Five Ways Therapists Are Clueless About Addiction
Even the best mental-health professionals are surprisingly blind to the symptoms of addiction in their patients. It needn't be so.
One of the sad truths about addiction treatment is that many of the most talented clinicians—the licensed psychologists and social workers that most people seek out when they have mental health concerns—don’t treat addictions. And, worse, this state of affairs exists because many of these clinicians fail to identify addictive disorders in their clients, even when fairly obvious signs and symptoms confront them.
Stories of unrecognized substance and behavioral addictions are common in 12-step programs and in addiction memoirs. Research supports such anecdotes. For example, many mental health providers struggle to recognize alcohol use disorder. In one study, half of the intake reports in a college counseling center made no mention of alcohol misuse, even though students’ self-reported consumption merited concern.
My own research yields the same conclusions. For example, I asked psychotherapists to read a series of vignettes in which the patient reported a variety of signs and symptoms commonly associated with alcohol use disorder. One vignette described a white, married middle-school teacher whose husband insisted she see a therapist after no medical cause was found for her presenting problems. (These included recurrent stomach aches, an ulcer, poor sleep, eating less without weight loss, irritability, preferring to be alone in the evening rather than with a spouse, a few careless accidents and forgetfulness.) When asked to provide an initial diagnosis, 50% of the psychotherapists considered her depressed; 27% thought the main problem was anxiety; only 7% thought the patient might have an addiction.
Curiously, the vast majority (93%) of these therapists said they routinely ask new patients about alcohol use, although less than 10% used standard measures like the Drinker’s Check-Up or AUDIT. Many may ask questions that are too informal (“Do you drink?” or “How much do you drink?”) and then fail to follow up because the answers they receive don’t elicit concern. “I file the information away,” one therapist told me. “I’m not sure what I am supposed to do with it.”
One reason for this failure to provide robust identification and treatment of addiction is the lack of addiction-specific training that psychology PhDs and PsyDs receive (the problem is paralleled by similar deficits in medical training). But the training factor doesn’t go very far in explaining the scope of the problem, because even many clinicians who have received extra training or self-identify as addiction specialists are no better at identifying alcohol use problems.
So why do psychotherapists often overlook addictions? To answer this question, my students and I interviewed psychotherapists and discovered a number of attitudes that impede their identifying addictions.
1. "Behaviors are not addictions." Many clinicians only inquire about, and consider, substance use when they think about addiction. They do a quick check about alcohol and other drugs but don’t delve deeply enough into a client’s behavioral history to uncover non-substance-related addictive patterns, such as gambling, shopping, Internet use, etc. The good news is that this oversight is likely to change given formal recognition in the DSM-5 of the first behavioral addiction: disordered gambling. This is a significant step forward in encouraging mental health professionals to be aware of their patients’ repetitive behaviors that are creating negative consequences
2. "Real addiction stares you in the face." In addiction treatment settings, addictions are indeed obvious because they are the presenting problem. But in other setting—perhaps due to the way that addiction is portrayed in media and entertainment—many mental health professionals believe that the signs and symptoms of addiction are blatant, like the disheveled appearance and outrageous behavior of Lindsey Lohan. But in fact addictions often are not obvious—even to the client. SAMHSA research has shown that only 1 in 10 people whose alcohol use qualifies as problematic self-identify it as such. One reason is that addiction can often masquerade as a mental health problem (as in my vignette study). When listening to a new patient report anxiety, lack of energy or low self-esteem, a therapist's thoughts turn to typical psychological disorders when, in fact, these symptoms can represent the adverse side effects of an addictive behavior.
3. "Alcoholics are men, shoppers are women…" Even clinicians with a more nuanced view of addiction can overlook the problem because of mistaken preconceptions. For example, more men than women have alcohol use disorders, so therapists may be more attuned to alcohol addiction in men. A woman’s drinking problem may be further enhanced because it may not create the kinds of apparent adverse effects (e.g., DUIs, arrests) typical for men. Gender is only one impediment to identifying alcohol use problems. Within healthcare settings, alcohol use disorders tend to go underdiagnosed in people who are insured, employed and Caucasian. Stereotypes also block identification of behavioral addictions. While many clinicians believe that women are more likely to manifest a “shopping addiction," research shows it to be equally common in men. Sex addiction is often incorrectly assumed to be associated with sex offenses or limited to unusual paraphilic interests; in fact it is usually found among people with fairly mainstream habits.
Clinicians influenced by mistaken beliefs about "addiction treatment" may overlook signs of addiction in order to continue working with a patient they like.
Significantly, a therapist’s personal behavior can also shape what he or she identifies as addiction. Research has shown this to be true of primary-care physicians. (Along these lines, I have often wondered how my self-created norms around Internet use and work may affect whether I consider a patient’s behavior in these areas to be problematic!)
4. “I don’t treat addictions.” Many mental health clinicians think of their patient population as generally not including addictions, and they don’t actively seek out evidence to the contrary. In fact, addictive disorders are so common that it’s nearly impossible not to work with people who have them. A recent review of the prevalence of substance and behavioral addictions found that the annual rate of emerging or diagnosable addictions among adults is 47%. Some of these people will take their distress to therapy. In other cases, an addiction develops over the course of treatment as a person who has poor emotional regulation or limited means of coping turns to a substance or behavior as a way to manage the discomfort of issues addressed in treatment.
5. "My patients aren't 'addicts.'" Despite the fact that addiction is widely viewed as a treatable disorder, the perception of “addicts” as unsavory, immoral, antisocial and unmotivated for treatment may still hold sway. Given that we often come to like the patients we treat, it may never cross our minds that our patient could have an addiction. Also, many therapists may believe that they are unqualified to help a patient with addictive behaviors; that addiction treatment cannot be seamlessly integrated into psychotherapy; that such patients need to be referred to a specialist; or that “you have to be an addict to treat an addict.” Clinicians who are subtly influenced by these mistaken beliefs may overlook signs of addiction in order to continue working with a patient.
Addiction is “the disease of denial.” But denial is only one reason patients do not report addictive behavior. Patients often need to establish rapport with the therapist before revealing a problem for which they feel ashamed. Like psychotherapists, patients may also hold mistaken beliefs about what an addiction looks like (the Lindsay Lohan syndrome). And again like psychotherapists, a patient’s attention may be drawn to the psychological symptoms created by addictive behavior.
Conducting formal addiction screenings at the start of any behavioral treatment is a first step toward better identification of addictive disorders. But given the myriad forms of addiction and the possibility that addiction can emerge during treatment, screening alone will not solve the problem of unrecognized addictions. Mental health professionals need to become attuned to the often-subtle psychological and physical effects of addictive disorders and to attend to the clinical dialogue for any evidence that a behavior or substance use is increasing in frequency.
Marilyn Freimuth, PhD, is a clinical psychology professor at Fielding Graduate University who practices in New York City and Wisconsin. She is the author of two books, Hidden Addictions: Assessment Practices for Psychotherapists, Counselors and Health Care Providers and Addicted? Recognizing Destructive Behavior Before It’s too Late. She also conducts trainings on how healthcare professionals can improve their ability to assess and treat addictions. She can be reached at firstname.lastname@example.org or through her website: hiddenaddiction.com.