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

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

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)

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

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 1970’s

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!

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
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

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

14. 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.

15. The Process Addictions
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

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!)

18. Sex Addict: Countertransference
Minimization – Joining in the client’s need to minimize their behavior -
Unsure or uncomfortable with content
Colluding with in the devaluation/blaming the spouse
Disgusted- “creeped out” by client’s history and behaviors OR by their lack of affect when discussing them
Angry- at client’s lack or empathy or affect
Angry- because maybe you dated this client once.
Over identifying with the patient’s victim stance
Frustrated - “Don’t you see what you’re 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

21. Set up Art Therapy Story
“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
Set up Art Therapy Story

22. From looking out of windows to looking at porn
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
From looking out of windows to looking at porn

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

24. The Betrayed Spouse
Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

26. How does he betray her right in this scene?
Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

27. In a Primary Relationship, Active Addiction by one partner results in both Betrayal and Trauma for the other
Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

28. Betrayal is the greatest source of pain to an addict’s spouse
Betrayal is the greatest source of pain to an addict’s spouse. It’s not so much the addict’s drinking, using, spending, sexing etc. that causes the most hurt to a loving spouse - it’s 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 -STD’s, 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…
Infidelity?

42. Access Affordability Anonymity
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 2004 - Present
Sexting and live video streaming from your smart phone
Smart Phones with GPS & apps
Social Networks (facebook, twitter, mySpace)
Virtual World Sex (2nd-Life, virtual games etc)
Virtual Sex and Teledildonics
QR, AR codes and Chat Roulette

44. 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 ...

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 let’s take a closer look at these apps ...
Ashley Madison
Grindr
And something to make you feel better after ...

58. \

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 ?
Increasing access means decreasing inhibitors to impulsive problem behavior
It’s just so easy to find, get, have and use ... and faster!
Increasing accessibility thru phones and pads means sexual acting out is easier to hide
Those with preexisting social/emotional deficits (read teenagers, among others) no longer need to evolve a social skill set in order to be sexual
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

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
Discuss that the therapeutic relationship is formed by the therapist acknowledging and confronting the defenses and adaptations that no longer work.

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

66. What is Sexual Sobriety?
A mutually agreed upon clear, written and signed, behavioral contract based on client goals.
Sobriety plans don’t change without prior discussion.
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 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
Sex Addict Support
SAA SA
SCA
SLAA-Women
SRA
Partner Support
S-Anon
Alanon
COSA
CODA
RCA - Couples

70. Sexual Addiction Information
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 CEU’s

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