in their area and able to provide details to their clients regarding how to access a meeting, what to expect during a meeting, the mission of the fellowship, and the traditions and common practices of 12-step programs. Many 12-step programs have brochures and literature specifically designed for counselors to help them make referrals to these programs. 

Additionally, in some instances, multiple 12-step programs exist for the same behavioral addiction (e.g., Sex Addicts Anonymous, Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sexual Compulsives Anonymous; Food Addicts in Recovery Anonymous, Overeaters Anonymous). Counselors should be aware of the differences between the programs so that clients can make an informed decision about which fellowship might be the best fit for them. Almost all of the 12-step programs for behavioral addictions have comprehensive websites, a basic text (e.g., the Sex Addicts Anonymous Green Book) and literature that can help counselors become better informed. Again, counselors are encouraged to attend open meetings themselves to learn more about the programs in their area. 

6) We need to be willing to advocate for clients with behavioral addictions 

Behavioral addictions are not well understood among the general public and often are stigmatized to a greater degree than is chemical addiction (consider potential societal reactions to someone with sex addiction compared with someone with an alcohol use disorder). Counselors, by the nature of their professional identities, are advocates and serve to remove barriers to clients’ wellness. Several prominent barriers exist among those with behavioral addictions. These barriers include societal and internalized stigma, public misinformation and bias, lack of available (and affordable) treatment options, lack of insurance coverage, lack of trained clinicians, and the prominence of the moral model of addiction (i.e., addiction is the result of a moral failing) rather than the biopsychosocial model of addiction (i.e., addiction is influenced by one’s genetic makeup, psychological factors, personal experiences and environment). 

Practical means of advocating for individuals with behavioral addictions include: 

• Ensuring that all counselors receive training (either during or after graduate school) to recognize and respond to behavioral addictions
• Ensuring that all local communities have counselors who are equipped to address behavioral addictions (e.g., certified sex addiction therapists, credentialing from the International Gambling Counselor Certification Board)
• Conducting research regarding behavioral addictions to support their inclusion in diagnostic manuals and to increase empirical evidence
• Engaging in efforts to ensure insurance coverage for behavioral addictions treatment
• Becoming involved in legislation related to the regulation of potentially addictive behaviors
• Dispelling myths and raising public awareness about the realities of behavioral addictions

All counselors can engage at the individual, community or public level to advocate for clients with addictive behaviors. 

In sum, behavioral addictions are prevalent in today’s society and affect individuals across the life span. All counselors should be familiar with behavioral addictions so that they are able to recognize them among clients and respond appropriately (whether that means addressing the behavioral addiction themselves or referring clients to another level of care). 

As we become more informed and receive more training, we can best attend to the needs of clients with behavioral addictions and ensure that they receive competent, effective care. The steps detailed in this article are not the responsibility of a select group of clinicians but rather a responsibility for all counselors so that we can best support clients with behavioral addictions.

Amanda Giordano is a licensed professional counselor, an associate professor at the University of Georgia and the author of A Clinical Guide to Treating Behavioral Addictions: Conceptualizations, Assessments, and Clinical Strategies. Visit her author page at facebook.com/amandaleegiordano.

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