How to Approach Treatment of Sexual Addiction
Providing appropriate and genuinely helpful treatment to sexual addicts and their partners calls upon clinicians to meet challenges in practice areas which can often be uncomfortable and unfamiliar. Regardless of clinical training and background it can be disquieting to initiate discussions about the most intimate and personal details of a patient’s sexual life and practices, particularly in early treatment phases. We may lack the confidence or understanding to explore specific details in areas such as compulsive masturbation, use of prostitutes, sexual massage, phone sex, affairs, anonymous sexual encounters, and the various types of sexual behaviors prevalent in sexual addiction. Yet a primary complaint of many sexual addicts in treatment is that previous clinical interventions either didn’t identify their problem at all or didn’t provide clear intervention, direction, and resources to aid them in addressing their sexual acting-out behaviors.
John, a 34-year-old heterosexual married man, entered treatment for his sexually addictive behavior when his wife of nine years asked for a separation upon discovering that he had given her yet another venereal disease. His secretive sexual acting-out behaviors included weekly visits for “sensual massage” and conducting multiple anonymous sexual affairs with women he had met on the Internet. Although John had been in therapy with an analyst two to three times weekly for over two years and had disclosed the nature of his sexual acting-out at the beginning of that clinical relationship, the behaviors were not fully explored in therapy nor were they ever directly intervened upon. He was never encouraged to take any direct action to change his behaviors, nor were any steps taken to protect the health and safety of his wife. John stated that he felt lead to believe in therapy that “when he felt less depressed and had a better understanding of his poor self worth” the behaviors would begin to go away.
Sexual addiction appears to be fairly common in the general adult population. In his Landmark 1987 study of over 1,500 identified sexual addicts Patrick Carnes, Ph.D. suggested that sexual addiction is present in as much as 8% of the adult male population, the number being around 3% for adult women. Sexual addiction as a clinical concern has clearly identifiable patterns of sexual behaviors, often starting in adolescence and childhood. The disorder is defined by the harmful consequences of the sexual behaviors themselves and the participants’ inability to discontinue them.
A helpful way to integrate a clinical understanding of sexually addictive behavior is to utilize a common definition of Criteria for an Addictive Disorder:
• Frequent engaging in the behavior to a greater extent or over a longer period than intended
• Persistent desire for the behavior or one or more unsuccessful efforts to reduce or control the behavior
• Much time spent in activities necessary for the behavior, engaging in the behavior or recovering from its effects
• Frequent engaging in the behavior when expected to fulfill social, occupational, academic, or domestic obligations
• Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem caused or exacerbated by the behavior
Sexual addiction and compulsivity can be defined as sexual behaviors which involve “escalating patterns of sexual behavior with increasingly harmful consequences.” Those consequences which often are indicators of the disorder appear in the full bIntensive Programsychosocial spectrum.
These consequences might include:
• Social
Loss of marriage/primary relationship, friendships, social networks due to sexual preoccupation and behavior
• Emotional
Depression or anxiety are common due to the shame, secrecy and lowered self-esteem of sexual addicts
• Physical
Injury due to frequency and type of behaviors; sexually transmitted diseases are common
• Legal
Arrests for sexual crimes (voyeurism, lewd conduct, etc.), loss of professional stature or licenser for sexual misconduct or sexual harassment
• Financial
Costs of pornographic materials, use of prostitutes, phone/computer sex lines; Loss of productivity, creativity and employment
Like alcoholics, drug addicts, and compulsive gamblers, sexual addicts employ typical defenses such as denial, rationalization, and justification in order to be able to continue to engage in their behaviors, while blaming others for the resulting problems. Diagnosis and subsequent treatment can be skewed by a patient’s minimization or outright denial of the type, amount, or consequences of their sexual activity. Misdiagnosis can also occur due to the concomitant mood disorder symptoms that the shame and stress of living a double life can facilitate.
While thorough bIntensive Programsychosocial assessment may reveal other underlying diagnosis or clinical concerns, some sexual addicts will report having been previously misdiagnosed with related, but inaccurate psychiatric disorders. Sexual addicts have been diagnosed as having Bi-Polar, Obsessive Compulsive, Generalized Anxiety or Dissociative Identity Disorders, all of which can be seen to hold some characteristics of compulsive sexual behavior by definition, but do not appear to be the underlying condition for most sexual addicts. In fact, with appropriate intervention and cessation of addictive sexual behaviors, along with shame reduction and a building of more healthy coping mechanisms, other “compulsive” or “mood disordered” symptoms will often discontinue or be greatly reduced on their own. When sexual addiction is found to exist solely on its own without any related primary Axis One disorder, it can be classified as Sexual Disorder NOS with Addictive Features (DSM-IV).
Billy, a 48-year-old homosexual man, engaged in anonymous sex in public parks, mall restrooms, and sexual bathhouses, having many multiple partner experiences weekly. Although HIV positive, he often had unprotected sexual encounters with several anonymous men on a weekly basis. Unable to sustain intimate romantic or social contacts due to his compulsive secret sexual life, Billy frequently suffered bouts of depression and anxiety which left him feeling hopeless and shameful. Upon learning about this behavior, Billy’s primary physician referred him to a local psychiatrist who prescribed Lithium for his “Hypomania” and an SSRI for his apparent “Depression and Anxiety”. Although the patient took the medications for several months he noted minimal change in his mood states and he continued his sexual behaviors until he was arrested for lewd conduct in a public park. Billy was subsequently referred for sexual addiction treatment and mandatory attendance at sexual addiction 12 step recovery meetings. Within the first 30 days of treatment Billy established and began maintaining a “sexual sobriety” plan, became involved in regular weekly 12 step meetings and began to explore the painful history of his sexual behaviors and emotional isolation. By 45 days into treatment, Billy demonstrated only transient and diminishing mood disordered symptoms. He states, “This has been the problem my whole life and I have never been able to change it on my own no matter how hard I tried. I never really understood or realized that my sexual addiction is the reason I have always felt so self-hating, isolated and unworthy of love.”
Multiple addictions are often present in sexual addicts and must be watched for. As with any addiction assessment and treatment model, careful interview and discussion should always consider the possible involvement/history of drug and alcohol abuse or dependency, eating, exercise or spending disorders, gambling, etc. It is not uncommon for this population to switch addictions during treatment, such as the sexual addict who while containing her sexual acting-out, gained 35 pounds in the first 90 days of treatment. Additionally, a thorough and current medical exam should be encouraged at the beginning of treatment as sexual addicts can often be inattentive to self care and also may need testing to discern the potential existence of any sexually transmitted diseases.
Successful outpatient treatment for sexual addicts differs significantly from traditional models of psychodynamic psychotherapy and more closely follows a cognitive/behavioral addiction approach. The stance of the clinician in addiction treatment is directive and reality based. Early sessions focus minimally on the transferential aspects of the relationship or upon childhood injury utilizing a clear directive focus in the here and now. Although an established positive and trusting clinical relationship is essential, the therapist’s initial role is directive, applying a task-oriented and accountability-based approach while always maintaining containment of the sexually addictive behaviors as the primary mutually agreed upon therapy goal. The initial process of treatment can be divided into three major stages:
Identification of the Problem
After carefully ruling out the presence of other related psychiatric or medical diagnosis, the utilization of assessment tools such as the G-SAST, close questioning and observation, helps the clinician and patient to identify the specific behaviors which make up the problematic addictive patterns
Behavioral Contracting
Defining in clearly written terms specific problem sexual behaviors which are to be eliminated. Contracts will often also include tasks assigned to encourage the use of alternative coping mechanisms, i.e. daily journaling, check-in phone calls and attendance at 12 step meetings.
Relapse Prevention
Working to identify and reduce patterns of experience and interaction which support or “trigger” the acting-out behaviors, i.e. stress management tools, relationship dysfunctions, work/financial problems, etc.
Typical Sample Treatment Goals
• Identification, assessment and containment of specific sexual patterns and specific sexual activities
• Clear definition of healthy sexual patterns vs. shaming and self harming activities
• Exploration of ego-syntonic dysfunctional behaviors working toward their becoming ego-dystonic utilizing the reduction of distortion and denial
• Relapse prevention: helping the patient to see and understand triggering behaviors and experiences
• Improvement of socialization, encourage healthy acknowledgment and support for meeting dependency needs
• Reduction of spousal conflict while encouraging partner participation in recovery work
• Identification and working through of immediate and long term grief and loss issues
• Increased understanding of need to control intimacy as a function of long standing early neglect and violation
The ongoing process of the sexual recovery process presents demands that cannot be met solely within the confines of an individual therapeutic relationship. Recovering addicts require external sources of social reinforcement and support for changing lifelong patterns of behavior. One extremely important tool utilized toward these goals is addiction-focused group therapy. A long-standing fundamental to sexual offender treatment, group therapy for sexual addicts is an invaluable resource for integrating the tools of honesty, self examination and commitment into the recovery process. Sexual addicts in group work are offered the safe, facilitated space to be able to confront their denial and rationalizations while more realistically redefining shameful self states. Group provides an invaluable resource toward building appropriately boundaried social support toward recovery. The other primary resource for sexual recovery is the 12 step support group. Functional meetings of at least one of the following programs can be found in any major metropolitan area and some in more rural areas as well as online via skpe, chatroom and tele-meetings. All provide the basic principles of honesty, integrity and spirituality long successful within Alcoholics Anonymous, while making that process applicable to the specific needs of the sexual recovery population.