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The Neuropsychotherapist

Vol 4 Issue 9 September 2016

Sex Addiction:
Holistic Treatment Goals and Protocols
for Body, Brain, and Relationship

(Part 1)
Alexandra Katehakis

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S

ince a host of psychological, neurophysiological, and cultural factors conspire to
create and maintain sexual addiction (SA),
only an equally holistic integration of addiction treatment and trauma recovery interventions can heal it. The most successful
model for repairing SAs’ affect dysregulation and relational deficits blends a 12-step addiction recovery protocol with one that develops affective powers through
the therapist’s coregulatory engagement with the patient to create a mutual, if “asymmetrical” (Benjamin &
Atlas, 2015, p. 50) dyad.
But effective, lasting treatment of SA needs to be holistic in more than its recipe of interventions. Clinicians
must not only tolerate, but treasure, the paradoxes or
seemingly contradictory truths that such patients exhibit and experience daily. For SAs harbor dramatic
conflicts in their selves. Shameful secrecy splits the self
into public bravado and private panic. Desperate thirst
for connection sports with utter incapacity for relationship. And every addict both bears pitiable injuries and
perpetrates horrendous hurt. As a result, therapists
must—paradoxically—confront and deconstruct the
patient’s defenses while simultaneously tending to the
equally hidden, equally powerful underlying dysregulation. Unless the therapist engages a “doubly double” approach—one integrating both left-brain and right-brain
powers, and both the patient’s and the therapist’s experiences—even proven treatments will fail.
The Stockdale Paradox, named after the American
general captured and tortured by the Viet Cong, exemplifies the dual vision therapists must carry. Refusing the role of “model prisoner” for his captors’ propaganda, Stockdale survived his POW experience through

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his ability to embrace the paradox of knowing he might
die at any minute and concurrently imaging his eventual release (Grosser, 2013, Loc 68). Likewise, clinicians
must recognize that SAs could lose their sobriety at any
time, and simultaneously must visualize their recovery.
Patients, on their part, must trust the therapist enough
to sacrifice sexual pleasures while experiencing desperately feared pain—no easy feat when the frontal lobes
that teach trust have been damaged, and instead predict only betrayal (McGilchrist, 2009). If the therapist
and the patient learn to tie such paradoxical truths together, they can brave the terrain of treatment by letting their genuine, gloriously imperfect human relationship unfold.

Overall Treatment Goals Require
a Holistic Healing Model
In the 1960s and 1970s, the medical community finally embraced practitioners’ use of an AA-style, abstinence-based, behavioral approach to addiction (Flores,
2003). While chemical dependency counselors borrowed
from cognitive psychology (“stinkin’ thinkin’ ”), they still
worked primarily from a mechanistic CBT model focusing on maladaptive behaviors and thoughts, while “real”
therapists kept to an analytic or psychodynamic model. In isolation, neither modality healed addiction: CBT
helped reveal, then change, the negative cognitions
and behaviors maintaining addiction (Potenza, Sofuoglu, Carroll, & Rounsaville, 2011, in Thomsen, Fjorback,
Moller, & Lou, 2014) but ignored the underlying trauma
and bodily based emotions driving it; classic psychotherapies provided insight but lacked effective interventions.
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Toward a Holistic Healing Model
Recall that in the late 1970s, Bessel van der Kolk put
PTSD on the map, and that some 20 years later, Martin
Teicher illuminated its origin in damage to abused children’s emerging brain/bodily systems, especially through
stunting of the corpus callosum, the rope of nerve fibers
connecting the two hemispheres and permitting information to travel between them. He hypothesized that
when hemispheres are less integrated, the unregulated
right brain may become dominant during stress, rendering the more rational left unable to reign in behavior.
Thus, callosal damage may hobble impulse control—a
disability that can manifest as addiction (Teicher et al.,
2004). And in the early 1990s, Allan Schore explored
the role of caregiver–infant attunement in body/brain
development and in the myriad of psychopathologies—
including addiction—ensuing from poor attunement.
Looking deeper, he found that not only was callosal
integration crucial to regulating affect, but that neural
integration between the cortical and subcortical right
hemisphere was required for impulse control. Without
a functional right orbital frontal cortex (OFC), the right
amygdala, and therefore the autonomic nervous system (ANS), could not be properly regulated. His findings
highlighted the centrality of affect to the growth of even

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the most logical capacities, and the recognition that unconscious processes form the core of the self throughout life (Schore, 1994; 2003a; 2003b). These thinkers’
work made researchers and practitioners appreciate
how both early relational trauma and later untreated
trauma lay the neural groundwork for an addictive
system. Most important, in the last decade, affective
neuroscience has shown that adults with insecure attachment styles can earn a secure attachment through
relational therapy centred on interpersonal attunement,
and finally achieve neural integration of affective states
(Siegel, 2009; 2007). The human longing for social affiliation motivates people to seek “warm, stable and intimate interpersonal relationships, form friendships, and
affiliate with specific groups” (Hecht, 2014, p. 1) in lieu
of addictive behaviors.
So aiming past merely managing addictive behavior
to creating neural and psychological integration and,
thus, real recovery, SA (or any addiction) treatment requires a unified constellation of psycho-biological and
affective goals and protocols to extinguish addictive behaviors and repair the underlying trauma fuelling them.
The psychobiological approach to sex addiction treatment (PASAT) blends a CBT approach that includes a 12step addiction recovery program with one using affect

Vol 4 Issue 9 September 2016

regulation theory to awaken and reclaim SAs’ disowned
self-states. Healing begins through the therapist’s active participation in a holistic, dyadic relational process
in which both the cognitive left brain and the coregulatory right brain and ANS of both parties engage. By interweaving interpersonal neurobiology and CBT, it is also
possible to link the patient’s mind and body.
As I describe in my book, Sex Addiction as Affect Dysregulation, this holistic practice demands the clinician’s
willingness to feel what the patient feels through a right
brain-to-right brain communication, which resonates
bodily in the intricate dialogue of the heart and gut areas (Pearce, 2002). Synchrony of the two persons generates a unique intersubjective third—a new experience
for each that mutually manages arousal states and matures both parties. Such knowing surpasses words yet
ties together relationship, emotions, cognitions, and
words. These intimate and loving communication states
let formerly untenable affects inch forward, be regulated, and thus become integrated within the patient’s

which only something outside them can—literally—fix.
For the only true fix and way out of hell, they come to
recognize, is, as in The Divine Comedy, right through its
center. And as the therapist-guide, you get to witness
the moment when one tiny spark catches, and the addict sees that the glimmer of something good and beautiful is her or his very own self—a surprise you made feel
safe (Bromberg, 2011).

Boundaries
SAs struggle with intrapsychic, interpersonal, and,
sometimes, physical boundaries. For example, a female
love addict abused by a male in childhood may later let a
male authority figure touch her inappropriately because
she does not feel entitled to say “no.” An interpersonal
boundary disturbance may be layered over the intrapsychic, manifested in her stalking an uninterested love object without registering the emotional and physical risks
to herself or the other.

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...this holistic practice demands the clinician’s willingness to feel
what the patient feels through a right brain-to-right brain
communication, which resonates bodily in the intricate
dialogue of the heart and gut areas
self. This synchrony may even repair damaged neural
structures and draw forth new neural functions in the
patient’s brain (Siegel, 2012). If sex addicts use autoregulatory coping techniques—the seeking of sex, fantasy,
compulsive masturbation, and orgasm—to manage
emotional states and dissociated affect, the therapist’s
attunement allows them to experience interactive regulation, sometimes for the first time, which tells them implicitly and explicitly that they are not alone, that they
are loveable, and that they can get their needs met in relational ways. Helping the patient focus on sensations in
the body begins to build bodily self-awareness and selfcompassion, especially while in a resonant state with
the therapist. The recognition that feeling states rise
up from bodily based impulses helps patients recover
previously discarded self-states, and helps their system
mature enough to tolerate affect; have less autonomic
reactivity, impulsivity, anxiety, and depressive symptoms; and use autoregulatory mindfulness practices in
lieu of isolating autoregulatory mindlessness habits.
Recovery from SA takes patients (and clinicians)
down a spiritual path in search of reality, presence,
honesty, keeping one’s word, and sane thinking (Kurtz
& Ketcham, 2002)—the 180-degree opposite tack from
believing that there is something wrong inside them
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Interestingly, the weakness of essential relational
boundaries common to addicts stems from an improperly rigid boundary they have drawn within themselves:
In separating the mind from the body, they consider the
mind, ego, or personality as their “real” self while their
body appears as a possession that supports and transports them, like a bicycle or car. Their body becomes a
commodity to be traded for money, power, favors, or
the illusion of love. This is especially true for the abuse
survivor, who had to detach not just from the environment or others but also from the very body and self in
order to survive. Thus, SAs have little or no sense of self
or of simple joy, but experience themselves as shameful
and disgusting—parasympathetic affects of a disintegrated right brain and a collapsed implicit self (Schore,
2012) habitually helpless from having to dissociate from
unbearable pain and danger.
This self-rejecting inner boundary is, once again, layered onto a general cultural bifurcation encouraged by
Western philosophical dualism segregating mind and
body (see Chapter 4 of Sex Addiction as Affect Dysregulation). This cultural disintegration may further alienate
addicts from bodily and emotional anchors meant to
ground, so that their self-loathing renders them unable
to live in integrity. Indeed, seeing oneself as made of inThe Neuropsychotherapist

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tegrated parts lets one live in integrity—a major goal of
recovery.
A holistic model for treating SA requires the therapist
to understand and welcome paradox, or the ultimate
unity and relationship of opposing parts (Wilbur, 1979).
If a clinician looks only with the left brain without engaging the right brain, whose gaze is intrinsically empathic
(McGilchrist, 2009), he or she will see only a one-dimensional human being. Worse, out of fear or discomfort, he
or she will indulge in prejudices about that person and
miss the play of opposites inherent in human nature.
Like stars best seen in deepest night, a person’s light is
revealed to another only if they sit together in the dark
of their trauma. The current field of psychology allows
and invites practitioners to take an integrated approach
by including all aspects of the patient, all aspects of the
self, and the best of many therapeutic modalities. Adding affect regulation theory (a unified model for change)
and practices into treatment for SA lets one include,
and transcend, clinical traditions (Wilbur, 2000) because
it unites all forms of psychotherapy under a new paradigm.

solutely no explicit, conscious memory of abuse while
their procedural memory system implicitly telegraphs
it through posture, tonicity, reactions to certain stimuli,
or repeated engaging in destructive sexual behaviors.
When no explicit memory of abuse exists, the left brain
colors in the blanks with a plausible story or by distorting
unexplained and disturbing emotional material (Joseph,
1992; McGilchrist, 2009; Panksepp, 2003, in McGilchrist,
2009). The left brain prioritizes local communication—
the transfer of information within brain regions—and
draws a representation of the life the right brain creates. And when treating addiction, it is especially important to note that the left brain also specializes in denial
(McGilchrist, 2009), deactivating or dampening the affective right. Thus, addicts masterfully minimize their
untoward behaviors and shore up their distorted cognitions to present themselves in a positive light. Indeed,
“looking good” at all costs is a hallmark of SA (though
not of LA, whose sufferers tend to present as victims),
and serves as a defense against their profound vulnerability.
In addition, a hobbled right brain leaves the entire
organ no choice but to let the dominant left take over.

Right, Left, Right . . .
Reviewing what is known about the brain clarifies why
and how clinicians should employ a holistic SA treatment. The hemispheres of the brain develop from right
to left, starting with the emotive right hemisphere’s first
major growth spurt at birth (Thatcher, 1992), and operate as two distinct yet interconnected systems in all
mental processes and states (McGilchrist, 2009). Later,
the left hemisphere expands in the posterior to accommodate Broca’s expressive speech area in the front and
Wernike’s receptive language area along the left temporal side, which consciously process emotional material
and expression in a linear, logical, linguistic, analytic,
and sequential manner. The needs for power and independence are also lateralized to the left and motivate
individuals toward competition and self-sufficiency
(Hecht, 2014).
Thus, the left constructs the world through denotative language and loves to draw conclusions, going as
far as to confabulate when gaps occur, especially when
information from the right brain is not available to it
(Joseph, 1992). For example, many patients retain ab-

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Unrealistically optimistic in their evaluation of circumstances, sex addicts really believe they will never get
caught cheating. This highly selective attention is typically associated with the left hemisphere (McGilchrist,
2009), as are antisocial traits like manipulation and
exploitation with “disregard for the welfare of others”
(Hecht, 2014, p. 2). And the tendency to use reason to
dominate interpersonal interactions lets the addict focus on his or her concocted, self-​serving reality in support of his or her denial. It also allows SAs to stay online
for hours cruising or looking at pornography, as well as
to create elaborate rituals for carefully organizing, executing and hiding all traces of the sexual experience.
The left brain “is more at home dealing with distorted,
nonrealistic, fantastic—ultimately artificial—images
(Laeng, Shah, & Kosslyn, 1999; Zaidel & Kasher, 1989,
in McGilchrist, 2009, p. 56). This may be “because they
invite analysis by parts, rather than as a whole” (McGilchrist, 2009, p. 56). Such minute management confirms
addicts’ belief that they are brilliantly handling the contradictory parts of their life. The left brain focuses solely
on its generated schema and suppresses as “irrelevant”
Vol 4 Issue 9 September 2016

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When no explicit memory of abuse exists,
the left brain colors in the blanks with a plausible story
or by distorting unexplained and disturbing emotional material

any discrepant thoughts such as reality—the bailiwick of
the right brain.
So patients approaching their denial structures in
the assessment process or in early recovery may argue
fiercely over what looks like mere semantics—especially
dismissive persons who present as avoidant, narcissistic,
or antisocial. Their attachment style actively suppresses
the right hemisphere’s generation of looser, more poetic
semantic-associations—​a tactic for keeping feelings and
people, including the clinician, at arm’s length. In the
room, this can feel like a power struggle. The very leftbrained patient constantly assesses your expertise and
factual knowledge, as well as the purpose of your treatment plan, because the left brain always has “an end in
view” (McGilchrist, 2009, p. 174) but never sees the “big
picture” (Joseph, 1992, p. 34). For this reason, a CBT approach proves useful at the very beginning of treatment.
Producing tangible results through a concrete treatment
plan soothes the left amygdala, creating a sense of relief
that something can be done that will address problems
in short order.
Ironically, although the left brain is “an instrument of
our conscious will” (McGilchrist, 2009, p. 127), addicts
cannot will themselves to stop their addictions. For the
left hemisphere “yields clarity and power to manipulate

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things that are known, fixed, static, isolated, decontextualized, explicit, disembodied, general in nature, but
ultimately, lifeless” (McGilchrist, 2009, p. 174). These
traits are the speciality, and the liability, of the highfunctioning sex addict.
However, when the therapist’s left brain is at work,
she or he is using denotative language to verbalize rather than to discount reflections and somatic or affective
experiences. Delivery of those interpretations so that
the patient’s right brain may receive them somatically—
may experience the interpretation (Quillman, 2011)—requires the therapist’s interoceptive, or bottom-up, process. In it the patient somatically grasps not so much the
therapist’s words but the impulses arising in the therapist’s body during the exchange. For regardless of the
patient’s literal communication, the therapist picks up
emotional meaning in a bottom-up fashion from his or
her own “inner world” (Schore, 2011, p. 77). Fortunately, because the left brain identifies by labels and not by
context, talking about attachment trauma, family-oforigin dysfunction, or implicit processes can be easily
assimilated by an addict in early treatment. So arriving
at a diagnosis of SA is a function of the left brain that can
greatly relieve some patients. Likewise, basic education
about neurobiology—how a child’s bodily based experi-

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ence of danger or shame can induce dissociation, and
that addiction replicates the same mechanism—may
help enormously.
In humans’ asymmetrical brains, the right hemisphere is longer, wider, larger, and heavier than the left
and generally matures first (McGilchrist, 2009). Its orbital prefrontal region expands in the right frontal lobe
and acts “as an executive control function for the entire
right brain” (Schore, 2003a, p. 61). This side of the brain
comprises a complex, nonlinear dynamic system that
likely has greater dendritic overlap, and may have greater interconnectivity, than the left. The right brain has
more white matter than its counterpart and therefore
greater transfer across regions. Such structural qualities have functional consequences: Unlike the left’s specialization in focused attention, the right hemisphere
enables global types of attention and therefore investigates more broadly and more flexibly. The right brain
does not know anything as factual certainty, but from
intuition, instinct, and bodily sensation (Joseph, 1992;
McGilchrist, 2009). Its gaze is intrinsically empathic, and

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the right amygdala has been called the seat of the unconscious, which guides and drives the individual. This
brain stores the internal working model of attachment
and generates love, connectedness, intuition, metaphor, and images. It has its own primarily nonverbal language of eye contact, facial expression, gesture, touch,
and prosody. Possibly the seat of spirituality, when fully
operational the right leans toward understanding the
world experientially and toward caring for something
beyond itself, while the left is disposed toward control
and its own concerns, both hallmarks of sex addiction:
“The right hemisphere is conscious of the Other, whatever it may be, the left hemisphere’s consciousness is
of itself” (McGilchrist, 2009, p. 175). And Lyons-Ruth
(1998) explains that, rather than literal communication,
implicit relational knowing—the right-powered intersubjective, affective, and interactive processes between
patient and therapist—is the bedrock upon which therapeutic change takes place.
A holistic treatment makes these two operating systems’ capacities (left-brain powers over cognitive-be-

Vol 4 Issue 9 September 2016

havioral tasks and right-brain processes of interactive
arousal regulation) work in tandem. Interestingly, the
more therapists draw on psychodynamic principles such
as addressing patients’ defenses, identifying recurring
themes, and engaging in and discussing the therapy
relationship, the better patients fare in either psychodynamic treatment or CBT. This means that when CBT
therapists include more affectively oriented practices,
CBT therapy is more beneficial (Shedler, 2010a; 2010b).
As Schore explains, “When a psychobiologically attuned

Distinguishing Treatment, Psychodynamic
Psychotherapy, and PASAT
Adapted from the medical field, the word treatment
in addiction circles connotes a discrete, short-term
cognitive or behavioral directive from an expert that
demands a high level of patient accountability. This
process uses the logic-dominant left brain and keeps
the patient in a moderate state of arousal. Relations
between the dyad are also moderate, voluntary, and
controlled, and conversations are explicit, conscious,

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“Self-unity is a shorthand term for the experience of being fully in
life—life being our connection with the rest of humanity.
And in therapy the patient’s connectedness with humanity is lived
by being fully in the relational experience with the therapist,
and vice versa”
dyad co-creates a resonant context within an attachment transaction, the behavioral manifestation for each
partner’s internal state is monitored by the other, and
this results in the coupling between the output of one
partner’s loop and the input of the other’s to form a
larger feedback configuration” (2001, p. 19). So consider
that “psychotherapy can be seen as the basis for a form
of attachment relationship, one in which the patient
seeks proximity to (i.e., wants to have physical and emotional closeness with) the therapist, has a safe haven (is
soothed when upset), and achieves an internal working
model of security (called a ‘secure base’) derived from
the patterns of communication between therapist and
patient” (Siegel, 2003, p. 106; see also Bowlby, 1969).
Persons who never experienced trust and safety
in the first 2 years of life, or had them destroyed by
abuse, keep those crucial needs buried in their unconscious body/brain/mind. Thus, the clinician has to cocreate with, or elicit safety and trust from, the patient on
a nonconscious level, so that two brains and two bodies mutually make an intersubjective relationship. This
right brain–to–right brain communication deepens the
connection between the two, especially when the therapist discloses her or his affective states to the patient,
making that personal experience explicit and, therefore,
making the implicit experience of the patient explicit.
This process exemplifies dyadic regulation, the royal
road to the self: “Self-unity is a shorthand term for the
experience of being fully in life—life being our connection with the rest of humanity. And in therapy the patient’s connectedness with humanity is lived by being
fully in the relational experience with the therapist, and
vice versa” (Bromberg, 2011, p. 27).
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and analytical, typically with mild and pleasant affect
(Schore, 2011). The left-brain window of tolerance allowing such treatment (Ogden, Minton, & Pain, 2006;
Siegel, 1999) is consciously regulated by the DLPFC,
which holds current circumstances in mind while referencing past memories in order to decide on a future
course of action (Carter, 2009). This process is especially
important for recovering SAs because they must be able
to reference the wreckage of their past in order to decide whether or not to embark on the tasks needed to
attain their preferred future. Engagement of the DLPFC
and cold cognition are the tools of CBT and counseling,
whose focus is on cognitive insight and changing leftbrain functions (Schore, 2011).
On the other hand, psychodynamic psychotherapy
uses psycho-dynamic rather than medical or educational
means. It is a longer-term approach focusing on interpersonal and intrapersonal processes revealed in the therapeutic relationship: body/brain/mind operations through
which all parties undergo an unconscious transformation
of “right-lateralized, unconscious internal working models of attachment that encode strategies of affect regulation” (Schore, 2011, p. 191). Psychotherapy recruits the
right brain/body, dominant for emotional arousal, and
moves patients to the edges of their regulatory boundaries to induce involuntary behaviors and implicit and unconscious affective states as well as explicit and conscious
emotional expression. Nonverbal and bodily based communications are privileged, tracked, and regulated via the
right OFC and the ANS.
So while CBT has a procedural and top-down tone,
neuroaffectively informed psychotherapy requires an
actual relationship between patient and therapist, not
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just the symbolic one of classic psychoanalytic or psychodynamic therapy. To work, the therapist and the patient both participate in the intense, difficult situations
that force change. Travelled together, these life-altering
experiences can prove salvific, as they demand learning, flexibility, adaptability, and emotional intensity not
heretofore experienced by the addict.
PASAT, then, merges treatment and psychotherapeutic approaches. It lets CBT dominate in the initial
phases, while also attuning to and regulating the patient, and reserves deeper affective investigations until
after the addiction abates. Once the destructive sexual
behaviors have been arrested, the healing process shifts
from treatment to psychotherapy: Bodily based and affective state changes move into the forefront to heal
trauma, while task work and exploration of faulty beliefs
and problematic behaviors receives ongoing monitoring
in group therapy, a 12-step program, and the therapist’s
regular tracking of the patient’s sexual sobriety to ensure his or her safety.

Initial Phases of PASAT Treatment

CBT
In the early stages of treatment, cognitive interventions challenge the addict’s distorted thinking—the
twisted thicket of attitudes and beliefs that protect behaviors and obscure the true self, the world, and others.
For SAs tend to externalize not just the fix, but the blame
for all their problems (onto parents, boss, or spouse),
creating a cozy harbor for resentments, major or minute, that globalize into a breathtakingly epic mythology
of victimhood by which they justify acting out sexually
as simple parity. That is, SAs have difficulty not just with
lofty insight but with basic mentalization. Compromised
in addicts, this “left-brain-​-dominant, cortically based,
voluntary, conscious, slow affect regulation system”
(Hill, 2015, p. 98), which develops later than the primary
system, lets one read one’s own mental state while simultaneously reading that of another (Fonagy, Gergely, Jurist & Target, 2002)—say, one’s betrayed partner.
Bona fide narcissists cannot access internal representations of healthy relationships in order to self-regulate or
to develop good bonds with other people (Keely, Stout,
Zywiak, & Schneider, 2006), and affective neuroscience
can now explain why even those with narcissistic traits—
like SAs—struggle to read reactions and to feel empathy
for their deceived spouse.
So at first, the cognitive type of empathy must be
taught like a school subject, until relational therapy elicits the higher reflective capacities of the right OFC, which
naturally foster heartfelt, affective empathy. The 12-step
adage, “Fake it ’til you make it,” is a cognitive directive
that puts addicts on the right path. Thus, cognitive interventions initially import an intellectual link since CBT
works with faulty beliefs—the domain of the left brain—
rather than with the crippled regulatory processes that

In many cases, defenses the addict used to distance
painful affect crumble with surprising rapidity. Thus, the
therapist using PASAT must from the start be internally
congruent—that is, nonjudgmental, trustworthy, and
safe—so the patient can immediately begin to tolerate
his or her feelings and potential loss of fragile internal
defense structures.
The earliest, properly treatment phases of PASAT
remain task-driven, directive, and focused on the addiction and other problematic behaviors (see Figure 1).
Depending on the patient’s needs, the first 8 to 16 sessions aim to maintain sexual sobriety by supporting the
patient’s following this directive plan for dismantling
faulty thinking and stopPsychobiological Approach to
ping unwanted behaviors.
Sex Addiction Treatment
Written work, reading, and
attending 12-step meetings
lets each session build on
the previous by attending to
Addiction – C.B.T.
Trauma – A.R.T.
what the addict is thinking,
doing, and feeling between
sessions—including getting
out of isolation by connectLate stage:
Assessment
Short term:
Middle stages:
Resolution of
ing with others in recovery.
period:
Addiction
Resolution
early relational
Self-tests,
treatment
Family-of-​origin issues and
of trauma —
trauma
psychological
C.B.T. &
such
as
SE,
EMDR
(3rd
trimester–
past trauma work are detesting
12-Step
4 yrs) A.R.T.
layed until the patient is
stable and demonstrates
the ability to follow treatFigure 1: The Psychobiological Approach to Sex Addiction Treatment
ment recommendations.

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Vol 4 Issue 9 September 2016

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created them. Ultimately, though, the therapist’s regu- regulation” (Hecht, 2014, p. 11).
latory capacities become the connection between the
It stands to reason, then, that attachment styles can
brain and body/mind, so that the body/mind can begin to be altered through the process of relying on others to
change some parts of the brain.
view oneself accurately and to get one’s needs met relationally. A 2009 study found that attachment styles
of AA members changed over time: They learned that
Why 12-Step Programs Impact
there was a “significant increase in ratings of secure atAttachment and Sexual Sobriety
tachment and significant decreases in ratings of anxSex Addicts Anonymous (SAA), Sex and Love Adious and avoidant attachment” (Smith & Tonigan, 2009,
dicts Anonymous (SLAA), Sexaholics Anonymous (SA),
p. 170), suggesting that meetings created a “secure
and Sexual Compulsives Anonymous (SCA)—​called “S”
base” built on safety, comfort, connection, and mutugroups—comprise slightly varying 12-step programs
ality. Those whose secure attachment increased found
for sexual recovery based on AA principles (Emrick &
it easy to get close to others and found great comfort
Tonigan, 2004; Gossop, Harris, & Best., 2003; Kelly,
in doing so; the avoidant reported a growing ability to
Stout, Zywiak, & Schneider, 2006; Moos & Moos, 2006;
trust others and less fear of getting close; persons with
Tonigan, 2001; see the Appendix for “Principles and Teran anxious attachment began to feel less worry about
minology of “S” Programs”). They all function through
both others’ being loving toward them or others’ wantthe intrinsic human need for affiliation, primarily latering to leave them (Smith & Tonigan, 2009). All in all, atalized to the right hemisphere (Hecht, 2014). Interesttachment, and therefore regulatory functioning (and
ingly, only one of AA’s 12 steps mentions alcohol; the
presumably sobriety), became more stable over time.
other 11 focus on relationship with a higher power and
Similarly, in very short order, the 12-step program
one’s sponsor, and on virtues like the humility needed
chips away at the SA’s core beliefs: I am basically a
to take action to improve one’s character. Indeed, 12bad, unworthy person; No one would love me as I am;
step programs may be understood as collective interacMy needs will never get met if I have to rely on others;
tive regulators because “engagement in social relationSex is my most important need. Walking into a meeting
ships and pro-social activities are essentially adaptive
and hearing the stories of others who have done similar
behaviors, evolutionarily designed to support emotion

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(and sometimes more) shameful actions rapidly diminishes shame, especially when those others seem wellmeaning. So much for core belief one. After the meeting, members invite the newcomer to coffee, comment
on the impact of his or her sharing, or simply say, “Welcome”—that starts to melt the second core belief. Addicts in recovery offer their phone numbers and remind
the newcomer to call anytime just to check in or when he
or she is tempted to act out; when the newcomer does
so and another person actually listens, core belief three
begins to fray. Finally, the dawning recognition that the
addict needs such relationship, not sex, to feel validated
starts to dissolve core belief four.
Yet in addition to attending 12-step meetings, meaningful engagement—connection with a trusted sponsor; gathering in “fellowship” with members before or
after a meeting, often for a meal; making outreach calls;
and genuinely working the steps are essential, if unconscious, agents in changing one’s attachment style:
The “prescribed AA behaviors activate shifts in attachment style, and . . . ​these shifts are not cognitively or
consciously directed” (Smith & Tonigan, 2009, pp. 171–
172). These results further support the recognition that
coregulatory processes central to optimal function and
well-being may be practiced and learned throughout
life. So even the treatment CBT phase for SA prepares
the soil for the psychotherapeutic relationship that can
finally bring healthy human connectivity.
Before he left for a 12-step meeting that evening,
“Robert” faced his bathroom counter and lined up all of
the pharmaceuticals he had amassed over years, unconsciously saved for just such a day. Percocet, Valium, Vi-

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codan, and Xanax—their mellifluously named contents
would comprise the cocktail ushering in everlasting
peace. He left for the meeting in despair, and the meeting was just ok, but he lingered to talk to some guy, a
real old-timer in the program. On his drive home, while
he debated what choice he would make in his bathroom,
his cell phone rang. This very same old-timer was on the
line, asking him if he could flush his pills down the toilet.
For some reason, Robert agreed. When he got home, he
emptied each of the precious containers into the toilet.
Upon flushing the pills, he later reported, he had a “spiritual awakening.” That single act seemed to liberate him
from pain and fear, and he knew that honesty was the
only way out of his despair, and that he could handle its
consequences.

The Long Haul of Psychoeducation
and Task Work
A study in the mid 1980s analyzed the first 5 years
of the recovery process for SAs and their partners, inventorying details month by month (Black, Kehrberg,
Flumerfelt, & Schlosser, 1997, in Carnes, 2000; 1998). In
the first year, most SAs reported feeling better despite
experiencing chaos, challenges, and slips; some found
symptoms actually worsening; and these responses
yielded no quantifiable results. Yet the second and third
years produced measurable improvements in friendships, self-​image, career, finances, spirituality, and coping with stress—-probably the benefits of engagement
in intense therapeutic and 12-step work. Once personal
recovery had been established, comments about the
third, fourth, and fifth years showed significant healing

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in familial relationships: Romantic partnerships and relationships with parents, children, and siblings were said
to have improved remarkably, and while some marriages proved irreparable, overall sexual and life satisfaction
were judged as high (Carnes, 2000; 1998).
The study discerned six stages of recovery. The first,
Developing Stage (up to 2 years), sees addicts reduce
or replace some damaging behaviors. Minimization, a
premier defense, may still operate even in the face of
a growing recognition of the problem. Interestingly, at
this phase, many therapists also seem to fail to confront
or appreciate the gravity of SA.
The second, Crisis/Decision Stage, may last for a
single day or up to 3 months, galvanized by a personal
catastrophe (being caught by a spouse, or arrested, or
fired; contracting an STI or being terminated by a therapist for noncompliance) or by a spontaneous recognition
of their life’s unmanageability. After the addict genuinely decides to change, the third, Shock Stage may continue from 6 to 8 months. Rather like mourning, shock
engenders reactions of denial, anger, depression, bargaining, and loneliness. In addition, many suffer intense
withdrawal symptoms of disorientation, numbness, and
despair. In fact, obeying limits set by therapists, family
members, or a sponsor can elicit these feelings until the
addict at last begins to experience a supportive sense
of community. The 12-step adages, “One day at a time”
and “Easy does it,” speak directly to this phase of recovery just before the addict appreciates actual relief.
Yet around 6 months into recovery, the Grief Stage
appears. Once the impact of the initial discovery, decision to change, and shock begins to wane, the underlying emotional pain of this fourth stage sears. The person
in recovery suddenly recognizes a new loss: He or she
had already acknowledged forfeiting a primary relationship, connections with family members, job, time,
money, or self-esteem. But this second one is the loss
of the addiction itself. For many, that behavior provided
the only stable, reliable succor. Saying goodbye to it can
feel like parting from an old, ever-understanding friend
and can evoke tremendous sorrow. In addition, forsaking the autoregulating actions exposes the deeper pain
of early relational trauma. Without this comforting behavioral bandage, horrendous childhood memories the
addiction served to cover lie raw. That agony helps explain the high relapse rates this stage of recovery invites
(Carnes, 2000; 1998).
For those who persist, the fifth, or Repair Stage occurs between 18 and 36 months. Respondents reported measurable improvement in satisfaction as they
brought structural and functional changes into their
lives. They stated that healthier beliefs about themselves, sex, and family had restored their values. That is,
www.neuropsychotherapist.com

this phase contains second-order change—what systems
theory labels a paradigm shift bespeaking new internal
rules rather than new applications of old rules. Sex addicts reported greater capacity for self-assertion and for
taking responsibility, including expressing their needs,
working to get them met appropriately, and deepening relational bonds (Carnes, 2000; 1998). Finally, the
Growth Stage arrives at 2 years plus. SAs described becoming more available to others as their own lives became more balanced, and they adopted genuine selfcare. Relationships and life satisfaction measures rose
in concert, and habitual self-loathing had been replaced
by self-compassion (Carnes, 2000; 1998).
These findings suggest strongly that in addition to
participating fully in a 12-step program with an effective
sponsor, a congeries of continued interventions work
to treat SA: in-patient treatment, intensive out-patient
treatment, group therapy, a distinct but limited period
of celibacy, long-term individual therapy, a meaningful
spiritual life, supportive friends and family, regular exercise, and healthful eating habits.
To be continued next issue...

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