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A biopsychosocial view of sex addiction

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In this article I explore both the name and the meaning of ‘sex addiction’ and offer a biopsychosocial view through which we might understand the complexity of cases presented before clinicians. Through published research and clinical experience, this paper looks at the biological, psychological and social influences of sex addiction in a hope that a broader understanding will increase dialogue between professionals of differing viewpoints and help develop multi-disciplinary approaches to treatment. The therapeutic dilemmas presented by this controversial and often maligned condition are also considered.
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A biopsychosocial view of sex addiction
Paula Hall
a
a
Private Practice, Leamington Spa, UK
Available online: 04 Nov 2011
To cite this article: Paula Hall (2011): A biopsychosocial view of sex addiction, Sexual and
Relationship Therapy, 26:3, 217-228
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A biopsychosocial view of sex addiction
Paula Hall*
Private Practice, Leamington Spa, UK
(Received 18 July 2011; final version received 26 September 2011)
In this article I explore both the name and the meaning of ‘sex addiction’ and
offer a biopsychosocial view through which we might understand the complexity
of cases presented before clinicians. Through published research and clinical
experience, this paper looks at the biological, psychological and social influences
of sex addiction in a hope that a broader understanding will increase dialogue
between professionals of differing viewpoints and help develop multi-disciplinary
approaches to treatment. The therapeutic dilemmas presented by this contro-
versial and often maligned condition are also considered.
Keywords: sex addiction; sexual compulsivity; hypersexuality; attachment; trauma
Introduction
Sex addiction is controversial, both within society and within the therapeutic
community and it is a topic that I’m sure will continue to be debated for many years
to come. What I hope to achieve in writing this article is to offer a broader view of
sex addiction that will give space for reflection on the multiple complexities of the
condition and allow consideration of the different issues sexual addiction may
present in the therapy room. Furtherm ore, I hope to address the therapeutic
dilemmas that worki ng with this client group can present and start a dialogue on
how best to manage these.
The biopsychosocial model, first theorized by psychiatrist George L. Engel at the
University of Rochester in 1977, has been a useful paradigm for exploring a number
of different psychosexual difficulties. The key advantages are that it allows us to
expand our thinking beyond the traditional medical model into psychological
considerations and further into the societal context and construct of the perceived
problem. Another advantage is that it enables us, as therapists and clinicians, to
focus on the client as an individual, rather than on our preferred theoretical model or
personal understanding. It can also encourage a comprehensive treatment approach
that addresses the complexities of individual cases. As Watson and Vidall (2011)
rightly said in a previous issue of this journal, ‘‘it is very likely that a client will not
stop buying sex or using drugs for that matter, if they are unaware of the underlying
relational mechanisms driving such behaviours’’ (p. 65). In addition, I would add
that it’s unlikely that a client will change their behaviour without having explored
*Email: paula_hall@btinternet.com
Sexual and Relationship Therapy
Vol. 26, No. 3, August 2011, 217–228
ISSN 1468-1994 print/ISSN 1468-1749 online
Ó 2011 College of Sexual and Relationship Therapists
http://dx.doi.org/10.1080/14681994.2011.628310
http://www.tandfonline.com
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and understood why it is a problem to them within their individual cultural and
social environment.
When looking at addiction generally, it is important to note that there are many
different theories from a variety of perspectives including medical, psychological and
sociocultural. Biopsychosocial views have increased in popularity (DiClemente,
2003; Perkinson, 1997; Ray & Ksir, 2004) and these new views allow addiction to be
understood and treated in a more holistic way with regard to how the person
becomes involved in addictive behaviour, stays involved in addictive behaviour and
stops the addictive behaviour. Sex addiction has also been viewed through this lens
before by Charles Samenow (2010), whose recent paper was published in the
American journal, Sexual Addiction & Compulsivity .
What’s in a name?
One of the biggest challenges facing clinicians at the moment is deciding what to call
‘‘sex addiction’’. Most peop le agree that an increasing number of people are
presenting to practitioners saying that their sexual behaviours feel out of control, but
we have yet to find a name for this that is clinic ally accurate. The term ‘‘addiction’’
is a grass roots term that seems to accurately explain how many ‘‘addicts’’ feel,
but without clinical evidence of escalation and withdrawal it remains disputed. The
term addiction, or rather ‘‘addict’’, is also highly stigmatising, especially with
the pervading, but un-evidenced, 12-step philosophy of powerlessness. Alternative
names have been offered but each has its limitations. ‘‘Sexually compulsive
behaviours’’ is a possible alternative but, unlike other compulsive behaviours, which
are classified in the American Psychiatric Association’s Diagnostic and Statistical
Manual of Mental Disorders (DSM-IV: APA, 1994), sex addiction offers a reward
and is not done repeatedly to alleviate anxiety in the same way as, for example, hand-
washing or checking. ‘‘Sexual dependency’’ is another term that is popularly used
and the term ‘‘dependency’’ is preferred by many working with alcohol and drug
problems, but it is a vague term that lacks any measurability. And while we may feel
that alcohol and drugs should not be an essential part of our lives on which we
‘‘depend’’, many wouldn’t say the same about the drive for sex, which many woul d
view to be innate.
The proposed terminology to be used in the forthcoming to DSM-V is
‘‘hypersexuality’’, which implies high or above average activity. My difficulty with
this is that many of the clients I have seen do not feel their behaviour, or their sex
drive, is higher than normal, whatever we deem that to be. The term hypersexuality
also implies that the behaviour is driven by sexual desire, which is misleading since
much addiction is motivated by another primary need. For example, sex addiction
may be used as a way of avoiding negative feelings such as boredom, depression or
anxiety, or it may be driven by a desire for intimacy or validati on by others.
Perhaps part of the problem is that there are so many different ways in whi ch sex
addiction can present. Some may be severe, some mild and, as with most diagnoses
or labels, one size rarely fits all. For example, a porn ‘‘addict’’ client who rarely
masturbates but feels compelled to go online and look at a minimum of 100 photos
before he can get to sleep and gets distressed if he is unable to do so, may fit the
definition of sexually compulsive. Another client whose sexual thoughts, fantasies
and behaviours dominate his every waking moment to the point where his work and
relationships are suffering, and who seeks sexual satiation multiple times a day, may
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fit the criteria for hypersexuality. Another client who is a recovering alcoholic and
drug user who turned to escorts to help him manage chemical sobriety rather than
addressing deeper psychological issues may be best described as sexually ad dicted.
And if the label ‘‘dependent’’ prevails, then a partner who chooses to leave a sex-less
marriage because expressing their sexuality is an important part of their life, might
find themselves wrongly accused of being sexually dependent.
The problem with any name or label is that it rarely fits all cases. Furthermore,
it can create an extra burden for the client. Whilst it is true that ha ving a
recognised name for a proble m can be a relief for many be cause it normalises the
problem and may offer community support from other sufferers, it can also
provide an opportunity to externalise the problem and overcome it. But for others,
a label increases the feelings of personal shame and can restrict power to change,
especially if the y believe a label to be fixed and permanent. The recognition of a
condition within the DSM-IV can similarly be both a blessing and a curse. It is
important to remember that the DSM-IV is bot h a political as well a s a therapeutic
tool. When a problem form ally exists in the DSM-IV then treatment and funding,
however limited, are more li kely to follow, but social and legal ramifications may
also arise.
While the medical and therapeutic communities continue to debate the best name
for the problem, the term ‘‘sex addiction’’ is becoming increasingly popular on the
street and in the media and many therapists rightly worry that it is also being
overused, misused and misdiagnosed. Whatever the problem is called, it should
represent those clients who seek help to change what they personally experience as
damaging sexual behaviours and not be a label for any wayward celebrity who has
failed to live up to societal expectations of monogamy or someone who enjoys a rich
and varied recreational sex life. I agree with the existential therapists, Kleinplatz
(2001) and most recently Barker (2011), when they say that sexual difficulties are
often not really about sex at all, but about the meaning constructed around it.
Unfortunately the only commonality in all the proposed alternatives for sex
addiction is the word ‘‘sex’’ but, in reality, sex often has very little to do with it.
For the rest of this article I will use the term ‘‘sex addiction’’ because, in spite of
its many shortcomings, it is the term most commonly used by the clients I work with.
I will now go on to explain how I define ‘‘sex addiction’’, from a biopsychosocial
viewpoint, and then go on to explore the dilemma’s faced by therapists.
The biology of sex addiction
Exploring the biological components of any problem may be constr ued as
medicalising or falling into the trap of biological reductionism. Therefore it is
important to stress that highlighting the physiological aspects of a problem does not
necessarily undermine any other essential e lements. Indeed, given the neuroplasticity
of the brain, biology is inseparable from psychosocial aspects of life anyway, as we
will see when we consider the ways in which our development and experien ce impact
on brain chemistry and physiology. For many clie nts and clinicians, an under-
standing of the biology, and especially the neurobiology, of sex addiction can
provide legitimacy for the psychological and emotional components. In my
experience, sharing our biological understanding of sex addiction with clients can
considerably reduce feelings of shame and confusion. There are still limited studies
specifically on sex addiction and many of the published papers are based on wider
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studies of other addictive disorders. However, there are a number of circulating
hypotheses that are currently under investigation.
Dopamine dysregulation
It is now clinically unde rstood that the common denominator in all addictions is
dopamine (Robbins & Everitt, 2010). Dopamine is the neurochemical responsible for
the experience of reward and pleasure and is naturally stimulated by eating, drinking
and having sex. From an evolutionary point of view, dopamine is essential for our
survival as it motivates us to continue to feed and reproduce. Dopamine can be
similarly he ightened through cognitive anticipatio n and fantasy, which is perhaps
why so many of us enjoy cookery programmes as well as porno graphy! Dopamine is
also involved in memory processing, and it biases the brain towards events that will
provide reward (Berke & Hyman, 2000). These memories become stronger with
repeated dopamine ‘‘highs’’. Evidence shows that addictive drugs, such as cocaine
and heroin, flood the brain with up to 10 times more dopamine than the brain’s usual
base level and, over time, conditions it to expect artificially high levels (Blum et al.,
2000; Duvauchelle, Ikegami, & Edward, 2000). With continued use, the brain
requires more dopamine than it can naturally produce, and it becomes dependent on
the drug, which never actually satisfies the need it has created. Current research is
exploring the impact of early exposure during adolescence to dopamine stimulants as
evidence suggest that early use increases the likelihood of adult addiction due to
neuro-adaptation in the dopamine system (Manning et al., 2001).
Although sex is known to significantly increase dopamine levels, it still remains a
hypothesis that a sim ilar bio-chemical process takes place that leads to chemical
addiction. There is also research underway to explore if early exposure to
pornography may have a similar long-term impact on dopamine regulation as
happens with addictive dugs. If this hypothesis turns out to be substantiated and
translates to sex addiction, then the current levels of adolescent exposure to Internet
pornography might result in the ‘‘Tsunami of sex addiction coming our way’’ as
predicted by Patrick Carnes at the UKESAD conference earlier this year.
Pornography is, of course, nothing new and young people have been
enjoying pornography long before the Internet. However, there is increasing
evidence that the Internet itself can become ‘‘addictive’’ (Weinstein & Lejoyeux 2010;
Young & Nabuco de Abreu, 2011) and when this is combined with powerful erotic
images, the Internet facilitates the addictive process (Hudson-Allez, 2009). This
may be why clinicians and researchers to the Senate’s Science, Technology and
Space subcommittee referred to Internet pornography as the new ‘‘crack-cocaine’’
(http://www.wired.com/science/discoveries/news/2004/11/65772).
While research continues to be undertaken, there is one field in particular that
appears to be supporting the hypothesis of dopamine involvement in addiction.
Parkinson’s patients are often prescribed dopamine agonists to improve motor and
memory functions and one of the unwanted side-effects of this is impulsive and
compulsive behaviours.
Brain development
There is growing evidence from neuroscience that deprivation of empathic care in
early childhood creates a growth-inhibiting environment that produce s immature,
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physiologically undifferentiated orbitofrontal affe ct regulatory systems (Schore,
2003). A child who does not receive its needs for attention, soothing, stimulation,
affection and validation may find the consequences structurally written into their
developing brain. The altered prefrontal function is associated with high risk of
drug and alcohol addiction (Bechara & Damasio, 2002; Fr anklin et al., 2002;
Goldstein, Volkow, Wang, Fowler, & Rajaram, 2001) and research from
Carnes (1991) also fou nd a high amount of neglect in his sample of sex addicts.
Hudson Allez (2009) proposes an explanation for this, saying that the insecure
attachment template is not able to produce its own endo genous opiates and
therefore individuals will reach for external opiates to stimulate their dopamine
pathways in order to stimulate the pleasure centres and reduce the pain.
Additionally, for the insecurely attached individual, the orbitofrontal area of the
cortex may no longer produce sufficient dopamine or noradrenaline to facilitate
sexual excitation and inhibition and, therefore, an external source may become
increasingly relied upon for something that the brain has not learnt to
manufacture for itself.
When a sex addict has e xperienced childhood trauma, it has been suggested
that the addiction is not necessarily a pleasure seeking strategy but a survival
strategy (Fisher, 2007). Van der Kolk (1996) found that the imprint of the
trauma is located in the limbic system and in the brainstem in our animal
brains, not our thinking brains and the amygdala, responsib le for ‘‘fight and
flight’’ may remain hypersensitive l ong after the trauma has passed. And indeed,
long after any conscious memory of the trauma has passed. This hypersensitive
amygdala may be triggered by any numbe r of external sources throwing the
body’s sympathetic nervou s system into hyper-aro usal, o r the parasympathetic
system into hypo-arousal and temp orarily by-passing the thin king part o f the
brain. Sexual behaviour may become a way for a trauma sufferer to numb
feelings of hyper-arousal such as hyperactivity, obsessive thinking, rage and
panic and also alleviate feelings of d isassociation, numbness, depression and
exhaustion experienced in hypo-arou sal. In short, it is thought that addictive
behaviours can become an effective technique to regulate the nervous system
(Fisher, 2007).
The psychology of sex addiction
There are numerous psychological factors that feed into addiction processes and
into the development and continuation of sexual addiction. An understanding
and exploration of the emotional and cognitive influences are important for
ensuring that treatment moves beyond biological symptom relief and change, to
the deeper psychological processes that can bot h cause and drive the unwanted
behaviours.
I hope that groupi ng the most common psychological exper iences u nder the
main therapeutic approaches will be a helpful way of presenting these issues,
although inevitably there are crossovers. One notable common denominator
throughout each theory is the role of shame in sexual addiction. Shame has been
highlighted by many clinicians from varying viewpoints as a key influence in sex
addiction and it is likely to arise in every modality sinc e it may be experienced and
endorsed personally, r elationally and societally. The latter is explored under social
influences.
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A psychodynamic point of view
From a psychodynamic viewpoint, sexual addiction can be seen to be rooted in issues
of attachment, trauma and/or object relations. Secure attachment is widely
understood by psychodynamic theorists to be an important precursor for healthy
adult relationships and healthy sexual expression. People with avoidant attachment
styles are more likely to seek relationships and sexual encounters where there is little
or no emotion or affection, such as sex workers and pornography, whereas those
with disorganised attachment styles may find themselves drawn into an ever
increasing number of sexual relationships or liaisons in order to receive validation
and affection. People with ambivalent attachment styles may choose additional
sexual relationships outsi de of their primary relationship as a way of warding off
fears of rejection or suffocation (Samenow, 2010). A further hypothesis is that once
an attachment has been made to an addiction as a source of comfort, it is harder for
an addict to create a secure attachment within a relationship and, hence, the cycle
of insecure attachments within relationships continues and the attachment to the
addiction becomes stronger.
Not everyone who has experienced trauma will go on to develop an addiction but
evidence suggests that sexual trauma, in particular, is over-represented amongst the
sex addiction population (Schwartz, Mark, & Galperin, 1995). The biological
explanations for this have been explored in the previous section but suffice to say
that links between trauma and problem atic sexual behaviours have been widely
written about within psychological literat ure, including the impac t of dissociation,
depersonalisation, trauma bonding, vandalised love-maps and trauma re-enactment.
Sex addiction can be viewed through an object relations lens either through the
splitting of the self or the splitting of the sex object. The self may be split into good
and bad where the good part is expressed as the loving and faithful partner and the
bad is acted out in shame inducing sexual behaviours. The sex object may be split
such that ‘‘good’’ sex is enjoyed within relationships but ‘‘bad’’ sex is enjoyed with
other sexual partners or online. The Madonna/whore syndrome would be one
example of how this is played out.
From a psychodynamic perspective, therapy is likely to focus on developing
secure attachment and self-integration whilst working through any trauma issues,
perhaps with additional resources such as sensori-motor work or EMDR.
A systemic point of view
A systemic view of sex addiction might look at the role the problem plays in relation
to other people within the systems which the individual is part of. Family of origin
work might identify learnt patterns of addictive behaviour, a history of secrets in the
family and/or poorly adapted coping skills. In my clinical experience, I have seen
many clients who have received significant negative messages about sex being
shameful and have consequently found it difficult to he althily embrace sexual needs
and feelings. Conversely, I have seen many clients who have experienced very liberal
attitudes to sex and sexual boundaries where pornography and the use of sex
workers was seen as the norm. Systemic exploration might highlight the role the
addict played in their original family and how an addiction, be that sexual or
otherwise, might have developed as part of that role.
In relationship therapy the addiction may be seen as being part of the system,
used for intimacy regulation or as part of an unhealthy collusive relationship. Seeing
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the partner as co-addict or co-dependent, either consciously or unconsciously, is
common from a systemic viewpoint.
Systems theory can also be helpful for exploring how sex addiction might fit
within the wider cultural setting. That may be part of a business culture or peer
group where what the addict may see as unwanted sexual behaviour is encouraged as
part of the norm. Treatment approaches with a systemic view are likely to focus on
every part of a client’s past and current system, not just the addiction, and to help
the client to understand the context and complex interplay of their problem
behaviour. Partners of sex addicts who often already feel shocked, confused and
betrayed when sexual addiction is disclosed, may feel pathologised and/or
responsible for their partner’s behaviour within this approach and therefore it is
essential that adequate focus is also placed on their individual needs as well as those
of the addict.
A cognitive-behavioural point of view
It is widely accepted within cognitive behavioural therapy that all addictions, both
chemical and process, are used as a form of affect regulation. There is, of course,
nothing wrong with using sex, or, depending on your viewpoint, alcohol, to alleviate
difficult emotions and to create a sense of wellbeing, but if alcohol or sex become
a primary coping mechanism on which a person depends, in spite of negative
consequences, then it might be considered an addiction.
Cognitive practitioners would likely focus on the thoughts, feelings and
behaviours triggered by sex addiction. Exploring impulse control, triggers, urges
and negative thinking patterns can all be a way of initiating behaviour change
towards coping mechanisms that the client feels mo re confident and comfortable
with and the use of motivational interviewing techniques may help to cement change
(Fuller & Taylor, 2010). A relative newcomer to cognitive therapy, developed by
Young, Klosko and Weishaar (2003) is schema therapy. Schemas are a stable,
enduring, negative pattern of beliefs and feelings about oneself that develop during
childhood or adolescence and are elaborated, usually without awareness, throughout
an individual’s life. By bringing schemas into conscious awareness a client can be
helped to re-write the script and thereby make more conscious choices about how
they wish to feel, think and behave in their world.
A transactional analysis point of view
Transactional Analysis can be another useful model for exploring sex addiction.
With some clients I have seen, the sex addiction behaviour is being expressed
through the ego state of the adaptive child, and work can focus on moving their
sexuality to either the ego state of their free child or adult. The deeper psychological
issues that drive the unwanted sexual behaviours can then be explored with the help
of the nurturing parent ego state, who might ensure that the free child remains safe
and secure.
In couple therapy I have noticed that partners of sex addicts have often lost touch
with their free child and found themselves trapped in critical parent, constantly
monitoring their partners sexual behaviour that is trapped in adapted child. I have
also found Karpman’s (1968) drama triangle a helpful lens to use with the trauma
client who may come to recogni se how their addictive behaviour has become
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alternatively both their rescuer and persecutor, keeping them endlessly trapped in the
victim role.
These different psychological approaches will be common to most experienced
therapists, many of whom work eclectically, integratively or pluralistically.
Obviously this list is far from exhaustive and there are exciting directions in, for
example, mindfulness, Gestalt, person-centred and existential therapies, which could
also be usefully explored. Needless to say there are many different ways to explore
a client’s psychological difficulties and for sex addicts, like any other clients, the
chosen approach should be the one that best fits their personal situation and
personality.
Social influences
Sex addiction is a considered by some to be a myth, a bi-product of culture and other
social influences. Some postulate that in our dominant hetero-sexist, monogamous
culture, non-relational sex and excessive sex has become pathologised. This view has
perhaps been compounded by the number of religious communities involved in
addiction recovery who promote sex within an intimate relationship as the only
‘‘healthy’’ alternative. It’s certainly true that the notion of sex addiction is a
relatively modern phenomena and to understand it fully we need to be aware of the
societal context within which a client brings their concerns and we as therapists need
to be aware of what may be influencing our response.
Cultural sexualisation
Much ha s been written a nd talked about of the sexualisation of c ulture and the
impact that this is having on people’s sex lives and many are becoming increasingly
awar e of the paradox of sexual freedom. On the one hand we are now, as a society,
more able to provide sexual education, information and advice, but there is also
more access to erroneous and unhelpful information. There are more opportunities
for people to explore their sexuality and mor e freedom to ex press their desires
and needs without shame or reprimand, but there is also an ongoing rise in
reported sexual crime (HM Government, 2011) and child sexual offences (NSPCC,
2011).
There is, of course, no evidence that a sexualised society is responsible for the
increase in crime, but the advent of the Internet has certainly presented the would-be
sexual predator with an increasing number of ways to find and groom victims.
Whenever there is more freedom, there is also more choice, and choice can be
experienced not only as a joy but also as a burden. With an ever-growing sexual
menu to choose from, there are an ever increasing number of choices to be made
about what might fulfil our appetite without damaging our chosen lifestyle. For
someone with a pre-disposition to sexual addiction, from their unique biological and
psychological make-up, our sexualised culture provides an environment within
which the addiction can flourish. Clearly that does not mean, and should not mean,
that as a society we should move towards prohibition we know from the history of
alcohol addiction that prohibition does not work. But as with the drink-aware and
more recent gambling-aware campaigns, perhaps we would benefit as a society if we
provided more information and support on sexual choices beyond the meagre sexual
health campaigns that currently exist.
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Shame
Both shame and guilt are emotions that can only exist within the context of others
since both are judgements made about the self as viewed in relation to the overt or
covert expectations of family, religious affiliation and/or society. Shame and guilt
have a long tradition as both causes and consequences in pe ople experiencing
addictions but recent research has shown that whereas shame is likely to increase
addictive behaviour, guilt can be a significant motivator to overcome it (Gilliland,
South, Carpenter, & Hardy, 2011).
Shame can be described as a painfully negative emotion where the self is deemed
bad and unworthy, whereas guilt is a negative judgement about a behaviour.
Hence a guilt script says ‘‘I have done something bad’’ whereas a shame script
says ‘‘I am bad’’. Unresolved shame experienced in childhood can result in
exaggerated feelings of shame in adulthood, which may be medic ated against
through an addiction. However the addiction often becomes a source of shame in
itself and hence perpetuates an addictive cycle. The distinction between shame and
guilt is particularly important for understanding sex addiction within a societal
context. Although our world may appear to be more open about sex, there is no
doubt in my mind that sexism, homophobia, sexual repression and religious
fundamentalism still exist, as well as societally assumed norms of monogamy. These
factors can fuel a sense of shame of those who step outside of these norms, taking the
power away from the individual to decide if guilt, or indeed acceptance, is a more
appropriate response.
Contrary to the belief of some clinicians, the shame experienced by sex addicts is
frequently not from any ethical or anti-sex perspective. On the contrary, most of the
clients I work with hav e no moral objection to watching pornography or visiting sex
workers, their shame comes from prioritising these activities over and above their
commitments to partners, children, friends, work, finances, health and career and
personal development. Shame can damage an addict’s sense of self to the point where
they no longer see themselves as worthy of the love of a partner, or the respect of
children, or the unconditional regard of friends, or the promotion from a boss. They
may experience a sense of guilt at the number of times they have lied or let down
others due to prioritising a secret sex life, but the shame can wound to the point
where change feels impossible. To overcome any addiction, the client can be helped
by empathically evaluating their behaviour and reducing shame. With shame
removed they may then decide that their behaviour is no longer a problem or by
reframing to guilt they may be more empowered to change (Gilliland et al., 2011).
Conclusion
As a therapeutic community, sex addiction presents many dilemmas not least what
we should call it. As discussed previously, all of the proposed names have their
limitations and although ‘‘addiction’’ continues to be the most popular, it is certainly
the most stigmatising. It seems we have two choices, we can either re-educate clients
and society about what ‘‘s ex addiction’’ really means or we can continue to try and
find a better word to define the problem. I would be happy to do the latter, but with
the term already so widely used within our culture, my fear is that we would be trying
to close the proverbial door after the horse has bolted.
Another dilemma is how we work wi th a client whose behaviour contradicts
their values and lifestyle choice. This is, of course, a dilemma we are faced with on
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a regular basis, be it a woman with low desire who feels that she should have sex with
her partner, or a man with erectile difficul ties who feels he should be able to
penetrate, or someone deciding whether or not to end a long-term affair, or a couple
grappling with how to tell their children that they are separating. Perhaps more so
than with any other addiction, sex addiction often contradicts a person’s core values
and they must choose whether or not to change their behaviour to fit their values or
change their values to fit their behaviour.
There are treatment challenges too. Developing a bio-psychosocial model
demonstrates the importance of not simply focussing on reducing behavioural
symptoms through relapse prevention strategies and arousal re-conditioning, but
also ameliorating the underlying psychological issues and exploring the societal
context within which a client has developed their meaning of the problem. Achieving
this requires multiple skills, which I believe are beyond traditional addiction
treatment strategies and basic training in psychosexual therapy. Clients are
understandably confused when professionals who not only cannot agree on whether
or not their problem exists, or what it’s called, then go on to dispute the mixed merits
of rehab treatment, 12-step fellowships, cognitive behavioural therapy, existential
therapy, Jungian analytical, psychosexual therapy, psycho-educational work, couple
counselling, individual work, group work and so ad infinitum.
In my view, the biggest barrier to understanding sex addiction is professional
defensiveness and misdiagnosis. We all have much to learn about this subject and
even more that we can learn from each other’s experience. In the meantime, clients
continue to come to our door. I feel passionately about this client group and it
frustrates me that so many are hearing the message that their problem does not really
exist or that they simply nee d to develop more self-control or come to terms with
their behaviour. I have heard countless stories of how sex addiction has devastated
lives: how men have lost their partners, families, friends, jobs, homes and, perhaps
most importantly, their self-respect and integrity. And the stories of women who are
shocked and confused to discover that their loving partner, who they assumed had
low desire since they rarely wanted to sleep with them, has been spending six hours a
day, every day watching pornography and having cybersex. I am reminded of the
estimated 250,000 UK Chronic Fatigue Syndrome/Myalgic Encephalopathy
sufferers who battled through the 1980s with the label of ‘‘yuppie flu’’ or even
‘‘shirker syndrome’’. While professionals debated if it was psychological or physical,
treatment services were stalled. It seems to me the same is happening now with sex
addiction but with the additional problem that the shame caused by widespread
misunderstanding further damages self-esteem and fuels the addictive cycle. Sex
addiction is a controversial and complex problem that requires lateral thinking and
multiple level s of therapeutic intervention let’s start talking about how we can
provide the services that these clients both need and deserve.
Notes on contributor
Paula Hall is a COSRT Accredited Sexual & Relationship Psychotherapist who specialises
in sex addiction from her private practice in Leamington Spa. She is one of the founder
trustees of ATSAC (Association for the Treatment of Sexual Addiction and Compulsivity)
and trains on their Professional Certificate in Sex Addiction Treatment. She also trains
other therapists on sex addiction and has currently been commissioned by Routledge to
write the first UK book on the subject, Treating Sex Addiction, due for publication
October 2012.
226 P. Hall
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Chapter
Die Zahl von Patienten, die professionelle Hilfe suchen, weil ihr exzessiver Pornografiekonsum und/oder ihr exzessives Sexualverhalten zu negativen Konsequenzen und Leidendruck geführt haben, hat in den letzten Jahren deutlich zugenommen. In der ICD-11 wird dafür erstmals die Diagnose „Zwanghaftes Sexualverhalten“ in der Klasse der Impulskontrollstörungen eingeführt. Als wichtigste diagnostische Kriterien gelten ein hoher Zeitbedarf für die Beschäftigung mit sexuellen Impulsen und Verhaltensweisen, der Einsatz exzessiven Sexualverhaltens als Reaktion auf negative Gefühle und belastende Lebensereignisse sowie erfolglose Versuche, das trotz negativer Konsequenzen fortgeführte Verhalten zu kontrollieren. Die häufigsten negativen Konsequenzen hypersexuellen Verhaltens sind partnerschaftliche und berufliche Probleme sowie sozialer Rückzug. In der Praxis muss die Selbstdiagnose des Patienten durch Screeningfragen, Fragebögen und eine Sexualanamnese verifiziert werden. Die Beratung zielt auf zunächst auf ein Selbst-Monitoring sowie auf eine gestufte Reduktion der problematischen Verhaltensweisen. Das therapeutische Vorgehen besteht in multimodalen Ansätzen mit den Schwerpunkten auf der Verbesserung (a) der Verhaltenssteuerung, (b) der Affektwahrnehmung und -regulation, (c) der Beziehungsfähigkeit und begleitender sexueller Funktionsprobleme. Eine unterstützende Pharmakotherapie beginnt i. d. R. mit SSRIs und geht in Einzelfällen bis zur Gabe von Antiandrogenen.
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