1. CSL 513: Sexual Disorders Matthew Tiemeyer, MA, LMHC Fall 2013 For PowerPoint and Word versions: http://www.blueharborcounseling.com/sstp In the Field: Sex Addiction

2. 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.”

3. 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

4. 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.

5. 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

6. 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.

7. Sex Addiction – Carnes’s Definition 6. Frequent engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations. 7. 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. 8. 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. 9. Giving up or limiting social, occupational, or recreational activities because of the behavior. 10. Distress, anxiety, restlessness, or irritability if unable to engage in the behavior.

8. 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, tension- relief, 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.

9. Sex Addiction – Collateral Indicators 11. 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. 12. Has history of deception around sexual behavior. 13. Reports other members of the family are addicts. 14. Expresses extreme self-loathing because of sexual behavior. 15. Has few intimate relationships that are not sexual. 16. Is in crisis because of sexual matters. 17. Has history of crisis around sexual matters. 18. Experiences anhedonia in the form of diminished pleasure for same experiences. 19. Comes from a "rigid" family. 20. Comes from a "disengaged" family.

10. 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

11. 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.

12. 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”

13. 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.

14. 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

15. The Addictive Cycle Belief System Impaired Thinking Unmanageability Preoccupation Ritualization Compulsive Behavior Addictive Cycle Despair Guilt Shame © 2008

16. Etiology and Theory understanding the addiction’s inner workings, informing intervention

17. Etiology Carnes: Addiction is a developmental disorder Schwartz et al. suggest that addiction is an intimacy disorder

19. 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

20. 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

21. Abuse Dynamics Addicts report startling frequencies of past abuse: 81% report a history of sexual abuse 72% report physical abuse 97% report emotional abuse

22. 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

23. Mirror of Erised

24. 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

25. Arousal Template Carnes: “(arousal template) … usually contains a scenario based on an abuse experience, a fantasy, or something historical.” Story Elements Arousal Template Acting Out Behaviors

26. 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

27. 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

28. 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.”

29. Recovery defining and pursuing

30. 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

31. 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

32. A Recovery Cycle (Phil Prothero)

33. 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

34. 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

35. 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

36. 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

37. 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…

38. 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

39. 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

40. Working With Partners affirming, including, addressing “Wrong Number”…

41. 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

42. 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.

43. 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

44. 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

45. 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.

46. 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?

47. Q & A