Despite the high prevalence of multiple addictions in patients seen in substance use treatment facilities, several factors can impede recognition of co-occurring compulsive behaviors, a clinical director at Mandala Healing Center in Palm Beach County, Fla., said at the Moments of Change conference this week. Some of those obstacles simply result from the difficulty of patient-therapist conversations about topics such as trauma and process addictions, said Jennifer Nelson, LCSW, CSAT.
“In order to be able to deal with multiple addictions, it is some uncomfortable stuff to hear,” Nelson said in a Sept. 29 afternoon breakout session at the Foundations Recovery Network conference. She said she's heard some clinicians say in reference to discussions about sex addiction, “I don't know if I can hear that.” However, “If I'm uncomfortable asking things, am I looking at the client as a whole?” she said.
Moreover, clients with co-occurring process addictions often will proceed through an entire course of treatment without talking about this, if the topic is never brought up in therapy. “A lot of clients will say, 'They didn't ask me, so I didn't tell,'” Nelson said. “So you have to ask, ask, ask, ask, in every realm.”
Nelson opened her presentation by discussing a case from a month ago at Mandala, which is expanding its services and transitioning from operations under the name Delray Recovery Center. Two weeks before the female patient's scheduled discharge date, she began acting out. She had been in treatment more than once for substance use and sex addiction, but it was learned only days before discharge that she also was inheriting large sums of money from her wealthy family—a potentially dangerous trigger for someone with her history. “We don't look at all angles sometimes,” Nelson said.
Nelson, who serves as clinical director at Mandala's north campus, used a definition of multiple addictions from renowned clinician Patrick Carnes that states in part, “Addictions more than coexist—they interact, reinforce, and become part of one another. They become packages.” Compulsive behaviors can be the more typical sex addiction, eating disorders and compulsive gambling, but also can be deprivation behaviors of compulsively going without something. “There is a high that comes with that as well,” Nelson said.
She discussed a variety of techniques that she has used in her work, such as having patients draw up a timeline of their traumatic experiences and compulsive behaviors; using patients' body drawings to illustrate how they experience cravings; and engaging in a “red, yellow, green” exercise to help patients set up proper boundaries for acceptable behaviors.