I am finding that process addictions and other compulsions blur in my mind. After all, process addictions (and substance addictions) are maintained through obsession and compulsive behavior in the face of adverse consequences. The Diagnostic and Statistical Manual of Mental Disorders now groups compulsive and formerly impulse-control disorders (body dysmorphic disorder, trichotillomania, hoarding, and excoriation) as Obsessive Compulsive and Related Disorders. These disorders seem to be united by tension and anxiety followed by gratification or relief by compulsive behavior. It seems to me that other possible behavioral addictions like work or exercise could be driven more by anxiety in the absence of the behavior, rather than the perpetuation of brain reward. Further, it seems to me compulsive behaviors grounded in anxiety instead of pleasure would manifest in the brain differently. As with substance addiction, research indicates that changes in reward-centers of brain perpetuate compulsive behavior in many process addictions too, including overeating , pathological gambling , and internet addiction . There is simply less research on workaholism and compulsive exercise for comparison.
I suppose this distinction is not all that important. Like other classmates who have commented on workaholism, I am hesitant to recognize a disorder that is not clearly supported by literature/research. Our textbook points out that work addiction has “no recognized diagnosis in current diagnostic manuals,” and that “there is little data available on the prevalence of workaholism.” The text mentions compulsive exercise, but does not dedicate any section of the text to it. Further, I worry about medicalizing activities that are within the scope of everyday behavior. This conversation seems theoretical. However, with a client, I know she does not need to be labeled with a disorder in order to work on problems in her life. I would want to help any clients reduce or eliminate behaviors (“disordered” or not) that are narrowing the scope of meaning in their lives and creating harmful consequences. I am sure that some of my biases are still unknown to me, but I make great efforts to see how dysfunctional behaviors develop out of needs, and in this way I can cultivate empathy for clients with diverse problems. Suggesting that someone has problems, but not a disorder, might imply that they are less ill. However, I think a problem should be measured, not by a label, but by the degree to which it interferes with one’s life, and the degree to which it can or cannot be explained by other problems.
Working in substance addiction now, I will say that there are times when I think “Can’t you see how much this is hurting you? How can you not want to give it up?” In those cases it does help to remember that I am seeing a symptom of a disorder rather than a intrinsic trait. It also helps to remember that all perpetuated behaviors have gain, and until you can help someone achieve these gains in other ways, change can be hard.
As I am new to the field, my beliefs are often in a state of flux. When I learn something new, I tend to see problems within this framework, when of course they are likely to be much more complex. Then I sometimes lose emphasis on some ideas as I adopt others. For example, I was just reading about sensation seeking traits of boredom susceptibility, adventure seeking, experience seeking and disinhibition. Accordingly, I started to see a lot of addictive behavior as the need for intense and novel stimulation. Given this tendency, I think it is necessary for me to ask myself “what am I leaving out?” and “is the client receptive to this idea?” I also think it is important for me to continue exposure to many concepts and theories. What we know and understand depends heavily on research and culture; this is perhaps why continued education is so important in our field.
Working in addiction, I have a lot of respect for my clients, in terms of their strengths and what they have lived through. It hurts me to know how that there is so much stigma attached to labeling someone an addict. One thing that does worry me is that I am interested in brain physiology, and I often explain addiction as a brain disease. I’ve read an article on the Americanization of mental illness, which suggests that approaching illness as a psychosocial problem rather than a brain-disease may not serve to reduce stigma, as commonly thought. We may actually treat people more harshly, and see them as more impaired with the later explanation. I have seen this too with clients who learn that their brain has been changed by use. Despite also hearing about brain plasticity, my clients who are ambivalent about change hear it as damning that their brains have been harmed, and this can reduce motivation (black or white thinking— “the damage is already there, so I might as well continue use”). This is a reminder to me that we have to explain well to clients the biopsychosocial influences in the development of addiction and other illnesses.