Behavioral Addiction Treatment
Marc Kern (Addiction Expert, Director of Addiction Alternatives) gives expert video advice on: What is "outpatient care" for behavioral addiction?; What is outpatient treatment like for behavioral addiction?; How can recovering behavioral addicts reduce the risks in their environment? and more...
What does "desensitizing" mean for a behavioral addict?
We can use the scenario of everytime one sees a video screen, one fantasizes about sitting down and playing on it. This behavioural addiction is called learned association, and desensitizing a behavioural addict only means continuing to present the object to the addict, the sensitized stimuli in their presense, and teaching the addict a way to relax in the face of being exposed to their addiction, and over time desensitizing them to the learned association between the video monitor and the action of playing on it. In phobias, desensitizing is a central technique where, for example, you were sensitized to spiders, and you were very afraid of spiders. During the first session a spider might not even be brought into the room. During the second session a spider may simply be discussed. During the third session a picture might be brought in, but all along the sufferer would be taught relaxation techniques, so they would learn to relax in th presence of a spider. Over time a real spider would be brought in, and then brought a little closer to you, a little closer to you and a little closer to you, therefore desensitizing you to the stimuli.
How does a cognitive therapist work with a behavioral addict?
Let's take two examples here, one being pornography and one being gambling. How would we desensitize someone to these sort of stimuli?Let's take the pornography first: let's say every time a person sees pornography, there's a sort of a "light bulb" that goes on inside and they fantasize about a woman or doing certain other things which brings them into a further involvement with the pornography. What we would do in the course of treatment is exactly sort of what we've talked about, but we would bring the images in and, in a slow, progressive, predetermined sort of set of stages where there may be a very obscure piece of pornography, it may be a pornography of a very mild type, and as we noted your arousal or your stimulation from the pornography, we would ask you to go through a relaxation technique. So, we would start to teach you that this does not cause that, that this stimuli need not cause that internal experience. Over time, we would bring it closer and closer, in a literal sense, that when you're in the presence of it, when the therapist isn't in the room, or something, that it won't automatically bring about an internal experience as it has become when you're quote-unquote "addicted". In a similar way, let's say it's gambling, let's say every time you drive by the casino or walk into a casino, you see the "object of desire", so-to-speak, you fantasize about winning a lot of money, your arousal goes up, you start getting excited, and things like that--that's part of the addiction, that's that "feeling" stuff that we were talking about earlier. So what we would do in a clinical session, is sort of, it would start with probably just talking about slot machines in a casino, and then ultimately we would be bringing in pictures of a slot machine in a casino, but as we noted, as a professional, that your arousal was going up as your stimulation, where that "trigger" was activated, we would go through a pre-rehearsed relaxation technique, so we would start to disassociate that high arousal with that trigger or that stimulation. And over the course of many, many sessions, we would eventually sort of even walk with you into a casino, in-hand, and if you would start to get aroused, we would ask you to go through the relaxation thing, and eventually be able to even touch a slot machine and not have that automatic, addictive-like response.
What is "inpatient treatment" for behavioral addiction?
Inpatient care in this country is a multi-billion dollar business. There are a variety of different sort of inpatient facilities, but they all are essentially the same as they last around thirty days. Why thirty days? Well, because the insurance companies deem that an appropriate length of time. I'm not a believer that it's a magic number; that thirty days is the magic cure. A twelve-step disease model, a treatment centre, would typically again last thirty days. You'd go to groups all day long. There would be some individual therapy. There would be twelve-step groups, of course, in the evening, and a follow-up that would be involved in the twelve-step community. Emphasis would be on doing the twelve steps; the twelve steps of Alcoholics Anonymous. Now, there's probably only five or six inpatient facilities in the whole United States that primarily the cognitive behavioural model, but they too sort of align with the thirty-day idea. They do, as well, focus on groups and individual talk therapy. There'd be more emphasis probably on relaxation techniques, and things to help the individual desensitise to the arousal one might get when in the presence of a video monitor, or something like that. However, in a traditional twelve-step or diseased model facility, I don't mean to say that they're awful, but generally speaking you're not going to get that much more than you would get in a traditional self-help group for substantially a lot less money.
What are the advantages of in patient treatment for behavioral addiction?
Inpatient care, even though I'm not a strong advocate of it, does have it's place. When an individual has true loss of control over their behavior, their quality of life has deteriorated to a point where they really can't function independently, inpatient care is what's called for. Again, the trouble I have with inpatient care as well, is that what happens the day you get out? Almost anybody can be absent from their addiction of choice when they're locked up in a facility or in a closet, but what happens when they get out and do the real thing? But, nonetheless, if the addiction has taken such a toll on you where you have no, seemingly anyway, control over your behavior and there is no safe zone from yourself, it's sometimes helpful to put yourself into a residential facility. But, you have to want to be given sort of an opportunity to get distance from all that, all those triggers out there, all that stimulation that has before sort of caused certain acting out, certain activities that are not in your best interest. So, it does have it's place, but limited and ultimately you must learn how to survive outside of that environment or the obvious is you'll have to live in seclusion.
What is the cost of inpatient treatment for addiction?
Inpatient treatment varies accordingly to the state, and the services provided; you can get inpatient treatment at a very reasonable price, but the quality is usually not so qualitative. Inpatient services are very, very expensive in general. It ranges anywhere from the very lowest that I've ever heard of is something like $10,000 $15,000 dollars for thirty days to a place in Malibu, or a couple of these island retreats, where we're talking $70,000 to $100,000 dollars a month. The quality of treatment is not directly correlated with the cost, it has a lot to do with who owns it and the motivation of the owners, and "What kind of philosophy does the treatment facility offer?"
What happens during a week at an inpatient behavioral addiction facility?
A week at a twelve step facility is very, very, very structured. When you walk into a twelve step facility, non-twelve step facility you are going to be handed a schedule and this schedule will be: eight o'clock in the morning or seven o'clock in the morning you wake up, seven thirty you make your bed, eight o'clock you have breakfast, eight thirty we have sort of a morning group, nine we have an educational group, ten o'clock we have this type of group or individual therapy, recreational therapy, lunch, dinner. It's a very, very structured week. There is very little room for little things other than following and going to services that they designed for you, that's one of the values of a inpatient facility is cause many people with addiction can not structure their day. In addition, it does set the stage to some degree of momentum when they get out of residential to have a basic structure how to formulate a day that is healthy and promotive of life enhancing activities.
What keeps patients from leaving inpatient behavioral addiction therapy?
Nothing keeps patients from leaving inpatient behavioural addiction therapy. As a patient you need not worry if you go in and you decide you really can't stand it or you really don't want it. You do have the right in this country. I do understand there are places outside of the U.S. where there are laws stating you can incarcerate someone against their will. But for a behavioural addiction patient in the U.S. or really in most places, you can check out if you don't like it. You need not feel that claustrophobic feeling. I've worked with people with behavioural addictions who are scared of a residential because they feel like they're going to be locked up and the key's going to be thrown away. Their family wants them out of their life, and this is just a stepping stone. But again, I can reassure you, to the best of my knowledge, there are very few of those types of inpatient facilities in the U.S. or around the world for patients with behavioural addiction.
What are the rules of a behavioral addiction inpatient facility?
Yes, there's quite a few demands on anybody that goes into any sort of residential inpatient facility. But they mostly revolve around not obviously using drugs, trying not to engage in their addictive behavior, generally speaking they do not have access to computers, cell phones, typical outside sort of connection. The goal, again, is to cut the individual away from the environment that fostered, literally fostered, part of this addiction. So there's a big disconnect, there's usually just one telephone on the ward where everyone has to use it calling in, calling out, and it's only allowed during certain hours. And you're not supposed to isolate, you know, not avoid groups and there's certain sort of each--depending on the facility and their rules, it gets more intense but those are sort of general rules that you might find in an inpatient facility.
What happens for behavioral addicts after inpatient care?
Outpatient, or after care, is probably one of the more controversial domains right now in the addiction field. It's come to be recognized that the greatest failure of addiction treatment right now lies in after care. Historically, people check-out after thirty days, or maybe even sometimes forty-five days, and they say, "Good-bye". then there's very little follow-up. The hospital never calls them again and they're just left to their own devices. Unfortunately, that still continues on a very large scale. There are some more progressive inpatient facilities that do follow-up, provide after care services, provide services via telephone, and annual meetings where you come back to the facility. Other places have developed contractual relationships to outpatient services within various communities around the country and you would be assigned a counsellor at a facility local to you, continuing with the same philosophy that you were taught while you were inside the treatment facility.
What is "outpatient care" for behavioral addiction?
Outpatient services are quite a bit broader than inpatient services. If you're looking for a particular orientation, be it more eastern, more cognitive behavioral for that matter, the choices are much broader than residential. The choices, therefore, lie everything from one on one individual therapy to group therapies that meet once a week, to support groups such as Smart Recovery or Moderation Management or, you know, the twelve step approach. Or there are very formalized outpatient programs, we go one, two, three hours a day, three, four days a week for 3 to 6 months. So the range is quite large and it is very helpful to stay involved. These addictions are not cured with a shot or any medication, they're cured through practice of doing things, doing life another way.
What are the advantages of outpatient care for behavioral addiction?
Outpatient services for behavioural addiction are preferable primarily because you're living in the environment that you're going to live in after all the treatment is completed. With outpatient care, you're going to be faced with the stresses of life that you're going to have to live with later. You're going to have to deal with your relatives or family or friends that you're going to have to confront later. So outpatient care, in my opinion, is the best. Beyond that, there's the cost. There's the idea that you will be able to stay at work and there is no shame and you don't have to leave your job and tell everybody that you're going away to some unknown destination for 3 days. It's convenient and it makes the recovery clear. Outpatient care for behavioural addiction is useful because you're going to talk about the dilemma that you face today and that isn't going to be that different from the dilemma you're going to face six months from now. It's real. It's not an artificial amount of stress or an artificial community of people. It's your real life. Therefore I'm a big advocate of outpatient resources.
What is the cost of outpatient treatment for behavioral addiction?
Outpatient care ranges from free of charge, meaning self-help groups like SMART Recovery, Moderation Management, but there's also some other ones like SOS, Women for Sobriety and Recovery Incorporated. These are all out-patient, free, self-help groups that are available via the internet. Not every single town has one, but please look at the internet, and you'll see if there's a meeting by you. Each of the philosophies are somewhat different, but they're free of charge. Now the price goes up from there, of course. You know, an individual therapist can range from, you know, $75 an hour to $350 an hour. You could go once a week, you could go twice a week, you could go three times a week, 'cause that could be quite expensive. Outpatient structured, outpatient is generally somewhere between the $3,000 and $5,000 range for three months.
What is outpatient treatment like for behavioral addiction?
A typical week, if a behavioural addict were involved in a structured outpatient program, would be very structured and monotonous. Let's say you joined a program three days a week, three days a week you would be going to the facility, you'd be having a group, maybe what's called a process group where you just talk about feelings and your experiences, followed by an educational group where there's a new topic discussed, followed by a third activity, and that would happen three times a week. Traditionally, outpatient treatment centers for behavioural addicts have one component, one night a week, where you bring your family in, and the family is involved in some part of your treatment. They're often separated groups; you're generally not in the same group as your family member. Some people integrate them as well. But for the course of three months, this what you're going to do the same amount of hours the same night for three months. Following that, or in addition to that, they always recommend a support group to adjunct, to fill in the spaces between the time the formal educational treatment is provided to the behavioural addict.
How can recovering behavioral addicts reduce the risks in their environment?
Just knowing that there are risks out there. It isn't only your behavioral addiction that you need to be worried about. The behavioral addiction doesn't happen without some sort of trigger, or stimulus, especially in the cognitive behavioral sort of conceptualization. So, knowing about them, and learning to relate to these stimuli in a different way. Let's say it's your spouse that makes you think about going gambling or looking at pornography. Part of your task, and part of the treatment, really is learning how to, I'll call it dance with your spouse in a different way, and I don't mean dance like the cha cha cha. I mean dancing like how do you talk, how do you communicate, how do you solve problems, how do you not solve problems? How do you deal with problems with the children? How to you deal with problems of money? How do you deal with problems of sex? All these things need to be renegotiated and reworked for a couple. I'm using this as the example, for you to minimize the dangers that truly do exist in your outpatient or in your real life environment.
What is the role of psychotherapy in outpatient care for behavioral addiction?
The role of therapy in outpatient care, depending on what professional you talk, to varies considerably from disease oriented people, twelve steppers tend to see psychotherapist as anti-therpeutic or anti AA. That's always where that schism that tends to happen. It's not a 100% of the time but generally speaking psychotherapy is not endorsed from my professional experience by 12 step community and things like that. Their belief is that psychotherapy pulls up to many anxieties and issues separate from the addiction itself and it may be better to postpone psychotherapy until 6 months, a year down the road. Others types of treatment actively encourage psychotherapy. Cognitive-behavioral programs definitely encourage psychotherapy as ongoing, working through the feelings, the thoughts, the behaviors, relating to the triggers differently, relating to the environment differently. When you pull an addiction away from somebody your, it's like pulling a blanket back and all of the sudden you notice all of these feeling that were underneath the addiction and that weren't seen by the individual or the world and those are the topics often that are discussed in psychotherapy.