Q&A for Clinicians

• Tips for Handling the Toughest Sex Addiction Cases
• Is it Sex Addiction?
• Should Sex Addicts Avoid Masturbation Permanently?
• Is 12-Step Work Important for all Sex Addicts?
• What Strategies Are Effective with Clients Who Continue to Act Out in Spite of Receiving Sex Addiction Treatment?
• What Does it Mean to Be in “The Bubble”?
• Is Medication an Effective Treatment for Sex and Love Addiction?
• What Strategies Are Most Effective in Treating Voyeurism?

Tips for Handling the Toughest Sex Addiction Cases

Sex addiction is a relatively new specialty, but it is one that impacts the lives of thousands of people. Because human sexuality is complex, each client presents unique issues, some of which can be extremely challenging to treat.

Few sex addiction experts have been practicing in the field as long as Sharon O’Hara, MFT, the Clinical Director at The Sexual Recovery Institute, and Michael Alvarez, MS, MFT, a Consultant for The Sexual Recovery Institute. Every few weeks, these experts sit down with a group of therapists, social workers, addiction specialists and interventionists to discuss ways to identify and treat sex and love addiction. Here are some of the questions explored during these presentations.

Is it Sex Addiction?

A client may seek counsel for relationship issues. In the course of treatment, you discover that this individual has been masturbating to the point of pain (e.g., their hand is in a splint). Is this a case of sex addiction? Does this fall within your area of expertise, or should you refer the patient to a sex addiction specialist?

Continuing to engage in a behavior despite negative consequences points to addiction, but could other issues be contributing to this behavior? First, it is imperative to rule out other disorders, such as schizophrenia, obsessive-compulsive disorder and bipolar disorder.

It also may be helpful to determine the start and stop mechanism for the behavior. For example, does the individual start looking at porn and masturbating when his spouse leaves, when he is stressed or when he has a lot of free time? Does he stop after orgasm? How long does that take? What is the individual thinking about when they’re doing this? All of these questions will provide insights into the depth of the problem and the need it is fulfilling in the client’s life (e.g., anxiety reduction or self-soothing).

Other questions to ask in determining whether a client may be suffering from sex or love addiction include:

• Does the client keep their behavior a secret?
• Do they feel guilty or ashamed about their sexual behavior?
• Does the behavior control their life?
• Do they feel powerless to stop this behavior?
• What types of negative consequences have resulted from the sexual behavior?

Should Sex Addicts Avoid Masturbation Permanently?

This is an area of debate among sex addiction specialists. Sexaholics Anonymous (SA) takes the stand that sex addicts must permanently refrain from masturbating in the same way drug addicts must abstain from all mind-altering substances. Other 12-Step programs believe it depends on the individual client. Some people can masturbate, especially without porn, without experiencing sex addiction relapse.

Therapists at The Sexual Recovery Institute typically recommend abstaining from masturbation for at least two weeks, and potentially one month or more. This temporary abstention is necessary to encourage the client to develop other self-soothing methods and coping skills. It is not that masturbation is “bad,” but it is an overused coping skill.

Like drugs, alcohol and other sexual behaviors, masturbation (particularly with orgasm) floods the brain with dopamine and other chemicals. As a result of the progressive nature of addiction, the individual builds a tolerance and needs to increase the frequency, intensity or forbidden nature of the behavior to get the same rush. This is why high-functioning individuals with no pedophilic desires may find themselves in trouble with the law for child pornography.

By abstaining from any sexual behavior for a specified time, the brain has a chance to return to baseline levels. This is not a moral issue but a purely physiological one, which has been confirmed by brain scans.

In just 7 to 10 days of celibacy, clients typically experience a reduction in cravings and acting out behaviors. Whereas everything was viewed through a lens of hypersexuality before (e.g., the simplest “good morning” from a receptionist could be construed as a come-on), abstaining from sexual behavior for a period of time can alter the client’s frame of mind. Once their thought process is clearer, sex addicts are typically very bright and can call upon their cognitive ability to support their recovery.

Is 12-Step Work Important for all Sex Addicts?

Although some sex addicts resist attending 12-Step meetings and getting a sponsor, 12-Step involvement should be a mandatory part of treatment. Most clients will benefit from participating in at least three 12-Step meetings per week, completing 12-Step work and having an interactive relationship with their sponsor.

When a client actively participates in 12-Step work, their time spent in therapy is more productive. Without 12-Step involvement, therapy sessions are often focused on overcoming denial, building motivation and grieving for the addiction. Behavioral contracts can also be an effective way to increase compliance and ensure the client gets the most out of therapy.

Sex addiction is an intimacy disorder. For this reason, part of treatment is expanding healthy human contact. Twelve-Step meetings are a safe place to challenge the client’s fear of closeness and to allow feelings about others to surface.

What Strategies Are Effective with Clients Who Continue to Act Out in Spite of Receiving Sex Addiction Treatment?

The client is working the 12 Steps, has a sponsor and attends meetings. They say all the right things and have a high level of self-awareness. They know the reasons for their behavior, but continue a pattern of acting out, feeling remorseful, and calling their therapist or sponsor vowing to never act out again. Despite ongoing sex addiction treatment, their behavior doesn’t change.

One strategy that may be effective is a “relapse autopsy.” During this process, the client and therapist revisit the client’s triggers for relapse and work to identify where the process broke down. Helpful questions include: What happened just before the client acted out? What were their thoughts and feelings at that time?

Once the triggers are identified, it is important to address those areas. For example, if a conflict with a spouse triggers the acting out behavior, couples therapy may be useful. Gender-specific group therapy is another helpful way to practice relationship skills in a safe environment with feedback from a therapist.

Some clients don’t reach out for help in accordance with their sexual sobriety plan because they don’t want to be talked out of engaging in the sexual behavior. These clients are treatment-resistant. Therapists must deal with resistance by finding its source and addressing those issues, or the acting out will not stop. For example, resistance may be driven by abandonment issues, low self-esteem or past trauma. Incorporating trauma work into treatment can help resolve the issues fueling the sexual addiction.

Another strategy is to ask the client to carry a card that lists emergency steps to take when the urge to act out sets in. Hands-on tools like these can give sex addicts a routine to follow regardless of where their urges and emotions are leading them.

A common cause of sex addiction relapse is feeling under control. Some addicts will stop attending meetings or talking with their sponsor because they believe they can handle the thoughts and emotions that typically lead to acting out. But part of admitting powerlessness and turning over their will is submitting to the structure of the 12-Step program.

Clients should set a goal of making 10 outreach calls a day, whether to a sponsor, friend, therapist or family member, with a requirement of making direct contact at least 50 percent of the time (i.e., not texting or leaving a voicemail). Clients must stick to this structure whether they feel secure in their recovery or not. This way, the client creates a pattern of reaching out to others even if they are not in crisis.

What Does it Mean to Be in “The Bubble”?

The Bubble is a concept from Sex Addicts Anonymous (SAA) that refers to the altered state of consciousness sex addicts feel when hit with the obsession to act out. Similar to being carried away in a bubble, the sex addict feels powerless to control the compulsion and feels cut off from the outside world. Like a drug addict on drugs, the sex addict is disconnected from reality and is narrowly focused on one specific goal. When the bubble bursts, usually after some type of climax, the individual is consumed with guilt and shame.

When a client is in The Bubble, they are encapsulated in their own self-distortion. It is unlikely that any outside force can intervene, including a therapist or sponsor. Even the client himself is unlikely to have the cognitive resources available to intervene on themselves when entering The Bubble.

The trick is to get the client to reach out for help before they enter The Bubble, though this window of opportunity is typically very small.

Is Medication an Effective Treatment for Sex and Love Addiction?

Certain medications, such as SSRIs and naltrexone, have been an effective component of sex addiction treatment. These medications may help control urges to act out, minimize intense sexual fantasies, and help address common co-occurring disorders such as anxiety and depression. Because research in this area is continually developing, therapists should remain open to the use of medication and have a conversation with clients who may benefit from medication in conjunction with ongoing therapy.

What Strategies Are Most Effective in Treating Voyeurism?

Voyeurism can be one of the most difficult compulsive sexual behaviors to treat. We live in a visually oriented culture. Unlike porn addicts who require the Internet or people who have multiple affairs who must attract a partner, there is a never-ending supply of readily available material for voyeurs.

Voyeurism is about the fantasy of seeing something one shouldn’t see. This means voyeurs are presented with triggers to act out thousands of times a day. All they need to do is drive to work, take a walk in the park or engage in any number of normal day-to-day activities to get a rush.

Because voyeurism is externally oriented (e.g., viewing someone’s body or a sexual act without their permission or knowledge), it may be helpful to ask the client to get quiet and turn their focus inward. What does your body want or need right now? What do you want out of life? This encourages the client to focus their voyeuristic behaviors on themselves in order to improve their own lives.

The dialectical behavior therapy (DBT) skill of observing may be useful here. The therapist can ask the client to become an observer of self, physically, emotionally and mentally. Rather than engaging in the automatic, reflexive behaviors characteristic of sex addiction, the client can work to slow down their thought process and take a type of emotional time-out.

In some cases, reframing the problem may help a voyeur recognize the nature of their behavior. For example, a therapist may approach the issue in a similar way as stealing, or looking to visually steal something from someone without their consent. Because it involves taking that which someone has not given freely, the therapist may frame voyeurism as a form of sexual offender behavior. This “reality check” may break through to some clients.

A therapist may also find it useful to draw a parallel to something important to the client. For example, if a client loves to surf, the therapist may challenge them to consider how it would feel to be intruded upon by someone snaking a wave from them. This can lead into a conversation or exercise about personal boundaries. In some cases, the client may have learned unhealthy enmeshment or inappropriate boundaries in their family of origin, which has manifested as voyeuristic behavior.

Although the client may be powerless over the thought entering their mind, they can make a choice to replace that thought with something else. For some clients, carrying a note card with alternative thoughts may be effective. Some of these thoughts may include, “This is none of my business” or “I’m giving love to that person.”

Because voyeurism is difficult to treat, clients may benefit from getting away from their familiar environment for awhile. The Sexual Recovery Institute offers two-week intensive sex addiction programs that provide the change of setting, intensive therapy and fellowship with other recovering sex addicts that voyeurs may need to eliminate acting out behavior.