Tag Archives: behavioral addiction

Addicted to sex?

By Amanda L. Giordano and Craig S. Cashwell August 7, 2018

Sex and sexuality are necessary, healthy and, arguably, sacred aspects of the human experience. What happens, though, when sex is used not to enhance intimacy and connection with others but, rather, becomes out of control? What happens when a person describes a clear set of personal values around sexual behavior yet consistently crosses his or her own boundaries and compromises personal sexual values? What happens when a person continues a pattern of sexual behavior despite detrimental consequences? Can a person be addicted to sex?

Although most forms of sexual expression are healthy, the sex addiction model posits that some individuals may develop compulsive, dependent relationships with sex. Critics of the sex addiction model suggest that the addiction label pathologizes nonnormative sexual behaviors (e.g., fetish, kink), yet true proponents of the model do not claim to define morally appropriate forms or frequencies of sexual acts. The focus, rather, is on one’s relationship with sex.

Just because a sexual behavior violates an individual’s personal values, religious or spiritual beliefs, or societal norms does not make it an addiction. Instead, sex addiction has specific defining characteristics:

Loss of control
Continued engagement despite negative consequences
Mental preoccupation or cravings

Thus, rather than being sex-negative, advocates of the sex addiction model work to identify those who are unable to control their sexual behavior, are experiencing distressing outcomes and are mentally preoccupied or craving sex. Once sex addiction is determined, individuals then can get the treatment and support they need to establish healthy sexuality.

A topic for debate

The notion that sex can be addictive still is debated among mental health professionals. Instead of addiction, alternative explanations for problematic sexual behaviors include impulse-control issues, obsessive-compulsive disorder, neuroticism, learned behavior, a form of sensation seeking, internalized sex-negative messages or manifestations of a mental health issue such as bipolar disorder.

The addiction model, however, purports that the primary issue is an out-of-control relationship with sex resulting from changes in chemical messengers in the brain. Specifically, naturally reinforced behaviors, such as eating and sex, are linked to the release of neurotransmitters (i.e., dopamine) related to pleasure and reinforcement. A naturally rewarding behavior such as sex can become a supernormal stimulus leading to dysregulation in the dopaminergic system. The resulting neuroadaptations affect reward, memory, attention and motivation. Thus, from an addiction model perspective, sex can hijack the natural functioning of the reward pathway in some individuals, leading to addictive behavior.

The sex addiction model contends that in addition to being positively reinforcing through the release of dopamine and other neurotransmitters, sex can be negatively reinforcing. Over time, sex can become addictive when it is used as the primary or, sometimes, sole method of regulating undesirable emotions. In other words, sexual behavior can be negatively reinforcing when it functions as an avoidance strategy and is used to escape emotional pain. In a negative feedback loop, however, the individual often feels shame as a result of his or her out-of-control sexual behavior. Paradoxically, this shame may become part of the undesirable emotions that the person then strives to regulate through sexual acts. From an attachment perspective, it is likely that these individuals never learned to coregulate emotionally and, instead, try to autoregulate emotions.

Scholars who primarily emphasize the negative reinforcement of sexual behavior often argue for terminology other than sex addiction, such as compulsive behavior or hypersexuality. However, the fact that sex provides both negative reinforcement (i.e., escape) and positive reinforcement (i.e., pleasure) seems to give credence to the addiction model.

Although controversy remains, the mental health field is steadily embracing the notion that behaviors can become addictive. For example, the fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5) included the diagnosis for gambling disorder in a chapter titled “Substance Use and Addictive Disorders.” In addition, internet gaming disorder and nonsuicidal self-injury (which some conceptualize as a behavioral addiction) were included in Section III as conditions in need of further study.

A diagnosis of hypersexual disorder was considered for the DSM-5 but ultimately was not included. The American Society of Addiction Medicine, however, revised its official definition of addiction to include both chemicals and naturally reinforcing behaviors. Furthermore, within the World Health Organization, the Working Group on Obsessive-Compulsive and Related Disorders for the 11th version of the International Classification of Diseases has recommended a diagnosis of compulsive sexual behavior. The organization determined the need for additional research to classify sexual behavior as addictive but clearly recognizes that out-of-control sexual behavior is a public health issue.

In addition, the recent surge of public concern related to pornography use and related erectile dysfunction among relatively young men (as evidenced by high traffic on websites dedicated to helping individuals “reboot” or discontinue use of pornography) has contributed to the influx of neuroimaging studies exploring addiction to pornography. Researchers have confirmed that the same regions of the brain activated by drug stimuli also are activated by online sexual stimuli and that addictive sexual behavior may be associated with decreased gray matter and diminished connectivity in the brain.

Types of sex addiction

Scholars conceptualize two types of sex addiction. The profile for the classic type includes early attachment wounds, family-of-origin issues and trauma histories, culminating in insecure attachment strategies in adulthood. Research shows a clear link between problematic sexual behavior and insecure attachment styles, and the majority of individuals in treatment for sex addiction have experienced trauma. For individuals with classic sex addiction, their sexual behavior may have been a primary means to fulfill attachment needs or escape emotional pain. Over time, however, the behavior became compulsive and out of control as the natural longing for sex became a need and then an addiction.

Recently, a second contemporary type of sex addiction has been identified among individuals without the classic profile of trauma or attachment wounds. Instead, the contemporary type emerges as a result of chronic, excessive exposure to sexual stimuli, especially in the form of pornography or cybersex, made more readily available when the internet became ubiquitous. Sex researcher Alvin Cooper referred to cybersex as a triple-A engine, offering affordability, anonymity and accessibility to users.

Online sexual images and videos are pervasive, and current estimates suggest that the average age of first exposure to pornography is 11. This initial exposure is often accidental on the part of the child, with pornography sites known to purchase domain names of commonly misspelled children’s websites (referred to as cybersquatting). Over time, however, pornography becomes a supernormal stimulus reshaping the brain by repetitive experiences of pleasure associated with online sexual images. The brain responds to this hyperactivity in the reward pathway by decreasing natural dopamine production and receptors. Consequently, with decreased natural dopamine production, those with sex addiction may feel mildly depressed at baseline, inducing cravings for sexual behavior to alleviate the negative mood. Thus, whether classic or contemporary, sex addiction leads to changes in brain circuitry, which, in turn, perpetuates the addictive cycle.

The nature of sex addiction

Among individuals for whom sex has become addictive, the condition is all-consuming. When those with sex addiction are not engaging in sexual behaviors (acting out), they likely are thinking about them (fantasy and mental preoccupation), getting ready for them (preparation and ritualization) or recovering from the consequences (physically and emotionally).

Sensitization caused by neuroadaptations may lead individuals to seek novel or more intense sexual stimuli to achieve the desired effect (otherwise known as tolerance). For example, an individual may shift from nonviolent to violent pornography or change from streaming cybersex to partnered anonymous sex. Those with sex addiction begin to live a double life as they hide their out-of-control sexual behaviors from others, withdraw and isolate. Furthermore, many people with sex addiction lose sexual interest in their romantic partners and experience sexual dysfunction because of classic conditioning in which arousal is paired with alternative stimuli such as a computer. The addiction affects the individual physically, psychologically, spiritually, relationally and emotionally. Although sex addiction begins to control these individuals’ lives, they often are reluctant to tell anyone about their experience because of intense feelings of shame and self-loathing.

Addictive sexual behavior can manifest in a variety of ways, from compulsive masturbation, anonymous sex and prostitution to compulsive sexual relationships, voyeurism or rape. Indeed, some sexual acting-out behaviors can cross the legal line and fall into the realm of sexual offenses, but the majority of those with sex addiction do not offend; rather, they engage in legal forms of compulsive sexual behavior.

Sex offenders generally have distinct profiles from sex-addicted nonoffenders. Specifically, sex offenders are more impulsive; engage in more intrusive behaviors; respond to offenses with hatred, anger and entitlement; and have low remorse. This profile differs from the progressive trajectory of sex addiction that tends to include more frequent, yet less intrusive, acting out; triggers shame, despair and powerlessness; and is met with high remorse. When sexual acting-out behaviors cross the line of legal offense, those who are sexually addicted are legally responsible for the consequences of their actions despite having an addiction (much like someone with alcohol addiction who injures another person while driving under the influence).

Although individuals with addiction are not responsible for “giving themselves” sex addiction, they are responsible for their recovery through seeking help and working a treatment program. Increasing public awareness about sex addiction can help promote early access to professional treatment, with the hope being that this step will aid in avoiding decades of negative consequences both for individuals with sex addiction and for others who may be affected.

Clinical considerations

Given that sex addiction can include myriad sexual behaviors, it is important for clinicians to assess and screen appropriately. Most sex addiction emerges in late adolescence and young adulthood, so school counselors and community clinicians working with young clients can provide early intervention by regularly screening for sex addiction. Counselors are encouraged to broach the subject of sex in counseling and explore clients’ relationships with their sexual activities, such as masturbating, sexting, hooking up, using pornography, engaging in cybersex, using sexual apps and engaging in compulsive sexual relationships.

Despite the fact that sex addiction emerges early, most individuals do not seek professional treatment until later in life as a result of experiencing often extreme negative consequences (i.e., “hitting rock bottom”). Accordingly, all clinicians should be screening for a loss of control over sexual behaviors, continued engagement in sexual behaviors despite negative consequences, and mental preoccupation or cravings. Along with informal screening and exploration, many formal assessments for sexual compulsivity and addiction exist, including the Sexual Addiction Screening Test, the Sexual Compulsivity Scale and the Sexual Dependency Inventory. The use of these instruments can help clinicians better understand their clients and coconstruct appropriate treatment goals.

Once counselors identify the presence of sex addiction, they have many tools and treatment programs to assist in helping clients reach long-term recovery. Unlike recovery from chemical addictions, the goal of sex addiction treatment is not abstinence from all sexual acts, but rather the development of healthy sexuality. It is the compulsive, detrimental sexual behavior that counselors and clients work to eradicate.

To help clarify recovery from sex addiction, many clinicians and 12-step recovery programs (such as Sex Addicts Anonymous) use the three-circles activity. With a sponsor or counselor, those with sex addiction draw three concentric circles. In the innermost circle, the client lists all unhealthy sexual behaviors that have led to negative consequences and over which the individual has lost control. These are the behaviors from which the client is choosing to abstain.

In the middle circle, the client lists behaviors that may lead to sexual acting out. Identifying middle-circle behaviors is important from a neurological perspective. The amygdala is responsible for emotional memory; thus, it remembers stimuli associated with the experience of pleasure. After years of sex addiction, individuals likely have associated specific locations, sounds, sights, smells and actions with sexual pleasure. The middle circle, therefore, includes any stimuli, such as excessive fantasizing, cruising or sexually objectifying others, that may trigger the amygdala and lead to sexual craving.

Finally, the client uses the outermost circle to identify healthy behaviors that will support the individual’s recovery. These behaviors might include participating in 12-step groups, engaging in counseling, fostering spiritual practices, exercising, eating healthy, keeping home and work spaces nonchaotic, spending time doing recreational activities and increasing healthy social support.

Many counseling approaches and interventions, including cognitive-behavioral approaches, psychodynamic approaches, acceptance and commitment therapy, motivational interviewing, art therapy, group counseling, couple and family counseling, and even psychopharmacology, are appropriate for work with sex addiction. It is important to note that recovery from sex addiction often spans years rather than months. Clients, family members and partners may erroneously believe that recovery occurs within a matter of weeks and can become disheartened when initial attempts to change behavior are unsuccessful. Providing psychoeducation about the neurobiology of sex addiction can offer a more accurate perspective and create realistic expectations. Clients can find hope in the fact that, in time, the brain can heal and resolve dysregulation in the reward circuitry. This healing process takes time, however, and the completion of specific tasks such as those outlined in Patrick Carnes’ 30 tasks of recovery.

Additionally, sex addiction may not be the only concern addressed in treatment. Given the common mechanisms underlying addiction, it is not surprising that coaddictions to gambling, food, gaming, the internet or substances often exist among those with sex addiction. Furthermore, research supports the prevalence of comorbid mental health problems, including bipolar disorder, major depressive disorder and attention-deficit/hyperactivity disorder, among those with sex addiction. Finally, a trauma-informed perspective may be necessary to help clients resolve trauma to improve emotion regulation.

Clinicians should take an integrated approach to address all addictive and mental health concerns in treatment. Integrated care may be more complex than addressing one concern at a time, but diverse treatment teams, supplemental or adjunct resources, and holistic recovery plans can best help clients reach long-term health and wholeness.

Advocating for clients

One of the most necessary forms of advocacy for this population is increased awareness related to sex addiction. During the Masters Tournament in 2010, roughly six months after the story broke concerning Tiger Woods’ sexual behavior and treatment for sex addiction, someone flew a plane over the Augusta National Golf Club with a banner reading, “Sex addict? Yeah. Right. Sure. Me too.”

It is inappropriate for anyone outside of Woods’ personal and professional circle to try to determine a clinical diagnosis for his case, but the plane and banner reflect a popular public sentiment: Sex addiction is not real. Advocates can work to increase public knowledge relating to sex addiction and dispense critical research about the condition.

Additionally, mental health professionals can take several practical steps to advocate for clients who are sexually addicted. Currently, many counseling centers do not include information about sex addiction on their websites or relevant items on their intake forms. This lack of acknowledgment may inadvertently communicate to clients that sex addiction is not an appropriate topic for counseling. Thus, one of the simplest forms of advocacy is to include the experience of compulsive sexual behavior on websites, advertisements and client intake forms.

Another important advocacy effort is to acknowledge that individuals of all genders can have sex addiction. Specifically, when community groups, media spokespeople or well-meaning educators leave women out of the conversation about addiction to sex or pornography, they add a layer of stigma for these individuals. Although prevalence rates may differ among genders (about 1 in 7 of those with sex addiction are women), it does not discount the salience of sex addiction among female populations.

Finally, the most recent standards of the Council for Accreditation of Counseling and Related Educational Programs require educators to teach students about theory and etiology of addictive behaviors. Therefore, counselor training programs can advocate for future clients by infusing relevant, up-to-date information regarding sex (and other behavioral) addictions in the counseling curriculum.

Conclusion

Much work is needed to decrease the stigma and shame associated with sex addiction. Although stigma exists with any addiction, it seems particularly poignant with regard to compulsive sexual behavior. In the cycle of sex addiction, shame serves as both a precursor and a consequence of sexual acting out. Raising public awareness regarding the nature of sex addiction can help combat this shame.

Rather than conceptualizing compulsive sexuality as a moral failing, the addiction model provides a framework to empower clients to manage their condition while offering effective tools for recovery. Controversy may always exist regarding the conceptualization of sex addiction, but it is imperative to continue the conversation, increase empirical evidence and engage in advocacy efforts to serve and support this population.

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Knowledge Share articles are developed from sessions presented at American Counseling Association conferences.

Amanda L. Giordano is an assistant professor at the University of Georgia. A licensed professional counselor, she specializes in addictions counseling and multiculturalism. Giordano serves on the executive board for the Association for Spiritual, Ethical and Religious Values in Counseling and the editorial review boards for the Journal of Addictions & Offender Counseling and Counseling and Values. Contact her at amandaleegiordano@gmail.com.

Craig S. Cashwell, a professor in the Department of Counseling and Educational Development at the University of North Carolina at Greensboro, is an American Counseling Association fellow. Additionally, he maintains a part-time private practice focusing on couple counseling and addictions counseling. He serves as editor-in-chief of Counseling and Values.

Letters to the editor: ct@counseling.org

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Opinions expressed and statements made in articles appearing on CT Online should not be assumed to represent the opinions of the editors or policies of the American Counseling Association.

Online gambling addictions up, despite absence from DSM

Heather Rudow December 5, 2012

(Photo: Wikimedia Commons)

The number of online gamblers who exhibit problem gambling behaviors has increased dramatically in the past decade, according to reports. However, online gambling addiction did not find its way into the soon-to-be published fifth edition of the Diagnostic and Statistical Manual of Mental Disorders (DSM-V), and future editions don’t seem to have plans to feature it any time soon — which troubles some addictions counselors and problem gambling specialists.

Julie Hynes, the problem gambling prevention coordinator at Lane County Public Health in Eugene, Ore., believes the reason online gambling has yet to be recognized by DSM-V is because it is still a relatively new problem on the radar of mental health professionals. InterCasino, the first online casino, launched in 1996.

What Hynes says she finds more controversial, however, is actually the classification of problem gambling itself in the DSM-IV.

“Many experts do not consider problem/pathological gambling as an impulse control disorder as it is currently classified,” Hynes says. “Many consider problem gambling to be a behavioral addiction.”

Proposed drafts of the DSM-V would categorize problem gambling as a behavioral addiction instead.

Pathological gambling was officially recognized as a disorder in 1980 when it was included in the DSM-III. The DSM-V, set to publish in May 2013, includes “Munchausen by Internet” and has Internet addiction listed under the category for “future study.”

Hynes is not a member of the American Counseling Association, but she delivered the keynote speech on online gambling at the Midwest Leadership Institute and Nebraska Counseling Association Annual Conference in October.

Doyle Daiss, an alcohol and drug counselor and current president of the Nebraska Counseling Association, believes online gambling addiction should be included as a part of the pathological gambling diagnosis in the DSM.

“I am hopeful that future research will focus on online gambling issues to identify what, if any, differences exist between traditional and online gambling addictions, as well as different interventions that can create a best clinical practice guideline when addressing online gambling behaviors,” says Daiss, a member of ACA.

Daiss has personally noticed an increase in online gambling behavior among his clients over the past five years. “Gambling behavior is an area that has largely been under-assessed during the pretreatment assessment, in my opinion, and yet it is often present in clients whose presenting problems are not gambling in nature.”

Because of this increased awareness of gambling being a possible secondary issue to mental health and substance abuse problems, Daiss began screening for it more earnestly and has found it to be present in many of his clients and in situations that he might previously have missed.

Hynes says gambling addictions in the U.S. have increased substantially due to the increase in online gambling sites.

“In the mid-1990s, there were only about 15 online gambling sites,” she notes. “Today, there are over 2,600 sites and, despite its illegality in the United States until 2012, over $4 billion a year has been spent on online gambling by Americans [according to 2011 statistics by the American Gaming Association]. It is expected that with the recent legalization of online gambling in the U.S., the amount of money spent will rise significantly — global revenue for online gambling in 2010 was $30 billion.”

Hynes has found online gambling to be most prevalent among the young adult population — especially among college students. She cites their tech savviness, newfound freedom from their families and “access to discretionary money” as key factors.

“I’ve seen and heard from many youth and young adults who’ve grown up with online gambling around them, whether it’s seeing ads for online sports books, playing at ‘free’ online casinos or other ways of engaging, online gambling has become an ingrained part of the Internet culture,” Hynes says. “I’ve talked with kids who play with their parents’ credit cards, often even together, as it’s seen as a way to bond. All too often, parents don’t even realize that online gambling can be very risky.”

Daiss echoes Hynes’ observation. “I have personally noticed online gambling becoming more prevalent among males, 21 to 30, who are also struggling with mental health or substance abuse issues in which isolation is an issue,” Daiss says. “Those individuals with whom I have worked have isolated themselves in their house with their computer and initially begin participating in online gambling in which token money is utilized. Within a short period of time, however, they begin utilizing sites in which real money is exchanged via a credit or debit card.”

Hynes says counselors often stereotype gambling addicts based upon general risk factors, which can be problematic.

“We need to remember that there are people from all walks of life that can and do develop addictions to electronic forms of gambling,” she says. “For example, the mom who stays at home might escape from her stress with some online games, and she develops a gambling problem. The disabled veteran who finds that gambling online gives him an outlet and connection to the outside world, and he finds himself borrowing money and against his mortgage payments to gamble. And so on. Counselors should be aware that gambling addiction can move quickly and can easily be hidden behind other addictions. Counselors need to screen for pathological gambling in their assessments and throughout the therapeutic process —particularly if there are warning signs [such as] suicidal ideation, mentions of debt, bankruptcy, relationship problems, etc.”

Daiss agrees, saying he believes that gambling behaviors as a whole often go undetected and that addictive gambling behaviors go undiagnosed due to counselors’ personal assumptions or lack of knowledge.

“Good, bad or indifferent, gambling is a prevalent activity in our culture that in recent times has experienced a perception that it is a legitimate form of entertainment,” he says. “Because of this ‘legitimacy,’ I believe counselors may be inclined to overlook online gambling behavior or may fail to educate themselves in the process of online gambling behavior. If the symptoms are missed, the addiction is allowed to continue toward the inevitable outcome that ruins lives.”

In one specific instance, the wife of a client Daiss treated made note of the manner in which her husband’s online gambling was done “right under her nose. She stated her husband would spend extended episodes of time on the computer gambling,” Daiss recalls, “but she was unaware of it because each time she approached him on the computer he would minimize the window of gambling and maximize a ‘legitimate’ window. She did not find out until several months later — when he was unable to pick up the mail ahead of her to secure the credit card bills — what was actually occurring.”

Hynes says that there are a multitude of side effects from gambling, impacting both the gambler and those close to them:

Suicide attempts and ideation: This is one of the most harmful effects of problem gambling in general. In Oregon, almost half (48 percent) of all problem gamblers entering into treatment reported suicidal ideation within six months of entering treatment; 9 percent actually attempted suicide. (Oregon Health Authority, 2012)

Increased withdrawal from family, friends and usual interests as greater amounts of time are spent gambling.

Mood changes and swings: The gambler can be excited about wins, dejected and/or angry after losses and exhausted from hours of being engaged in gambling.

Debt: The average problem gambler in Oregon owes $30,000 in gambling-related debts. (Oregon Health Authority, 2012)

Criminal behavior: It could be crimes of theft but often is “white collar” crime, i.e., writing bad checks, embezzling from employers, etc.

Concurrent addictions: Problem gamblers have high rates of co-occurrence with other mental health and addictions issues.

Daiss believes the harmful effects of online gambling are similar to other addictions, “inasmuch as the person becomes preoccupied with the behavior and begins to lose control over the activity and how much is spent,” he says. “Those with whom I have worked state that they did not begin experiencing financial problems immediately due to the nature in which credit cards can be repaid, thus the financial amount that is repaid is a fraction of that which is actually borrowed. Within a short period of time, however, they begin applying for and receiving new credit cards, causing a financial ‘house of cards.’ Eventually, the financial burden impacts their life and their family’s life, as monies set aside for staples in life have to be used to repay credit cards. Unfortunately, the addiction remains in place and becomes secondary to the financial turmoil, so the cycle continues. Before ‘rock bottom’ eventually occurs, the addict and their family are tens, if not hundreds, of thousands of dollars in debt, with no legal way to repay it.”

Hynes says online gambling and electronic gambling, however, differ from other kinds of gambling because of the time it takes to become addicted.

“Where ‘analog’ problem gambling [such as] sports bets, horse track betting, etc. often takes years from onset to [become] pathological behavior,” she says, “electronic gambling addiction has the tendency to develop rapidly.”

Hynes attributes this to a variety of factors, including:

Easy access.

The isolative, anonymous nature of the medium and the ability for individuals to hide their behavior.

Rapid rate of play (e.g., casino card games have an average rate of play of about 30 hands per hour, compared to online poker, which can average 60 to 80 hands per hour, and many players play more than one hand at a time).

Decreased perception of the value of cash (i.e., players are forgetting that they are spending real money).

“The above factors can all too easily create a perfect storm for addiction,” Hynes continues. “Add in other risk factors, such as ADHD or concurrent substance addiction, and [it] is easy to see how electronic gambling can be highly addictive and very difficult to manage.”

In the clients Daiss treats — primarily people suffering from drug and alcohol addiction — who eventually disclose having an online gambling addiction, many “[indicate] that the primary difference is how the gambling can occur from the safety of the home,” he says, “thereby allowing them to participate in gambling behavior without requiring them to enter the traditional gambling world of casinos or other public venues. Again, this is a lucrative element to those individuals who are struggling with mental health and substance abuse issues in which public interaction is problematic.”

Daiss believes the best approach for professional counselors in helping clients with a gambling addiction is to ensure that pretreatment assessments include a gambling screening instrument and that they continue to screen for gambling behaviors throughout the treatment session. “Once an online or traditional gambling addiction is identified, the best approach is for that therapist to make a referral to a qualified counselor,” he says, if they don’t already specialize in that area.

Hynes says counselors “can and should” screen for problem gambling with a two-question test called the Lie/Bet Questionnaire for Screening Pathological Gamblers. Visit preventionlane.org/lie-bet for more information and to download the screening tool. Hynes says it is also important for counselors to get connected with problem gambling resources and specialists in their region.

“If counselors are unsure about resources, they might start with contacting the National Council on Problem Gambling for information about local resources,” she says. “The council’s website, ncpgambling.org, provides a ‘counselor search’ resource for all states. While there are many similarities between problem gambling and other addiction and mental health disorders, there are also distinct differences in problem gambling that are important to address. Access to money is one example.”

Additionally, the National Council on Problem Gambling operates a 24-hour helpline, 800.522.4700, and Gamblers Anonymous (gamblersanonymous.org) provides information about problem gambling and locations of groups around the country.

Heather Rudow is a staff writer for Counseling Today. Contact her at hrudow@counseling.org.

It’s not about sex

Stacy Notaras Murphy December 1, 2011

Q: Sexual addiction is a result of:

A) Overactive libido

B) My partner’s disinterest

C) Cultural permissiveness

D) None of the above

The answer may be obvious to those familiar with the multiple choice trope: D) None of the above. But the point remains true: There are many common misconceptions surrounding sexual addiction. Counselors, with their confidentiality policies and empathic personas, may be the only people to ever hear the true extent of a client’s interior struggle with an addiction to pornography or sexual compulsivity. Positioned on the front lines for educating clients, families and colleagues about this pervasive problem — a problem the Society for the Advancement of Sexual Health conservatively estimates affects 3 to 5 percent of the U.S. population — counselors must know how to identify sexual addiction and formulate appropriate treatment plans and referrals.

But this tremendous responsibility demands one thing that many counselors find difficult: We have to actually talk about sex.

“Professional counselors under-recognize sex addiction,” says Barbara Steffens, an American Counseling Association member and certified clinical sexual addiction specialist in West Chester, Ohio. “Sexual addiction exists in secret and often does not come to the surface until there is a crisis or several negative consequences. Few clinicians are prepared to ask about sexual history or sexually compulsive behaviors when this is rarely the presenting problem in treatment.

“I specialize and work primarily with partners [and] spouses of sex addicts, and they tell me of participating in years of marital therapy where either the issue was not asked about or it was minimized. Partners most often have little to no awareness of the extent of the sexual acting out and so do not know to bring it up in treatment. Often the partner may initiate counseling in response to knowledge of one affair, while additional sexual behaviors remain secret.”

After making the therapeutic space safe to talk about sex, counselors might find that the treatment quickly returns to traditional topics of family history and thought patterns. “Sexual addiction is not about sex,” says Todd Frye, an ACA member and clinical sexual addiction specialist in Olathe, Kan. “Some clinicians assume that sexual addictions are driven by an overly active libido that simply has an abnormal level of craving for sexual images and acts. The bulk of those who present with sexual addiction really have more of an intimacy disorder than a sex disorder.” He explains that sexual addicts might use sexual gratification as a way of creating “metaphoric connections” to serve unmet intimacy needs, while others may use sex to deal with feelings of disconnection and the inability to create relationships with others.

The number of people struggling with sexual addictions is growing daily due to the online availability of sexual material, Frye says, noting that counselors with specified training on the topic are in high demand. “We now have access to a worldwide sexual smörgåsbord,” he says, adding, “I receive referrals often by very competent counselors who feel ill-equipped to work with this addiction.” Although the larger counseling community is more familiar with a generalized approach to addictions treatment, Frye has found that specialized training for sexual addictions is needed to help clients truly achieve recovery.

Jodi Conway, a certified sex addiction therapist and ACA member in private practice with offices in New Jersey and Massachusetts, believes education is necessary to get counselors past preconceived notions about sexual addiction. “There are many [counselors who] don’t believe this is an addiction or think that viewing porn is normal male behavior,” she says. “I think with the increase in high-profile people getting caught in sex scandals and talked about in the media, there is much more awareness that sex addiction exists, but few know what types of treatment options there are or how to find qualified therapists.”

Frye agrees: “Though there is overlap in all addictions work, there are some things that are unique to sexual addictions treatment that are important for the counselor to know in order to work more effectively with the sexual addict.” He points out that traditional addictions treatment focuses on the ingesting of chemicals — taking in alcohol, drugs or food — while sexual addictions are internally based, resulting in chemicals produced inside the body, often through a thought or the sight of an image.

Counselors have many options for obtaining specialized sexual addictions training. The best-known program may be the C-SAT certification program designed by sexual addictions treatment expert Patrick Carnes and administered by the International Institute for Trauma and Addiction Professionals (IITAP). There are also other, faith-based training programs for professionals and laypeople, including a new Sexual Addictions Treatment Provider (SATP) certification at MidAmerica Nazarene University in Olathe, Kan., which, with Frye as co-chair, is set to launch in January.

“Most counselors did not receive specific training in the treatment of sexual addictions in their grad programs or found a one-day seminar to be insufficient to meet their clinical needs in this area,” Frye says. “We wanted to offer them a training opportunity that would equip them to feel adequate in effectively working with the sexual addict and their family. In addition, there has been no university-affiliated and accredited program in the U.S. We wanted to offer an accredited program that draws upon the rigor and resources that a university [can] provide.”

What to expect

Clients coming to counseling for sexual addictions might not have any idea where to start, and for most, the traditional “cold-turkey” abstinence treatment model will not apply. As with food addiction, controlled access to the “risky behavior” is part of human nature and must be considered in the treatment plan.

“The important thing to remember is that the sexually addictive behaviors are a part of the symptom and not the underlying disturbance,” notes Todd Bowman, a counselor and professor who, with Frye, is cochairing MidAmerica Nazarene University’s SATP certification program. Bowman explains that trauma, deficit, conflict and characterological dysfunction are the primary underlying disturbances with most diagnoses. “Without fail, in the lives of individuals struggling with sexually addictive behaviors, I have come to uncover one, if not multiple, of these underlying disturbances that is the drive for their sexual acting out. In addition, it is important to explore the relational dynamics created by the sexual acting out,” he says.

Frye has found that treatment usually starts with working on sobriety from acting-out behaviors such as spending time on pornographic websites. Once some level of sobriety has been achieved, the counselor assists the client in determining the primary function that the acting out behavior played and the relational experiences that helped create the addictive behavior as a coping strategy.

For example, sexual compulsivity provides immediate gratification without risking the vulnerability of having to connect within a true relationship. Sex addicts may be compensating for low self-esteem resulting from an abusive childhood, seeking to avoid unpleasant feelings such as work anxiety, or circumventing the process of having to relate to others in order to have their sexual needs met. Much like addictions to alcohol or food, the compulsivity distracts sex addicts from a reality that feels too difficult to navigate. Counselors can help those struggling with sex addiction to recognize these underlying motivations and stop self-destructive patterns of behavior.

Conway urges counselors never to shame or judge these clients or even to assume a thing about their experiences of sexual addiction. “Most clients have a history of trauma that is underlying their addiction. It is important to explore their acting out behaviors — what are the behaviors, what is their arousal template, what kind of porn are they viewing? The addiction is not to sex, it is to lust, to intensity,” she notes. “Recovery from sexual addiction is about letting go of the fantasies, obsessions, acting out or bottom-line behaviors that were self-defeating and [instead] beginning to have healthy relationships with themselves and others.”

Working with the 12-step model

Many treatment modalities are aimed at sexual addiction, ranging from individual counseling to couples work, anonymous organizations to therapist-led groups. Because the general public is well acquainted with the 12-step model for addiction recovery, the first stop for many individuals struggling with sexual addiction might be a group such as Sex and Love Addicts Anonymous (SLAA) or Sexaholics Anonymous (SA). Counselors often suggest that clients consider these groups because they offer structured accountability and support for new members. However, counselors must be careful when making such referrals because each group (and often each separate meeting) comes with its own norms and expectations. Some groups are not accepting of homosexual relationships. Some groups subscribe to a very strict version of sexual sobriety (for example, no masturbation), while others allow members to define their own abstinence plans that make room for certain behaviors.

“I think the 12-step groups are a great supplement to counseling,” Frye says. “The accountability and support that is included in these groups is fantastic and necessary, particularly toward the beginning of recovery. Getting the sexual addict sober is necessary early on for the counseling to be effective. Groups really assist with this. … Sexual addiction is so complex and powerful that we as counselors need to come with ‘all guns blazing’ and use any resource available to assist in the work we do.”

Bowman describes 12-step groups as “necessary but ultimately insufficient in and of themselves” when it comes to sexual addiction recovery. “Many folks who just go to recovery groups end up white-knuckling it through their addiction,” he says. “Individual counseling is imperative in examining the deeper psychosocial implications and precursors to the addiction … which must be intentionally identified and processed through for freedom to exist at its greatest degree.”

Conway adds that it also can be challenging to get a client to attend regular meetings. “Many are reluctant for obvious reasons, but also because they may have social challenges, or are full of shame, [have a] fear of being recognized or believe that everyone there is ‘bad,’” she says.

Partner preparation

Sexual addiction obviously has an impact on the addict’s family, and on the partner or spouse in particular. Frequently, the client comes to treatment directly because the partner has discovered the behavior. The 12-step approach to family addictions has been applied to this circumstance as well, with S-Anon and COSA (Codependents of Sex Addicts) groups providing support and psychoeducation for the partners of the identified addicts.

But that sort of support might not be enough, and in certain circumstances, may prove even more harmful to the relationship, according to Steffens, coauthor of Your Sexually Addicted Spouse: How Partners Can Cope and Heal.

“The partner or spouse of the person with the addiction is often ignored in treatment or becomes involved only as a support to the treatment of the addict, neglecting the severe stress and trauma experienced by the partner in response to ongoing betrayal, deceit, infidelity and potential abuse in the relationship,” she explains.

Operating from a non-codependency approach, Steffens has developed a “partner trauma model” for working with the partners of sex addicts. “At the time treatment is initiated, most partners are in crisis and in need of their own support and counseling,” she explains. “They are likely displaying traumatic stress symptoms due to the significant deceit, betrayal and threat to their safety brought on by the sex addiction discovery. The partner is assaulted with the reality of repeated infidelity, betrayal, years of deceit, often loss of financial resources, possible infection with sexually transmitted disease and fear for her own safety.” (Note: Steffens sometimes uses “she” and “her” when referring to partners of sexual addicts; she is not insinuating, however, that only men are susceptible to sex addiction or that only women need help recovering from the discovery of a partner’s sex addiction.)

“To ask them to come in to support the person with the addiction is asking a lot early in recovery,” Steffens says. “For many partners, being asked to join sessions to support the addict’s treatment is like being asked to do so for someone who has just assaulted them. The person they love the most has now become the person who has hurt them the worst.” She adds that early in the process, “many partners are reeling with the sudden disclosure of years of sexual acting out and infidelity and are often traumatized by this information.”

In 2006, Steffens performed a study of women whose partners were sexual addicts and found that nearly 70 percent of these women showed symptoms that were akin to those for post-traumatic stress disorder. “For someone with post-traumatic stress, they experienced something that resulted in a sense of horror and helplessness. For many partners of sex addicts, this describes their experience,” she says.

“So, rather than say that a partner of a sexual addict has their own disease or addiction — coaddiction or codependency — I acknowledge and respond to the post-traumatic stress found in those who have had their lives and hopes shattered by the sexual betrayal/infidelity that occurs when the addiction is sex.” Steffens recommends that these partners first find their own support systems and individual counselors, while using couples therapy for crisis management and psychoeducation. “When both individuals have stabilized, more traditional marital work is in order,” she says, while also emphasizing the importance of finding a counselor with specific understanding of sexual addictions.

“I am hearing stories from partners who have gone into … intensive treatment settings only to be told they are ‘just as sick’ as their husbands,” Steffens says. “These partners experience this as retraumatizing and being treated as an appendage of the person with the addiction rather than as an individual with their own mental health needs as a result of the traumatic events they’ve experienced.”

Real recovery

In terms of sexual addiction, the definition of sobriety can vary greatly depending on a client’s specific circumstances and choice of treatment. For some, sobriety is about abstaining from any online content of a sexual nature. For others, it is about limiting sexual contact to a single partner within a committed relationship. Still, one regular theme in recovery is the challenge of finding healthy ways to be in connection with those around them.

“Throughout sexual addiction recovery work, treatment continues to include some element of the counselor assisting the client to engage in current relationships,” Frye says. “Helping the client find healthy, intimate ways of connecting both sexually and nonsexually are put in place to supply the intimacy that most sexual addicts have longed for their entire lives.”

Frye also stresses that counselors must partner with clients to create a sobriety plan or structure that can provide support when the client relapses or feels anxious about relapsing. “A comprehensive plan is necessary so the client can feel equipped to maintain the progress achieved in counseling,” he says.

Conway adds that in recovery, spouses or partners should witness the addicted individual’s defenses going down. “They will have access to their partners’ cell phones, computers, emails, etc.,” she says. “There will be accountability and remorse. Therapists will begin to see the same accountability, vulnerability and willingness to do whatever is required to maintain abstinence. A client’s defenses will lower, and he will get in touch with his feelings.”

Further, real recovery often includes the couple’s relationship changing, not just the addicted person refraining from engaging in acting out behavior. “The person in recovery will be accountable to others in his behaviors and transparent with his partner regarding his life,” Steffens explains. “He actively participates in a treatment program or process. He works to demonstrate consistency. He acknowledges that trust has been violated and begins repair attempts. As the partner is supported in their own restoration following betrayal, they come to watch for and appreciate these signs of deeper change. Recovery is not just behavior cessation or management; recovery becomes an opportunity for holistic change.”

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Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C.

Letters to the editor: ct@counseling.org

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Supporting partners of sex addicts

For too long, partners of sex addicts have been asked to support the addict’s recovery without having attention paid to their own experience of trauma. In some cases, these partners are even asked to label themselves as “coaddicts” to help frame the addiction within the couple’s relationship. Barbara Steffens is an American Counseling Association member and certified clinical sexual addiction specialist in West Chester, Ohio. She argues that treatment professionals must develop more effective and respectful treatment protocols for partners of sex addicts. To that end, she makes the following recommendations for counselors (Steffens refers generically here to the partner being female, but that is not always the case):

1) Ask her what she needs. Partners have a wealth of wisdom and strength, as well as experience. We need to learn from them.

2) Assess her needs and history. What is unique about this partner, her experience, the relationship, her history? What are her current symptoms? Why is she acting the way she is? Is it safety-seeking behavior that is often viewed as symptomatic of her own disease?

3) Conduct research. We need a more complete understanding of the experiences and needs of those in relationship with sex addicts.

4) See her as a primary patient, a client in her own right, not just as a member of the family who needs information on addiction. She has her own mental health needs as a victim of another person’s infidelity, deception and betrayal.

5) Think safety first. How would you respond to a victim of sexual assault or domestic violence? Help her establish a sense of empowerment. How else can we assist her in finding safety?

6) Join with other treatment providers who specialize in working with partners. There is a growing group of clinicians and sex addiction specialists who are seeking to improve treatment for partners.

7) Consider specializing in helping partners. There are growing numbers of trained specialists in treating sex addiction; we need an array of providers who are educated, experienced and passionate about helping partners recover from betrayal and trauma, and gaining a sense of empowerment.

Steffens adds that partners of sex addicts are struggling with many messages as they seek to heal from their wounding. “In the midst of what most say is the most painful time of their lives, they must attend to their pain, accept the reality of the state of their relationship with the one they love, manage their safety needs [and] consider the needs of family/children, while being told they need to wait and see what recovery looks like before they make any major decisions about severing the relationship/marriage,” she explains. “A counselor can be a lifeline for someone navigating this most difficult time.”

— Stacy Notaras Murphy