Disclosure of Extramarital Sexual Activities by Persons with Addictive or Compulsive Sexual Disorders: Results of a Study and Implications for Therapists

Excerpts from this paper regarding the nature of sexual addiction

Brown (1991) classifies affairs as:

• conflict avoidance strategies, in which couples who cannot discuss their differences use affairs to make it clear that there are significant problems,
• intimacy avoidance, where “it feels safer to keep things stirred up a bit”,
• empty nest affairs, in which the marriage feels empty,
• out the door affairs, in which the affair gives one or both partners the impetus to leave the marriage, and
• sexual addiction, in which people “deal with their emotional neediness by winning battles and making conquests in the hope of gaining love”.

Several authors cited believe that sexual disorders with compulsive or addictive features may be implicated when sexual infidelities recur in ritualized patterns. There is disagreement among professionals about whether compulsive sexual behavior should be viewed as sexual addiction.

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How to Recognize the Signs of Sexual Addiction

Excerpts from this paper regarding the nature of sexual addiction

About 3% to 6% of Americans have sexual addiction.

Sexual addiction often coexists with chemical dependency, and untreated sex addiction contributes to relapse to chemical use.

Milkman and Sunderwirth have classified sex addiction as an arousal addiction because its effects on the brain are similar to the effects of cocaine, amphetamines, compulsive gambling, and risk-taking behaviors. In contrast, addiction to alcohol, sedatives or hypnotics, and food are considered satiation addictions.

Like chemical dependency, sexual addiction is a family disease. Spouses of sex addicts, or “coaddicts,” usually grew up in a dysfunctional family, where they acquired a set of core beliefs that resulted in low self-esteem and difficulty in relationships. They may believe that they are not worthwhile, that no one could love them for themselves, that they can control and are responsible for others, and that sex is the most important sign of love.

Sexual addiction is often accompanied by other addictions. Physicians’ understanding of this fact is important because sex addiction contributes significantly to the AIDS epidemic and because efforts to control sexual addiction are often confounded by coexistent problems.

Since many patients are reluctant to talk about sexual problems, primary care physicians are not likely to suspect sexual addiction unless they ask the right questions

Excerpts from the paper regarding the treatment of sexual addiction

Unlike the goal in treatment of chemical dependency, which is abstinence from use of all psychoactive substances, the therapeutic goal in sex addiction is abstinence only from compulsive sexual behavior with adaptation of healthy sexuality. Sexual addiction treatment programs suggest that patients abstain from all sexual activities, including masturbation, for 30 to 90 days to demonstrate that they can live without sex.

The most important predictor of relapse after treatment of sexual addiction is failure of the spouse to be involved in the treatment program.

For patients who are suicidal or who need a change of environment to begin their recovery, several inpatient treatment programs for sex addiction are available in the United States.

Facilities that do not address sex addiction may refer patients to other centers or to therapists if sexual issues are detected during treatment for chemical dependency.

The 12 steps of Alcoholics Anonymous have been adapted for use in programs for eating disorders, compulsive gambling, sex addiction, and other addictions. Attendance at a program dealing with sexual addiction can be extremely helpful in the recovery process.

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Famous People and Sexual Addiction

We frequently receive media requests related to public figures who engage in problem sexual behavior (such as Tiger Woods, Elliot Spitzer, and Bill Clinton). While it may be tempting to diagnose a public figure’s problems based on media accounts, accurate assessment requires a face-to-face evaluation of the individual and knowledge of the circumstances surrounding the behaviors.

Many psychiatrists and some addiction specialists do not accept the idea that sexual behavior can be addictive. They use other diagnoses to describe out-of-control sexual behaviors, such as mania, impulse-control disorder, or personality disorder. We believe that in many cases of repetitive problem sexual behaviors, the addiction model readily explains apparently irrational behavior, which is easily understood by patients and family members, and leads to effective treatment.

Many pleasurable and life-affirming behaviors can be healthy for most people but addictive in others (such as food and gambling addictions). Addiction is a concept that was traditionally applied only to substances like drugs or alcohol with the potential for physically or psychological dependency. Today, the term “addiction” is routinely used to describe and diagnose behaviors such as gambling, overeating, and sex when they are repeated, seemingly out of the person’s control, and causing obvious losses and consequences to the user. To addiction specialists familiar with these behaviors, the parallels with substance addictions are obvious. In many cases, addiction treatment has been successful when “will power” or traditional therapy has failed.

The key elements of any addiction, whether chemical or behavioral, are:

• Loss of control over the behavior; continuing to engage in a particular behavior after repeated attempts and promises to self and/or others to stop)

• Continuation despite adverse consequences, such as loss of job, money, marriage, or health, or arrests or public humiliation

• Preoccupation or obsession with obtaining and using the substance or participating in the behavior to the detriment of other essential life activities or goals such as important relationships, family, career, etc.

Addictions are defined not by the amount of using or engaging in the behavior, but rather its effects on the person’s life. Addiction may be present when the behavior has made the person’s life unmanageable.

Some clues regarding sexual addiction are:

• The problem behavior is not an isolated occurrence; there is a pattern of this behavior over a significant time span.

• Despite a previous significant adverse consequence, the behavior is repeated. Sexual decisions do not appear to be made on a rational basis.

• Increasingly greater risks are taken over time. For example, sexual encounters may initially take place only out of town, but later closer to home.

• The person denies to him/herself and others that there is a problem when it is evident to others, using minimization, rationalization, and justification to continue to engage in the behavior while trying explain the problem away.

For the sex addict, sexual behaviors that are secretive, illicit, or dangerous carry an even greater internal experience of intensity or arousal (high), which encourages irrational choices. This is no different than the compulsive gambler who will gamble far beyond his or her limit to do so, as her or she is aroused and distracted by the intensity of the process.

Some sexual behaviors that may represent an addictive disorder are:

• Multiple extramarital affairs, betrayal, and infidelities

• Compulsive masturbation

• Excessive viewing of porn

• Using a position of power to gain sexual access to multiple partners

• Use of prostitutes, escorts, and sexual massage

• Excessive expenditure of time and money on pornography, phone sex, or cybersex

• Multiple anonymous sexual encounters

• Touching others without permission

The majority of sex addicts, like most other addicts, have parents or other close family members with histories of alcoholism, drug dependency, mental illness, abuse, or other significant family dysfunction. Often these families are sexualized or have exposed the child to an overwhelming sexual experience at an early age. This type of history distorts their adult relationships and can encourage the isolation and superficiality, which is a hallmark of addictive disorders.

Effective treatment for sexual addiction involves the same approach as for any other chemical or behavioral addictions. The process brings the addicted person out of their distortions and denial, forcing them to realistically confront themselves and the damage their behaviors have caused. Family members must be involved in the process, learning the full reality of the sex addict’s disorder.

There are numerous 12-step recovery programs, similar to Alcoholics Anonymous, which help the sexual addict to learn to live and cope in a more honest and healthy manner. Treatment is best provided by a specialist in behavioral addictions, as traditional psychotherapies are not the treatment of choice. For those seeking help, most major metropolitan areas provide outpatient specialists in sexual addiction as well as residential specialty programs.

The Role of Grief and Loss in Addiction Recovery

Addicts and family members in the early stages of recovery may not consider the strong role that the grief process plays in their experience. There are obvious times when we consider grief to be a natural reaction to life circumstances like when someone has died or moved away or when an important job or possession is lost. However the experience of grief is not only stimulated by losing loved ones or possessions, grief is also engaged when someone loses a way of living or a way of looking at themselves which had been a way of life. In the process of recovering from an addiction, grief emerges in reaction to the intense changes taking place in an individual and in a family as the addiction problem is addressed. Understanding and accepting this process of grieving helps recovery to be less of a mystery. Before exploring the grief process itself, it might be helpful to identify some of the losses that may be brought forth.

Samples of Addict Losses

Loss of the Addiction Itself (Substance or Behavior)
No matter how much havoc or trauma the addict’s drug/alcohol use or other addictive behaviors caused themselves and loved ones or how grateful they or others may be that the using or acting-out has stopped — the addict is going to miss their drug. They are going to miss the distraction, relaxation, intensity and high the behavior or substance offered to them. The addict is going to miss their “easy” way to escape difficult feelings and experiences and will in fact be overwhelmed at times by all they are now having to experience without a buffer.

Rituals
Addicts come to miss the rituals surrounding their acting-out behaviors. The places, patterns and secret activities of their substance or behavior addiction were built into their life just as solidly as a job or home and changing these is difficult and sometimes painful.

Addict Relationships
The addict often loses relationships that were maintained with people they involved in their acting-out or using. For some whole social groups and specific activities like “happy hour”, “being online” or “sensual massages” have to be given up in the name of avoiding a return to the addiction.

Freedom
Living an addictive life involves avoiding accountability and responsibility to people and activities that might interfere with the freedom to use substances or act out with sex, gambling etc. The life of a recovering person involves a great deal of being accountable, checking-out decisions and actions with other people as well as meeting all commitments and responsibilities.

As with the addict, the partner will experience losses as the transitions and challenges of addiction recovery take place. Despite the partner’s desire to have the addict stop using or acting-out, there remain painful challenges arising in this process of change even as that person gains sobriety.

Sample of Partner/Spouse Losses

Relationship Role
Certain patterns of relating become ingrained into relationships particularly in those relationships where addiction is present. A partner who has been in the caretaking role for an addicted person, i.e. covering up their problems, smoothing over problems, making up for the addicts’ shortcomings (parenting, financial, etc.); will have a difficult transition in retaking the reigns of their own lives and trusting the addicted person to now actually be more responsible. Not being needed can be a difficult challenge for partners of addicts.

Loss of predictability
As difficult as being in a relationship with an addict can be, at least there is some emotional and situational predictability once the patterns of the addiction are established. Addicts in recovery can actually be more moody, vocal about their needs and wants and assertive than someone living in the shame of their addiction. These can be difficult changes for a partner to understand and tolerate.

Unhappiness
Strangely enough, a lonely, disappointed partner, consistently abandoned, rejected or let down in their relationship with an active addict, can become comfortable in their misery. Having an identifiable person and situation to blame for ones’ unhappiness keeps the burden of self-examination and self-understanding away. A partner, now in a relationship with a more functional, responsible and connected recovering person, has to look more closely at himself or herself when feeling unhappy, disappointed or unfulfilled.

Time Taken by the Recovery Process
As the recovering person gets more involved in their 12 step program, therapy and self care, they may not be any more available for relating and spending time then they were in the days of their addiction. Once kept apart by substance use and acting-out, couples may now find themselves separated by support groups, sponsors and time spent in the recovery process. This can be a real disappointment to the partner expecting a lot of time to be closely spent together following the addict’s return to sane living.

Stages of Grieving

The process of grief itself follows a fairly understandable pattern first made clear in a 1970’s landmark book by Elizabeth Kubler-Ross called 0n Death and Dying. In her book, Dr. Kubler-Ross was able to identify and differentiate the stages a person goes through when grieving a loss. We now understand that not everyone goes through each and every stage, nor do these stages follow a predictable pattern. Nevertheless, the feelings and situations that people go through in the recovery process can be aligned with these concepts. These stages exist primarily to shield the person who is grieving from being overwhelmed by their feelings and experiences. Grief is a process that takes time, support and self-acceptance to move beyond.

Stage One: Denial
This is the earliest stage of the grief process that occurs when someone has not yet fully comprehended or been able to integrate the depth of the change to their lives. Typically a person in denial, when confronted with a major loss, will say things like “No this can’t be true” or “It must be someone else, not me or my loved one.” Denial is a safety mechanism that protects one from being overwhelmed by their feelings; it is a form of shock. Addicts utilize denial to avoid taking responsibility for their substance use or behavioral acting-out. They will not be able or willing to make the connection between the consequences of their addictions and the behaviors themselves. Addicts in denial will blame other people and circumstances for their problems as they deny any responsibility. “I’m no alcoholic, those kind of people live in the gutter and drink cheap wine, I just have a cocktail now and then” or “It clearly wasn’t my being high that caused me to get stopped by that cop it was the bad attitude the policeman had. When are those cops going to do the work they are supposed to do instead of picking on good citizens like myself?” Spouses in the denial stage avoid drawing logical conclusions about the addict’s problems. They will instead cover up or make excuses for the addicts’ behavior, sometimes even blaming themselves rather than being able to see the issues for what they are. “He really doesn’t gamble regularly, just on the weekends, besides, he only plays cards with his friends and goes to the track occasionally. It’s not like he goes to Vegas to gamble, besides we can afford for him to have some fun now and then.”

Stage Two: Anger
The anger stage of grief exists as an attempt to avoid the true underlying addictive problem. By using anger, blaming, nagging and shaming addicts and loved ones can seemingly throw around responsibility for the personal, family, financial, legal and other problems without identifying and acknowledging the addiction problem itself. The addict will conclude that it is the fault of a partner, job, children, etc. that causes them to use or act out. They will unconsciously but deliberately pick fights or create negative situations in order to justify their addictive behavior. They will blame partners for poor handling of finances or childcare despite the fact that their addiction is the real source of these problems. Partners will vent anger on the addicts’ friends, work and recreation time. They attempt to use control, complaining and negativity to tolerate their unhappiness, all the while hating themselves for the ways that they are acting.

Stage Three: Bargaining
In the bargaining stage of grief, the person is beginning to come to some realization that there is or might be a problem but to compensate they are working hard to try to continue to avoid fully facing the solution or reality of their circumstances. To bargain is to try to maintain control and continue to live without real change taking place. For addicts, this is the time for “Just give me one more chance and I promise I will never…” kinds of statements. Rather than being fully surrendered to the problem, the addict is attempting to hold on to control by making up new excuses and promises, thereby avoiding the inevitable. For partners, bargaining is a last ditch attempt to maintain the status quo. Not wanting to take the risk of confrontation of the real problem, partners may accept promises they know will not be kept or try to make changes to make life easier for the addict in the hope that they will stop their addictive behavior. “If I just look more like those women he is looking at online and offer the same kind of sex as his online sites, then his cybersex behavior will stop.” Or “If I just keep the kids out of her way and give her more time on the weekend, she will stop drinking during the day like she promised.”

Stage Four: Depression
This stage marks the beginning of true surrender to the depth and meaning of the addictive problem. No longer trying to assign blame or find a way out addicts begin to delve into the sadness and fear of not knowing themselves as they thought they did. Addicts struggle to come to grips with the meaning of their history of addictive actions and the costs these problems have created individually and in relationship to others they love. Often ashamed and confused in this early stage of recovery addicts may also be in unable to conceive of a life without their acting-out behaviors or substance use. Unfamiliar with a life outside of their addiction the addict despairs of ever feeling comfortable or “in control” as they have known it. For partners the depressive stage is one of beginning to comprehend the depth of the losses and challenges that the addiction has cost. Not fully understanding how addiction works and that the hope for recovery, partners may despair that their relationships will ever be right. As they experience the addict going off to 12-step meetings, making phone calls to other addicts and sponsors, the partner may feel left out of the process and fearful of the new barriers that seem to be encouraging separation rather than support and connection.

Stage Five: Acceptance
This stage is inevitable provided that addicts stay in recovery and that partners begin to join the process. For the addict at this stage, they can now begin to see that there is a path laid out for their recovery which others have followed successfully. They can begin to entertain a new vision of how their life will be lived without being in relationship to active addiction. New healthy recovery relationships and support have begun to replace isolation and lies. The addict has been sober long enough to begin to develop new ways of coping and managing their life circumstances, often utilizing hidden creativity and ingenuity formerly lost to their addiction. Partners at the acceptance stage can see light at the end of the tunnel. Now informed and involved in recovery through their own support groups, therapy and self-education they are beginning to redefine their role to their addicted partner, their families and to themselves.

The paragraphs below outline an understanding of the differences between a grief reaction and an episode of depression. Since the symptoms of grief and depression are similar and often vary only in the degree of the symptom, it is best to utilize the support of a professional counselor or clergy to help clarify and work through these issues.

Identifiable Differences Between Grief and Depression

Many of the symptoms outlined below are typical of the experiences people have when going through the early stages of a loss and are very normal. Usually these are accompanied by some reduced day-to-day functioning which passes as the person integrates the change and reorients to new life circumstances. These symptoms in their most severe form might persist for several weeks with gradual reduction over 2-3 months depending on the severity of the loss.

Normal Grief Reaction

• Feelings of being overwhelmed and less capable than normal
• Some day-to-day confusion and memory loss (loss of keys, forgetting appointments, etc.)
• Reduced interest in things which usually are interesting or pleasurable
• Sleeplessness and fatigue or oversleeping
• Tearfulness and feelings of loss and longing
• Imagining or dreaming about being back in addictive behaviors
• Self-blame, self pity, anger at the situation
• Reduced interest in eating or overeating

Signs of Depression
Many of these signs are similar to the above grief experiences except that these occur in a more severe and long-term form. Persistence of symptoms such as those listed below often indicate the need for professional counseling and the possible use of anti-depressant medication.

• Inability to function in job or family roles
• Constant waking up or early morning awakening with ruminating thoughts, consistent loss of sleep
• Extreme fatigue or loss of energy
• Depressed mood
• Diminished concentration or confusion on a daily basis
• Strong feelings of hopelessness, panic — suicidal thoughts or plans
• Loss of interest in social activities, friends/family and or work
• Constant tearfulness, inability to feel emotionally stable
• Significant unintentional weight loss or gain (more than 5% of overall body weight in less than a month)

The Adjustment to Loss Depends On:

• The flexibility of the person to adapt to change
• The emotional and physical state prior to the loss
• The amount of dependency the person has on that past relationship or experience
• How much the relationship to that person, thing provided self-definition
• The amount of social and/or family support
• Physical health and age
• Status and financial stability

A Word of Hope

One common misconception about ending active addiction and entering recovery is that there will be immediate relief and positive benefits for all. In fact recovery is a lengthy process which often can bring painful emotional and circumstantial realities forward in the early stages before the more comforting and feel-good benefits take place. Part of recovery is allowing long hidden secrets to be disclosed and long-buried disappointments and fears to be revealed.

This is painful and difficult stuff. The real challenge is more than just sobriety for the addict; it is tolerating clearing of the wreckage of the past while holding on to hope for the future. Some sayings common to the various 12 step programs may be helpful in passing through the grief stages of recovery. Saying such as “This too shall pass”, “Trust the process” and “One day at a time” have their roots in the hope that has been passed on to recovering addicts and their loved by others who have been down the same road.

One of the most important gifts of the 12 step meetings themselves is the opportunity to experience and even celebrate those who are in recovery a bit longer and have a more hope to offer then the person(s) behind them. There is not doubt that process of 12 step work; therapy and living in spirituality do create meaningful change for those who work to have that happen.

Cybersex Addiction: Internet Hook-ups, Online Sex, and Porn Addiction

The Internet is profoundly transforming our culture and our world in ways similar to the introduction of the telephone 100 years ago. In addition to its function as a source of information, the Internet, Smartphones, and iPads have led a revolution in the delivery of sexual connection and sexual content. Cybersex, which is any form of sexual expression accessed through the computer or the Internet, is now a major industry. Currently, over 60 percent of all Internet visits involve a sexual purpose.

These days, cybersex activities include not only viewing and/or downloading pornography, but also live web-cam sex with prostitutes or strangers met online, responding to ads to meet sexual partners, visiting sexually oriented chat rooms, and using Smartphones with GPS locators to find instant sexual partners. Many people allow themselves to engage in sexual behaviors online (such as S&M, child porn, bestiality, or presenting themselves as persons of the opposite gender) that they would not normally partake in. Spin-offs of cybersex activities are virtual world sex and sexual online affairs that progress to “real” or “offline” affairs.

For most cybersex participants, the Internet provides a fascinating new venue for experiencing sex. As many as 8-10% of users, however, become hooked on the intensity and accessibility of Internet-driven sex and experience significant life problems as a result.

Consequences for compulsive and addictive cybersex use include:

• The user’s life becomes constricted and lonely. Many hours are spent alone with the computer, involved in fantasy sexual activities, while real-life friendships and social contacts fall away.

• If the user is married or in a relationship, the partner feels lonely, ignored, unimportant, neglected, or angry because the user prefers to spend time on the Internet rather than with the partner and family.

• Children are neglected or ignored because of the parent’s involvement with the computer.

• If online sex leads to real-life sexual encounters, the user risks contracting HIV and other sexually transmitted diseases.

• If the user downloads Internet pornography on his or her work computer or engages in cybersex while on the job, he or she risks job loss.

• Cybersex participants who view child porn risk arrest and imprisonment.

• Many users lie repeatedly about their sexual activities; in response, their partners feel distrust and betrayal.

“It’s just happening online, so how can it really hurt anyone?”

• The devastating emotional impact of an Internet-related romantic or sexual affair is described by many partners as similar or equal to that of an “offline” affair. This is equally true when the cybersex user has also had “real” affairs. The partner’s self-esteem is damaged; strong feelings of hurt, betrayal, abandonment, devastation, loneliness, shame, isolation, humiliation, and jealousy are evoked. Cybersex activities are considered particularly destructive in that they often take place right in the home or office and are so time-consuming, taking time away from the family.

• A couple’s sexual relationship suffers, not only because the addict spends so much time on the computer, but also because the spouse (and often the user) compares his or her body and sexual performance to that of the online men and women, and believes he or she can’t measure up. Often, the user loses interest in having sex with his or her partner. Many couples have no relational sex in months or years.

• Partners may retaliate or seek solace in extramarital affairs.

• Children may be exposed to pornography and sexual acts, which can have a devastating effect on their adult development.

Fortunately, help for cybersex addiction is available. Those whose use of Internet sex has become addictive or compulsive can benefit from counseling specific to Internet-related sexual problems. This type of therapy can help alleviate a crisis, set limits and structure around online activity, and restore life priorities and balance.

Love Addiction Part I: The Problem

Healthy romantic love is a unique experience which can encourage bonding, intimacy, and the opportunity to play and explore with that special new person.

Romance, with or without sex, encourages personal growth as each new relationship forces new insights and self-knowledge. The beginning stages of a potential love relationship can be intense and exciting. Most people easily relate to that “rush” of first love and romance; it’s the stuff of songs, greeting cards, and warm memories. Healthy intimacy, however, is characterized by more than romance, intensity, and sex. Intimacy evolves over time. Loving relationships develop partially through utilizing those first exhilarating times to begin to build a bridge toward deeper, longer-term closeness.

The love addict, however, craves that initial rush. As a relationship matures they become anxious and restless. They may begin searching again for “the one.” You may know a love addict: they typically have short, highly intense relationships that never seem to develop into long-term healthy partnerships.

It can be difficult for anyone who is not a love or sex addict to understand how love or sexuality can be exploited or devolve into destructive patterns of addiction and compulsion. Yet for the love and sex addict, romantic love, sexuality, and the closeness they offer are experiences most often filled with pitfalls, anxiety, and pain. Living in a sometimes chaotic emotional world of desperation and despair, fearful of being alone or rejected, the love addict endlessly longs for that “special” relationship.

Caught up in the constant search for a partner, the addict’s endless intrigues, flirtations, sexual liaisons, and affairs leave a path of destruction and negative consequences. Ironically, the love or relationship addict usually has few options to resolve these painful feelings except by engaging in even more searching for the perfect mate, which creates an ever-escalating cycle of desperation and loss. Just when they are seemingly “safe” in the rush of a new romantic affair or liaison, the troubled love or romance addict grows steadily more unhappy, fearful, and bored; they end up pushing their partner away or looking outside the relationship for yet another high-intensity “love” experience.

Thus the cycle begins anew.

Unlike the healthy person seeking partnership and sex as a complement to their life, the love and sex addict is searching for something outside of themselves (a person, relationship, or experience) to provide them with the emotional and life stability that they themselves lack. Similar to a drug addict or alcoholic, love and sex addicts use their arousing romantic/sexual experiences in an attempt to “fix” themselves and “feel” emotionally stable.

When love and sexuality are used as a way to cope, rather than a way to grow and share, partner choice becomes skewed. Compatibility becomes based on “whether or not you will leave me,” “how intense our sex life is,” or “how I can hook you into staying” rather than on whether you might truly become a peer, friend, and companion.

Addictive relationships are characterized over time by unhealthy dependency, guilt, and abuse. Convinced of their lack of worth and not feeling truly lovable, love and sex addicts will use seduction, control, guilt, and manipulation to attract and hold onto romantic partners. At times, despairing of this cycle of unhappy affairs, broken relationships, and sexual liaisons, some love or sex addicts may have “swearing off” periods (like the dieting cycles of overeaters). The addict believes that “not being in the game” will solve the problem, but find the same issues reappear when they later engage in any relationship with the potential of intimacy.

Typical Signs of Love or Sex Addiction Include:

• Constantly seeking a sexual partner, new romance, or significant other

• An inability or difficulty in being alone

• Consistently choosing partners who are abusive or emotionally unavailable

• Using sex, seduction, and intrigue to “hook” or hold onto a partner

• Using sex or romantic intensity to tolerate difficult experiences or emotions

• Missing out on important family, career, or social experiences in order to maintain a sexual high or romantic relationship

• When in a relationship, being detached or unhappy; when out of a relationship, feeling desperate and alone

• Avoiding sex or relationships for long periods of time to “solve the problem”

• An inability to leave unhealthy relationships despite repeated promises to self or others

• Returning to previously unmanageable or painful relationships despite promises to self or others

• Mistaking sexual experiences and romantic intensity for love

For a love or sex addict, the above signs or symptoms consist of pervasive patterns of emotional instability inevitably leading to isolation, heartache, and loss. Not everyone who has engaged in one or two of the above has an addiction problem; many people may have their judgment skewed by a difficult person or situation from time to time in their lives. However, when these situations become the norm, lived over and over again in some form or another, the diagnosis of love addiction can be made. Active love and sex addicts, like any addict, do not learn from the consequences of their behavior or their mistakes. It is only when the pain of these behaviors and situations becomes greater than the pain and challenges of creating change that they can begin a path to recovery.

Sexual Addiction Defined

Sexual addiction is a persistent and escalating pattern or patterns of sexual behaviors acted out despite increasingly negative consequences to self or others.

Some out of control repetitive behaviors, which may reflect sexual addiction include:

• Masturbation
• Simultaneous or repeated sequential affairs
• Pornography
• Cyber sex, phone sex
• Multiple anonymous partners
• Unsafe sexual activity
• Partner sexualization, objectification
• Strip clubs and adult bookstores
• Prostitution
• Sexual aversion

Some consequences which may result from sexual addiction and indicate the existence of sexual addiction.

Social
Addicts become lost in sexual preoccupation, which results in emotional distance from loved ones. Loss of friendship and family relationships may result.

Emotional
Anxiety or extreme stress are common in sex addicts who live with constant fear of discovery. Shame and guilt increase, as the addict’s lifestyle is often inconsistent with the personal values, beliefs and spirituality. Boredom, pronounced fatigue, despair are inevitable as addiction progresses. The ultimate consequence may be suicide.

Physical
Some of the diseases which may occur due to sexual addiction are genital injury, cervical cancer, HIV/AIDS, herpes, genital warts and other sexually transmitted diseases. Sex addicts may place themselves in situations of potential harm, resulting in serious physical wounding or even death.

Legal
Many types of sexual addiction result in violation of the law, such as sexual harassment, obscene phone calls, exhibitionism, voyeurism, prostitution, rape, incest and child molestation, and other illegal activities. Loss of professional status and professional licensure may result from sexual addiction.

Financial/Occupational
Indebtedness may arise directly from the cost of prostitutes, cyber-sex, phone sex and multiple affairs. Indirectly indebtedness can occur from legal fees, the cost of divorce or separation, decrease productivity or job loss.

Spiritual
Loneliness, resentment, self pity, self blame.

These consequences are progressive and predictable. The addict tends to minimize the consequences and tends to blame others for them. Family and friends minimize consequences by believing the addict’s promise that the behavior will change. When blaming and minimizing stops, recovery begins. The consequences can become the instruments for change if they can be truly recognized and accepted instead of denied.

How sexual addiction resembles other addictions.

• Brain chemistry changes are similar.
• Family background of addiction.
• Lack of nurturing and other forms of emotional, physical or sexual trauma in childhood.
• Multiple addictions can co-exist.
• The treatment focus is the same involving counseling. Twelve Step spiritual recovery programs and medical intervention.

Is recovery possible?
Yes. Thousands of recovering addicts know that recovery is a process that works when these principles are followed.

• Acceptance of the disease and it’s consequences.
• Commitment to change.
• Surrender of the need to control the compulsion.
• Willingness to learn from others in recovery in sexual addiction Twelve Step support groups, and from trained therapists.

Is recovery possible for families and friends?
Yes. Certainly.

• Acceptance of the disease and how they themselves have been affected.
• Make a commitment to change.
• Surrender of self will and no longer seek to control the addict.
• Willingness to seek help from Twelve Step support groups for co-dependency plus therapy from trained therapists.

Healing the Shame-based Self in Sexual Recovery

As long as the sex addict is acting out, he or she can never see how their own emotional needs have gone and often continue to go unmet, as intense sexual acting out provides too many reasons for anger and hurt to be turned toward the self. Much of the important work of recovery is to encourage the painful longing of the addicts’ unmet needs to become exposed and acceptable, often through years of 12-step work and good therapy. In early recovery, however, sex addicts will often continue to express various forms of their control issues and self-hatred through perfectionism, judgment of self and others, and strong black-and-white views of healthy sexuality.

The saying, “There is nothing worse than a reformed smoker,” applies even more so when dealing with sexual addicts in early recovery. While it is true that early recovery requires a clear and well-defined sexual plan and often may require a period of celibacy, I never cease to be amazed by the degree of judgment, sexual anorexia, and fear that can be generated by sex addicts who actually choose to engage in some form sex during the early part of their recovery. Desperate to “do it right,” knowing the stakes are very high, most sex addicts have good reasons to be guarded about their early sexual choices and behaviors. However, what often gets dragged into the sexual decision-making process is the perfectionism, shame, and self-hatred that drove the addictive behaviors in the first place. While the first few months of sexual recovery necessarily require somewhat rigid boundaries, beyond that it is essential to help addicts negotiate the line between healthy sexual recovery and a healthy, nurturing self.

One part of the self-love that is essential to help reverse a lifetime of self/other abuse, neglect, and trauma needs necessarily to be directed toward the addiction itself. Despite all the negative behaviors, the losses, and the harm caused by the addiction, recovering sex addicts need to find ways to love and value the addiction within themselves even when the desire to act out remains active. If the desire to act out, indeed the addiction itself, are merely emotional alarm bells going off within the addict telling him that he is in some kind of need, that it is time to reach out, then the addiction can really be seen as an ally, a part of the self to be valued and appreciated, not disparaged. As long as he or she responds to these addictive longings by calling someone in recovery, going to a meeting, or otherwise replacing shameful behavior with self-nurturing and healthy attachment, then the call of the addict will have been served and is deserving of appreciation.

No matter how hurtful the past has been, no matter how strong the current desire to act out may be, the addict must come to understand that their behavior came about in an early attempt to cope with unmanageable circumstances. They must learn that the addict part of them allowed them to emotionally survive until they could get the help they needed to let him go. Healthy 12-step work and therapy must help to replace self-hatred with grace and guide the addict toward a more objective understanding that what happens in a dysfunctional family can leave a child needing their addiction to “survive.” Only in this way can the shame of the past be left behind to be replaced with compassion and empathy.

Written by Rob Weiss to commemorate the 20th anniversary of Dr. Patrick Carnes book, Out of the Shadows.

How to Approach Treatment of Sexual Addiction

By Robert Weiss, LCSW, CSAT

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.

Treating the Family of the Sexual Addict

The effects on children in a household in which one or both parents suffer from an addictive sexual disorder have been overlooked in much of the literature related to sexual addiction. Most children in these households are aware of some part of the sex addict’s acting-out ritual, are often asked to keep secrets for the addicted parent, or have been overtly or covertly victimized in some other way by a parent’s acting-out behaviors and the marital discord that is present. Therefore it is vital to the recovery of the patient and to the healing of the family to include work with the family system as part of the therapeutic process.

In a study of 56 patients diagnosed with an addictive or compulsive sexual disorder who were married with children, 100% cited martial discord as one of the five most powerful stimuli or triggers for wanting to act out. In the same sample, 74% stated that their children had direct knowledge of some part of their acting-out behaviors.

Common Types of Family Interactions

Three types of family interactive patterns are seen most often in families in which addictive and compulsive sexual disorders are a problem.

• Rigid, estranged or disengaged “perfect family”
• Enmeshed and angry family
• Chaotic and unnoticing or separated family

“Perfect Families”
The “perfect family” type is characterized by a high value placed on external “proof” of perfection. The prime directive in this system is to maintain an appearance of social acceptability based in actual or perceived social status and accomplishments. This necessitates rigid role structures, especially gender-bound roles.

Enmeshed Families
In enmeshed families, there are extreme forms of proximity and intensity in family interactions. Communication within these families is frequently based upon indirect patterns. For example, instead of people talking to each other, messages may be relayed from one family member to another, blocking any direct interactions. If a member crosses the family’s boundary and seeks emotional connection with someone outside the family, it is experienced as betrayal; if a member tries to set a boundary within the system, it is seen as rejection.

Chaotic Families
In the third type of family interactive style, the household is chaotic and children’s emotional needs are unnoticed. This family dynamic is marked by the complete absence of consistent structure, rules, or appropriate roles. The family appears to be in a constant state of change or transition and may be marked by multiple residential changes.

Competency-Based Models for Family Healing
(Case & O’Hanlon, 1993; Durrant and Kowalski, 1989; Walter and Peller, 1992)

• The problem is the problem, the person is not the problem
• Problems occur within the context of human interaction and are a part of life
• People experience problems as problems and usually want things to get better
• Every problem-dominated behavior includes exceptions when the problem doesn’t occur
• People are engaged in a constant process of making sense of their experience

A Structure for Doing Family Therapy

Sharing the Family Story
Narrative therapy techniques (White & Epston, 1990), such as having patients tell their story of how the addictive or compulsive sexual behaviors have influenced their life, are useful.

Creating a Context for Change
It is important to recognize that the old way of doing things was an attempt to solve things that were not working in the relationship or life.

Externalizing the Problem
Externalizing the problem takes into consideration what might be stopping things from being different and draws a distinction between unhealthy behavior and being a bad person.

Locating Exceptions
Having established how the family has become driven by their ways of viewing the family, the next stop is to identify the exceptions to their dominant story. The focus is on occasions when the family members are more functional.

Leaving the Old Ideas Behind, Practicing New Ways, and Experimenting
Many times in addiction work we hear: “Fake it until you make it.” It may be useful to change that slightly to “Practicing doing it a different way helps you make it.” If people change their behavior, the change in their attitudes about the behavior and their ability to continue to do the healthier behavior will last.

Other Tips for Working With Young Children and Teens

• Spend time joining with the child as part of the family unit
• Help the family members consider memories of abuse, neglect, or disappointment as experiences in their lives rather than as predictors of how life is always going to be
• Look for little changes
• Build on existing strengths
• Use in-session props to support discussion and metaphor
• Use the “miracle question” described by Steven de Shazer (1988): “Suppose that one night, while you were asleep, there was a miracle and this problem was solved. How would you know? What would be different? How will your husband know without your saying a word to him about it?”

How Much to Tell

Preschool and Early Elementary School Age
Usually preschool children only want to be assured that parents are not going to die or leave them.

Older Elementary School Age
These children are also concerned that the parents will end the marriage or that they have done something wrong; some have been witness to inappropriate behavior.

Middle School/High School Age
The same type of information can be shared with these children. However, depending on the level of sex education the children have received, addicts may also want to give specific information about sex addiction and their behavior as it relates to the family.