Client Populations Clinical Interventions

Interview with Dr. Amanda Giordano: Working with Addictions

This article is an adaptation of our Fireside series video interview with Dr. Amanda Giordano, on working with addictions.

By Mental Health Academy

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This article is an adaptation of our Fireside series video interview with Dr. Amanda Giordano, on working with addictions.

Click here to watch the video recording.

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Introduction

This broad-ranging interview, featuring Dr. Amanda Giordano, explores the ins and outs of working with clients with behavioural addictions and/or substance use disorders. Topics covered include recent advances in clinical practice, the effect of societal factors and family dynamics in addictive behaviours, addressing the impact of trauma and dual diagnosis, how to tailor treatment for specific client populations, and much more.

About Dr. Amanda Giordano

Dr. Amanda Giordano is an award-winning scholar, educator, and advocate in the field of addictions. She is an Associate Professor at the University of Georgia in the United States; the sole author of the clinical reference book, A Clinical Guide to Treating Behavioral Addictions; co-author of the textbook, Addiction Counseling: A Practical Approach. Over the past 12 years, Dr. Giordano has trained thousands of graduate students and mental health professionals in addictions treatment. She is a prolific scholar in the field, having written 62 journal articles and book chapters. Last but definitely NOT least, Dr. Giordano is the creator of two Mental Health Academy micro-credential courses: Working with Behavioural Addictions, and the newly released Working with Substance Use Disorders.

Working with Addictions: Interview Transcript

Tell us a bit more about your professional background and why you decided to become a mental health professional and researcher.

Yes. So, I actually went to school thinking I was going to be a forensic scientist, mostly because I really liked shows like CSI and Law & Order SVU, and I thought that I wanted to work with crime scenes. When I took my first course in college, we were talking about blood spatter and all of these things, and I kept saying, but how did this person end up here? Was it just the wrong place at the wrong time? Where were their parents? Did they have support people in their lives? And so I had a professor tell me they thought I should work with living people rather than deceased people and that maybe I should look into a mental health field. So I got an internship, started learning about what counseling was, fell in love with it, and then became a counselor, counselor educator. I’m a licensed professional counselor, and now I train future counselors.

The research piece I’m really excited about because I believe that research is a really powerful form of advocacy. It’s really hard to argue with data. So when you have facts and statistics and numbers to back up what you’re saying about treatment access or treatment quality or what works in terms of addictions counseling, what doesn’t work, again the data is very persuasive. And so I kind of saw it as my responsibility to advocate for marginalized groups, for addicted populations, by doing research to shed light on some of the disparities that exist and try to move the field forward. So I love being a researcher. It is my favorite part of my identity. I’m a clinician, an educator and a author researcher, and I really love the scholarship piece.

You’ve mentioned that working with marginalized groups caught your attention. How did you end up focusing a lot on addictions? And did you go through any other areas before you got to that?

Yes, I I tell this story to my students just so they know that they don’t have to have this epiphany in Grad-school about where they want to work that it could happen outside of school so addiction runs in my family. If I were to draw my genogram and you saw three generations of my family, I would highlight quite a few who struggle with addiction, both chemical and behavioral. So my parents tried to shelter my sisters and I from that. And so we didn’t talk a lot about addiction. There were members of the family I just knew we didn’t visit with a lot and I wasn’t quite sure why. So they really tried to just protect us from that. So I never felt any kind of draw towards working with addictions. I actually thought I was going to work with children. And when I started my counseling journey and started getting trained, I actually was a graduate assistant, and my university had to cut our funding because of budget cuts.

And so I was like, well, I just signed a lease on an apartment and I am not going to be able to afford it unless I get a part-time job. I applied to an Italian restaurant down the street. I think they hired me only because of my last name being Giordano, because I have no experience at all as a server, and I was actually really bad at it. But I ended up working there for a year and a half to help pay for my master’s and doctoral degrees and I came face to face with people who were struggling with addiction and I had never seen this before. I had a pretty sheltered life. I didn’t have a lot of friends who were using substances and when I started working as a server I really came to care very deeply about the people that I was working with and they started disclosing to me how they’ve tried to stop drinking or they’ve tried to stop using cannabis or they had tried to stop using some of the prescription stimulants they were using and were unsuccessful and they’ve they worked as a server because they didn’t get drug tested and they got cash and so I learned a lot about what it was like to live with addiction but then I realized I don’t know how to help I’ve never gotten training in this area so because of that experience I switched my focus to addictions counseling.

So I got a new internship site. I changed my dissertation. I started co-teaching the addictions class and learning as much as I could about addiction because of that experience and really just having a lot of compassion and empathy for people who I saw firsthand struggling with substance use disorders. I had my first client say that he was addicted to pornography. And I went back and thought, I have never been trained on this. Like my addictions class was all about substance use disorders. No one’s ever taught me or I’ve never been exposed to training around behavioral addictions as well. So probably for the last decade, I’ve been focused on addictions counseling with an emphasis in behavioral addictions.

One common thread in the courses that you’ve done at Mental Health Academy is the idea that all mental health professionals, regardless of setting, need to be trained in addictions. Can you elaborate a bit more on why you believe that’s the case and what the implications are for clinical practice?

Yes, I’m so passionate about this. I could spend the rest of our hour just on this question. I won’t, but I’m very passionate about it because what we see is that clinicians and mental health professionals in any setting will work with addiction. Even those working with small children doing play therapy, they are going to work with children who live in a home with active addiction and that might come out in their play, in their work with children. A lot of addictive behaviors begin during adolescence, so those who want to work in the schools and those who want to work with adolescent clients are on the front lines of early intervention for some of these addictive behaviors. Colleges, I just looked up all of these stats for the credential course, but just looking at university settings globally, there is this uptick in substance use, especially in the U.S. We see a lot of binge drinking and other substance use in the college setting. And then in the community, just looking at the prevalence rates for the mental illnesses that we’re all trained to address.

So I think for a long time there was this really unfortunate separation between mental health clinicians and addictions professionals. And now we’re starting to see that all mental health professionals need this training in addictions work. They need to be able to recognize and respond to addictive behaviors. Whether that means treating the individual yourself or making a referral to the appropriate level of care, it has to be something that we all recognize. If not, you might work with a client for a long time addressing other issues like symptoms of the addictive behavior and not seeing the treatment gains that you’re hoping for. So just looking at prevalence rates, we know that counselors in any setting are going to address addiction and that doesn’t even count working with loved ones and family members of those who have addiction. We just have to have the training so we understand what partners and parents and children are going through living with someone or being in relationship with someone with So I am, I, in my program, I teach the addictions class to school counselors, to undergrads, to clinical mental health counselors, because I just firmly believe if any setting that you’re going to work in as a mental health professional, you need this training. And our clients need us to be trained to recognize and respond to addiction.

On the topic of behavioral addictions, what’s the difference between behavioral addictions and substance use disorders, and how does the research support the conceptualization of behavioral addictions?

We do see an increased prevalence rate of behavioral addictions, particularly because of technology, and as technology continues to progress. And we’ll talk more about that later on, I’m sure. But when you ask about this distinction between a substance use disorder and a behavioral addiction, I like to talk about addiction as one disorder that manifests in a variety of ways, whether that’s alcohol use disorder, cannabis use disorder, sex addiction, internet gaming disorder, social media addiction, food addiction, it’s impacting the same region of the brain. And it really has the same hallmarks that it’s a compulsive engagement in a behavior or compulsive consumption of a drug of abuse. It continues despite negative consequences. The individual loses control over either their use of the substance or their engagement in the behavior, and they experience cravings when they’re not using the drug or they’re not engaging in the behavior. So I think it’s really important we have a basic understanding of the neuroscience so we can communicate this to our clients and our clients’ families. And when you’re talking about addiction, you’re talking about a disorder that’s impacting a very specific region of the brain in the midbrain called the reward circuitry. So we have lots of regions of the brain, but the reward circuitry is a specific pathway of the neurotransmitter dopamine. So neurotransmitters are just chemicals in the brain that neurons use to communicate. So neurons are specialty cells in the brain. They communicate by releasing these chemicals that go from one neuron to the adjacent neuron. And so those chemicals do a lot of different things. So everything we think and we feel and how we behave is being influenced by the neurons and the neurotransmitters. Dopamine, I’m sure you’ve heard of dopamine. We used to call it the pleasure neurotransmitter. Now we know there’s more to it than that.

It really has to do with desiring reward or wanting reward or anticipating reward. But the brain is very smart and it pays attention to what causes the release of dopamine. And that is something that is hardwired into us to help us survive. So there are natural rewards like eating, drinking when we’re thirsty, social interaction, sexual activity that cause a release of dopamine. The brain pays attention to it and says, that must be important to survival. I’m going to pursue that again. And that keeps us eating. It keeps us procreating. So our species survives. powerful stimulating behaviors like gaming or gambling and they cause a spike of dopamine that is more than what we would find in nature. So it hijacks the brain or tricks the brain into thinking this must be really important for survival and so we start to feel a strong urge or motivation to pursue it again because of that positive reinforcement that comes from the dopamine release and other neurotransmitters. So all that to say, whether it’s drinking alcohol, using meth, gaming, gambling, it’s impacting the same region of the brain, it’s causing a release of dopamine at different levels. So we’re not going to say that gaming has the same level of dopamine release as methamphetamine use, but it is causing the release of dopamine in this region, which is training the brain to want to pursue that activity or that drug of abuse again in the future, thinking this must be really important for my survival.

So I think explaining that can be really helpful to our clients and their families to understand just like the American Society of Addiction Medicine has defined addiction as a brain disease. This is a disease in the brain with our neurocircuitry that’s being adapted and changed by drugs of abuse or behavioral addictions. So a lot of similarities between the two. They both can lead to very detrimental negative consequences. Sometimes I’ll have students say, but isn’t substance use disorders that’s got to have more negative consequences than a behavioral addiction like gaming or gambling. But when you work in the field, you see people with severe gambling disorder or gaming disorder who are very much in debt, who have lost extremely important relationships, who have put themselves in risky situations. We know that gambling addiction is linked to one of the highest suicide attempt rates than other disorders in the DSM or the Diagnostic Statistic Manual of Mental Illnesses. And so there’s a lot of negative consequences associated with behavioral addictions too. So I don’t kind of compare them in that way, but just try to help people understand that we see the same hallmarks with both substance use disorders and behavioral addictions, that loss of control, the compulsivity, and continue despite negative consequences.

How important is it for clinicians to understand the neuroscience of addiction? And the second part of this question is, can you provide an example of how this knowledge may be relevant in clinical work?

Yeah, I think one of the best things we can do in terms of advocating for addicted populations is to help society at large move away from what’s called the moral model of addiction, where people think that addiction is just a character flaw, it’s a sign of moral weakness or a moral failing, that people choose to use substances or engage in these behaviors, and if they were good people, they would just choose to stop, but they’re selfish, and that’s why they continue. That moral model of addiction is extremely prevalent across the globe, despite the fact that it was in the 1950s that we first called alcoholism a disease. And so we know that there is a genetic, there is a biological component to addiction, and I think the more we understand it, the more we can articulate it, it helps society change that narrative and move away from the moral model of addiction to really embrace the biopsychosocial model of addiction that says addiction is a complex disorder that is the culmination of a lot of different factors, including one’s genetics. So it’s estimated that about 40 to 60 percent of addiction is related to one’s genes. And that’s why with my clients as well, I have them draw three generations of their family. Let’s look at any addictive behavior, chemical or behavioral, in these three generations so they can see that there’s often a genetic component.

Now, genes is just a part of it. It’s not the whole picture. It’s just a piece of the picture. But I think understanding that the way our brains start from birth, some people can have a genetic predisposition to addictive behaviors. And there’s actually some research that just came out in 2023 that I thought was really fascinating because they were looking deeper into the genetic predisposition of addiction. And these scholars who are the best names in addictions research, they found that there were abnormalities from birth in the reward pathway, specifically with regard to dopamine receptors among those who had addiction later in life, that there was a statistically significant correlation between abnormalities in dopamine receptors and other areas of the reward pathway and later development of addiction. And this is what people have been saying for decades, that there are some people that from birth, because of how their DNA coded and their neurological makeup, are more predisposed to addiction than others. And so, again, that’s just a piece of the puzzle. There are other risk factors that make people more susceptible to addiction, like a history of trauma, and we can talk about that if that comes up, early exposure to a drug of abuse or a potentially addictive behavior, mental health concerns. So there’s a lot of factors that go into how addiction emerges and progresses, but the neurobiology part is such an important piece. One of the things, so Pedro asked for an example and I’ve probably already given too much, but one thing I wanted to share is what we know about addiction. Let’s just take drugs of abuse.

So let’s say a stimulant like cocaine. When individuals start using a drug of abuse, they do it because of positive reinforcement, that it feels euphoric, it feels pleasurable, it’s actually a pretty reliable way to change the way a person feels. So they consume the substance, it causes this release of dopamine and other neurotransmitters that are implicated in the experience of reward, they feel high energy. They feel euphoric. There’s a lot of pleasure And then they have the crash right so it’s euphoria and then the crash after the drug wears off When this happens over time what we see in the progression of addiction is that the brain starts to recognize? That’s a lot of dopamine release that that’s actually a startling amount of dopamine release. So the brain starts to adapt and we call this neuroadaptations. What we see is that with chronic stimulation, this over-simulation of the reward pathway and these spikes of dopamine, the brain will start to down-regulate the dopamine system, meaning it will decrease the natural production of dopamine, it will reduce dopamine receptors or transporter molecules. So now, at baseline, the individual, because of those neuroadaptations, if they used to feel here at baseline, they’re feeling here when they wake up in the morning.

So people are using substances just to feel okay. They’re not getting that high euphoria anymore. They’re just using it to absolve those withdrawal symptoms and that negative feeling, that negative mood state that they’re in. So I’ve worked with clients who would say, you know, I’m still chasing that first high. Like the first time I used this, it was this pleasure I’ve never experienced before. But now I don’t experience any pleasure. I just use so I’m not in pain. And that’s called negative reinforcement. They’re using the substance to take away pain and negative mood states rather than feeling something positive like pleasure and euphoria. So the brain changes with continued substance use in this very predictable pattern. When I used to work in a college counseling center, I would draw this out for my clients and say, right now you’re still feeling that euphoria, but how do you feel afterwards? And when you drink now, are you getting that same level of euphoria as you did two years ago when you started? And when they start to see the progression, that the highs are never as high, but the lows are getting lower, that’s a real motivation for a lot of clients to make a change because they see how they are changing their brain on this path. So that’s just one example of where I think the neuroscience can help us educate our clients so they’re informed, they’re working with their brains and bodies instead of against them by having this information, and it also helps us tailor our treatment plans by being more informed about the neuroscience.

Does the change with dopamine levels also occur with alcohol addiction? Obviously, alcohol is more of a depressant, so they may follow a slightly different curve. What does that look like?

All drugs of abuse impact our dopamine either directly or indirectly. So we do see dopamine being affected by all drugs of abuse. But if you dive down into the classes of drugs, you can see which neurotransmitters are more impacted by the different drugs of abuse. So when it comes to alcohol, yes, it is a depressant. We see a lot more influencing the GABA system, and then that indirectly influences the dopamine system. So, yes, there are differences in each class of drugs stimulating different neurotransmitters, either excitatory or inhibitory, and that’s how it can impact dopamine in an indirect way. But they all impact dopamine, and that’s something that all drugs of abuse have in common, but they influence other neurotransmitters as well. So, like alcohol is linked to the GABA system.

Is there any research around the changes that occur when problem behavior becomes addiction? The addictive behavior is the obvious thing. You can see it happening. But are there any other common behavioral markers that might be an indication that clients are transitioning from a problematic behavior to a “full” addiction?

Yes, and that is a great question because especially when we’re thinking about drugs of abuse or behavioral addictions, it’s only a subset of individuals who engage or who use those substances who end up meeting criteria for a substance use disorders or behavioral addictions. That’s why there are risk factors that make certain individuals more vulnerable or susceptible to the development of addiction. Things like genetic predisposition, early experiences of trauma, early exposure to the drug of abuse or the behavioral addiction, co-occurring mental health concerns. So all of those increase an individual’s susceptibility or vulnerability to developing addiction. So it varies from person to person, but there are some things we can pay attention to to see, is this person demonstrating the signs that they are developing an addiction? I like to use the four C’s model.

So there are a lot of things you can use. The ICD-11, the DSM-5, they have criteria for substance use disorders and for behavioral addictions. The ICD-11 recognizes gaming disorder as well as gambling disorder as official addictions. But another way we can look at this is paying attention to the four C’s model I think is easy for us to remember. Everything starts with C, but it helps us start to differentiate between high involvement in a behavior, like high involvement in gaming, versus having a gaming disorder or really meeting that criteria for a gaming disorder. So the four C’s is simply what I mentioned earlier, that the activity has become compulsive, meaning it’s not planned, it’s not intentional anymore. It is the result of a really strong urge.

So you might have individuals who are engaging in this behavior in really inappropriate or inopportune times, putting themselves in risky situations. I worked with a client who lost his job from accessing pornography on his work computer. He knew from the onboarding process that if he was to go to a pornographic website that it would alert the company’s main server. They would know and he would lose his job instantly. He knew that, but the urge to use was so strong that he checked a pornographic website at work and lost his job that day. So I think that’s a really good example of the compulsivity of addiction. And then very tightly related to that is the loss of control. So individuals may have tried to limit their own use. So you hear people say, you know, I’m only going to game for one hour and then I’m going to stop, or I’m only going to have two drinks and then I’m going to stop, or I’m only going to use on the weekends. And they start setting their own limits but they’re not able to keep even their own rules and limits around the behavior. So that’s a loss of control. They’re engaging more frequently than they intended for longer durations of time than they intended. They’re using more of the substance than they intended. So it’s compulsive. There’s a loss of control and it continues despite negative consequences. So a lot of times with individuals if they drink too much and then they have a terrible hangover the next day, that’s a negative consequence that tells them, I shouldn’t do that again. I’m going to change my behavior because of this very negative consequence. If that’s typically what happens just throughout our lives, when we experience negative consequences, we change behavior. With addiction, they experience negative consequences, but they don’t change the behavior.

They continue to use, they continue to engage despite these negative consequences. So that’s another one of the four hallmarks. And then finally, the craving or mental preoccupation that comes with the behavior or the drug. And so again, if you go back to gaming, we’re living in an interesting world right now with eSports and professional gamers. time spent gaming is not enough to, it’s not a sufficient criteria for addiction. Instead, we have to look at these four C’s. And if an individual stops gaming, either because they choose to or they have to, and they are mentally preoccupied with it, they are craving getting back into the game, it’s hard for them to even be in the present moment because they’re fantasizing about the last time they were in the game, the next time they’re going to game, they are so mentally preoccupied and craving it with this physical urge. That is another hallmark of addiction. That’s the fourth C is craving. So that’s what we’re paying attention to. If you are a mental health professional and you’re working with someone and you’re hearing these four C’s, the negative consequences, the compulsivity, the loss of control, and the craving, that should alert you that this might be a behavioral addiction, this might be a substance use disorder, and then we can move to more formal assessments or pulling out our diagnostic manuals and looking at the criteria. But that’s kind of the first warning sign is, wow, they’ve experienced quite a few negative consequences and haven’t been able to change their behavior. They’ve set some limits for themselves and they keep breaking it. They keep trying to quit and they’re unsuccessful. So that’s really the signs that we might be moving into an addiction.

What’s your view on replacing one addiction with another? For example, stimulants that have fewer negative effects.

This is actually fairly common because remember, the brain doesn’t really care what form it’s coming in. People with addiction become addicted to changing the way that they feel. And that can be with cannabis, with alcohol, with sex, with gaming. And so it is very likely that when you are treating one substance use disorder or one behavioral addiction, that another might emerge. That’s something that in the field we look for because we know that people might say, okay, how do I get this need met to change how I feel to have this dopamine release in another way? And so they might just go to a different substance. I had a lot of clients when I worked in an intensive outpatient program for substance use disorders, they would stop drinking and they would start using cannabis or they would stop using an opioid, but then they would start gaming or engaging in a lot of compulsive sexual behavior. So it is common for another addictive behavior to emerge when you are working on abstaining from one. The question that you’re asking is, you know, is it okay to kind of replace one with another? When you’re thinking from a harm reduction model, we do have people who say, you know, if we’re able to abstain from the heroin use or abstain from the opioid use, which we know is a dangerous substance and really linked to this opioid epidemic that we have here in the U.S. and they’re still using cannabis, but it’s not as dangerous of a drug as the opioids, that would be the harm reduction model. And there are people who use that model. We actually see it quite a bit with nicotine, that we will say you need to abstain from all of these drugs, but they continue smoking. And so I do think that that is a potential plan to say we’re going to kind of step down from these harmful addictive substances to less harmful. What I would say is that all drugs of abuse and all addictive behaviors can lead to negative consequences and it can have detrimental effects if you are using high potency cannabis and driving.

And so I think that we have a really good opportunity when we’re working with clients and we are getting their motivation to change, really increasing that. I’m a big fan of, am I, motivational interviewing. But when they’re at that place that they’re willing to make a change, I think that’s a great time to say let’s abstain from these behaviors and let’s really start to implement some adaptive coping strategies that are going to help you regulate your emotions, deal with life’s distress, deal with life’s adversities without turning to a substance. And so there’s kind of this window of opportunity where individuals are saying I think I am ready to quit. I think I’m ready to make this change, we’ve developed that motivation, and now we can turn to some adaptive forms of emotion regulation, rather than only a maybe less dangerous drug. And so that’s more of the camp I fall into, is using some MI, increasing that motivation to change, but you also have clients who say, okay, I’m not drinking. I’m still smoking. I’m not drinking and that is still progress. And so I think you’re working with individual clients where they are trying to map out. What are their goals? What does progress look like for them? What’s the end goal? The end goal might be absence from all substances, but they’re starting with alcohol, then they’re moving into nicotine. So I do think that there is is there’s benefits to both, but it’s really going to depend on the individual and what they’re willing to do, what they’re motivated to do. I have found that when we’re using MI, when we’re working with clients, especially when they came to my level of care, which was an intensive outpatient, they were ready to abstain from all substances. And that’s when we really started working on replacement behaviors that would help them regulate emotions without using a drug of abuse or turning to a potentially addictive behavior like sex addiction, food addiction, or gaming or gambling.

Are there people who never get addicted to substances? And if not, are there people that look like they never get addicted to substances, and what is that?

Yep, so that’s another really great question that when we look at individuals vulnerability to addiction, you’ve got the genetic predisposition, the history of trauma, co-occurring mental health concerns, early exposure. If you are a person who doesn’t have a lot of risk factors for addiction, you may be able to drink socially, gamble socially, you don’t have the negative consequences or if you do, it’s enough to deter you from engaging in that behavior again. I had a client who used to say it drove him crazy that his brother could drink half a glass of wine and leave the rest and he never had enough.

He never left alcohol. He would finish it and then go find more. He’s like, how can we have the same genetic line but I need it so badly and my brother can drink half a glass and walk away. So there are definitely differences when it comes to genetic predisposition, but also trauma histories, also other mental health concerns or even personality traits like sensation seeking and impulsivity that change an individual’s degree of vulnerability to developing an addiction. Now all that to say, if you engage in substance use over time, you will experience neuroadaptations. And so if you start using meth and you don’t necessarily have a genetic predisposition for addiction, but you use meth over and over, you’re spiking that dopamine and your reward circuitry is overstimulated over time, you will start to see that down regulation of the reward pathway, of the reward circuitry, and start to see changes in your brain. You’ll start to have withdrawal and that can lead people to using the substance just to alleviate the withdrawal symptoms. And so people can end up with a substance use disorder from having a lot of initial risk factors and genetic predispositions or just chronic use of very addictive substances that are causing changes in the brain. So it can kind of happen in both ways.

But there are a lot of people who they call it maturing out of substance use. So people who say, oh, but in college people binge drink. If you look at how they’re using substances during those years, you would say they have addiction, but we know that when people get a job, when they find a romantic partner, when they start a family, substance use decreases. And I would say that those individuals probably didn’t have a genetic predisposition. They probably were using in a way that was causing neuroadaptations. When they stopped, their brain goes back to its initial set point and they’re able to move on without substances. It’s only between 6 and 10 percent of individuals who use different substances that end up meeting criteria for a substance use disorder. So yeah, it varies considerably.

When looking at prevention within the field of addictions, what are some of the underlying factors that lead individuals to addictive behaviors, so we can better understand the early onset and try to exert influence through that?

I love this, and I wanna spend some time talking about preventative measures. But I did wanna focus on one specific risk factor that has a very robust relationship with addiction, and that is trauma. I’ve mentioned it, but I wanna walk through it with everyone. So when an individual experiences a traumatic event, particularly an early traumatic event, their stress response will be activated. So our stress response system is what keeps us alive. So if a tiger walked in the room right now, my stress response system would be activated. I would have my stress hormones, cortisol and adrenaline would be coursing through me. I would be breathing much faster and shallow. I would not be able to like learn very much or pay attention to things because I’m focused so much on the danger. And I am ready to either fight the tiger or run. So I’m in fight or flight mode because of this danger, because of this threat. My body changes, my muscles tighten, my heart’s beating faster. All of that happens to keep us alive when we have a threat or a danger. So that’s how our stress response system should operate. When the tiger walks away, or I run away from the tiger, and the threat is gone, our stress response system will return to baseline. It kind of dissipates back to baseline. And we start breathing more regularly, we have our heart slows down, we’re able to focus on other things, we’re no longer in that state of hypervigilant fight-or- flight mode.

With trauma, particularly adverse childhood experiences that happen between the ages of 0 and 18, let’s imagine that that tiger never goes away. That tiger is in the home or in the community or at school. And this child is learning to live with that constant threat. That can lead to what’s called toxic stress. Not the stress that helps us survive, but toxic stress, which is prolonged, it is unpredictable, and it occurs outside of the buffering of an attuned caregiver. So if a child is experiencing toxic stress, that can lead to a dysregulated stress response system, which is everything I just described when the tiger comes in, except it’s constant. It never dissipates and goes back to baseline. So this child, and then later teenager, and then later young adult, may be living life in a constant state of fight or flight mode. So they may be hypervigilant, they are having a hard time paying attention to things or learning or focusing because they’re very aware of the danger. They have stress hormones coursing through them, so they have cortisol and adrenaline at high levels in their body, which can actually lead to a lot of negative physical outcomes in adulthood. And they’re living in this fight or flight mode. So if you just imagine what that would be like to live with a dysregulated stress response that’s always turned on and doesn’t return to baseline, then you come across alcohol. Then you come across gaming, something that changes how you feel, albeit temporarily, but it can be very hard to walk away from. literature for decades that adverse childhood experiences are linked to adult substance use and adult addictive behaviors. And the hypothesis that was actually posited back in 1998 is that substances and addictive behaviors like eating, sexual activity, gambling are used as coping devices for this dysregulated stress response that comes from early trauma. So it could be that early trauma keeps us living in fight or flight mode. So we come across a depressant or alcohol, a benzodiazepine, even an opioid, something that has a calming intoxication effect. That can be a really powerful experience for someone who’s living in a hypervigilant state.

We also know that for some people who experience trauma, their arousal might shift the opposite direction. So they are hypo-aroused, so they’re living in a state of numbness, detached from their emotions. When they come across a stimulant or sexual activity or even non-suicidal self-injury, that causes an excitatory effect that, again, can be really hard to walk away from when people are used to living in this numb state. So this is why we see such a robust relationship between early trauma and young adult and adult addictive behaviors. So prevention then would entail identifying children who’ve experienced trauma and getting them the support services that they need. I tell my school counseling students that when you are working with a child who’s experienced trauma and you are helping them work through that trauma, either themselves with trauma-focused CBT or trauma-informed care, or they’re getting them connected to community resources where they can process their trauma and they can work with the family system to address trauma and help them build up their distress tolerance and their emotion regulation skills, that’s actually prevention work for addiction. That is prevention work for later substance use disorders that might emerge as a form of self-medicating or coping with these trauma symptoms that have been unresolved and unaddressed. So I think prevention can be helping to identify kids who’ve experienced trauma, getting them into support services and settings, trauma-informed schools, trauma-informed care with a clinician.

The other form of prevention that we, if I was in charge of everything, I would ensure that all kids everywhere are taught emotion regulation skills. Because remember, people with addiction are addicted to changing the way that they feel. When they use that drug of abuse, when they engage in that addictive behavior, they are feeling pleasure and euphoria. They are not feeling pain or negative mood states, it becomes a really reliable and predictable way to change the way that you feel. So if we can teach kids at an early age how to identify their emotions, how to label their emotions, how to express them effectively, and then how to modify them effectively, we can teach kids that you can change how you feel. You can use strategies and tools that we call emotion regulation skills. If we are to teach these to all kids, that can be a great form of prevention against substance use disorders. They have so many tools in their toolbox to address life’s adversities, to address pain, to address these negative mood states, that they can turn to these more adaptive coping strategies and adaptive emotion regulation strategies rather than turning to a drug of abuse or a behavioral addiction that has positive and negative reinforcement attached to it. So that’s the prevention I would mention here.

Well, let’s move from prevention straight to treatment. When you do identify that trauma is an underlying factor in an addiction, how do you approach treating that trauma?

Yeah, so there are a lot of empirically supported approaches to working with substance use disorders and trauma simultaneously. So what we need, kind of the gold standard, is integrated care. So we need to be able to address how trauma and the substance use relate to each other. There’s this bidirectional relationship. It could be that when the trauma symptoms are flaring up, they cope through the substance use. It could be that when they’re using substances, they have flashbacks to the trauma or they don’t feel in control, and that can lead to feeling or re-experiencing that trauma. So they really relate to each other. We don’t want to address them separately as if we are dealing with just pieces of a person. We want to deal with the person holistically. So there are lots of different treatment manuals out there that can get you started.

You don’t have to reinvent the wheel. Seeking Safety is a really popular one that addresses substance use and trauma and PTSD simultaneously. And so that’s really the goal. We want to help our clients understand how their trauma and their trauma symptoms relate to their substance use and when we start to look at what feelings and thoughts precipitated your substance use, a lot of those are thoughts about the trauma or trauma symptoms that are leading to negative mood states which lead to coping through substance use. So it’s all about setting our clients up for success by saying, let’s dive into how your addiction and your trauma are related, and we’re gonna address them at the same time. And while we’re here, I would just also say, when you look at co-occurring mental health concerns, whether that’s PTSD, depression, anxiety, bipolar, we see that there is a higher prevalence rate of substance use among individuals with mental health concerns, and there is a higher level of mental health concerns among those in treatment for substance use disorders. This is why I think it is imperative that all counselors are trained in addiction, because if you’re working with people with mental health concerns, they have a higher risk of having a substance use disorder or using substances, so we have to be able to address them together. And that’s what integrated care is, that we’re addressing the mental health concern and the substance use disorder simultaneously with the same team.

We’re not saying, go here for your addictions treatment, go here for your mental health concern treatment, and we hope that eventually everything comes together. But we are providing integrated care, where we’re addressing all of it simultaneously. The last thing I’ll say here is, we have to be able to rule out substance use with any psychiatric symptom that we see. So just take hallucinations. You have a client who is experiencing hallucinations. That could be schizophrenia, that could be a mental health concern with psychotic features. It could also be withdrawal from chronic severe alcohol use. It could be using a hallucinogen. It could be intoxication on some of the stimulants and some of the other synthetic drugs. So how are we to know as mental health professionals, are these hallucinations from a mental health concern or from substance use? We have to be able to make that distinction. And without the training in addictions, it’s really possible to do that. And I’ve worked with a lot of counselors who’ve said, yeah, I really thought they were having a psychotic break or I really thought that this was an acute mental illness that was coming up, but really, after I dug a little deeper, they were using high potency cannabis that was causing paranoia, or they had just used cocaine and were having these psychotic symptoms or methamphetamines. And so we have to be informed so that we can differentiate between substance-induced symptoms and psychiatric symptoms so that we can get our clients the best care that they need.

What type of adaptations have you had to make or you know with regards to intervention strategies that are effective for clients with complex disabilities living with substance addiction?

Yeah, even when we say clients with disabilities, that is such a huge range of physical disabilities or mental health concerns would fall under disabilities. And then we also have the visible and invisible disabilities. So when I worked in addictions treatment we did adapt a lot of our treatment strategies to meet the ability status of our client whether that was working with a client who had an interpreter because they were deaf whether that was working with a client who had a visual impairment. When we start looking at some of the developmental delays and then these neurodiversity when it comes to different cognitive ability statuses. We really have to meet our client where they are. And that might mean bringing in caregivers with releases of information to have more people involved in the treatment, to have support around this person. We do a lot of family work when we’re working with someone with disabilities. But I would say that I tell my students this too, when you’re working with addiction, you’re still relying on all of your basic counseling skills, your theoretical orientation, as well as your multicultural and social justice counseling competencies. And so we tailor our approach to the unique cultural identities of our client, whether that’s socioeconomic status, religion, spirituality, sexual orientation, race, ethnicity, gender.

We are taking into account our clients’ unique cultural identities. We’re looking at our unique cultural identities, how they’re coming together in session. And then we use intervention strategies that are appropriate for that client in light of their cultural identities. And so I think that we have to do our due diligence to see what does addictions treatment look like with this particular drug of abuse, with this particular client, with this disability, or with this cultural identity, and then make sure we’re tailoring our interventions. Addictions counseling is not one-size-fits-all. There are lots of ways to long-term recovery, and so there are a lot of different types of support groups and individual counseling, group counseling, family counseling.

We can use a variety of methods. And I think it’s meeting the client where they are to make sure that they’re getting their needs met and that we’re tailoring and adapting our strategies to our client. Yeah, there’s a lot more I could say about cultural diversity, but hopefully that gives you a little sense of relying on your multicultural competencies.

In your experience, whether it is through direct clinical work or via research, are neurodiverse people more vulnerable to addiction due to ongoing stress from micro-events and trauma?

It’s interesting because if you look at the data that’s out there right now, we do see that there are certain aspects of neurodiversity that have been linked to different types of addictive behavior. So, for example, there’s quite a bit of research out there looking at folks on the autism spectrum and gaming disorder. And there have been some other investigators who have looked at, for those who have neurodiversity or really other disabilities, if you think of a physical disability in a game, you create your own avatar. People only know about you what your avatar presents. There is this link between gaming addiction and some of these marginalized statuses and disabilities, because in the game, they aren’t known as someone who has a disability.

There’s also some aspect of gaming that can really tap into certain individuals, either personality traits or neurodiversity, that we do see higher levels of gaming addiction among subsets of the population. I think that that’s great research for rehab counselors and for folks who are working with neurodiverse populations to start to see what is it about gaming or other addictive behaviors, what’s the function of that behavior for the client. So one of the things that we know about addictive behaviors is people turn to them for a variety of reasons. Like for gaming, for instance, there are recreational or social reasons to game, but there’s also achievement motives for gaming, like I’m not great at math, I’m not great at sports, but I’m really good in the game and people respect me in the game. And then there’s also the motive to escape, that I want to escape my life in the virtual world. I want to immerse myself in the virtual world and really escape my offline life. We know that achievement and immersion or escape are more linked to gaming addiction. So I think with any client we need to ask what does this addictive behavior do for you? What is the motivation? For any Adlerians out there we talk about teleology which is the function of the behavior that all behaviors serve a function. So really looking at each unique client of what does this addictive behavior do for you and then how can we meet that need in a more adaptive way without drugs of abuse or behavioral addictions.

What unique challenges do adolescents and young adults face with addiction and how does treatment differ for this age group?

Yeah, such a great question. So we know that the majority of addictive behaviors begin, they have their initiation sometime during adolescence. And so this is why I think school counselors and people who are working with young clients are in such an important position to recognize addictive behaviors early and intervene early to change the trajectory so they don’t end up in residential treatment in their 50s or 60s. So it looks a little different in adolescent and young adulthood. A lot of people say, well, this is just developmentally appropriate exploration of substance use.

We do know the adolescent brain is different. So when you think about brain maturation, it starts at the base of the brain and then moves to the prefrontal cortex, which is our goal-oriented, logical, rational, reasoning part of the brain. That maturation process usually doesn’t end until 25, 26 years old. So during adolescence, the reward pathway in the midbrain and the limbic system is moving faster, it has myelinated, it’s matured before the prefrontal cortex.

So, it’s as if during adolescence, the part of the brain that’s saying, that felt good, let’s do it again, or I really enjoyed that, I want to, let’s go use that again or do that again. While the part of the brain that’s saying, wait, let’s pause and think this through, what happened the last time you use that or what kind of negative consequences you experienced. Do you really want to experience that again? Is that aligned with your goals and values? It’s as if that part of the brain is quieter and the part of the brain that’s saying go that felt good let’s do it again is louder. So that’s what adolescents are working with. They are more sensitive to rewards, they approach rewards more, they return to rewards more often. And again, that’s part of their cognitive, their brain development.

They’re also very influenced by peers. We know that peer socialization is, becomes more and more important during adolescence. That’s not to say that parent influence is less important. It’s just now competing with peer influence. So we’ve got a lot going on in adolescence that kind of sets the stage for addictive behaviors to begin. That’s why I think intervening early, recognizing the signs of addiction, recognizing when a student might be using substances. So are we seeing a change in peer group, a loss of interest in school and activities, even how they show up at school, bloodshot eyes, or they have poor coordination. Once we recognize that substance use could be occurring, we can intervene early.

And there are lots of intervention strategies for adolescents. There’s residential treatment for adolescents. There is outpatient group and individual counseling for adolescents. Family counseling is huge. We look at adolescent substance use from a family systems perspective, so multisystemic therapy and getting the whole family involved. There’s family checkups, which is an intervention to really help parents to improve or consider new strategies of parental monitoring and supervision and support, and working with adolescents to decrease risk of substance use. So there’s a lot of approaches out there, but unfortunately a lot of the referrals that adolescents get to treatment is through the criminal justice system. It’s when they have broken a law, when they have some kind of illegal substance, and that’s ushering them into treatment rather than a parent or a teacher, someone at a school. So we really want to increase awareness of addiction so that we can start to make those referrals before the criminal justice system is even a part of this picture.

A lot of people don’t know there’s also recovery high schools, which I just think are amazing. They are schools for adolescents who are in recovery from a substance use disorder and want to be in an environment with other people who are in recovery. When you get to collegiate settings, there are collegiate recovery programs that are becoming more and more popular here in the U.S. where if you think of college as an abstinence hostile environment. They’re so important for people to pursue their college degree by being a part of a collegiate recovery program where there are dry dorms and there are social events without any alcohol, without any drug use. So there’s supports in play, but I think we need more people who can recognize the signs of substance use among adolescents, recognize the signs of addictive behaviors. When do we start seeing those 4 C’s in our adolescent’s gaming or social media use, and we’re able to intervene early. And again, there are lots of effective treatment strategies once we’re able to recognize that this particular adolescent might benefit from counseling and support.

When relapse occurs, what are some of the key learnings that clinicians and clients can derive from, and how does it shape subsequent treatment?

I always encourage my students to think about what a client’s relapse will bring up for you as the counselor. There’s a lot of emotions that happen when a client relapses for you. And so we need to do our own work so that we can walk into the space with our client and support them, that we are not using shame-based strategies, that we are meeting them where they are with compassion and empathy, and then helping them get back to their goals. And so we know that the majority of individuals who try to make any kind of behavior change are going to relapse. We use relapse like it’s just about addiction, but people relapse all the time.

If you think about a diet or changing your exercise regimen, any kind of behavior change, it is very rare that you make that behavior change perfectly on the first try. Many of us have experienced cycling back through the stages of change and needing to try again. The same thing happens with addiction. So how I like to describe it to families is rather than saying, okay, they’re in counseling now, they’re going to be cured and never use a substance again, that’s really not an accurate conceptualization of the change process, and it’s not necessarily helpful. Instead, what is more typical is that individuals come to treatment, they come to different levels of care over time, and their using days get smaller and smaller and smaller over time, their abstinence periods get longer and longer and longer over time until they’re in sustained recovery, long-term recovery. And so that is very different than saying you’re either a hundred percent using or you’re a hundred percent abstinent with no overlap and nothing in between.

Unfortunately when clients endorse that narrative, when the people around them are endorsing that narrative, when they leave counseling and they have that first high-risk situation and they find themselves taking a drink, what we see is called the absence violation effect where they say, well, I just took a drink, there goes the 120 days of sobriety that I had, there go all the treatment methods that I’ve tried before, all of the counseling I’ve had before, it’s all down the drain because here I am taking this sip of alcohol and then that of course, that kind of thinking and that shame leads to a full blown relapse where instead we prepare for, you may have a lapse which is that first drink or first substance use. That lapse is a choice point.

What do we want to do there? Do we want to have the absence violation effect, say it’s all for nothing, what’s the point, and then go to a full-blown relapse? Or do we want to plan ahead for what we can do in that moment? Even something like keeping a card in your wallet that has self-statements that the client wrote in advance, like you don’t have to keep drinking, you don’t have to keep using, call your sponsor, you know what to do, do it for this person, and can get them back on the path of abstinence even after that first drink or first use of the drug that we would call a lapse. So relapse is such an important component. Relapse prevention starts the first day that people enter treatment, is identifying what are those high-risk situations and then how can we cope effectively with those high-risk situations. When a relapse occurs, as a clinician, that’s data for me. That’s me saying, okay, our relapse prevention plan has some holes in it. There are some areas that we can strengthen. Was this a new high-risk situation that we didn’t plan for or did you try a coping strategy that didn’t work? And so we need to come up with new coping strategies or build your self-efficacy around that coping strategy.

What is the weak area in your relapse prevention plan and how do we strengthen that area moving forward? So that’s a way that we can use relapse as a learning opportunity. My clients who came back to counseling after a relapse, they couldn’t even make eye contact. They had so much shame. They don’t need shame from their counselor. We know that shame is not a good motivator for any kind of behavior change. So instead we say, I see it’s so disappointing for you. Let’s look at your relapse prevention plan and see what was faulty. Where do we need to strengthen? How can we learn from this so that now when you face that high-risk situation you know what to do. We have a new coping strategy to use. We have role-played this. We have practiced our refusal skills. So that’s really a way that relapse can be a learning opportunity rather than this failure where the client thinks I’m back at square one. That’s really not an accurate way to think about behavior change.

Looking ahead, what do you think would be the biggest challenges and opportunities in the field of addiction treatment?

There are so many, but I will end on this one. I would say that technology is changing the game. So when we think about behavioral addictions in particular, technology is what’s been referred to as a supernormal stimulus. So it is an artificial exaggeration, an imitation of a natural instinct that can have a stronger pull than the real thing. So think about pornography.

There is unlimited novelty when it comes to pornographic videos and images, and we have more dopamine release as a result of novelty. So people start to condition themselves to become more aroused with pornography than an offline romantic partner. And now with virtual reality, there’s all these different dimensions of cyber sex and sexually stimulating material through technology. But even think about online gaming, how the virtual world can be more stimulating and more rewarding than the offline world. It would be another example of a supernormal stimulus, that it’s an artificial exaggeration of a natural stimulus, but it can exert a stronger pull. It can be more rewarding because it is this exaggerated imitation.

We also see that with condensed, concentrated sugar in foods, refined sugar that if you compare hard candies and desserts, processed foods to the sweetness of a strawberry, it’s just going to dwarf the sweetness of the strawberry because it is this supernormal stimulus. It’s more rewarding, more of the sugar than we would find in nature. And so it’s hard for nature to compete with something like that. So we’re seeing the evolution of these supernormal stimuli. And just like drugs of abuse that cause more dopamine release than natural rewards, once we are exposed to these supernormal stimuli and they are exerting that stronger pull and they’re more rewarding, it can be really hard to walk away from. And this is where we’re seeing a lot of the technology-based addictive behaviors are increasing in their prevalence as technology continues to develop. I think that there are a lot of opportunities for advocacy when it comes to young people and screens and digital media addiction. And so I think that’s kind of on the frontier of what we need to be paying attention to when it comes to addiction.

There’s also a lot more selling of drugs using social media. So there’s ways that technology are now coming into the substance use disorder world as well, ordering synthetic drugs offline. So there’s a lot of ways that technology is kind of changing the field. So we have to be aware of that. I think we have to be able to address it effectively. We have to have a category for what behavioral addictions are and how gaming, online gambling, sports betting, online shopping, all of these things are continuing to evolve. And so we’re likely to see the prevalence rates of these behavioral addictions continue to evolve as well.

And then the last thing I would say is just working in this field, there is still so much adherence to the moral model. I was getting a root canal last year and he asked, you know, what do you do for a living? I said, I teach. What do you teach? I teach addictions and addictions treatment. And he was like, oh, you’re not one of those people who thinks it’s a disease. Right. And it was just this really moral model view of addiction. And I think as we can continue to educate the public and share knowledge about the neuroscience of addiction, about the bio-psycho-social model, rather than the moral model, if we can humanize people with addiction and have their recovery stories be known so people can see them as human beings who didn’t wake up in the morning and say I’d like to destroy my whole life with substance use and hurt people around me, that there’s all of these factors that go into it.

I think increasing empathy for this population can be a great form of advocacy, helping people to understand what it’s like to live with an addictive behavior. And so there are ways we can develop our own empathy and help other people develop empathy. So going to open 12-step meetings or peer support group meetings to hear the stories of people who are struggling with addiction or living in recovery, watching those documentaries, reading those autobiographies about what it’s like to live with addiction. And then I also I challenge my students to have an abstinence project. So the whole time they’re in class with me, 15 weeks, they have to abstain from something desirable. And that’s not going to emulate recovery from a drug of abuse, but it does help them develop empathy for what it’s like to be without something they desire.

And so to go the whole 15 weeks is very hard. I rarely have students make it to the end without turning back to what they chose to abstain from, and that really helps us stop thinking about addiction as us and them and start thinking about it on a continuum, that that everyone has addictive propensities and some become more severe than others. And we can really start to have accurate empathy, which is linked to positive clinical outcomes when we can have that accurate empathy for folks with addiction. So I would say that those are some things moving forward. How do we combat the moral model? How do we increase knowledge of the neuroscience and the biopsychosocial model? How do we ensure access to treatment with quality treatment providers who are providing integrated care and then doing our own work as clinicians to make sure we are ready to provide that care. Those are a lot of things that I would say we’re going to be missing.

Key takeaways

  • Addiction is a complex disorder that impacts the brain’s reward system, whether it’s substance abuse or behavioral addictions. Understanding the neuroscience behind addiction helps clinicians become more effective in this field.
  • Early intervention and education for mental health professionals on addictions is vital. Clinicians need to be prepared to address addiction in various settings, given its prevalence across different age groups and demographics.
  • Clinicians should consider integrated treatment approaches that address both addictions and underlying factors (such as trauma). Addiction can be a coping mechanism for trauma; clients with mental illnesses are at a higher risk of being impacted by addiction.
  • Technology can bring both challenges and opportunities in addictions treatment. One growing challenge is how it creates new avenues for behavioral addictions, requiring adaptations in treatment strategies.
  • It’s important that clinicians embrace empathy, understanding, and non-shame-based strategies when treating addiction, advocating for a shift from the moral model of addiction to a more compassionate, biopsychosocial approach.

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