The Challenges of Treating Sex Addiction
Is it correct to say that sex addiction encompasses a fairly wide range of behaviours? Originally the way that we started understanding sex addiction from a clinical perspective was to put it at three different levels. Level one behaviours were low level behaviours, they did not affect others in a strong way. This includes behaviours like chronic masturbation, excessive pornography, and cyber-sex or phone sex. Level two behaviours includes things such as using prostitution, public sex in bathrooms or parks, making obscene phone calls, and exhibitionism. The highest level behaviours would be offending behaviours such as rape, child molestation, sexual coercion by professionals, and viewing certain types of pornography such as child pornography. Now we have broken these behaviours out into 10 types of sex addiction — there is fantasy sex, seductive role sex, anonymous sex and so on. However, there can be a lot of overlap, and over the course of time there can also be movement between different types of sex addiction. These are general categories being used to understand the dysfunction better, but they are in no way the end all and be all. How does sex addiction develop, and is it similar to substance addictions? It is similar to substance addictions in that some substance addictions are developed over time, and some people from the first drink are drinking alcoholically, it depends on the individual. In terms of the neurobiology it does involve the same reward pathways. All of the addictions have to do with the reward circuitry and a malfunction in the reward circuitry. Does sex addiction often co-occur with other addictions? There’s a strong interaction between stimulant addiction and sex addiction. Some of the brain researchers are finding that this is because the specific areas in the brain that fire off with stimulant addiction and sex addiction are similar. However, this is not to say that other substance addictions cannot co-occur with sex addiction as well. One of the challenges of treating sex addiction is that it is unrealistic to abstain from sex life-long. How do you define abstinence when treating a sex addiction? The verbiage they use in one of the 12-step programs for recovery from sex addiction is that it is the abstinence from the behaviours that lead to pitiful and incomprehensible demoralization. It is going to be really important for us as professionals to get a thorough assessment of the client’s behaviours. Clients often will come in and not want to talk about the specifics of the behaviour because of the embarrassment that comes up for them. They might say “I’m looking at too much porn,” in which case it is up to the therapist to investigate further into what that behaviour really looks like and how it is affecting the client. They may say “I only masturbated to porn once today,” but if you really investigate you will find they have been looking at it all day. They will want to discount the times they have been looking at pornographic images but not masturbating. We therefore would work with them to pinpoint the addictive behaviours and these become the key behaviours that one would need to abstain from. How would you define relapse? How do practioners work with clients to prevent relapse? First of all the behavioural addictions have a very high incidence of relapse, even higher than substance addictions. The metaphor for this is that the alcohol or drug addict can take their monster and lock it up in a cage and never let it out again. As a recovering alcoholic I never have to have a drink for the rest of my life. For the food addicts, or sex addicts, or spending addicts, they have to take the monster out of the cage a few times a day or a few times a week and walk it around the block then put it back in. That’s why the incidence of relapse is high. To define relapse, first we have to clearly identify the addictive behaviour. What we create is called either bottom line behaviours, which is used in the SLAA (Sex and Love Addicts Anonymous) programme, or inner circle behaviours which is taken from SAA (Sex Addicts Anonymous) programme. These are the addictive behaviours that we have defined, and if you do those you have relapsed. In SAA there are the middle circle behaviours, which are not necessarily good for you, but also are not necessarily relapse, and we want to watch out for them because they could lead to relapse very easily. At The Cabin we have taken this concept and applied it to all addictions to create the Recovery Zones Programme. The ‘Active Zone’ is active addiction and the behaviours that when they are taking place define relapse. The ‘Danger Zone’ may include impaired thinking patterns, toxic emotions, slippery behaviours, and triggers that an addict needs to stay away from. These are the behaviours that can quickly lead to relapse. The Outer Circle, or ‘Recovery Zone’ includes all the affirming, healthy, nurturing types of behaviour such as going to meetings, seeing a therapist, spiritual practices, healthy family time, participating in sports or exercise. Can healthy sex sometimes be a trigger for relapse? How do you help clients manage that? Yes, healthy sex can certainly trigger the addictive neuro-pathways and could lead to cravings for the other types of sexual behaviours. The way we treat that is really the way that we treat all of the addictions. When the addict finds himself or herself triggered or craving the addictive substance or behaviour it is important that they talk about it, that they ask for help, and they get firmly and deeply entrenched in their recovery zone behaviours. For some types of sex addiction, such as fantasy sex, the addiction in and of itself consists of compulsive thoughts. In treatment what type of cognitive work do you do to help change these thinking patterns? One of the terms that we use is called ‘fantasy contamination.’ The sex addict may be sitting at work all day keeping himself in a heightened state of arousal by thinking about the prostitute that he is going to hire that night. Fantasising about this all day could very easily lead to acting out on it, so what we will do is try to contaminate that fantasy in a number of ways. One method is what we call ‘playing the tape forward.’ We will get them to think about what happens after the fantasy, because that is usually when the shame kicks in. What will it feel like when you go home to your spouse and you are holding this secret, and what will it feel like when you show up to your next group and have to admit that you did this behaviour? We will try to bring all these realities into that fantasy to contaminate it. What are some of the other specific methods you use to treat sex addiction and how do they differ from treating substance addictions? One thing that would be different is that gender specific group work is important with sex addiction because there is a lot of shame that is attached. There is a lot of shame that is attached with all the addictions, but even more so with the sex addiction and we want to create a safe environment so that clients can feel free to share about what is really going on for them. Another piece of sex addiction treatment for clients who are in relationships involves a full formal disclosure at some point during their treatment. It is part of the repair work to the relationship and this can be a long process. Other than the shame that is attached to sex addiction do you find there are other barriers to seeking treatment? Perhaps some sex addicts do not know that they have a sex addiction? I’m grateful for people who are putting sex addiction out there to the common discourse, because now not only are people are becoming more aware that their sexual behaviours might be addictive — but that they have a treatable disorder. If you are wondering whether you need professional help, there is a free online tool that clinicians and even ordinary people can use called the SAST (Sex Addiction Screening Test), and it is available on the website www.sexhelp.com which is run by Patrick Carnes’ organisation. Carnes is the most prolific writer about sex addiction and he oversees all the sex addiction training in the United States. All addiction is shrouded in shame and even more so sex addiction. People just do not want to face that truth about themselves. So in terms of being a therapist and having somebody come into the office that is struggling with some of their sexual behaviour, I want to be careful that I’m not bringing in my own judgements about healthy sex and I’m open to my client’s experience about their behaviour and how it is affecting them.The treatment of sex addiction has its own unique challenges that many general addiction and mental health specialists may overlook if they have not had much hands-on experience treating the disorder. In order to shed some light on what sex addiction is and how it is treated we spoke with The Cabin’s Clinical Supervisor and sex addiction therapy expert, Dave McGuire.