The use of 12-step programs based on the Alcoholic Anonymous program is common in many substance abuse treatment programs and has proven effective for many people. Recently, new types of addictions have been identified that do not involve drugs or other substances, such as gambling, shopping, viewing pornography, cutting, sex, use of computers, use of cell phones, playing video games, the Internet, etc. These are generally referred to as behavioral addictions, although only compulsive gambling is recognized in the DSM-5. Various forms of treatment are currently in use, primarily psychotherapy and psychopharmacology. The question to be considered here is whether 12-step programs can be effective treatments for non-substance-abuse addictions.
[AAS #2048, 1/19/2016]
What do you picture when you think of an addict? The most common image is an alcoholic or a drug addict, but addiction is not restricted to substance abuse. We are hearing more and more frequently about other types of addiction – gambling, overeating, Internet porn, gaming, cell phone use, sex, shopping – and the heavy toll these can take on the individual and the family. These are generally referred to as “behavioral addictions.” The fact is that almost anyone can be an addict. It’s time to widen our view and realize that the problem is much more common than we want to think.
Characteristics of Addiction
The Diagnostic and Statistical Manual of Mental Disorders lists the following characteristics of addiction:
- The patient persists in engaging in the addictive behavior despite being aware of the potential or already-realized risks involved.
- The addictive behavior is compulsive and repetitive (with both substance and behavioral addictions).
- In cases of substance dependence, the patient displays an increasing tolerance for the drug and its effects, and will take higher doses to achieve the desired effect even though there may be serious risks involved in doing so. [In behavioral addictions, the person will need to engage in the behavior more frequently or at a higher risk level.]
- The patient experiences withdrawal symptoms if he or she attempts to discontinue use of the addictive substance. With behavioral addictions, the patient is unable to resist compulsions to continue the addictive behavior despite attempts to stop.
There are many similarities among the different types of addictions. According to Peter Martin (2005), “The areas of overlap among behavioral and drug addictions are more compelling than are the differences… various irresistible, repetitive, and harmful behaviors, such as out-of-control gambling, eating, sexuality, and internet use, not only resemble each other clinically but share neurobiological underpinnings with drug and alcohol dependence” (1). According to the National Institute of Health, the activity causes the release of dopamine, resulting in a feeling of euphoria, but over time the brain requires more dopamine to experience the same response. This means the person addicted to a certain behavior must either engage in the activity more often or take more risks to increase the dopamine level (“What is Behavioral Addiction,” 2016).
As the behavior progresses, the person develops an inability to find pleasure in normal day-to-day activities and is able to respond only to stimulation related to the behavior. This leads to psychosocial complications such as social withdrawal, anxiety, and depression, resulting in enhanced vulnerability and greater reliance on the addictive behavior, and, eventually, to loss of control over the behavior (Martin).
The treatment of any addiction must begin with the individual recognizing and admitting the problem. Denial is the most common issue preventing the treatment of addiction and must be overcome before treatment can begin. Recognizing and admitting the problem can be difficult with behavioral addictions because, unlike drug abuse, many of the behaviors are seen as normal and most are not illegal or socially unacceptable. The person must realize that he or she is experiencing an uncontrollable compulsion to engage in the activity more frequently than is usual or is doing it in inappropriate places or times. Often this becomes apparent when the person finds that the behavior is becoming less satisfying or pleasurable, but still cannot stop doing it. He or she also might try to hide the activity and lie about it to friends or family members.
Once the person admits the existence of the problem, treatment can begin. Many treatment programs take multiple approaches including education, individual therapy, behavioral therapy, and support groups (“Behavioral addiction treatment”). In some cases psychopharmacology is also used, primarily to relieve anxiety or depression. The main focus of treatment often is educational, teaching the addict how to live without the behavior; this is important to minimize the chance of relapses, which are very common. Individual therapy can be effective in helping the addict understand the underlying causes and triggers for the behavior, as well as learn how to recognize and deal with stressors that might cause a relapse. Behavioral therapy can teach specific techniques to overcome compulsive feelings and to make life-style changes to avoid temptation. Group therapy is often based on 12-step recovery programs modeled on Alcoholics Anonymous (“Behavioral addiction treatment”). Participation in such therapy programs allow people with similar additions to meet together in a supportive environment, realize they are not alone, overcome feelings of isolation and shame, and learn new coping skills (Hall, 2014; “What is Behavioral Addiction”). In addition, involvement in a formal 12-step program can offer addicts access to other assistance programs (“12-Step Programs for Addictions”).
The 12-Step Model
The 12-step model can be successfully applied across the spectrum of chemical and behavioral addictions. The 12 steps developed by Alcoholics Anonymous are as follows:
- We admitted we were powerless over alcohol – that our lives had become unmanageable.
- Came to believe that a Power greater than ourselves could restore us to sanity.
- Made a decision to turn our will and our lives over to the care of God as we understood Him.
- Made a searching and fearless moral inventory of ourselves.
- Admitted to God, to ourselves and to another human being the exact nature of our wrongs.
- Were entirely ready to have God remove all these defects of character.
- Humbly asked Him to remove our shortcomings.
- Made a list of all persons we had harmed, and became willing to make amends to them all.
- Made direct amends to such people wherever possible, except when to do so would injure them or others.
- Continued to take personal inventory and when we were wrong promptly admitted it.
- Sought through prayer and meditation to improve our conscious contact with God as we understood Him, praying only for knowledge of His will for us and the power to carry that out.
- Having had a spiritual awakening as the result of these steps, we tried to carry this message to alcoholics and to practice these principles in all our affairs.
Twelve-step programs for other groups use these basic steps while making minor changes in wording to adapt the steps to addictions other than alcoholism. Typically, groups have changed the word “alcohol” in Step 1 and “alcoholics” in Step 12 to reflect the specific addiction.
There is little reliable information on the success of recovery programs for any type of addiction, but there is general agreement that success rates are not high for any program and agreement that the vast majority of addicts must cycle through treatment several times before overcoming their addiction. Twelve-step programs have detractors among health care professionals, primarily due to the fact that most success reports come from AA and other support groups rather than from independent and objective research. However, at the present time 12-step programs, used in conjunction with education, individual therapy, and behavioral therapy, represent the most successful approach to treatment. The most important factor in successful recovery remains the addict’s conscious action in admitting the addiction, accepting responsibility for recovery, realizing they are powerless to overcome it alone, and consistently following the 12-step approach.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders: DSM-5. (5th ed.). Washington, DC: APA.
Behavioral addiction treatment. (2016). Retrieved 1/17/2016 from Addiction Treatment.com website: http://www.addiction-treatment.com/research/behavioral-addiction-treatment/
Hall, P. (2014). Sex addiction – an extraordinarily contentious problem. Sexual and Relationship Therapy, 29 (1): 68-75. doi 10.1080/14681994.2013.861898
Martin, P. R., & Petry, N. M. (2005). Are non-substance-related addictions really addictions? : Affirmative viewpoint. American Journal on Addiction, 14:1-7, doi 10.1080/10550490590899808
12-step programs for addictions. (2016). Retrieved 1/12/2016 from 12-Step.com website: http://www.12step.com/articles/sober-living/12-step-programs-addictions
What is behavioral addiction? (2015). Behavioral addiction. Retrieved 1/17/2016 from Recovery4Addiction website: http://www.treatment4addiction.com/addiction/behavioral/