Dr Sean Sullivan, presentation at SPINZ Symposium, Christchurch 2005. http://www.spinz.org.nz

1. Behavioural addictions and
suicide
an under-estimated relationship?
Sean Sullivan PhD
Abacus Counselling & Training Services
Ltd

2. What is an ‘addiction’
 A lay term that hasn’t been fully accepted by
many mainstream health professionals
 Originally referred to chemical dependence
 Generally included preoccupation with the
addictive substance (funding, obtaining,
reflecting)
 Also development of a tolerance (more required
to attain desired effect), negative withdrawal
effects when reduce/stop
 Includes persistence despite negative outcomes
arising from the use of the substance

3. An open category
Examples of behavioural addictions are:
 Problem gambling at its more extreme end
(Pathological Gambling Disorder)
 Pornography addiction, particularly via the
Internet
 Compulsive spending/buying
 Sexual addiction
 Internet addiction
 ‘Video’ game addiction

4. Can ‘addiction’ be expanded to a
behaviour?
 Often a reluctance to allow this term to be
extended beyond its ‘substance dependence’
base
 Reasons appear varied and not well argued.
They include:
 Lack of biological adaptation markers for behavioural
‘addiction’
 No independent proof of lack of control – may choose
not to moderate their behaviour
 Weakens the acceptability or importance of the term
‘addiction’ –where will it end (Internet ‘addiction’,
pornography ‘addiction’ and even chocolate (?) or
coffee ‘addiction’)

5. Why include behaviours in
‘addictions’
The only differences may be the absence of
an external chemical introduced into
person’s system and less acute withdrawal
effects–insufficient reasons in themselves
 Preoccupation similar
 Tolerance occurs
 Some withdrawal – irritability, anxiety
 Persistence despite negative outcomes can be very
high
 But need for some definition to avoid ‘devaluing’ the
term, even when chemicals involved (eg coffee,
chocolate, and behaviours, movie ‘addictions’)

6. Why include behaviours in
‘addictions’ (contin)
As the new kid on the block, behavioural
addictions must overcome many barriers that
prevent them being taken seriously:
 Behavioural addictions are often seen as habits, that
the absence of a drug means that there is greater
control retained to resist (the drug is to blame)
 Those affected are often perceived as weaker, at-risk,
and unlike the general population
 They are often regarded as less important, less
problematic, and less life-threatening –often a
hierarchy of addictions even by those affected

7. A range of impacts similar to all
addictions
 As with chemical/drug addictions there is often
more severe outcomes with different behavioural
addictions eg illegal drugs (P, cocaine etc) can
have additional consequences to legal drugs eg
alcohol
 However, greater accessibility for legal drugs
can have its own problems, as can their
widespread social use (I can control my use of
alcohol, so why can’t they?)
 Some behavioural addictions can have
widespread consequences, and result in harm
for many others

8. Two examples in more detail
Internet pornography addiction
 Not a recognised mainstream mental health
disorder
 Unknown prevalence but probably widespread
(can’t survey for it) and largely males
 Often perceived as leading to paedophilia or
risk to others through self-gratification
 General negative perception, especially if work
with children (regardless of whether their
focus is adults)

9. Typical development process
 Viewing pornography is commonplace, especially
with males, so what is different?
 Extent and consequences place those with this
addiction at high risk (objectionable images
subject to DIA surveillance and prosecution)
 Typical development is casual accessing of
pornography that increases to substantial
preoccupation and at a time when increased
likelihood of disclosure
 Time spent and extent of the explicitness of the
pornography increases (tolerance)

10. Crisis
 Shame and attempts to hide the behaviour
increases, but impulsiveness also increases
 Behaviour increases at both work and home
(late evening) – discovery common at home
 Crisis common – discovery at work, or even
identification by DIA
 Commonly, contrary to employment policy and
termination of that employment common
 Reluctance to seek help by males (often
distressed female partner initiates counselling

11. Process
 Marital stress
 Shame and guilt
 Attempts to stop often unsuccessful due to high
accessibility of the Internet at work, at Internet
cafes, and home
 Powerful process – unlike graphic magazines,
images can be changed immediately, more explicit
images always available, prompts can invite viewing
even when legitimate Internet use
 Powerful reinforcement particularly for males–
sexual gratification with a number of ‘partners’ who
are perfect through digital enhancement
 Perception of total control and no possible rejection

12. Consequences
 For many, real relationships become less
desirable (less than perfect, lack of control,
possible rejection)
 Boredom equates to tolerance, greater
explicitness required, higher risk
 As with addictions, preoccupation leads to
decreased effectiveness and sociability, and
isolation
 Accessing images increases, and becomes the
preferred status to avoid negative reality
 As stress increases, accessing images becomes
a way to self medicate, and with more graphic
images, possible consequences increases stress

13. Consequences
 For many, the damage to their social support,
loss of employment, loss of the stress relief
provided by the behaviour, and ambivalence
around common relapses, often leads to
depression and anxiety
 Depression and anxiety may not be overt as
these emotions are often suppressed by
dissociation with males
 Many of these people were already depressed
and/or anxious and the dissociation provided
by pornography on the Internet relieved the
constant stress without conscious awareness

14. Additional issues
 Unlike chemical/drug addiction, where once
stopped there is often a rapid improvement in
health, behavioural addictions often result in
increased depression
 Reason may be that the problems still exist
(disclosure of unacceptable behaviour, loss of
employment, loss of trust where symptoms of
recovery unclear) while use of the behaviour
to escape these dysphoric consequences is lost
 Social repugnance can lead to other ways to
avoid this new reality or may lead to suicidal
ideation
 An example

15. A second behavioural addiction
Pathological or compulsive gambling
 More known about this addiction
 Is recognised by mainstream health providers
 Negative consequences may be one of the highest for
both chemical and behavioural addictions
 Affects individuals and on average 7 family members
or others
 Process is similar in many cases to other addictions
(gradual adaptation from reward, tolerance,
preoccupation, persistence
 Added factor of an inbuilt solution and no satiation

16. Additional factors
 Gambling, especially electronic modes which
have high addictiveness, are becoming more
accessible, and have high current accessibility
in NZ
 Currently, males and females have similar risk
 High co-occurrence of other problems that
often, but not always, develop as the
gambling becomes more problematic
 These additional issues include depression,
anxiety, alcohol abuse, family and work
dysfunction, poverty, criminal activity to
sustain addiction, and suicidal ideation

17. Factors that enhance self harm
 As with pornography addiction, although
gambling is widespread, excessive gambling is
viewed as indulgent, untrustworthy, trying to
take the easy way to riches, stupid, and
because associated crime common, the
individual is viewed as inherently bad
 Relapses are common (cued by advertising,
pressure from creditors, dissociation that leads
to ‘casual’ gambling opportunities)
 Continued lack of trust from others due to lack
of symptoms of recovery
 Guilt, shame, relapses entrench depression and
anxiety, with addiction impulsiveness

18. A perceived solution
 Many problem gamblers choose suicide as an
impulsive solution
 Many will prepare for it over time, others
respond impulsively
 Most do not attempt suicide to draw attention
to their circumstances
 An estimate is that 20% of those diagnosed
with Pathological Gambling Disorder will
attempt suicide
 A recent study of those admitted to hospital
after a suicide attempt found that 17% were
positive on a problem gambling screen
(2%-3% in the general population

19. Males and behavioural addictions
 Because of the lack of prevalence data for these,
for many we can only look to presentation rates
 Few seek help for pornography addiction, but those
that do are invariably males
 Half of those that seek help for gambling are males,
largely because gambling machines are the major
contributor for problems (75%-85%) and perhaps
more than half of players are female. More than 90%
of sports and track betting clients are male and view
their behaviour as skillful (an ego component).
 Many male clients present as defensive, and with
cognitive rather than emotional perspectives

20. Factors in addressing problem
gambling addiction in males
Thoughts around suicide are often common-place
but sometimes discounted as unlikely
 When raised, reasons are often given why they
wouldn’t (‘I couldn’t do that to my children’) but this
can change quickly (‘My children would be better off
without me’)
 Levels of anxiety and depression are poorly self-
monitored and emotions often suppressed (response
often to partner’s overt emotion to the addiction)
 However, addressing this with males in a cognitive
approach without emotion can assist to raise
awareness of this possibility, discuss consequences

21. An approach
 Often ‘normalise’ these ideations in order to avoid
barriers of shame/being unable to cope and to
identify extent of risk (thoughts-planning-past
attempts)
 Often use of Motivational Interviewing can assist
by the counselor emotionally ‘sitting on the fence’
but with empathy, resolving ambivalence,
motivating self-statements of ability to resolve
issues
 Because of the possible impulsive decision of
suicide may occur at any time in the future
(continued stress, greater depression) this topic is
often raised early in counselling some behavioural
addictions, especially problem gambling

22. Some important questions
 Is this approach successful?
 Does the raising of the topic of suicide put the
idea in the head of a stressed person?
 Is this cognitive approach always the best
approach – are all males the same?
 Is reaching a ‘contract’ with a client not to
attempt suicide ( or at least without first
accessing help) effective?

23. Summary
 Some behavioural addictions, particularly gambling, may
have higher risk for suicide than chemical addictions –
sudden condemnation on disclosure, criminal
prosecution, financial loss (Durkheim’s egoistic/loss of
social connections, and anomie/loss normal life)
 Less understanding by society, greater willingness to
attribute weakness/indulgence, less overt symptoms
result in less willingness to trust, greater isolation, less
support, greater co-occurring addictions and dysphoria
 Late help-seeking
 Those counselling these clients should be aware of
greater risk for self-harm and be prepared to address it
proactively
end