Download SSTPSexAddiction - Blue Harbor Counseling

In the Field: Sex Addiction
CSL 513: Sexual Disorders
Matthew Tiemeyer, MA, LMHC
Fall 2013
For PowerPoint and Word versions:
http://www.blueharborcounseling.com/sstp
Perceptions of Sex Addiction
 “It doesn’t exist”

Sexologists, for example, see the notion of sex addiction as regressive
and anti-sex

Some assumptions sexologists make regarding the “sex addiction
model”:
It focuses on the "dignified purpose" of sex (no “heat”)
 Eliminates responsibility for sexual choices
 It encourages people to split (e.g., Jimmy Swaggart)
 Confuses what’s normal with true sexual compulsivity (lumping those
who masturbate “too often” with sex offenders and
psychosis/personality disorders, etc.)

“(Addictionologists) are missionaries who want to put everyone in the
missionary position.”
Perceptions of Sex Addiction
 “It doesn’t exist” (cont.)
Some clinicians and researchers reject the word “addiction,”
saying it applies only to things that activate the brain’s reward
system directly
 “It’s a nuisance”
Some therapists urge clients engaged in compulsive behavior to
do a better job of hiding it
 “It’s a lucky break”
Believing that becoming addicted sexually would be a benefit,
like “catching a little bit of anorexia” to lose some weight
Practical and Clinical Reality
 Real issue is idolatry
 Critiques matter politically, but clients who meet sex
addiction criteria are engaged in a level of worship
that is profound and crippling.
Stats and Stuff
 Men outnumber women 3 to 1 (3 to 2 online)
 Among addicts…








70% report severe marital or relationship problems
42% of women reported unwanted pregnancies
58% report severe financial consequences
79% report “serious losses in job productivity”
38% report physical injury from acting out
19% of men and 21% of women were involved in automobile
accidents
60% of women were physically abused during sex, and 50% were
raped
16% of men reported physical battering
Sex Addiction – Carnes’s Definition
Minimum of 3 (most have 5, over half 7 or more):
1. Recurrent failure (pattern) to resist impulses to engage
in specific sexual behavior
2. Frequent engaging in those behaviors to a greater
extent or over a longer period of time than intended.
3. Persistent desire or unsuccessful efforts to stop, reduce,
or control the behaviors.
4. Inordinate amount of time spent in obtaining sex, being
sexual, or recovering from sexual experience.
5. Preoccupation with the behavior or preparatory
activities.
Sex Addiction – Carnes’s Definition
6.
7.
8.
9.
10.
Frequent engaging in the behavior when expected to fulfill
occupational, academic, domestic, or social obligations.
Continuation of the behavior despite knowledge of having a
persistent or recurrent social, financial, psychological, or
physical problem that is caused or exacerbated by the
behavior.
Need to increase the intensity, frequency, number, or risk of
behaviors to achieve the desired effect, or diminished effect
with continued behaviors at the same level of intensity,
frequency, number, or risk.
Giving up or limiting social, occupational, or recreational
activities because of the behavior.
Distress, anxiety, restlessness, or irritability if unable to
engage in the behavior.
Sex Addiction – Collateral Indicators
Minimum of 6 must be met. Patient:
1.
Has severe consequences because of sexual behavior.
2.
Meets the criteria for depression and it appears related to sexual acting
out.
3.
Meets the criteria for depression and it appears related to sexual
aversion.
4.
Reports history of sexual abuse.
5.
Reports history of physical abuse.
6.
Reports emotional abuse.
7.
Describes sexual life in self-medicating terms (intoxicating, tensionrelief, pain-reliever, sleeping pills).
8.
Reports persistent pursuit of high risk or self-destructive behavior.
9.
Reports sexual arousal for high risk or self-destructive behavior is
extremely high compared to safe sexual behavior.
10. Meets diagnostic criteria for other addictive disorders.
Sex Addiction – Collateral Indicators
11.
12.
13.
14.
15.
16.
17.
18.
19.
20.
Simultaneously uses sexual behavior in concert with other
addictions (gambling, eating disorders, substance abuse,
compulsive spending, etc.) to the extent that desired effect is not
achieved without sexual activity and other addiction present.
Has history of deception around sexual behavior.
Reports other members of the family are addicts.
Expresses extreme self-loathing because of sexual behavior.
Has few intimate relationships that are not sexual.
Is in crisis because of sexual matters.
Has history of crisis around sexual matters.
Experiences anhedonia in the form of diminished pleasure for
same experiences.
Comes from a "rigid" family.
Comes from a "disengaged" family.
Hypersexual Disorder (DSM-V Proposal)
A. Over a period of >= 6 months, recurrent and intense sexual
fantasies, urges, and behavior in assoc. with four or more of
the following:





excessive time consumed by sexual fantasies and urges, and by
planning for and engaging in sexual behavior
repetitively engaging in these sexual fantasies, urges, and behavior
in response to dysphoric mood states (e.g., anxiety, depression,
boredom, irritability)
repetitively engaging in sexual fantasies, urges, and behavior in
response to stressful life events
repetitive but unsuccessful efforts to control or significantly reduce
these sexual fantasies, urges, and behavior
repetitively engaging in sexual behavior while disregarding the risk
for physical or emotional harm to self or others
Hypersexual Disorder (DSM-V Proposal)
B. There is clinically significant distress or impairment in social,
occupational or other important areas of functioning associated with
the frequency and intensity of these sexual fantasies, urges, and
behavior.
C. These sexual fantasies, urges, and behavior are not due to direct
physiological effects of exogenous substances (e.g., drugs of abuse or
medications), a co-occurring general medical condition or to Manic
Episodes.
D. The individual is at least 18 years of age.
Actual DSM-V Diagnosis (Suggested)
 312.89 Other specified disruptive, impulse-control
and conduct disorder: hypersexual disorder
 302.9 Unspecified paraphilic disorder – APA says…


Person must “feel personal distress about their interest, not
merely distress resulting from society’s disapproval” OR
Person must have “a sexual desire or behavior that involves
another person’s psychological distress, injury, or death, or a
desire for sexual behaviors involving unwilling persons or
persons unable to give legal consent”
What Makes a Sex Addict?
 Addicts may be any class, gender or age
 Shame crushes potential for intimacy
 Isolation (and thus loneliness) is highly likely
 Multiple addictions are often present (alcohol, eating,
drugs, gambling, work, etc.)
 A small sample of sexual acting out behaviors includes:
obsessive masturbation, sexually explicit images and
stories, fantasy, heterosexual and homosexual
relationships, prostitution, exhibitionism, voyeurism,
visiting strip clubs and massage parlors, indecent phone
calls, frotteurism, incest, rape, and child molesting.
Key Beliefs of the Sex Addict
 Self-image: I am a flawed and unworthy person
 Relationships: If people knew me, they wouldn’t
love me
 Needs: They will never be met if I have to count on
others
 Sexuality: Sex is my most important need
The Addictive Cycle
Belief
System
Unmanageability
Impaired Thinking
Addictive
Cycle
Preoccupation
Shame
Ritualization
Despair
Guilt
Compulsive
Behavior
© 2008
Etiology and Theory
understanding the addiction’s inner
workings, informing intervention
Etiology
 Carnes: Addiction is a developmental disorder
 Schwartz et al. suggest that addiction is an intimacy
disorder
Family Systems
From the circumplex model of family systems:
 77% of addicts come from rigid families
 87% of addicts come from disengaged families
 68% come from families that are both rigid and disengaged
Role of Attachment
Addicts fall into predominant attachment styles:
 Fearful/Avoidant
 Suppress expression of emotions, even as infants
 Lack solutions to their emotional needs
 Attachment figure averse to physical contact?
 Preoccupied/Ambivalent
 Anxious about attachment figure’s whereabouts and actions
(unpredictable)
 Sometimes exaggerated affect; hard to soothe
Abuse Dynamics
Addicts report startling frequencies of past abuse:
 81% report a history of sexual abuse
 72% report physical abuse
 97% report emotional abuse
Why There Aren’t Easy Fixes
 Rigid, disengaged families, leading to…
 insecure attachment, punctuated by…
 frequent instances of abuse results in:


No confidence in relationships or intimacy
Distrust of authority and accountability
Mirror of Erised
Attachment and Acting Out
 We may pursue different ways of responding to a
lack of secure attachment



Dating/marrying someone like my parent (OR exact opposite)
Isolation
Positive: Adaptive, active choices designed to heal
 One opinion: Acting out may be seen as a
misguided attempt to secure attachment at any cost
and without risk
Arousal Template
Story
Elements
Arousal Template
Acting
Out
Behaviors
Carnes: “(arousal template) … usually contains a
scenario based on an abuse experience, a fantasy, or
something historical.”
Arousal Template
 Voyeurism
Parents could be distant or absorptive; addict gains a sense of
power by “knowing” others in more intimate ways than he has
known his parents without exposing himself
 Exhibitionism
Important figures unwilling to notice client or are impacted by
nothing
 Bestiality
 May have been comforted by animals more than parents
 May have seen animals slaughtered by caregivers
Arousal Template: Case Example
 The incredibly deferential man…




Early 20s, socially isolated, soft-spoken, extremely aware of the
harmful image men have created
Makes sure women are not frightened (or even inconvenienced) by
him
Has never dated
Lives at home with parents and brother
 Arousal template:



Monsters with tentacles violating young girls (anime)
Externalizes his own violence and yet allows him to indulge it
Consider issues with mom and with contempt for his own innocence
 Overt gaming behavior – defending women
Filling a Need or Killing Desire?
 Allender, 2004: Addicts don’t really think that
they’re going to get their needs met by acting out yet
again
 Initial draw and form of acting out likely to be based
on attachment needs, but addictive process takes
over. Then acting out becomes:


A way to mock needs
A way to reconcile circumstances and self-opinion – e.g., “I’m
a whore. When I do this it just makes it clear.”
Recovery
defining and pursuing
Making Peace With Desire
 It takes more energy to follow and enjoy desire fully
than it does to mar yourself with it
 Evil joins with desire to add momentum, taking it
past its target and creating/reinforcing shame
 So…aversion therapy not a long-term solution


Cultivates disengagement, usually executed rigidly
Encourages a conflicted internal world; i.e, ambivalent
preoccupation
 Alternative – objectify no one, honor everyone
Recovery
 Addiction is usually defined as the presence of
certain symptoms…so what’s recovery?
 The client’s view


“Just make it stop,” ending symptoms (and killing desire if
necessary)
What’s still okay to do?
 What does genuine recovery look like?
 More than what the client believes
 Grief, positive intimacy, healthy desire
 A bigger, stronger, deeper story
A Recovery Cycle (Phil Prothero)
Journeying int o life
Addiction System
1
Another option
A journey toward isolation
A journey toward grace & relationship
Balanced
belief system
Fault y belief
system
Life becomes
unmanageable
Impaired
thinking
Life becomes more
manageable &
joy filled
Preoccupation,
obsessive thoughts
Shame, despair,
depression, anger
2
Healt hy
thinking
Awareness of
desires, emotions,
needs & wants
Ritual behaviors,
isolat ion strategies
Compulsive
behavior
1. Adapted from Patrick Carnes, PhD.
2. Phil Prot hero, MA, MDIV. Redeeming Stories, 2006.
Experience subt ly
of emotion & lif e
Recovery
community
Activities that
fulfill life &
enhance self
www.redeemingstories.com
 Redeeming Stories, 2006
Carnes’s Model – Client’s 30 Recovery Tasks
1. Break through denial
2. Understand the nature of the illness
3. Surrender to the process
4. Limit damage from behavior
5. Establish sobriety
6. Ensure physical integrity
7. Participate in a culture of support
8. Reduce shame
9. Grieve losses
10. Understand multiple addictions to
addictive shame
11. Acknowledge cycles of abuse
12. Bring closure and resolution to addictive
shame
13. Restore financial viability
14. Restore meaningful work
15. Create lifestyle balance
16. Build supportive personal relationships
17. Establish healthy exercise and nutrition
patterns
18. Restructure relationship with self
19. Resolve original conflicts-wounds
20. Restore healthy sexuality
21. Involve family members in therapy
22. Alter dysfunctional family relationships
23. Commit to recovery for each family
member
24. Resolve issues with children
25. Resolve issues with extended family
26. Work through differentiation
27. Recommit/commit to primary
relationship
28. Commit to coupleship
29. Succeed in primary intimacy
30. Develop a spiritual life
Recovery Process
Stage 1: Intervene in the cyclical compulsive process




Define the problem
Break denial
End most dangerous/destructive behaviors first
Make 12-step and/or group referral
Stage 2: Initial treatment






Determine abstinence definition—abstinence list, boundaries list,
and sex/relationship plan
Create relapse prevention plan
Ensure group attendance and beginning of 12-step process
Establish period of celibacy
Reduce shame
Assess for trauma and for multiple addictions
Recovery Process
Stage 3: Extended treatment (only possible when
behavioral change has been in place)




Address family of origin and developmental issues
Deal with grief (including the loss of acting out)
Marital and family therapy
Trauma therapy
Importance of Group Work
 Begins to break barriers to intimacy
 Safe place to speak
 Healthier way to approach attachment needs
 Possibly even the presence of healthy touch
 Choosing the right group
 Some recommend that a faith-based 12-step program alone
will encourage striving for perfection
 SA, SAA, SLAA, SCA, Prodigals, Celebrate Recovery all have
strengths and weaknesses
Slips, Relapses, and Shame
Relapses are usually part of the recovery process




6 months: Addict’s emotions (and/or those of partner)
awaken, destabilizing the process
Tendency is to flee and pour on self-contempt (fits in
with the rigid/disengaged attachment style)
Shame keeps the addict from entering the healthy sexual cycle
Leaving the shame cycle requires engagement instead of
flight…
Therapeutic Stance
Strength and tenderness

Without strength, client won’t believe you can help
Being willing to confront (and even to end treatment when
necessary). Boundaries, though often painful, are likely to increase
the client’s internal safety
 Being willing to push through shame to lend dignity to the data
(client’s shame and your own shame)


Without tenderness, client won’t trust you
Empathy
 Focusing on the pain created by consequences

Barriers to Relational Work
 The addict’s brain wiring is not generally receptive to
relational matters.
 Therapist must be more active, doing more defining,
more teaching, more leading.
 Style of relating is highly important. But addicts’
behavior is designed to reduce self-awareness, and if
behavior is in place, barriers will stay up.
 Alternative “back doors” include art therapy / music
/ film
Working With Partners
affirming, including, addressing
“Wrong Number”…
Crazymaking
 Partner can’t distinguish between valid and invalid
threats, leading to hypervigilance
 Addicts use the spouse’s devotion against them


Attempt to discredit
Parallels domestic violence
Disclosure to Partner
 96% of addicts have found that disclosure was the
proper course in retrospect (60% initially) - Corley
and Schneider, 2002
 Must be as complete as possible (though perhaps not
as detailed as possible)
 Partners…


want to be empowered to decide how much to be told
often wish they had sought/received more support from peers
and counselors at disclosure
 Disclosing partner needs to be able to have emotions
congruent with what’s being disclosed.
Should the Partner Leave?
 Hard consequences vs. “seventy times seven”
 Prime area for conflict between therapists of addict
and partner
 Leaving should NOT be a threat alone. Partner must
be willing to back up whatever is laid out as a
consequence for future behavior.
Note: Partner should not be responsible for
accountability
Reconciliation Process – Three Letters
 Disclosure Letter – extent of behaviors, as
completely as possible
 Clarification Letter – counteracting crazymaking
behaviors and confirming the partner’s uneasiness
where possible
 Empathy Letter – solidifying alignment with partner
What About Offenders?
 Some addicts are sex offenders; some aren’t (and
vice versa)
 A registered sex offender has engaged in sexual
behaviors judged illegal by the state:


Level 1 (vast majority): Low risk of re-offending. May be first
time offenders; usually know their victims.
Level 2: Moderate risk of re-offending. Generally multiple
victims and abuse may be long term. Usually groom their
victims and may use threats to commit their crimes. Crimes
may be predatory with the offender using a position of trust to
commit them. Typically do not appreciate the damage they
have done to their victims.
What About Offenders (cont.)?
 A registered sex offender has engaged in sexual
behaviors judged illegal by the state:

Level 3: High risk to re-offend. May have committed prior
crimes of violence. May not know their victims. The crimes
may show a manifest cruelty to the victims; these offenders
usually deny or minimize the crime. Commonly have clear
indications of a personality disorder.
 Food for thought: Where does an ego-dystonic sex
offender go for help?
Q&A