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The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs:

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Presentation on theme: "The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs:"— Presentation transcript:

1 The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs: Elements Behavioral Health Promises The Ranch The Sexual Recovery Institute (SRI) The Recovery Place

2 Myths: Sexual Addiction is not... A symptom of a separate major mental health disorder. We first assess for ADD/OCD/Bipolar Disorders and Active Drug Abuse Poorly Researched Fun Symptomatic of Moral or Religious failing Sex negative or a cultural bias Fetish Behavior Same Sex Interest or Activity Crystal Meth Addiction Sexual Offending - non consensual A symptom of a separate major mental health disorder. We first assess for ADD/OCD/Bipolar Disorders and Active Drug Abuse Poorly Researched Fun Symptomatic of Moral or Religious failing Sex negative or a cultural bias Fetish Behavior Same Sex Interest or Activity Crystal Meth Addiction Sexual Offending - non consensual

3 Typical Sex Addict Behaviors Compulsive Use of Porn (with or without masturbation) Anonymous Hook-ups (met online) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and Sensual Massage Parlors Cruising, Intriguing, Objectifying, Seduction Pushing Boundaries, Viewing no as a challenge Multiple Affairs / Anonymous Infidelity SmartPhone Hook-ups -using APPS Sexting / Abusing Social Networks / Virtual Sex Crossing Professional Boundaries Living a Double Life - compartmentalization Compulsive Use of Porn (with or without masturbation) Anonymous Hook-ups (met online) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and Sensual Massage Parlors Cruising, Intriguing, Objectifying, Seduction Pushing Boundaries, Viewing no as a challenge Multiple Affairs / Anonymous Infidelity SmartPhone Hook-ups -using APPS Sexting / Abusing Social Networks / Virtual Sex Crossing Professional Boundaries Living a Double Life - compartmentalization

4 Addiction 2011: Current Definition Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. ASAM 2011

5 Is Sexual Addiction a valid Mental Health Diagnosis ? Was in the DSM III - as a descriptor Was out of the DSM IV No longer being considered for the DSM 5 as: (Hypersexual Disorder) Was in the DSM III - as a descriptor Was out of the DSM IV No longer being considered for the DSM 5 as: (Hypersexual Disorder)

6 The Sexual Addiction Diagnosis Follows the Characteristics of All Addictions Criteria closely parallels guidelines for assessing Substance Dependency, Alcoholism, and Compulsive Gambling: Loss of control Continuation despite adverse consequences Obsession or preoccupation The presence of all three criteria operationally define addiction to any drug or behavior Criteria closely parallels guidelines for assessing Substance Dependency, Alcoholism, and Compulsive Gambling: Loss of control Continuation despite adverse consequences Obsession or preoccupation The presence of all three criteria operationally define addiction to any drug or behavior

7 What does it mean to not have a Diagnosis Moral Judgement Religious Abuse Misdiagnosis Misdirected Treatment- often with meds Think Alcoholism prior to the 1970s Moral Judgement Religious Abuse Misdiagnosis Misdirected Treatment- often with meds Think Alcoholism prior to the 1970s

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10 How Can You Be Addicted to... Sex? Increased Heart Rate Pupils Dilate Hearing More Acute Shallow Breathing Perspiration- palms, underarms, etc. Rush or Intensity Feeling Reduced Intellectual Functioning! Increased Heart Rate Pupils Dilate Hearing More Acute Shallow Breathing Perspiration- palms, underarms, etc. Rush or Intensity Feeling Reduced Intellectual Functioning!

11 Sexual Addiction is the use of Intense Fantasy to Induce Neurochemical Release Serotonin - mood stability Dopamine - pleasure Adrenaline - energy, jolt Endorphins - calm Oxytocin - love/jealousy Serotonin - mood stability Dopamine - pleasure Adrenaline - energy, jolt Endorphins - calm Oxytocin - love/jealousy In essence it is a mechanism of neurological compensation or simply put- a brain problem

12 ADDICTS CALL IT… The Bubble The Trance Spaced Out Think... Dissociative State Trauma Self Soothing The Bubble The Trance Spaced Out Think... Dissociative State Trauma Self Soothing

13 In 12-Step Language... In 12-Step Language... POWERLESS!

14 Sex Addiction is not about sex or orgasm. It is about the search for sex and desire for orgasm. Its a Process Addiction.

15 The Process Addictions Gambling Internet / Video Gaming Workaholism Binge Eating Sex Exercise Spending Gambling Internet / Video Gaming Workaholism Binge Eating Sex Exercise Spending

16 Sexual Addiction Symptoms in Residential or Outpatient Clients In Assessment History Multiple abortions (females), multiple STDs (both sexes), repeated unprotected sex Previous arrest or major life consequences related to sex Drugs/Alcohol used to help tolerate or enhance sex History of previous sexual acting out in treatment Drug use fused with sexual behavior Multiple past failed relationships due to affairs or infidelity - intimacy disorder Chronic or Compulsive Masturbation with or without porn Leading an ongoing double (romantic or sexual) life In Assessment History Multiple abortions (females), multiple STDs (both sexes), repeated unprotected sex Previous arrest or major life consequences related to sex Drugs/Alcohol used to help tolerate or enhance sex History of previous sexual acting out in treatment Drug use fused with sexual behavior Multiple past failed relationships due to affairs or infidelity - intimacy disorder Chronic or Compulsive Masturbation with or without porn Leading an ongoing double (romantic or sexual) life

17 Sexual Addiction Symptoms in Residential or Outpatient Clients In Behavior Seductive Dress (especially after it is pointed out) Seeking out special relationships with other attractive clients or staff for advice, friendship and direction Giving the stare, being sexual in treatment History of CD relapse – especially females Encouraging Dependency as a form of seduction Sneaking & using porn in treatment - sharing porn in treatment. Consistent sexual references and objectification in jokes and conversation Lack of empathy about how their sexual behavior affects others. (13th step!) In Behavior Seductive Dress (especially after it is pointed out) Seeking out special relationships with other attractive clients or staff for advice, friendship and direction Giving the stare, being sexual in treatment History of CD relapse – especially females Encouraging Dependency as a form of seduction Sneaking & using porn in treatment - sharing porn in treatment. Consistent sexual references and objectification in jokes and conversation Lack of empathy about how their sexual behavior affects others. (13th step!)

18 Sex Addict: Countertransference Minimization – Joining in the clients need to minimize their behavior - Unsure or uncomfortable with content Colluding with in the devaluation/blaming the spouse Disgusted- creeped out by clients history and behaviors OR by their lack of affect when discussing them Angry- at clients lack or empathy or affect Angry- because maybe you dated this client once. Over identifying with the patients victim stance Frustrated - Dont you see what youre doing?! Caught in your own abandonment fears Seduced by their intellect, charm & encouragement of your dependency Minimization – Joining in the clients need to minimize their behavior - Unsure or uncomfortable with content Colluding with in the devaluation/blaming the spouse Disgusted- creeped out by clients history and behaviors OR by their lack of affect when discussing them Angry- at clients lack or empathy or affect Angry- because maybe you dated this client once. Over identifying with the patients victim stance Frustrated - Dont you see what youre doing?! Caught in your own abandonment fears Seduced by their intellect, charm & encouragement of your dependency

19 Brief Etiology of Sexual Addiction

20 How Do You Grow an (Sex) Addict? Sexual Abuse -overt and covert Early Attachment Deficits Social Anxiety- Social Avoidance Early trauma, neglect and abuse Parental Enmeshment - narcissistic parenting Pre-existing, untreated character pathology All of which keep the individual from learning to utilizing basic intimacy, socialization and support to meet healthy human dependency needs. Sex addicts seek... Intensity vs. Intimacy Sexual Abuse -overt and covert Early Attachment Deficits Social Anxiety- Social Avoidance Early trauma, neglect and abuse Parental Enmeshment - narcissistic parenting Pre-existing, untreated character pathology All of which keep the individual from learning to utilizing basic intimacy, socialization and support to meet healthy human dependency needs. Sex addicts seek... Intensity vs. Intimacy

21 The child who is used and/or abandoned emotionally by their parent has the chance to develop his intellectual capacities undisturbed, but not the world of his emotions and this will have far-reaching consequences for his well-being. Alice Miller: The Drama of the Gifted Child

22 Maladaptive, survival-based emotional coping (addiction) offers a sense of being in control when feeling needful (out of control) Self soothing Self Regulation- Calm Distraction / Dissociation Stimulation In the absence of and/or limited experience with healthier, more integrated relational means of self stability. To Show Vulnerability = SHAMEFUL

23 Most (sex) Addicts desperately seek something they can never achieve... Controllable Intimacy

24 The Betrayed Spouse

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26 How does he betray her right in this scene?

27 In a Primary Relationship, Active Addiction by one partner results in both Betrayal and Trauma for the other

28 Betrayal is the greatest source of pain to an addicts spouse. Its not so much the addicts drinking, using, spending, sexing etc. that causes the most hurt to a loving spouse - its the lying, broken promises and loss of trust. Betrayal is the greatest source of pain to an addicts spouse. Its not so much the addicts drinking, using, spending, sexing etc. that causes the most hurt to a loving spouse - its the lying, broken promises and loss of trust.

29 What is the Emotional State of a Betrayed Spouse? The betrayed spouses initial emotional state is a form of trauma: Fearful of further loss and abandonment Ashamed, remorseful, self doubting and isolated Anxious and Hypervigilent - easily triggered to previous levels of trauma Worried about the future -parenting, finances, separation Having intrusive thoughts and images Often having problems w/sleeping, eating, self-care

30 Diagnose this client Acts out in angry, vengeful, acts superficially supportive of treatment while actually undermining it. Often shifts from idealizing her spouse, therapist and treatment - to devaluing and dismissing them. Can be demanding and boundary-less. Expresses feeling out of control. Engages in compulsive behaviors such as detective work and stalking. Often seems to be on a mood roller coaster, it can hard to tell what mood will predominate, why and when. Mistrustful, suspicious, at times can be rageful and verbally abusive. Can act out by overeating, spending and other compulsive behaviors. Inconsistent and uncommitted to looking at her part or her issues - tends to externalize and blame.

31 Which one is she (he)? An Axis II Diagnosis -Borderline Profoundly and inexorably co-dependent. poor dear, she lost her self to him. A client who suffering from a profound life- trauma and grief reaction without meaningful support or direction. It might take a while before you know...

32 At SRI & The Ranch we believe she/he is on a trauma-induced emotional roller-coaster (PTSD)

33 How long can it take to get off this ride? 9-18 months, post-discovery/disclosure. Provided there is an active recovery process in place in place for both.

34 Stay I stay or should I go? We advise: If violence or harm to spouse are family are not present, give it 6 months to a year. Considerations for leaving involve: Social and Family Resources Finances Childcare Health Commitment to Healing (on both parts)

35 Initial clinical concern for spouse is safety Physical health -STDs, pregnancy Family safety - Children at risk? Specific betrayals that might overwhelm or undermine later

36 What are the clinical needs of this spouse? Concrete Direction regarding self-care, health issues, talking to family etc. Education about addiction, disclosure, family dynamics, support. Holding and Validation of her reality and her feelings Disclosure and clarity regarding their unknown history Social support by professionals (peers and family where useful) Structure toward moving forward Hope

37 At the heart of the spouses concerns... How do I know if this is all there is to know? How will I know if he acts out again? How is trust re-established?

38 This is how we explain his or her situation to the addict...

39 Sex and Technology The Evolving Influence of Social Media and Technology on Hypersexuality

40 Note the increasing pace of technological change in our lifetime. Radio - 38 years to 50 million people Television - 13 years to 50 million people Internet - 4 years to 50 million people Social Networking - 16 months to 50 million Smart Phone apps - 9 months to 50 million Whatever comes next will happen nearly instantaneously and in our lives before we know or even fully understand it. So get ready...

41 Online sexual content, chats and interaction has forced us to reassess sexuality in our culture. For example, today what do you consider to be… Online sexual content, chats and interaction has forced us to reassess sexuality in our culture. For example, today what do you consider to be… Infidelity?

42 What are the most profound changes in our experience of sexual content & sexual contact over the past 20 years? Access Affordability Anonymity * Cooper, Del Monico et al

43 Sexual Content Access Present 1. Sexting and live video streaming from your smart phone 2. Smart Phones with GPS & apps 3. Social Networks (facebook, twitter, mySpace) 4. Virtual World Sex (2nd-Life, virtual games etc) 5. Virtual Sex and Teledildonics 6. QR, AR codes and Chat Roulette

44 About Sexting Eewwwwwwwww! And some are using it to offend...

45 About Ashley Madison Started as a website - now also a mobile app - perfect example of content access progression AM Slogan: Life is short, have an affair. AM Mission Statement: To provide an interactive way for like-minded users to explore whether they wish to meet each other, chat with each other and/or explore extra- marital relationships Over 16-million members internationally In May million men and women used the service to contact a sexual partner in that single month 92% of males on the site sign in as married 68% of female members sign in as married

46 This ad was turned down by the 2010 Superbowl Committee but airs on late night cable and you-tube

47 Smartphones Wow! They have built-in GPS locators that can locate you in time and space! Universal Internet access anywhere! Live video streaming to phones and pads! They use Apps, which are individualized software programs written for a specific task!

48 Smartphones have apps to help you find friends too right here! Ashley Madison Grindr Blendr Spice Dice Etc.

49 Now lets take a closer look at these apps... Ashley Madison Grindr And something to make you feel better after...

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59 Smartphones have apps to help you pleasure yourself Flesh-light Companion My Pleasure-Vibrator

60 Teledildonics = Rudimentary Virtual Sex By hooking up the hardware components up to the two Wii- motes, wiggles and thrusts on the first Wii-mote are detected and sent via Bluetooth to a nearby computer. From there this information is sent over the Internet and reproduced by the other Wii-mote which acts as a Wii-brator on the other end,

61 Why Does Technological Advance Lead to Behavioral Escalation ? 1. Increasing access means decreasing inhibitors to impulsive problem behavior 2. Its just so easy to find, get, have and use... and faster! 3. Increasing accessibility thru phones and pads means sexual acting out is easier to hide 4. Those with preexisting social/emotional deficits (read teenagers, among others) no longer need to evolve a social skill set in order to be sexual 5. Certain sexual behavior considered illegal/offending/consequential in the real world is not so online

62 Sexual Addiction Treatment

63 Elements Has Three Levels Sexual Addiction & Related Sexual Disorders Treatment Intensive (SRI) - 2 weeks day-treatment while staying in a recovery residence- Los Angeles. Residential (The Ranch) (trauma/crisis related) - sex addicts and exhibitionists, voyeurs, some child porn offenders -non- contact - Tenn. Residential (SSDP at Promises Malibu) Drug addiction program for stimulant-drug addicts with concurrent sexual behavior. - Malibu, CA Intensive (SRI) - 2 weeks day-treatment while staying in a recovery residence- Los Angeles. Residential (The Ranch) (trauma/crisis related) - sex addicts and exhibitionists, voyeurs, some child porn offenders -non- contact - Tenn. Residential (SSDP at Promises Malibu) Drug addiction program for stimulant-drug addicts with concurrent sexual behavior. - Malibu, CA

64 Addiction Treatment Method vs. Psychotherapy Behavioral problems REQUIRE behavioral forms of intervention and treatment This includes structured steps and tasks Problem behaviors have to be contained FIRST before psycho-dynamic therapy and trauma work begins in earnest Group work is more effective than individual Healing maladaptive attachment is the slow work of long- term therapy, living honestly and 12-step involvement (2-3 years minimum). This is where Psychodynamic, Analytic, Jungian, Somatic and other forms of therapy are most effective

65 Required Treatment Steps When Working with Sex Addicts Do a thorough psycho-sexual history/assessment Confront Denial Identify the genuine client treatment goals and co-create a sexual sobriety contract or plan aligned with those goals. Hold clients accountable to all their agreements! Have client evaluated for psychotropic medication Educate and teach relapse prevention Get them into a sex addiction group therapy Find support for the spouse Direct healthcare, family and crisis resolution Refer to long-term 12-step, therapy or faith-based group support Do a thorough psycho-sexual history/assessment Confront Denial Identify the genuine client treatment goals and co-create a sexual sobriety contract or plan aligned with those goals. Hold clients accountable to all their agreements! Have client evaluated for psychotropic medication Educate and teach relapse prevention Get them into a sex addiction group therapy Find support for the spouse Direct healthcare, family and crisis resolution Refer to long-term 12-step, therapy or faith-based group support

66 What is Sexual Sobriety? A mutually agreed upon clear, written and signed, behavioral contract based on client goals. A mutually agreed upon clear, written and signed, behavioral contract based on client goals. Sobriety plans dont change without prior discussion. Sobriety plans dont change without prior discussion. Similar to how we handle eating disorders Similar to how we handle eating disorders A mutually agreed upon clear, written and signed, behavioral contract based on client goals. A mutually agreed upon clear, written and signed, behavioral contract based on client goals. Sobriety plans dont change without prior discussion. Sobriety plans dont change without prior discussion. Similar to how we handle eating disorders Similar to how we handle eating disorders

67 Sexual Sobriety Contract List of Behaviors I Want to Stop A B C D E F List of Behaviors I Want to Stop A B C D E F List of Behaviors I Want to Add A B C D E F List of Behaviors I Want to Add A B C D E F

68 The good news... Treatment and recovery are also entering the new media frontier. We all need to be aware of these options for our clients: Tele-meetings Online 12-step Chats Face to Face Skype Meetings Face to face video sponsorship Virtual Reality de-sensitization techniques...

69 12-step Support Groups for Sexual Addicts and Partners 12-step Support Groups for Sexual Addicts and Partners Partner Support S-Anon Alanon COSA CODA RCA - Couples Partner Support S-Anon Alanon COSA CODA RCA - Couples Sex Addict Support SAA SA SCA SLAA-Women SRA Sex Addict Support SAA SA SCA SLAA-Women SRA

70 The Sexual Recovery Institute The Ranch IITAP - International Institute for Trauma, and Addiction Professionals SASH - The Society for the Advancement of Sexual Health E-summits Online and video learning with available CEUs The Sexual Recovery Institute The Ranch IITAP - International Institute for Trauma, and Addiction Professionals SASH - The Society for the Advancement of Sexual Health E-summits Online and video learning with available CEUs Sexual Addiction Information

71 The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs: Elements Behavioral Health Promises The Ranch The Sexual Recovery Institute (SRI) The Recovery Place


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