A few years ago, a man stopped me in a public place, somewhere ordinary, the kind of errand that fills a weekend. He was in his forties, healthy, well-dressed, easy in his manner. He called me by name and asked if I recognized him. I didn’t, and I said so.
He told me he had been my patient. For two years he had come to see me regularly. During that time he had been hospitalized more than once, diagnosed with a serious mood disorder, and treated accordingly. He had done everything asked of him. He came to his appointments, often with his wife beside him. He took what I prescribed. And he had not gotten better in the way any of us hoped.
The man standing in front of me bore little resemblance to the patient I had known. He told me he had been off all medication for several years and was, in his words, doing just fine. He had come to believe he was never mentally ill at all. His real problems, he said, had been gambling and compulsive sexual behavior. When he finally got help for those, when he finally named them, his life began to change, and the psychiatric symptoms gradually faded.
I have thought about that conversation many times since.
For two years, the things that were actually consuming his life never entered my office as the problem. We talked about mood, about sleep, about energy and despair. We did not talk about what he was doing at night, because he did not raise it and I did not know to ask in the right way. The gambling and the rest stayed outside the conversation and what stays outside the conversation, in this work, may as well not exist. I treated what was speakable. I missed what was load-bearing.
I don’t offer this as a confession of unusual carelessness. He was seen weekly, by someone experienced, with a spouse in the room who loved him and wanted him well. If the real trouble can hide under those conditions, it can hide anywhere.
What strikes me, looking back, is that this is the central difficulty with behavioral addictions and it is not the one the public worries about. We are used to thinking of addiction as something with visible signs: a substance, a smell, a slurred word. Behavioral addictions have none of that. And the behaviors underneath them are, at the harmless end, entirely normal and often admired. We praise the person who works without rest. We respect discipline that looks like exercise and ambition that looks like striving. The line between devotion and compulsion is not merely blurry; it is hidden behind approval. No one stages an intervention for a behavior the culture rewards.
There is a further problem. Because most of these behaviors have no settled place in our diagnostic language, they do not announce themselves as what they are. They borrow the appearance of conditions we do recognize. A man drowning in compulsion and its consequences does not arrive saying “I have a behavioral addiction.” He arrives anxious, sleepless, despairing, erratic, and we, trained to recognize mood and anxiety disorders, see mood and anxiety disorders. We are not wrong, exactly. We are treating the distress in front of us and missing what is generating it.
Key Insight
The most dangerous behavioral addictions are not the ones that look extreme. They are the ones that look like something else — or like nothing at all, because no one has yet found the words to call them a problem.
One thing I have learned, slowly, is to distrust the surface. The same behavior, a young man who plays games every waking hour, say – can mean entirely different things in two different people. In one, it is the cause of a life coming apart. In another, it is the response to a life that already had. In one it is a reaching toward something: absorption, mastery, relief. In another it is a flight from something he cannot sit still with. I cannot read which it is from the hours logged or the money spent. Those numbers are what the world counts, and in my experience they are precisely what mislead. Two people can behave identically, one dragged to my office by worried family, the other cushioned by circumstance and never spoken to at all, and the difference between them is often not the behavior but who around them was inconvenienced enough to say something.
So what I attend to, instead, is which of those meanings is operating in the person in front of me. And I try to stay honest that it is frequently more than one at once.
Which brings me back to the man who stopped me. He believes one thing was wrong with him, and that he cured it. My impression is different from his; though I would not claim to be certain. I suspect he did have a real vulnerability, a fault line that was always there, quiet and unstressed. The addictions and their consequences were the load placed upon it, and under that load the fault slipped, again and again, in the form of the crises I treated. When he finally lifted the weight, the fault stopped moving. From where he stands, the illness is gone. My impression is that it was unburdened, not erased. It may well hold for the rest of his life, and I hope it does, but I would not assume the fault line is gone. Only that, for now, nothing is pressing on it.
He is certain. I am not. And I have come to think certainty is the more dangerous of the two positions, because it stops a person from staying watchful.
If this site has a reason to exist, it begins here; with a reluctance to accept that these problems have a single cause, a single name, or a single cure. I treated a man for two years and saw one layer of him clearly while another, underneath, did the real damage. Looking back, the real issue may be this: not that I failed to pay attention, but that I did not adequately consider how many things can be true of one person at the same time. That, more than any statistic, is what I hope to keep from repeating.