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The Effectiveness of Psycho-Educational Group Work in Treating Compulsive Sexual Behavior Disorder (CSBD): Clinical Outcomes Using CORE OM and Supplement at Three-Month and Six-Month Follow up

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This paper evaluates the efficacy of treatment of 119 clients who sought help for CSBD (Compulsive Sexual Behavior Disorder). Using CORE OM and a tailor made supplement for CSBD, clients were evaluated at the beginning of a psycho-educational groupwork program and then again at three-month follow-up. 36 clients were evaluated a second time six-months later. The study identified, through CORE OM, that 85% of the sample were experiencing ‘clinical distress’ and 67% were at risk on intake. At three-month follow-up, there was ‘significant’ or ‘reliable’ improvement for 58% on clinical distress and 30% on risk. Compulsive sexual behaviors reduced for 97% of the sample group and 87% experienced a reduction in intrusive thoughts and feelings. However, for approximately 30% of clients, this reduction in problem symptoms was accompanied by negligible change in clinical distress and a worsening for some. A discussion is provided on why this may be and the implications of this research for treatment providers.
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Sexual Addiction & Compulsivity
The Journal of Treatment & Prevention
ISSN: 1072-0162 (Print) 1532-5318 (Online) Journal homepage: https://www.tandfonline.com/loi/usac20
The Effectiveness of Psycho-Educational Group
Work in Treating Compulsive Sexual Behavior
Disorder (CSBD): Clinical Outcomes Using CORE
OM and Supplement at Three-Month and Six-
Month Follow up
Paula Hall, John Dix & Christine Cartin
To cite this article: Paula Hall, John Dix & Christine Cartin (2020): The Effectiveness of Psycho-
Educational Group Work in Treating Compulsive Sexual Behavior Disorder (CSBD): Clinical
Outcomes Using CORE OM and Supplement at Three-Month and Six-Month Follow up, Sexual
Addiction & Compulsivity, DOI: 10.1080/10720162.2020.1751364
To link to this article: https://doi.org/10.1080/10720162.2020.1751364
Published online: 11 Apr 2020.
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The Effectiveness of Psycho-Educational Group Work in
Treating Compulsive Sexual Behavior Disorder (CSBD):
Clinical Outcomes Using CORE OM and Supplement at
Three-Month and Six-Month Follow up
Paula Hall , John Dix, and Christine Cartin
ABSTRACT
This paper evaluates the efficacy of treatment of 119 clients
who sought help for CSBD (Compulsive Sexual Behavior
Disorder). Using CORE OM and a tailor made supplement for
CSBD, clients were evaluated at the beginning of a psycho-
educational groupwork program and then again at three-
month follow-up. 36 clients were evaluated a second time six-
months later. The study identified, through CORE OM, that
85% of the sample were experiencing clinical distressand
67% were at risk on intake. At three-month follow-up, there
was significantor reliableimprovement for 58% on clinical
distress and 30% on risk. Compulsive sexual behaviors
reduced for 97% of the sample group and 87% experienced a
reduction in intrusive thoughts and feelings. However, for
approximately 30% of clients, this reduction in problem symp-
toms was accompanied by negligible change in clinical dis-
tress and a worsening for some. A discussion is provided on
why this may be and the implications of this research for
treatment providers.
Overview
Psycho-educational group work has been used in the treatment of a variety
of addictive and compulsive disorders for many years, ranging from smok-
ing cessation and weight reduction to drug and alcohol dependency
(Brown, 2018). Thaddeus Birchard pioneered the use of group work in
working with clients presenting with compulsive sexual behavior in the UK
and the Hall Recovery Course, which this study is based on, was originally
based on his pioneering work.
The controversy around sexual addiction/sexual compulsivity has abated
a little since the acceptance of Compulsive Sexual Behavior Disorder
(CSBD) by the World Health Organization for the ICD11, but debates
around appropriate treatment continue. As a client facing organization, we
CONTACT Paula Hall paula@thelaurelcentre.co.uk The Laurel Centre, 52-54 Regent Street, Leamington
Spa, Warwickshire, CV32 5EG, UK.
ß2020 Taylor & Francis Group, LLC
SEXUAL ADDICTION & COMPULSIVITY
https://doi.org/10.1080/10720162.2020.1751364
continue to use the popular terms sex addictionand porn addictionin
the same way as many services use the term drug addiction, rather than
Substance Use Disorder as it is clinically known, but like many treatment
providers, we use an integrative, bio-psycho-social, treatment approach
rather than a pure medical addiction model. It is hoped that now that
CSBD is becoming better recognized, this research will help to demonstrate
efficacy of an integrative, psycho-educational treatment approach. (NB
research is currently also being undertaken to compare outcomes from
individual counseling and psychotherapy with group work).
Measuring outcomes is particularly important in the field of addiction
recovery, not least because clients expect treatment that provides reliable
and effective long-term behavioral change, but also because we know that
compulsive behaviors are often a consequence of deeper unresolved psy-
chological issues. Therefore, effective treatment should not simply focus on
stopping the compulsive behavior, but also on working to address deeper
psychological and emotional needs. Hence the purpose of undertaking this
ongoing research is two-fold; to demonstrate lasting behavioral change and
to evidence increased psychological wellbeing.
This study followed 124 clients from 20 six-day programs over the past
three years. Of the 124 clients, 119 returned for the three month follow up
day where they completed a second evaluation. All of the 124 clients were
assessed individually before starting the group to ensure the program was
appropriate for their needs and only the 119 who completed outcome eval-
uations at the start and at three month follow up have been included in
this study. A further 36 clients completed a second follow-up outcome
evaluation six months after the three month follow up, in other words,
nine months after completion of the course.
The outcome measurement tools used in this study were CORE OM,
and a supplementary evaluation designed to measure outcomes specific to
compulsive sexual behavior disorder.
The hall recovery course
The Hall Recovery Course has continually evolved since it began in 2009
and it is currently delivered in two formats; a workshop/evening intensive
and a six day residential. The content of the groups is identical, though the
delivery format changes to meet the differing geographic and practical
needs of clients. All groups are limited to a maximum of eight clients and
groups are delivered by two therapists who are trained both in group work,
and sexual addiction.
At its core, the Hall Recovery Course is a psycho-educational program
following the precept of growth through knowledge(Erford, 2018). It
2 P. HALL AND J. DIX
follows the philosophy of the CHOICE Recovery Model (Hall, 2018) and
incorporates principles from cognitive behavioral therapy, acceptance and
commitment therapy, psychodynamic and relational psychotherapy theory
and positive psychology. The objective is for participants to leave the pro-
gram with greater insight into the root causes of their compulsive behavior,
practical skills for preventing relapse, positive goals for the future and
motivation to change, along with a long-term support network.
In addition to ongoing evaluation, facilitators also attend regular group
work supervision to ensure content and process is balanced and to provide
space for clinical and personal growth and development.
History and description of CORE OM
The CORE-OM (Evans et al., 2002) is a 34-item, client self-report question-
naire developed to measure generic psychological distress. It has been used
in a variety of health and psychological settings around the UK and further
afield for nearly 20 years, including within a number of psychosexual serv-
ices (Penman, 2009, Irwin & Pullen, 2017, Francis, Hejda-Forde, Miriam
Grant, & Farley, 2019). The tool is described as pan-theoretical and pan-
diagnostic because it is not associated with any particular modality of ther-
apy nor focused on any single presenting problem (Barkham et al, 2006).
The client is asked to respond to 34 questions about how they have been
feeling over the last week, using a 5-point scale ranging from not at allto
most or all of the time. The 34 items of the measure cover four dimen-
sions: The CORE-OM comprises 4 domains:
Well-being (4 items)
Problem Solving (12 items)
Life Functioning (12 items)
Risk (6 items).
In the early 2000s numerous studies were undertaken in a range of psycho-
logical settings to confirm validity and identify the differences between clinical
and non-clinical populations when measuring overall distress (Mellor-Clark
et al., 2006, Connell et al., 2007). The clinical distress score is calculated as a
mean of completed items multiplied by 10, thus scores can range from 0 to
40. The published clinical cut off score is 10 (Connell et al., 2007) and clinical
scores are categorized into Mild 10-14, Moderate 15-19, Moderate/Severe 20-
25 and Severe <25 (Barkham, Mellor-Clark, & Stiles, 2015).
The CSBD supplement
The CSBD Supplement was devised for the client to self-record three areas
of their problem behavior as they perceive it during a time of active
SEXUAL ADDICTION & COMPULSIVITY 3
addiction. Initially the questionnaire asked for scoring based on the previ-
ous week, in the same way as CORE OM, but since many clients will have
been shocked into abstinence, and hence not engaged in any behaviors in
the week prior to joining a group, it soon became clear that this measure-
ment would be meaningless. Regrettably this meant disposing of much of
our earlier data. The three questions on the CSBD Supplement are:
Q1 How often have you acted out?
Q2 How often have you fantasised about your acting out behaviours?
Q3 How often have you struggled with intrusive thoughts and feelings about
your behaviour?
The type of acting out behavior will vary from client to client and
includes any behavior that the client has determined as compulsive,
whether thats viewing pornography, visiting sex workers, cruising or using
adult hookup apps. Like CORE OM, there is a 5-point scale ranging from
0not at all to 4 most of the time. At three-month and six-month fol-
low up, the CORE Supplement asks for a self-report of the same three
questions over the previous week.
Scoring
For practitioners to assess meaningful improvement over the course of
therapy, two numeric changes are essential: reliable change and clinically
significant change. Reliable change is change that exceeds that which might
be expected by chance alone or measurement error and for the CORE-OM
is represented by a change of 5 or more in the clinical score. Clinically sig-
nificant change is indicated when a clients CORE score moves from the
clinical to the non-clinical population, i.e. client scores above 10 at intake
and below 10 after therapy (Barkham et al., 2006).
The CSBD Supplement is scored on the principle that the maximum pos-
sible change of 4 is clinically significant and rating lower score changes
simply as þþþve for a 3 point change, þþve for a 2 point change,
and þve for a 1 point change.
Participants and method
Over the past 10 years, 305 clients with sex and/or pornography addiction
have attended a Hall Recovery Course. Approximately 30% of these clients
have been referred onto the group program by an external therapist or
health professional who they are working with individually and the rest are
working with therapists within the Laurel Centre. All clients are assessed
using the Sex Addiction Severity Assessment Tool (SASAT) to confirm the
4 P. HALL AND J. DIX
presence of sexually compulsive behaviors (Hall, 2018) and all those who
are eligible will be offered a place on the Hall Recovery Course. Recovery
group work is not suitable for all clients, such as those who have commit-
ted a sexual offense or have been diagnosed with a personality disorder.
Furthermore, some clients prefer not to engage in group work, in spite of
the additional benefits that it can provide (Hall & Larkin, 2019).
We began using CORE OM along with a supplement tailored for CSBD
from the first cohort in 2009, but regrettably it wasnt until we began to
analyze the data in 2016 that we discovered an error in reporting, as dis-
cussed earlier. Hence the participants used in this study are those who have
attended courses since 2017. The eight clients who did not attend the
three-month follow up day where the first follow up evaluation is com-
pleted have not been included.
During contracting, clients are informed of our evaluation protocol,
namely to complete the self-assessment forms on day one of the course, at
the follow up day three months later, and thereafter electronically at four
further six monthly intervals, and signed consent is received. We do not
ask for completion at the immediate end of the six-day program as six
days of sobriety is not deemed to be meaningful. Furthermore, most clients
leave the course on day six with feelings of hopeful elation, which inevit-
ably wear off over the next few days. We will explore this later, but need-
less to say, measuring psychological outcomes on that day would also not
be meaningful. The vast majority of clients do return for the three-month
follow up, but regrettably there is significant drop out at the subsequent six
monthly points. Consequently this study only extends to the first six month
evaluation though it is hoped that a later paper will extend further.
Analysis of data CORE OM
Severity of distress
On intake, a total of 85% of participants scored above the cut off on CORE
OM and were therefore categorized to be experiencing clinical distressas
can be seen by Table 1. It is widely accepted that sexually compulsive
behaviors are widely used to anesthetize against painful and difficult
Table 1. Measures of clinical distress.
On intake 3 months 6 months
n%n%n%
Healthy 18 15% 73 61% 26 72%
Mild distress 27 23% 25 21% 5 14%
Moderate 27 23% 13 11% 5 14%
Moderate-Severe 29 24% 7 6% 0
Severe 18 15% 1 1% 0
TOTAL 119 119 36
SEXUAL ADDICTION & COMPULSIVITY 5
emotions and many people do not seek addiction recovery until they have
hit some kind of rock bottom. Therefore, it is not surprising that so many
of the cohort were struggling. Recovery means much more than simply
stopping the behaviors, but also resolving underlying causes and developing
positive coping strategies, hence measuring distress is an essential compo-
nent of measuring efficacy of a recovery program. The figures in Table 1
represent a significantchange of 36%, ie moving from a measure of clin-
ical distress to healthy; and a reliablechange, ie more than might be
expected by chance, of 30%.
Risk
In the survey conducted for Understanding and Treating Sex Addiction
(Hall, 2012), 19% of the 350 participants had actively considered suicide as
a direct consequence of their acting out behaviors. In light of these statis-
tics, measuring risk on intake is essential for ethical practice. According to
CORE OM, of the 119 participants in this research, on intake, 67 (56%)
were at risk of harming themselves, 19 (16%) of these were at serious risk
of harm. At three-month follow up, that had reduced to 40 (34%), 10 (8%)
of which were at serious risk of harm and at six-month follow up, 11
(30%) with just 1 person at serious risk of harm.
General scores
Improvements were seen across the board in subjective well-being, problem
solving and also life functioning. For those who completed the six-month
follow up, these improvements had mostly maintained or improved further.
Those that achieved a significant or reliable change, as explained earlier
under scoring, at three-month follow up and six-month follow up are sum-
marized in Table 2.
Summary
At three-month follow up, of the 101 participants experiencing distress,
66% reported a significant or reliable improvement and a further 6 partici-
pants had moved to clinically healthy by six month follow up. 30% of the
67 participants who reported risk had significantly or reliably improved at
three-month and an additional 3 had significantly or reliably improved by
six-month follow up. When looking at overall scores for well-being, prob-
lem solving and life-functioning, 61% reported a significant or reliable
improvement and this increased by a further 5% at six months.
6 P. HALL AND J. DIX
Analysis of data CSBD supplement
When considering compulsive behaviors its important that attention is
paid not just to the time spent actively engaged in the behavior, ie acting
out, but also the level of preoccupation, both cognitively and emotionally.
Some of the preoccupation, such as fantasy, will be pleasurable, but at other
times it may be perceived as intrusive and unwanted. On intake, 82% of
clients acted out most of the time(36%) or often(46%). A total of 76%
fantasized about their acting out behavior most of the time (34%) or
often42%, and a total of 80% struggled with intrusive thoughts and feel-
ings about their compulsive behavior, 18% most of the timeor
often(62%).
As you can see in Table 3, there is a significant reduction in all three
areas at three-month follow up, though proportionally this has increased
slightly at six- month follow up. However, of the 36 that have been fol-
lowed from intake to six month, all but one participant had maintained the
changes from their three-month follow up.
When looking at overall improvement on the CSBD Supplement at
three-month follow up, 97% had a positive improvement in acting out with
the final 3% remaining the same. 88% saw an improvement in fantasy and
87% had improved with regard to intrusive thoughts and feelings. In these
two areas, 4% reported an increase in fantasy and intrusive thoughts and
feelings, which is perhaps to be expected if physical acting out has reduced.
Discussion
Due to the relatively low response rate at six month follow up, this discus-
sion focuses on the results at three-month follow up.
A significant percentage of clients struggling with CSBD present for ther-
apy whilst also experiencing clinical distress and just over half of these are
also at risk of harming themselves with 1 in 6 at serious risk of harm. At
three-month follow up, 58% report a reliable or significant improvement in
distress, but this leaves 23% reporting negligible change and 18% reporting
that they feel worse. And whilst risk had improved significantly or reliably
Table 2. Measures of well-being, problem solving and life functioning.
3-month (119) 6 month (36)
Significant Reliable Total Significant Reliable Total
n%n%n%N%
Well-being 24 21% 48 42% 63% 16 44% 5 14% 58%
Problem Solving 27 24% 36 32% 56% 14 39% 8 22% 61%
Life Functioning 37 33% 24 21% 44% 12 33% 8 22% 55%
All items (less risk) 35 29% 34 28% 58% 18 50% 4 10% 60%
SEXUAL ADDICTION & COMPULSIVITY 7
for 30% of the at-risk clients, the change had either been negligible (45%)
or had increased (25%) for others.
When this is held in contrast to the reported improvement in compulsive
behaviors of 97% improvement in acting out behaviors, with just 3%
reporting negligible change and 0% reporting worse, the simple conclusion
could be that giving up compulsive sexual behaviors is bad for your mental
health! So whats going on?
In addiction work, sobriety and recovery have long been recognized as
separate. Sobriety describes the state where someone has achieved abstin-
ence, be that from dependency on substances or behaviors, whilst recovery
describes an active engagement in behaviors that create a meaningful and
fulfilling lifestyle, without the dependency. Sobriety without recovery is
often referred to as white-knuckling, the unwanted behaviors have ceased,
but there has been no positive replacement of healthy coping strategies and
no resolution of underlying emotional and psychological issues that may
have contributed to the development of the dependency. As these differen-
ces have gained wider acceptance, there has been growing recognition
within the field of chemical addiction that outcome measures need to focus
on quality of life measures, not just sobriety, and indeed that improved
quality of life, may significantly decrease the likelihood of relapse (Dennis,
Foss, & Scott, 2007, Kaskutas et al., 2014, Laudet, 2011).
A common finding in field of chemical recovery is that in the first year,
things may get worse, in particular during the first six months, notably
happiness and self esteem (Kelly, Greene, & Bergman, 2018). If compulsive
behaviors and addictive substances are an anesthetic, then perhaps its inev-
itable that life will get worse as the anesthetic wears off and the difficulties
that have hitherto been numbed, come back into sharp relief. Furthermore,
for many struggling with sexually compulsive behaviors there may be
immediate harmful consequences that need to be faced, such as the impact
the behavior has had on a partner and family life, and/or work and social
life. For many people with CSBD, the point of seeking therapy is one where
Table 3. Measures of acting out.
Intake (119) Most of
the time or often
3-month (119) Most of
the time or often
6-month (36) Most of
the time or often
n%n%N%
How often have you engaged
in compulsive
sexual behavior?
98 82% 5 4% 4 11%
How often have you fantasized
about your
compulsive behavior?
90 76% 9 7.5% 5 13%
How often have you struggled
with intrusive thoughts and
feelings about your
compulsive behavior?
96 80% 21 17% 7 19%
8 P. HALL AND J. DIX
their life feels completely out of their control and they have the least
resources to be able to manage it.
Another phenomenon that may be contributing to the reduction in out-
comes at three-month is whats commonly known as pink cloud syn-
drome. The term pink cloudis thought to come from the AA fellowships
where it was used to describe the very early days after detox when many
people describe themselves as being high on life. Without the haze of
intoxication, or perhaps the numbness of compulsive behaviors, the rest of
life begins to be seen. There can be a renewed sense of hope, greater
insight and self-awareness, a renewed commitment to achieve a fulfilling
life and when group work is undertaken, a community of friends who may
know you more intimately than anyone else in the world. This is certainly
our experience on day six of our residential program when attendees depart
amidst joyful hugs and tears and resolute determination to change their
life. Whilst we have always known that this experience is temporary, the
results of this survey give us the facts to back up our encouragement to
continue in individual therapy. No doubt many clients are disappointed
when they return for the three-month follow up with the realization that
their compulsive behavior really was a symptom of other issues in their
life, issues that they must now address if they want to maintain recovery.
Indeed, it may be that without the distraction of their behaviors, clients are
faced for the first time with the reality of their impoverished lives.
Whilst group therapy such as the Hall Recovery Course can be a life-
changing experience, as many of our testimonials bear witness, for most it
marks the beginning of the recovery journey, not the end. It is not an alter-
native to ongoing individual therapy to address trauma and attachment
wounds and develop positive self-soothing strategies, nor couple therapy to
repair trust and rebuild intimacy. Without these additional therapeutic
interventions, the common phenomenology of intense remorse, regret, guilt
and a sense of hopelessness may not be navigable and relapse becomes
more likely (Kelly et al., 2018).
Conclusion and implications
According to CORE OM, 85% of people struggling with compulsive sexual
behaviors present during a time when they are also experiencing clinical
distress and hence its important that clinicians take a holistic therapeutic
approach and do not simply focus on reducing unwanted sexual behaviors.
Furthermore, 67% who present for help are at risk and therefore it is
imperative that therapists undertake a detailed assessment and are equipped
to refer when appropriate.
SEXUAL ADDICTION & COMPULSIVITY 9
The Hall Recovery course is effective in significantly reducing compulsive
sexual behaviors along with fantasy and intrusive thoughts and feelings.
For most, the course is also effective at improving general feelings of well-
being and reducing risk. However, for an important minority, risk of self-
harm increases as does psychological distress. These statistics emphasize
the importance of an integrative treatment approach that includes individ-
ual and couple therapy in addition to group work programs to ensure
improved quality of life and long-term recovery.
Further research is needed into this data to drill down into the four
domains of CORE OM to understand more about the specific changes in
well-being, functioning, problem solving and risk. And as more follow ups
are undertaken, it will be beneficial to see how clientsemotional, psycho-
logical and behavioral recovery continues at the six-month, 12-month, 18-
month and 24-month marks. In the meantime, this data will be used to help
clients on the Hall Recovery Course to understand the importance of con-
tinuing their journey of recovery with on going therapeutic interventions.
Conflicts of interest
As lead author, I am also creator of the Hall Recovery Course and clinical
director of the Laurel Center where the services and research
was undertaken.
Funding
No financial support was received for this study
ORCID
Paula Hall http://orcid.org/0000-0002-3012-0201
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SEXUAL ADDICTION & COMPULSIVITY 11
... Five further studies focused on treatments for CSBD with reporting that PPU is the main problem or one of the main problems (Hallberg et al., 2017;Hardy, Ruchty, Hull, & Hyde, 2010;Kjellgren, 2018;Raymond et al., 2010;Savard et al., 2020). The majority of studies (n 5 12) investigated CSBD without further information on the extent of pornography use (Coleman, Gratzer, Nesvacil, & Raymond, 2000;Efrati & Gola, 2018;Hallberg et al., 2019Hallberg et al., , 2020Hall, Dix, & Cartin, 2020;Hartman, Ho, Arbour, Hambley, & Lawson, 2012;Kafka & Hennen, 2000;Klontz, Garos, & Klontz, 2005;Wainberg et al., 2006;Wan, Finlayson, & Rowles, 2000;Wilson & Fischer, 2018). ...
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Background and aims: Compulsive sexual behavior disorder (CSBD) which includes problematic pornography use (PPU) is a clinically relevant syndrome that has been included in the ICD-11 as impulse control disorder. The number of studies on treatments in CSBD and PPU increased in the last years. The current preregistered systematic review aimed for identifying treatment studies on CSBD and PPU as well as treatment effects on symptom severity and behavior enactment. Methods: The study was preregistered at Prospero International Prospective Register of Systematic Reviews (CRD42021252329). The literature search done in February 2022 at PubMed, Scopus, Web of Science, and PsycInfo, included original research published in peer-reviewed journals between 2000 to end 2021. The risk of bias was assessed with the CONSORT criteria. A quantitative synthesis based on effect sizes was done. Results: Overall 24 studies were identified. Four of these studies were randomized controlled trials. Treatment approaches included settings with cognitive behavior therapy components, psychotherapy methods, and psychopharmacological therapy. Receiving treatment seems to improve symptoms of CSBD and PPU. Especially, evidence for the efficacy of cognitive behavior therapy is present. Discussion and conclusions: There is first evidence for the effectiveness of treatment approaches such as cognitive behavior therapy. However, strong conclusions on the specificity of treatments should be drawn with caution. More rigorous and systematic methodological approaches are needed for future studies. Results may be informative for future research and the development of specific treatment programs for CSBD and PPU.
... Twelve-step programs, couples therapy, and psychodynamic therapy have also been suggested for the treatment of CSBD, although there is less supporting research for these approaches [46]. Psychoeducational group therapy for CSBD reduced intrusive thoughts and compulsive sexual behavior for most group members but did not reduce clinical distress, which may require additional ongoing support [67]. ...
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