Appeared in The Therapist Magazine of California Marriage and Family Therapy (May/June 2016)
Buzz Words in the Chemical Dependency and Process Addiction Field
Jerry Brown MA, PsyD, LMFT
In the ever-growing world of chemical dependency and process addiction treatment there are a plethora of words used to describe types of addiction and the people who live with addicts. It is not uncommon for a person to enter a treatment program with one diagnosis and come out with five, with few fitting any formal diagnostic category. Many of these terms are ill-defined or poorly understood by therapists and patients alike. Part of the responsibility of LMFTs, LCSWs, and licensed Psychologists is to diagnosis the five Axis codes (which are slated to change as of October 2015), and form a treatment plan. The new DSM-5 (American Psychiatric Association, 2013) separates the various chemical dependency issues and takes away “polychemical drug abuse”, instead distinguishing each dependency in separate categories. One would think many of the other categories of process addiction (such as Gambling Disorder 312.31 which appears in the DSM-5) will go a similar way….but don’t bet on it.
Chemical dependency counselors are dedicated hard working people, but they cannot diagnosis in their scope of practice. With less than 6 months of education, they often dive into the language of psychopathology without understanding the impact of misrepresenting these terms to their patients. Applying labels of diagnostic impression can be misleading and irresponsible, so we as professionals need to help our patients with corrections to such labels when appropriate. It is also prudent to challenge other professionals when using ‘labels’ which are not formally defined. Clinical diagnosis is an ever-changing area of our professional work, but we need to stay consistent with terms and diagnosis which can be both agreed on, and verified via testing, observation and disclosure.
As this specialty grows, more and more therapists are working for treatment programs and often slip into the same trap as non-licensed persons with regards to language used to describe psychopathology. Treatment programs are competing for LMFT and LCSW interns with increasing frequency, and many employment opportunities are emerging for the professionally trained therapist as chemical dependency is treated with parity with other mental disorders. As we enter or work in this field, we need our alarm bells to go off if a fellow professional or patient uses such terminology. Let’s take a few examples:
CODEPENDENCY Represents one of the most commonly used and poorly defined words in this genre. There is no reference anywhere in diagnostic categories (past or present) for such a word and it shames persons who are around the addict into thinking they are, or may be, directly responsible for the addict’s disease. This malady does not even have a name of its own; it is an appendage to another disease. When the book Codependent No More (Beattie, 1986) is opened and read at random, most persons would find they have engaged in some of the behavior, or had similar feelings, of the ‘codependent’. This word does not even have a disease of its own as it is an appendage to another disease. What if the patient had an accident, heart attack, cancer or a neurological disorder not related in any way to addiction? Would the loving and concerned persons around the patient act in a similar concerned manner? Would they not help, sacrifice anything, and disagree with doctors or other loved ones about the best course of action to heal or help the patient? What about love for a dog or cat who is sick? Does the patient need to be referred to DOGANON? When parents are asked if they agree on the approach to take in disciplining adolescent children and adult children who have a failure to launch due to chemical dependency, they are seldom in complete agreement, and it is an enormous strain on the relationship. This is normal, it is a dilemma on which few people agree. Common approaches to discipline include shaming and enabling. (Brown, 1997) While enabling is alive and well, it should not be confused with, nor referred to as, ‘codependency’. This word does not even have a disease of its own, as it is an appendage to another disease.
LOVE ADDICTION Here is an interesting kerfuffle in our modern language of process addiction. Neither love addiction nor sexual anorexia are defined terms, and if one looks at a list of what possible issues these terms entail, most people could identify with either one at some time in their life. We are “wired to connect” (Goleman, 1996), and if we did not have a powerful desire to love, we would not survive as a species. Love is a powerful verb which changes nations, families and has the power to transform. While some people do have a “broken picker” and consistently make poor choices in partners, the desire to merge is natural and with practice through a lifetime, people often get better at choosing. While love addiction is not real, what is present is the ongoing myth of perfection in another. Everyone has “Bellybutton Lint and Ear Wax…” (Brown, 2003), but one can learn about and challenge the illusion. Love isn’t something natural. Rather it requires discipline, concentration, patience, faith, and the overcoming of narcissism. It isn’t a feeling, it is a practice.” (Erich Fromm) To label or categorize is not only to shame the patient but to lack understanding of the mystery of love.
WORKAHOLIC Another buzzword which is part of the non-standardized psychopathology labeling system. Compulsive behavior does exist in many people, but happiness, making a living, and the love of work is not an addiction. Mihaly Csikszentmihalyi identified this in Flow (Csikszentmihalyi, 1990) and Finding Flow (Csikszentmihalyi, 1998). Fortunately, he and other social scientists and writers are beginning to study resiliency and happiness rather than pathologizing everything we do. They represent a minority however in the “something has to be wrong with me” categorization of our humanity.
SEX ADDICTION While once under consideration as a diagnostic category (hypersexuality) in the DSM-5, this diagnosis is still not recognized by the formal medical community and was not even included in Conditions for Further Study in the DSM-5. In a lively debate hosted by Larry Mantle (http://www.scpr.org/programs/airtalk/2010/11/15/16831/sex-addiction/) two featured guests, Marty Kline Ph.D., LMFT, and Robert Weiss, LCSW, participated in an exchange which provides an excellent example of the controversy of labeling regarding Sex Addiction. I encourage the reader to use this link to hear the entire segment. Pat Carnes, the author of Out of the Shadows (Carnes, 2001), has changed his original theories about the levels of sex addiction in the many years he has been writing and researching. This label is a work in progress. This is not to say compulsive behaviors are not a problem, but using the label for a patient or cosigning the label with someone we do not know is irresponsible.
EATING DISORDER This is an example of an important diagnostic category, which we must recognize, although, like alcohol and drug dependency, some people challenge even the precept of it being an addiction. Eating disorder (ED) diagnosis are among the highest mortality rates in the US, with bulimia, anorexia nervosa, and compulsive overeating (binge eating disorder) being both well documented and treatable. However, the singular diagnosis of this disorder often overlooks overlapping issues such as alcohol other drug addictions, anxiety disorders, and OCD when they are co-occurring. The term (not validated in the DSM) ‘drunkorexic’ well describes a person who is drinking calories instead of healthy eating, and often in a psychological evaluation represents a real challenge as to the specialty of the person doing the diagnosis. There is often war between the factions of ED and chemical dependency as often the patients are suffering from both.
ALCOHOL IS A DRUG: Alcohol has the highest mortality rate of all the addictions (NSVR, 2014) and the deaths outnumber all the other addictions combined. Despite this, it is still not categorized as a drug. We refer to drug addiction, rather than “alcohol and other drugs”. This phrase redefines the issue and helps professionals to recognize a legal substance can still be an addictive substance. All one has to do is pick up an issue of The Therapist to see the impact and the loss of licensure for LMFTs, LCSWs and Psychologists driving under the influence. Teachers, doctors, nurses, and other professionals continue to use this legal drug, and unfortunately, the tendency is to not see it as the severe drug problem it is.
SUPPORT GROUPS: Having said all the above, a referral to a support group is an excellent therapeutic tool. Churches, synagogues, mosques, community education, and 12-step groups provide excellent resources for our patients. If we become dedicated to working ourselves out of a job by helping people connect to either a recovery and/or a spiritual community, we are doing them a greater service. Of course some of these support groups provide questionnaires, buzz words and misrepresentation of some of the above, but they also provide avenues for healing, fellowship and a feeling of community. Because they are anonymous, many of these groups cannot publish success rates. However, all one has to do is talk to someone who has overcome an addiction to discover that the best help comes from contact with others who suffer with life’s maladies and share the pain of addiction. Addiction is a disease and a disease of isolation.
Endnotes
American Psychiatric Association. (2013). Diagnostic and Statistical Manual of Mental Disorders, 5th Edition: DSM-5. American Psychiatric Publishing.
Beattie, Melody. (1986). Codependent No More: How to Stop Controlling Others and Start Caring for Yourself. Hazelden Publishing.
Brown, Jerry. (1997). Militant Parenting: A Survival Guide For Parents With Problem Kids. Dr Jerry Brown.
Brown, Jerry. © (2003) (Compact Disk). Bellybutton Lint, Ear Wax, and Boogers: Finding Out Your Partner is Not Perfect.
Carnes, Patrick J. (2001). Out of the Shadows: Understanding Sexual Addiction. Hazelden Publishing.
Csikszentmihalyi, Mihaly. (1990). Flow: The Psychology of Optimal Experience. Harper and Row.
Csikszentmihalyi, Mihaly. (1998). Finding Flow: The Psychology of Engagement with Everyday Life. Basic Books.
Goleman, Daniel. (1996). Emotional Intelligence: Why It Can Matter More Than IQ. Bantam Books.
Larry Mantle Air Talk KPCC-FM, KUOR-FM, KVLA-FM. (n.d.). ttp://www.scpr.org/programs/airtalk/2010/11/15/16831/sex-addiction/.
CDC (2014). Deaths: Final Data for 2013. US Centers for Disease Control.
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Jerry Brown PsyD, LMFT is in private practice in Costa Mesa, CA. Author of Militant Parenting, A Survival Guide For Parents With Problem Kids, He has worked in the chemical dependency field for 37 years and leads parenting groups, lectures in numerous chemical dependency programs and is a national speaker.