The Clinical Assessment and Treatment of Sex and Porn Addiction Robert Weiss LCSW, CSAT-S Founding Director - The Sexual Recovery Institute Director of Sexual Disorder Programs, Elements Behavioral Health Promises, The Ranch & The Sexual Recovery Institute Note: This presentation will demonstrate methods utilized to access online sexual experiences. Explicit images will not be shown, however please carefully consider if learning such information might prove harmful to your personal recovery.

The Problem

Fmr. Congressman Anthony Weiner Fmr. President Bill Clinton Actor David Duchovney Actor Jesse James Fmr. Governor Elliot Spitzer Fmr. Governor Mark Spencer Fmr Sports Hero Tiger Woods Fmr. Chief Dominique Strauss-Kahn Fmr. Governor Arnold Schwarzenegger Fmr. Congressman Anthony Weiner All are men whose sexual behavior MORTALLY WOUNDED their ability to lead. But what if their problem had been drinking or drugs like Congressman Patrick Kennedy?

Is Sexual Addiction A Mental Health Diagnosis ? Was in the DSM III Was out of the DSM IV Now being considered for the DSM V (Hypersexuality)

Sex Addiction is not Axis I Symptom- we r/o out ADD/OCD/Bipolar A Moral or Religious Stance Fun Fetish / Paraphilia Same Sex Interest or Activity Crystal Meth Addiction Sexual Offending - non consensual

Sexual Addiction Symptoms Follow the Characteristics of All Addictions Criteria for Sex Addiction parallels guidelines for assessing Substance Dependency, Alcoholism, and Compulsive Gambling: Loss of control Continuation despite adverse consequences Obsession or preoccupation The presence of these three criteria operationally define addiction to both substances and behaviors

Typical Sex Addict Behaviors Compulsive Use of Porn (with or without masturbation) Anonymous Sex (met online or in sex clubs etc.) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and Massage Parlors Cruising, Intriguing, Objectifying, Seduction Pushing Boundaries, Boundary Violations Multiple Affairs / Anonymous Infidelity GPS SmartPhone Hook-ups Sexting / Abusing Social Networks

Addicted to sex? Increased Heart Rate Pupils Dilate Hearing More Acute Shallow Breathing Perspiration- palms, underarms, etc. “Rush” or “Intensity” Feeling Reduced Intellectual Functioning!

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

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

In 12-Step Language ... POWERLESS!

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

The Process Addictions Gambling Internet Gaming Workaholism Binge Eating Sex Exercise Religion Spending High Risk Behavior

Sexual Addiction Symptoms in Residential or Outpatient Clients By 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 Chronic or Compulsive Masturbation with or without porn

Sexual Addiction Symptoms in Residential or Outpatient Clients By 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.

The Betrayed Spouse

Initial concern for this spouse is physical and emotional safety Physical health -STD’s, Pregnancy Family safety - Children at risk? Specific betrayals that might overwhelm or undermine later

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.” Can engage in compulsive behaviors such as ‘detective work’ or stalking Often seems to be on a mood ‘roller coaster’. 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.

Which one is (s)he? An Axis II Diagnosis -Borderline, extreme Codependency etc. Profoundly 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 ...

We believe she is on an Emotional Roller-coaster

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.

The clinical needs of this spouse. 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 PEER SUPPORT as well as support by professionals Structure toward moving forward Hope

Sex and Tech

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?

Access Affordability Anonymity What has changed in our experience of sexual content & sexual contact over the past 20 years Access Affordability Anonymity * Cooper, Del Monico et al 1998 - 1999

How long did it take for the following technologies to reach 50 million participants following public introduction? Radio - 38 years Television - 13 years Internet - 4 years Social Networking - 16 months! Whatever comes next will happen close to instantaneously. It will be in our lives before we know it our fully understand it. So get ready.

Sexual Access Timeline 1.0 Pre-history - 1890 Recreational and Intimate Sexuality Cave, drawn and painted pornography Affairs & Infidelity Public Baths Prostitutes & Harems Masturbation to fantasy

Sexual Access Timeline 2.0 1890 - 1970’s All of the above plus ... Photographic Porn Porn Movies (XXX) Adult Bookstores, Porn shops Bath-houses & Strip clubs

Sexual Content Access 3.0 1977 - 1990 All of the above plus ... Video = VCR and BETA Phone Sex Softcore on cable TV- at home “Adult” and “Escort” Sections in Yellow Pages, magazines and newspapers

Sexual Content Access 4.0 1990 - 2004 All of the above plus ... BBS - Online bulletin board systems (BBS) Websites for porn and prostitution Online Porn and file transfer sites Chat Rooms Online Hook-ups - i.e. craigslist Webcams and interactive live sex

Sexual Content Access 5.0 2004 - Present All of the above plus ... Sexting and live video streaming from your smart phone Smart Phones with GPS hook-up apps Social Networks (facebook, twitter, mySpace) Virtual World Sex (2nd-Life, virtual games etc) 3-D Imagery and Teledildonics

And some are using it to offend ... About Sexting Tell story about young offender at SRI - Exhibitionist/Voyeur Eewwwwwwwww! And some are using it to offend ...

facehooked? “Before entering treatment I was spending up to 5 hours a night some nights cruising facebook for sex. Well, not for sex exactly, it was more cruising for faces and profiles I thought might respond to me. I was looking for friendly, engaging women, then leaving messages, poking them, trying to get a response from someone who cared. Then we would take it from there ... ” - A 32 year old married SRI-IOP client

About Smartphones GPS locators mean immediate live access to sexual partners and sexual content- Universal Internet access anywhere - to porn, to sexually oriented environments (strip clubs, adult bookstores, etc) Not ‘trackable’ like a computer history Live video streaming to phones and pads- Let’s look at this more closely ...

There’s an app for that! So what’s an app? Apps are applications that you load from the Internet onto your smart phone or ‘pad’ to perform specific functions. For example - if you load a dictionary app onto your phone- you can then use your phone to look up words and spelling from your phone Sex apps are the same - loaded from to your phone to help find sexual partners.

Apps you should know about Ashley Madison - for married men and women Grindr - for gay men

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 9-million members internationally In May 2011 – 1,3 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

Teledildonics with your Wii... 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, allowing remote partners to simultaneously enjoy each others stimulations.

Treatment

Initial Sexual Addiction Treatment Is Cognitive Behavioral Behavioral disorders require behavioral forms of treatment -not Jungian, Psycho-analytic, Somatic Narrative etc. In Outpatient- we don’t delve deeply into trauma or transference until 90-days sober at minimum In Residential - we can delve into deeper issues sooner and more directly - but still stay focused on the primary goal which is always establishing sobriety and relapse prevention

Required Treatment Steps When Working with Sex Addicts Do a thorough psycho-sexual history/assessment Identify the treatment goals of the client and then co- create a sexual sobriety contract aligned with those goals. Hold clients accountable to all their agreements! Confront denial 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

Elements Behavioral Health Assessment & Treatment Options - The Sexual Recovery Institute (SRI) - Los Angeles- 2- weeks of Intensive Treatment- Structured, manualized programming. Clients stay at a men’s recovery residence - Psycho-sexual and Fitness for Duty Assessment, www.sexualrecovery.com The Ranch in Tennessee - 35 Days of Residential Sexual Addiction Treatment with Extensive Trauma and Family Component - www.recoveryranch.com Promises Malibu or West Los Angeles- Primary CD Treatment with a focus where needed on Sexual Disorders and access to SRI clinicians or full IOP where needed. www.promises.com

What is Sexual Sobriety? Rarely complete abstinence A mutually agreed upon clear, written and signed, behavioral contract based on client goals. Sobriety plans don’t change without prior discussion.

Sexual Sobriety Contract 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

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

Want to Learn More? The Sexual Recovery Institute www.sexualrecovery.com The Ranch www.recoveryranch.com IITAP - International Institute for Trauma, and Addiction Professionals www.iitap.com SASH - The Society for the Advancement of Sexual Health www.sash.net E-summits www.e-summits.com Online and Video learning with available CEU’s

The Clinical Assessment and Treatment of Sex and Porn Addiction Robert Weiss LCSW, CSAT-S Founding Director - The Sexual Recovery Institute Director of Sexual Disorder Programs, Elements Behavioral Health Promises, The Ranch & The Sexual Recovery Institute Note: This presentation will demonstrate methods utilized to access online sexual experiences. Explicit images will not be shown, however please carefully consider if learning such information might prove harmful to your personal recovery.