Finding Therapeutic Help and Healing
Melissa, a Fifty-Year-Old mother of three, really wants her third marriage to be a lasting one. She has worked as a flight attendant for nearly thirty years. From the very beginning of that job, men would occasionally proposition her on flights, and once in a while she would take them up on their offers, even though she was married. Her first husband never found out about this; they got divorced because of his cheating, not hers. Nor did her second husband find out; they got divorced because he was physically abusive when he drank (and he drank every day). Over the past few years, ever since Melissa first heard about Ashley Madison and various other hookup apps, the frequency of her illicit liaisons has increased, even though she’s now married to husband number three (who neither cheats nor drinks). She now finds herself flirting and cheating almost daily when on the road, despite the fact that she really loves her new husband and wants them to stay together for the long haul. So far, because of her travel schedule, she’s been able to hide her ever-increasing sexual infidelities, but she feels as if her life is spinning out of control, and that she’s pulling away from her husband and her kids. She worries that another divorce is inevitable, and that this time it will be her fault rather than her husband’s. Depressed and filled with anxiety, she is nevertheless resistant to therapy because she thinks it won’t help. She thinks this because her vision of therapy consists of sitting in a room with a pipe-smoking man who says things like, “Tell me about your relationship with your mother,” and, “Hmmm, I see,” and, “How do you feel about that?” Melissa doesn’t want help with her childhood issues, whatever they may be; she wants active, directed help with her in-the-moment sexual behavior and her marriage.
Melissa is far from the only sex addict to resist seeking treatment for sexual addiction because she doesn’t understand the process and therefore thinks it won’t help. In reality, sex addiction treatment is straightforward, beginning with with a very “here and now” focus on the identification and containment of present-day problematic sexual and romantic behaviors, leaving the past in the past until the client is ready (and wants) to deal with it. Furthermore, if the addict is motivated, engaged, and willing to take direction, the likelihood of long-term success is quite good. In an effort to alleviate misperceptions about the therapeutic treatment of sex addicts, this chapter presents a simple, point-by-point explanation of the process.
Generally speaking, sexual addiction treatment utilizes the same basic motivational strategies and task-oriented techniques that work with drug and alcohol addiction. For the most part, early treatment focuses on a very thorough life/relationship/sexual history, breaking though denial, managing the crisis or crises that drove the addict into recovery, and relapse prevention. Techniques utilized typically include individual and group therapy—most often a highly directive, behaviorally focused form of psychotherapy like cognitive behavioral therapy (CBT), coupled with psycho-education, social learning, twelve-step and/or other addiction-focused social support. Once sobriety and some level of life stability is achieved, there is potential, depending on the client, to add in various alternative therapeutic modalities like art and movement therapies, psychodrama, equine therapy, exercise, meditation, eye movement desensitization and reprocessing (EMDR), etc. Following professional evaluation, some clients may also begin a trial run of an antidepressant or anti-anxiety medication, as these medications sometimes help to reduce not only depression and anxiety, as well as emotional reactivity but also cravings (to act out sexually).
If some of this stuff sounds confusing, don’t worry, I’ll clarify as this chapter progresses.
Inpatient and/or Intensive
Outpatient Treatment
Despite their initial resistance, many (perhaps most) recovering sex addicts do seek some form of professional assistance and good for them. For many of these men and women, inpatient rehab and/or intensive outpatient treatment serves as the initial step on the pathway to healing. The length of these programs varies depending on the treatment facility, typically running anywhere from two weeks to two months. To achieve long-term success, these intensive programs should be followed up with outpatient therapy paired with twelve-step, faith-based, and/or other forms of support groups. (This process is very much in line with treatment for other forms of addiction.)
One common misconception about inpatient and intensive outpatient treatment for sexual addiction is that after completing the recommended program, sex addicts will never again struggle with problematic sexual behaviors. This is not in fact the case. In reality, there is no cure for sexual addiction (or any other addiction), and sex addicts will battle the issue at various levels of struggle on an ongoing, lifelong basis. The desire to act out sexually, when experiencing emotional stress and the unexpected turns life takes, does not go away. It lessens, certainly, and recovering sex addicts learn to respond in healthy ways when triggered, but the desire to engage in the addiction does not disappear entirely, no matter how good the treatment center or how motivated the addict especially when stress shows up. So rather than trying to cure sex addicts, treatment programs focus on the following:
√ Helping sex addicts determine which of their sexual behaviors are problematic and which are not
√ Creating awareness of and helping addicts distance themselves from the people, places, and things that trigger their problematic sexual behavior patterns
√ Reducing sex addicts’ denial by helping them gain insight into the full extent of their past dependency on sexual fantasy and behavior as a means of distraction and emotional self-stabilization
√ Educating sex addicts about the full extent of their consequences, looking at harm not only to themselves, but to their family, friends, employers, and others
√ Identifying sex addicts’ triggers and developing relapse prevention tools that they can utilize when those triggers arise
√ Coaching and supporting sex addicts while they build the ego strength, social skills, and support network necessary for lasting sexual sobriety
√ Breaking through sex addicts’ resistance to participation in lifelong, ongoing recovery and healing from sexual addiction
√ Working to address underlying early trauma negelect, and abuse
√ Encouraging healthy long-term lifestyle changes and self care, stress reduction, increased healthy recreation, and new ways to simply have “fun” without intensity.
As stated above, residential and/or intensive outpatient treatment is often the first step on the road to long-term sobriety and a healthier, happier life. However, these intensive programs do not cure addiction. Instead, they help addicts to break their long-established behavior patterns and to begin the process of building needed awareness and coping skills. In short, intensive treatment programs, both inpatient and outpatient, are meant to prepare addicts for the lifelong work to come. (therapy, self care, community support, etc.)
The Therapeutic Process
It is not unusual for sex addicts starting treatment to expect that much of their work in therapy, whatever the setting, will focus on the identification and resolution of childhood issues via traditional talk therapy. (This is why Melissa, in an earlier example, was so resistant to treatment.) And even though addressing early-life trauma is often an aspect of sexual addiction treatment, it’s just one among many, and it’s usually not an initial priority. Other concerns, mostly involving client safety and present-day behaviors, are always paramount early in the process.
So what does happen in psychotherapeutic treatment for sexual addiction?
Individual Therapy
The progression of addiction treatment is actually quite logical. The first step is a thorough bio-psycho-sexual-social assessment. This careful evaluation explores and evaluates nearly every aspect of the addict’s life, including his or her sex and relationship history. Individuals are assessed not just for sexual addiction but for other psychological issues (including other addictions), along with relationship, family, legal, work, social, recreational, and financial concerns that may need to be dealt with.
Typically, as stated earlier, the preferred methodology in sexual addiction treatment is cognitive behavioral therapy (CBT). CBT differs from traditional talk therapy, in that it is moe proactive and directive. This highly focused accountability-based approach recognizes that sexual addiction, like all other addictions, is a behavioral problem, and it therefore responds best to behavioral forms of treatment.
With CBT, the work of therapy is reality based, focusing on the sex addict’s behaviors and well-being in the here and now, instead of looking at and seeking to resolve past traumas. As such, the process is task-oriented, with assignments (reading, writing, attending support groups, etc.) to be completed between sessions and discussed during sessions.
Group Therapy
Typically, healing from sexual addiction presents challenges that can’t be dealt with solely in individual, one-on-one therapy. In fact, sex addicts nearly always require external reinforcement and support if they want to permanently change their deeply rooted patterns of behavior. Sex addiction-focused group therapy can be extremely helpful in this regard. Generally, a treatment specialist works with between six and ten same-gender sex addicts. (Co-ed sex addiction therapy groups are, for obvious reasons, a bad idea.) Generally these groups run ninety minutes to two hours per session. Sexual orientation is not considered part of this equation, meaning that men work in groups with men, regardless of orientation, and the same goes for women. These types of groups help promote healthy, intimate (but nonsexual) same-sex bonds and relationships, and thus it is a primary treatment method.
Group therapy helps sex addicts learn that their problems are not unique (thus they feel less alone), which goes a long way toward reducing the shame associated with their behaviors. It is also the ideal place to confront the denial that is so integral to sexual addiction. Such confrontations are powerful, not only for the addict being confronted, but for the addicts doing the confronting. In this fashion, everyone present learns how justification, minimization, and rationalization sustain sexual addiction. Addicts are also able to learn which interventions and coping mechanisms work best based on other members’ experiences. Most important, sex addicts learn that helpful support and direction are available from many caring people, not just a primary therapist or a lone accountability partner.
Twelve-Step Sexual Recovery Groups
In addition to individual and group therapy, sex addicts who are willing to push beyond their fear of “being seen” in a more public (though anonymous) setting will nearly always benefit from twelve-step sexual recovery meetings. Sexaholics Anonymous (SA), Sex Addicts Anonymous (SAA), Sexual Compulsives Anonymous (SCA), Sex and Love Addicts Anonymous (SLAA), and Sexual Recovery Anonymous (SRA) are nationwide programs in which sex addicts can find non-shaming, nonreligious peer support and guidance. Generally speaking, SCA is the most “gay friendly” program, and SLAA is the most “female friendly” program. Some meetings are open to anyone who wishes to attend, while others are open only to those who identify as sexually addicted. A few meetings are gender- or sexual-orientation specific. It is best to check ahead by looking meetings up online or calling the group’s local hotline number. (For more information about twelve-step groups and how they work, see the Resources chapter.)
Sometimes recovering sex addicts resist attending and/or participating in twelve-step recovery groups. Usually they’re worried about a loss of privacy. Frankly, it’s more than slightly ironic that people who act out sexually—often in very public ways (putting nude pics on dating sites and hookup apps, hiring prostitutes, having affairs, etc.)—are suddenly worried about what other people will think if they are “caught,” standing outside a church, school or recreation hall. Plus, the odds of being talked about after attending a twelve-step meeting are actually rather slim. Honestly, what sex addict wants to say to others, “I was at this sex addiction meeting the other evening talking about my porn problem and guess who I saw there?”
Certainly twelve-step sexual recovery groups are not as confidential as a therapist’s office, but the word “anonymous” is part of the title, and anonymity is heavily talked about and encouraged in most meetings. And again, if anyone sees you at one of these groups, it’s because that person is there for the same basic reasons as you, and he or she probably doesn’t want to be gossiped about any more than you do.
Finding the Right Therapist
Sandro, a thirty-five-year-old writer, saw three different therapists before he found someone who actually helped him with his problematic patterns of compulsive sexual activity. His first therapist, (even though Sandro stated very clearly that his loss of control over hookup apps had cost him several good relationships) and more recently, his job, just saw him as a relatively young man with a healthy sexual appetite. Instead of looking at Sandro as a possible sex addict, this therapist encouraged him to accept his “need for sexual fulfillment.” Sandro worked hard at this, but his issues worsened and he fell into a deep depression. He eventually recognized that this therapist wasn’t helping him, so he sought help elsewhere, this time with a clinician specializing in men with depression. This therapist never even asked about Sandro’s sex life. Instead, he focused entirely on techniques for dealing with depression, and on uncovering and resolving Sandro’s childhood trauma issues. Unfortunately, discussing childhood traumas left Sandro more emotionally raw than ever, thus his sexual acting out escalated even further. Eventually, he read an online article discussing sexual addiction, written by a certified sex addiction treatment specialist. He immediately began his search for a similarly credentialed therapist in his town, finding several. Once he was being treated for his primary disorder, sexual addiction, he felt immediately better about himself, as he felt both understood and was given tools to help with behavior change. Thus, his depression lifted and his need to act out diminished significantly.
Unfortunately for sex addicts, the process of locating a qualified treatment specialist is not always easy. For starters, a basic understanding of sexual addiction is not a standard part of the training for most psychotherapists. As such, sex addicts sometimes encounter therapists who are unfamiliar with sexual addiction but knowledgeable about various related and co-occurring issues, most notably: trauma, depression, family systems, and relationship problems. These clinicians often correctly diagnose and then treat these secondary issues while never quite touching on the addict’s primary concern, which is their problem sexual behavior, because the professional has not been trained to assess or treat this. So they mistakenly end up misidentifying the issue as a mood or relationship problem, not knowing about or not addressing the client’s active sexual behavior patterns. These may be highly skilled, caring professionals, who simply don’t understand what they are treating. Add to this the fact that clients, often feeling shameful about their behavior, will minimize, and dismiss the extent of their sexual acting out—especially with a therapist who seems disinclined or even uncomfortable bringing it up.
Put simply, mood disorders (depression, anxiety, and the like) are far more common than sexual addiction, and therapists are generally well-trained when it comes to diagnosing and treating them. Thus, these common side effects of sexual addiction get misidentified as the primary issue. And even when a therapist knows about the addict’s out-of-control sexual activity, the addict can still rather easily be misdiagnosed, with bipolar disorder, obsessive-compulsive disorder (OCD), a dissociative disorder, or even attention-deficit/hyperactivity disorder (ADHD)—any and all of which can manifest with an element of sexual compulsivity.1 Nevertheless, these disorders are not usually an underlying condition for many sex addicts. In fact, issues such as depression and anxiety that manifest in conjunction with sexual addiction often alleviated or at least minimized once the addict achieves a modicum of sexual sobriety, as we saw in the example with Sandro above.
About Sex Therapists
While one might think that someone certified as a “sex therapist” surely would understand the issue of sexual addiction, this is often not the case. Sex therapists are generally trained to be fully “sex positive,” meaning their goal is to help people feel better about their sexual interests or patterns, rather than trying to eliminate those interests and patterns. And while this type of validating, supportive, nonjudgmental treatment can be a highly effective approach when managing other sexual issues, such as feeling uncomfortable about sex in general, same-sex attractions, gender identity issues, or a fetish of some sort, this type of well-intentioned advice is counterproductive for sex addicts, as we saw with Sandro and his first therapist. These clinicians tend to offer advice like, “What if we helped you to just loosen up and to become more comfortable with your sexuality.” This, of course, is the exact opposite of what a sex addict needs to hear. Imagine, if you will, a therapist telling an alcoholic with two arrests for drunk driving while intoxicated to loosen up a bit and drink without shame! Well, this is what sex therapists often unknowingly do with sex addicts.
At the other end of the spectrum there are misguided mental health professionals who will label a person as sexually addicted as a way to marginalize and pathologize sexual activity that does not mesh with their personal or religious belief system. In essence, these therapists are trying to be the “sex police,” imposing broad-brush moral, cultural, and/or religious values on human sexuality, thereby creating a narrow version of sexual health. Many such therapists routinely misapply the sex addiction diagnosis, using it to “treat” homosexuality, bisexuality, recreational porn use, casual sex, non-monogamy, fetishes, kink, and a wide variety of other sexual behaviors that fall well within the boundaries of normal and healthy adult sexuality (even if the client is uncomfortable with those desires and/or behaviors).
Needless to say, finding the right therapist is imperative, because the wrong one can inadvertently do much more harm than good. As such, when choosing a therapist, sex addicts should look not so much at the clinician’s academic degrees, but at whether that person is certified in and/or has extensive experience with the treatment of sexual addiction. A “CSAT” designation (for “certified sex addiction therapist”) after the clinician’s name is one primary indicator of these qualifications. If a sex addict is already attending twelve-step support group meetings, he or she might ask around for referrals. If already in therapy, targeted SA treatment can be adjunctive. Otherwise, the addict may consider the International Institute for Trauma and Addiction Professionals website, (iitap.com), or SASH, the Society for the Advancement of Sexual Health (sash.org), for referrals. IITAP is the organization that offers CSAT training and certification; the website lists certified therapists by city and state. Other places to seek help are listed in the Resources chapter.
Evaluating a Potential Therapist
Before entering any therapeutic relationship, it is wise to make sure that a particular clinician is the right fit. You should feel comfortable (not shamed or devalued) and understood (supported and guided) by this person, and you should feel as if he or she has the requisite knowledge and experience to help you. If you are dealing with sexual addiction, you also need a therapist who will professionally confront you about your behaviors and your distorted thinking (your denial), even when holding you accountable feels uncomfortable. Asking certain questions either prior to or during the initial session can be quite helpful in terms of choosing the right therapist. A few sample questions for a potential sex addiction therapist include:
√ Are you trained in the diagnosis and treatment of sexual addiction? If so, what training have you received?
√ Do you have experience working with sexually addicted clients? If so, to what extent?
√ Have you helped clients with other addictions such as alcoholism, drug addiction, and the like?
√ Do you recommend that your sexually addicted clients attend twelve-step recovery meetings and/or a support group? (Most good sex addiction therapists will say they not only recommend this, they insist on it.)
√ Do you offer sex-addiction focused group therapy and/or recommend it to your clients? (Again, most good sex addiction therapists will say they not only recommend this, they insist on it and can help guide clients to it.)
√ How would you help me if I relapsed? (Good sex addiction therapists take a non-shaming approach that looks at the underlying causes of the relapse and how the addict might avoid similar relapses in the future.)
√ If applicable: are you comfortable working with gay and lesbian clients?
√ If applicable: how will you address or handle my religious beliefs?
√ If applicable: what kind of direction and/or support can you offer my spouse? (Typically, good sex addiction therapists will suggest that your spouse see a different therapist, so long as that other therapist is knowledgeable about sexual addiction and experienced in working with spouses of sex addicts.) Note that spousal involvement is essential to a couple’s healing.
As much as you may want to find someone who can help you right now—especially if you are in the midst of an addiction-related crisis—it is a good idea to interview more than one potential clinician before deciding whom to see. And there is nothing wrong with doing this. In fact, good therapists understand the need for a mutual fit, and they will not be offended if you choose someone else. The best clinicians sometimes encourage potential clients to sit with several people before making a decision on who suits them and their situation the best.
Couples Treatment
Sex addicts who are in a long-term relationship when they enter recovery and begin the process of healing may want to consider, in addition to individual and group therapy, couples counseling. Usually it is best if the therapist is familiar with sexual addiction and the process of healing. Otherwise, he or she may be highly reactive to the sex addict’s disclosures (even taking sides as a result), and this helps nobody. And sometimes these clinicians simply don’t understand that partners of sex addicts, despite their anger and hurt, are often not anywhere near ready to end the relationship.
As such, it is critical to find a couples counselor who understands the basics of sexual addiction and is willing to work toward the couple’s individual and relationship goals, whatever those goals might be. In other words, the clinician should be able to objectively and impartially hear both the addict’s and the betrayed partner’s stories, responding to them without judgment or a hidden agenda.
With couples counseling, it is always best to work with a therapist who has a “no secrets” policy, meaning he or she will work to facilitate the process of disclosure rather than working to protect one or both parties from full knowledge about the addiction. Though it may be effective to hold on to some information until it is ready to be healthfully disclosed, a good therapist will promise not to keep any secrets in the long run. More about couples healing to come.
To close, a reminder here, there is no cure for addiction. Similarly, there is no cure for complex trauma, depression, or anxiety. Treatment for these issues does not make them go away, never to return. Instead, treatment provides people with knowledge, skills, and tools that can reduce the power and impact of addiction and related issue(s), allowing the individual to live a healthier, happier, more connected, and more emotionally fulfilling life. The treatment goal for addiction of all kinds is more like cancer treatment, where the goal is healthy, long-term remission from a chronic symptom or problem. Those who expect the endpoint of addiction treatment to be a cure (like setting a broken bone that then mends permanently), are holding out unduly high expectations of the process.