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CBT for Compulsive Sexual

Behaviour
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Increasing numbers of therapists are coming into contact with the problem of
­compulsive sexual behaviour disorders. However, it is still a relatively new field
and there is little in the current literature available that enables the therapist to
work with and treat this problem. CBT for Compulsive Sexual Behaviour: A guide
for professionals addresses this by providing a guide to cognitive-behavioural
theory and practice which includes the assessment, diagnosis and treatment of
addictive sexually compulsive disorders.
Beginning with a description of addictive sexuality and an overview of cogni-
tive behavioural therapy in which CBT is presented as the most useful response,
Thaddeus Birchard provides clear therapeutic information about the implementa-
tion of CBT treatment intervention. The chapters included cover the neuroscience
that underpins the addictive process; a ‘how to’ chapter on the use of groups;
paraphilias; trauma and attachment; comorbid disorders and cross-addictions
and analysis on the function of internet pornography, all written from a cognitive
behavioural stance.
Using case vignettes throughout, Thaddeus Birchard draws on his own expe-
rience as a psychosexual therapist, along with the latest research in the field, to
enable the therapist to treat a range of compulsive sexual problems in a way that
can be applied in individual practice or in a group setting as well as how to prevent
relapse. This book will be essential reading for psychosexual therapists, cogni-
tive behaviour therapists and other professional working with sexual compulsive
disorders.

Thaddeus Birchard is the founder of the Marylebone Centre for Psychological

Therapies and the Association for the Treatment of Sexual Addiction and
Compulsivity. He is widely acknowledged as the pioneer of all work on sexual
addiction in the UK and as an expert on working with men with out of control
sexual behaviours.
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 CBT for Compulsive
Sexual Behaviour
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A guide for professionals

Thaddeus Birchard
 First published 2015
by Routledge
27 Church Road, Hove, East Sussex, BN3 2FA
and by Routledge
711 Third Avenue, New York, NY 10017
Routledge is an imprint of the Taylor & Francis Group, an informa business
© 2015 Thaddeus Birchard
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The right of Thaddeus Birchard to be identified as author of this work

has been asserted by him in accordance with sections 77 and 78 of the
Copyright, Designs and Patents Act 1988.
All rights reserved. No part of this book may be reprinted or reproduced or
utilised in any form or by any electronic, mechanical, or other means, now
known or hereafter invented, including photocopying and recording, or in
any information storage or retrieval system, without permission in writing
from the publishers.
Trademark notice: Product or corporate names may be trademarks or
registered trademarks, and are used only for identification and explanation
without intent to infringe.
British Library Cataloguing in Publication Data
A catalogue record for this book is available from the British Library
Library of Congress Cataloging in Publication Data
Birchard, Thaddeus, author.
CBT for compulsive sexual behaviour : a guide for professionals /
Thaddeus Birchard.
p. ; cm.
Cognitive behavior therapy for compulsive sexual behaviour
I. Title. II. Title: Cognitive behavior therapy for compulsive sexual
behaviour.
[DNLM: 1. Behavior, Addictive—therapy. 2. Sexual Dysfunctions,
Psychological—therapy. 3. Cognitive Therapy—methods. 4. Sexual
Behavior—psychology. WM 611]
RC560.S43
616.85′83306—dc23
2014043143

ISBN: 978-0-415-72379-4 (hbk)

ISBN: 978-0-415-72380-0 (pbk)
ISBN: 978-1-315-72482-9 (ebk)

Typeset in Times New Roman

by Swales & Willis Ltd, Exeter, Devon, UK
 About the author
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Thaddeus Birchard moved from New Orleans to the United Kingdom in 1966
to study theology at the House of the Sacred Mission, Kelham, Newark and
Nottingham University. After some years in parish ministry, he moved into psy-
chotherapy. He trained in psychosexual therapy at the Whittington Hospital and
London South Bank University. He proceeded to a Doctorate in Psychotherapy
at the Metanoia Institute and Middlesex University. He then trained in cognitive
behavioural therapy (CBT) at London Metropolitan University. First working as
Dr Thaddeus Birchard and Associates, he founded the Marylebone Centre for
Psychological Therapies in 2007. He is accredited with the College of Sexual and
Relationship Therapists and the British Association for Behavioural and Cognitive
Psychotherapies, and registered with the United Kingdom Council for Psycho-
therapy. He is the founder of the Association for the Treatment of Sexual Addic-
tion and Compulsivity. He founded the first treatment programme for sexually
compulsive men in the United Kingdom. Along with Joy Rosendale, he i­nitiated
a partners’ programme. He works in three main areas: marriage and relationships,
psychogenic sexual disorders and CBT; he works with depression, anxiety disor-
ders, obsessive compulsive disorder and trauma. His doctoral research was in the
field of hypersexuality and he has focused on sexual addiction since 1988.
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 This book is dedicated, with affection, to:
Marie Baker
Kenny, Chan and Alyssia Birchard
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 Contents
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List of figures and tables x

Foreword xi
Preface xii
Acknowledgements xviii

1 Sexual addiction 1
2 Cognitive behavioural therapy and sexual addiction 14
3 The neuroscience of sexual addiction 31
4 The therapeutic alliance 43
5 The primary interventions 54
6 The principal interventions 62
7 The ancillary interventions 81
8 Group work 91
9 Paraphilias 114
10 Internet pornography addiction 131
11 Trauma and attachment 140
12 Cross addictions and comorbid disorders 150
13 Conclusion 157

Case studies 162

Appendices 174
Bibliography 184
Index 195
 Figures and tables
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Figures
2.1 Generic formulation 22
2.2 Sex addiction formulation 23
2.3 Two minds 25
2.4 Generic hot cross bun 28
2.5 ‘I might fail’ hot cross bun 29
2.6 ‘I am fed up’ hot cross bun 30
6.1 Trauma egg 71
8.1 Clinical outcomes in routine evaluation 105
8.2 Sexual symptom assessment scale 105
8.3 Sexual compulsivity scale 106
8.4 Sexual addiction outcomes in routine evaluation 106
8.5 Composite sexual addiction recovery scores 107
A.1 Cycle of addiction 177
A.2 Descriptive statistics 180

Tables
8.1 The primary treatment programme 97
8.2 The schedule of the women’s groups 102
 Foreword
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In his new book, CBT for Compulsive Sexual Behaviour: A guide for professionals,
Dr Thaddeus Birchard captures the essence of effective assessment, diagnosis and
treatment of sexually compulsive disorders in the twenty-first century. Although
the field of sexual addiction treatment is a relatively new and emerging one, indi-
viduals who currently present for treatment do so with a very different clinical
presentation from those who sought clinical intervention 20 years ago. The vast
capability of the internet continues to make our world increasingly smaller, and
contributes to those who suffer from sexual addiction having much greater access
to material that has only led them to become more captive.
Dr Birchard paints a very clear picture of sexual addiction as a disorder, cou-
pled with the neuroscientific processes that make the clinical presentation so dif-
ficult to break out of. Focus is given to the aetiology of the disorder and the role
of trauma and attachment failure in its development. He also addresses paraphilia
disorders and internet pornography, and how they sometimes fuel and are fuelled
by the addiction itself.
Ultimately, he addresses sound diagnostic principles coupled with effective
interventions that, if properly applied by the skilled clinician, will help to bring
relief to those who suffer from this illness and desire treatment. Cognitive Behav-
ioural Therapy for Compulsive Sexual Disorders: A guide for professionals will
prove to be a valuable resource to clinicians of all skill levels who are in the field
of treating sexually compulsive disorders.
Dr Matthew Hedelius
Director, Comprehensive Treatment Clinic, Logan, Utah
 Preface
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Introduction
This book is the product of two things: the outward journey and the inward. It is
a combination of the extrinsic and the intrinsic, the visible and the invisible, the
external and the internal. It is a fusion of these things, a composite of academic
research, clinical and pastoral care. Underneath this external journey there is a
more complicated inner journey. I will begin by writing about the outward and
then write about the inner.

The outer story

I was in pastoral ministry for many years. Most of the time was spent in a parish
in the West End of London. I had been ordained when I was 22 years old and had
served in parishes in Plymouth, Southend-on-Sea and in the East End. I felt I had
to do something else before the end. Psychotherapy seemed an obvious next, and
final, step. It fitted with a tradition of pastoral care. It also dealt with the same
issues as the faith community: meaning, purpose, suffering and transformation. I
had been drawn to Christianity, not so much by what it said about God, but what
it said about humanity. I was interested in individual and societal transformation,
even transfiguration. It came to pass that I left the parish after 21 years to set up
the Marylebone Centre for Psychological Therapies.
Before this transition, I had completed an MSc in psychosexual therapy at Lon-
don South Bank University and the Whittington Hospital. This was put together
by the redoubtable Judi Keshet-Orr. It was followed by accreditation with the
College of Sexual and Relationship Therapists and registration with the United
Kingdom Council for Psychotherapy. I went on to study for a doctorate in psycho-
therapy at the Metanoia Institute and Middlesex University. My dissertation was
on the diagnosis and treatment of hypersexual disorders. Because psychosexual
training was about a subject and not a modality, I trained as a cognitive behav-
ioural therapist and was accredited by the British Association for Behavioural and
Cognitive Psychotherapies. I then founded the Association for the Treatment of
 Preface xiii

Sexual Addiction and Compulsivity, an organisation to train and accredit ­people

to work with men and women with addictive compulsive patterns of sexual
behaviour.
The Marylebone Centre for Psychological Therapies focuses on four areas of
therapeutic work: marriage and relationships, psychogenic sexual disorders, sex-
ual addiction and a number of disorders treated under cognitive behavioural pro-
tocols: depression, obsessive compulsive disorder, anxiety disorders and trauma.
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We developed the first United Kingdom group treatment programme for men
with sexual addiction. This treatment programme, and the subsequent training
extended to other therapists, has been the foundation for all further work on sexual
addiction in the United Kingdom. As far as I know, all the treatment programmes
operating in this country are based on the original model that we put together in
2000. This was based on a non-residential programme developed by the late Al
Cooper. I had correspondence with him and he encouraged us to use his base for
our base. There was much revision to make it compatible with British culture and
it has since, at least by us, been adapted and extended in scope and content over
the years. We now run a three-part group treatment programme. The first part
involves all the major interventions for addictive sexual behaviour; the second
part uses art therapy to further the themes of recovery; and the third part uses
straightforward cognitive behavioural exercises for the restoration of self-esteem.
I say ‘restoration’ but for many it is building self-esteem for the first time. This
three-part programme lasts 36 weeks and is followed by a rolling aftercare pro-
gramme. To date, we have run over 60 treatment groups.
We were also the first to initiate a women’s programme to meet the needs
of female partners. The design of this group was first created and developed by
Joy Rosendale, an associate of the Marylebone Centre. We were concerned that
women who were traumatised by the revelations of male sexual addiction were
receiving no help. Their needs were not met. It was clear that, while the men
were recovering from sexual addiction, the women were sitting at home without
help. Having lost their partners to sexual addiction, they lost them to addiction
recovery. The formation of these groups was a way of redressing this balance and
helping women deal with what most experienced as severe trauma. The person
who had been considered a ‘safe haven’ proved not to be a safe haven after all. I
pay tribute to Joy Rosendale whose contributions to our centre have been beyond
substantial.
All this work has been accompanied by a certain amount of direct and indirect
research. In 1998, I did a research project on the clergy and sexual misconduct
(Birchard 1998). This was a combination of interviews with professionals, focus
groups and a qualitative and quantitative random survey of serving clergy in the
Church of England. This remains the only United Kingdom research done on
this subject. We found that the clergy have higher rates of sexual misconduct
than those in other caring professions. This was matched by results reported by
a number of American researchers (Fortune 1989; Loftus 1994; Moeller 1995;
 xiv Preface

Sipe 1995). I then undertook another direct research project on the presentation
of sexual addiction to psychosexual therapists in the United Kingdom (Birchard
2004). I have also published a small number of articles on religion, sexuality and
the paraphilias (Birchard 2011).
Finally, we have tried to blend a tradition of pastoral care with the therapeutic
frame. We are less scrupulous about the frame than would be normal for other
psychotherapeutic modalities. For example, I give out my personal mobile num-
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ber. We are flexible about appointment times and we will often see people at
short notice. We sometimes see people individually and at the same time work
with them in a group. We also engage in email correspondence and text messages
with our patients. In addiction recovery work, there is often more self-disclosure
than would be normal in other therapeutic approaches. This self-disclosure must
be done prudently, for the benefit of the patient and not as an indulgence for the
therapist. We regard these adjustments as enlargements of the frame rather than
disruptions to it.
The Marylebone Centre started with me as sole practitioner. We now have a
psychiatrist, an existential psychotherapist, a forensic specialist, an integrative psy-
chotherapist, a psychoanalytic psychotherapist formerly from the Portman Clinic, a
specialist in eye movement desensitization and reprocessing (EMDR) and a sexual
health nurse. The clinic is located in Marylebone Lane in central London.

The inner story

The previous story is the outer story. There is a more complex inner story. I was
invited to a conference in the United States, entitled ‘Healing addictive compul-
sive disorders’. This was a revelation. I became aware that I was an addict. I was
using sex, food, alcohol and religion as my addictive substances and behaviours.
Furthermore, I came to understand that my addictions were attempts to manage
the intolerable ‘burden of selfhood’ (Baumeister 1991: title page). My addictions
grew out of a sense of self that was both unacceptable and painfully experienced. I
began to know what was wrong and so the repair work began. The repair involved
psychotherapy, Twelve Step (90 days, 90 meetings), co-sponsorship and time
spent in treatment at the Meadows in Arizona. In 1988, I was a founder member
of the first Sex Addicts Anonymous meeting in London. I write all this because
my understanding of addiction is not just based on academic interest. It is based
on a personal experience of the nature of the addictive process.
I retrained as a psychotherapist and left parish ministry to undertake this new
work. My decision to move out of parish ministry and into full-time psychother-
apy has not been about the loss of a vocation but rather the fulfilment of a voca-
tion, unifying, harnessing and gathering together all that has gone before. When I
was inducted to my last parish, I knelt before the Bishop and held the seals of the
induction document as the Bishop said “receive this cure of souls which is both
yours and mine”. Psychotherapy also means ‘cure of souls’. I have not left the
ministry: this is the ministry.
 Preface xv

The story behind the story begins long ago in my family of origin. I was the
child of an unhappy, narcissistically damaged and emotionally needy mother.
She was addicted to nicotine, alcohol and prescription drugs. She lost what little
money we had. Everything was sold. Eventually she was arrested for prostitution.
She was emotionally seductive towards me in childhood and sexually seductive
towards me in adolescence.
By contrast, my father avoided me. I am not sure he was my biological father.
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The family was divided but stayed together. I belonged to my mother and my
elder brother belonged to my father, thus depriving me of a father and him of
a mother. My brother became a medical doctor and then a psychiatrist. He was
eventually diagnosed with a bipolar disorder and lost his licence to practice medi-
cine. For a time, he lived on the streets. This promising psychiatrist ended up as a
yard man (not even a gardener) for the town’s medical doctor. He died in poverty.
I write about him to give an indication of the level of disturbance in the family and
the severity of the consequences.
I grew up in New Orleans in the 1950s, an uncoordinated, fat child in a slim
athletic male-dominated culture, poor in a place of competitive affluence and gay
in a violent society that hated and despised gay people. Life was experienced as
fearful and dangerous. I felt myself to be contaminating and loathsome. In con-
trast to the violence all around me, I found in the Church acceptance and refuge. A
vocation to the priesthood offered me a way out. I know now that I sought ordina-
tion to quieten the shame. At the same time, before I knew what addiction was, I
became an addict. I used substances and behaviours to anaesthetise loneliness and
self-contempt. Looking back, there were other symptoms of the damage: a need
to control others to keep myself safe, fear of exposure, a marked tendency to split
and compartmentalise, chronic low self-worth masked by grandiosity, difficulty
in setting functional boundaries or respecting the boundaries of others, cyclical
depression, sexual shame, seductiveness, a need for admiration that could not be
requited, and the capacity to manipulate and cajole. I had never been in a relation-
ship with anyone and had little capacity for intimacy. We all have a past and I
would like to apologise to anyone I dismayed during this part of my life. I was, in
the words of a colleague, “a man more driven than called”.
Alongside addiction recovery, there have been a number of startling unexpected
beneficial side effects. I lost my fear of flying, fear of public speaking, my hypo-
chondria, anorexic/bulimic eating patterns, cyclical depression and indebtedness.
Perhaps most indicative of all was the development of a capacity for ­relatedness,
evidenced by the establishment and maintenance of a first and only committed
relationship. These were the fruits of recovery, not only from addiction but also
from the damage that creates the addictive hunger.

Content
Chapter 1 of this book defines and describes sexual addiction. It contains a brief
overview of the history of the concept. There is a short survey of the most recent
 xvi Preface

contributions to the theory of sexual addiction. Sexual addiction is placed in its

medical context. Attention is given to aetiology, the role of shame and the regula-
tion of negative affect states. Counter-arguments and objections are cited.
This is followed by an elucidation of the underlying principles of CBT and its
relevance to working with sexual addiction. After a cursory glance at the history
of behavioural and cognitive therapies, the fundamental tenets of CBT are deline-
ated. Various assessment scales are described. The use of the formulation is given
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and the role of cognitive behavioural tools described, including Socratic question-
ing and the downward arrow technique. A variety of behavioural techniques are
outlined.
In order for our therapeutic work to be well grounded, the neuroscience of
addiction is explored. Genetics are discussed. Attention is given to learning and
impaired executive function. There is reference to the brain chemistry of addic-
tion. Pharmacological interventions are assessed. A section is given over to attach-
ment and the role of neuroscience in the relationship between the patient and the
therapist. It concludes with a consideration of the addiction as a temporary escape
from an impaired sense of self.
CBT has not emphasised the therapeutic alliance. The therapeutic relationship
is seen as important but not sufficient to effect change. However, when working
with sexually addicted men, there is an emphasis on the therapeutic relationship.
There is also an introduction to schema therapy in this chapter. Attachment and
erotic transference are discussed.
The discussion on interventions for sexual addiction is divided into three chap-
ters: primary interventions, principal interventions and ancillary interventions.
The primary interventions are teaching units. The principal interventions are out-
lined and explained in detail. The ancillary interventions include sexual health and
relapse prevention.
There is a chapter on group work that includes an examination of the theory
and practice of group psychotherapy (based upon Yalom and Leszcz 2005). The
three-part group treatment programme used in our clinic is explained in detail.
The chapter includes information about our outcome studies. Attention is given to
the Twelve Step programmes.
In our experience, most paraphilic behaviour is driven by addictive processes.
Paraphilic behaviours are listed in the Diagnostic and Statistical Manual of Men-
tal Disorders (DSM-V) and designated ‘disorders’, if they cause wide-ranging
impairments or undue subjective distress (American Psychiatric Association
2013). Aetiology of paraphilic behaviour is considered and, while there are a vari-
ety of opinions, I take the view that the causes always emerge from the develop-
mental history. Consideration is given to treatment with particular reference to
CBT and pharmacological intervention.
There is a chapter on the internet. It highlights the positive contributions of
the internet to stigmatised sexual minorities. Prevalence data are made available.
Because of the rapid expansion of the internet, the statistical information will
inevitably be out of date within days of writing. The internet has an impact on
 Preface xvii

s­exuality. It allows exposure to supernormal stimuli. This chapter explores the

negative impact of internet pornography on male sexuality and provides ideas
to help internet sex addicts to manage and limit their behaviour. Attention is
given to the neuropsychology of internet addiction. A final section of this chapter
researches an interconnection between dissociation and internet overuse.
This is followed by an overview of traumatic attachment. This term is used to
note non-optimal attachment patterns that leave the individual with an inability to
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internally regulate their feeling states. These individuals look to substances and
addictive behaviours to self-regulate. The standard treatment for trauma is dis-
cussed. This comprises creating the alliance, establishing safety, teaching ground-
ing techniques, re-telling the trauma with the original affect and the creation of a
coherent narrative. This treatment protocol leads to resolution. Attachment styles
are reviewed and the sequelae of traumatic attachment considered.
The final chapter before the conclusion is on cross addictions and comorbid
disorders. Cross addictions are considered not as just another addiction running
alongside the sexual addiction but rather as a package. Addictions combine in
distinctive ways. The comorbid issues that are presented are the ones most regu-
larly seen in our clinic. These include depression, loneliness, anxiety, boredom
and shame. While loneliness and shame are not ‘disorders’, they are difficult and
unmanageable feeling states that are often anaesthetised by sexual behaviour. For
this reason, I have included them in the section on comorbid disorders.
The concluding chapter considers three interrelated subjects that flow from
work on sexual addiction and CBT. The first is the pathologising of male sexu-
ality. We then consider whether the sexual addiction narrative, as I have put it
forward, is yet another attempt to police the difference between the acceptable
and unacceptable in human sexual behaviours, this time by psychologists and
psychotherapists. Finally, we consider a major paradigm shift in our understand-
ing of addiction, moving from addiction as a word only applying to substances to
a word that applies also to behaviours.
The book ends with a list for further reading and a guide to facilities and organ-
isations that might be helpful to recovering sex addicts or to therapists working
with them. The term ‘acting out’, which is used in this book, is a widely used one
to describe addictive sexual behaviour. Throughout this book, I have used the
male gender in reference to the sex addict. While there are undoubtedly women
who are sexually addicted, they rarely present at our clinic. To work with them
is outside my field of professional expertise and the scope of this book has been
limited to male sex addicts.
 Acknowledgements
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Particular thanks go to Dr Neema Chudasama, Dr Matthew Hedelius, Dr Dean

Krechevsky, Dr Robin Lawrence, Dr Stirling Moorey and Dr Bhaskar Punukollu.
Thanks to our associates, Sarah Alpert, Victoria Appleyard, Leigh Brown, How-
ard Martin, Joy Rosendale and Alex Smith. Thanks to Pavlo Kanellakis and Geor-
gia Masters. Special thanks to our practice manager, Raj Khera.
I wish to thank Francesca Hall, an art therapist, for designing part of our treat-
ment programme for men with sexually addictive behaviours.
Warm thanks to Wiktor Kumala.
The writing of this book would have been impossible without the help of my
researcher and personal editor, Jo Benfield. Her meticulous attention to detail and
useful advice on the content have been invaluable. I hold her in the highest regard.
In memoriam Giles and Cecilia.
The author and publishers would like to thank the following for granting per-
mission to reproduce material in this work:
Alcoholics Anonymous: the Twelve Steps are reprinted with permission of
Alcoholics Anonymous World Services, Inc. (AAWS). Permission to reprint the
Twelve Steps does not mean that AAWS has reviewed or approved the contents
of this publication, or that AAWS necessarily agrees with the views expressed
herein. Alcoholics Anonymous is a programme of recovery from alcoholism only;
use of the Twelve Steps in connection with programmes and activities that are
patterned on Alcoholics Anonymous but which address other problems, or in any
other non-Alcoholics Anonymous context, does not imply otherwise. In addition,
while Alcoholics Anonymous is a spiritual programme, it is not a religious pro-
gramme. It is not affiliated or allied with any sect, denomination or specific reli-
gious belief.
Every effort has been made to contact copyright holders for their permission
to reprint material in this book. The publishers would be grateful to hear from any
copyright holder who is not acknowledged here, so that they can rectify any errors
or omissions in future editions of the book.
 Chapter 1

Sexual addiction
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Introduction
The term ‘addiction’ comes from the Latin addicare, which means ‘to be bound
over by judicial decree’. It suggests a loss of will. It describes a state or condition
that seems beyond individual control. There are overtones of slavery to a substance
or a behaviour that is outside volition or personal determination. This chapter will
describe and define sexual addiction. It will outline the historical antecedents and
explore nomenclature. The aetiology of sexual addiction will be considered and
the concept will be located in a variety of contexts. The chapter will examine the
drivers for sexually compulsive behaviour and briefly explore addiction as a means
of affect regulation, as well as considering comorbid conditions. The objections to
the concept of sexual addiction will be considered. The chapter will end with two
illustrative case studies of sexually addicted men. I will use the following terms
interchangeably: sexual addiction, sexual compulsivity, hypersexuality and ‘out of
control’ sexual behaviour. By this use, I attribute no particular preference for one
term over another and no term implies any particular aetiology.

Definitions
Sexual addiction is the label given to a pattern of sexual behaviour that is compul-
sive and preoccupies, that is difficult to stop and stay stopped, and that brings with
it harmful consequences. The behaviour is continued in spite of these harmful
consequences. It is largely used to anaesthetise intolerable affect states. It emerges
from the life story of the addicted individual.
Goodman gives the following definition of sexual addiction: ‘A condition
exists in which the subject engages in some form of sexual behaviour in a pattern
that is characterised by two key features: recurrent failure to control the behaviour
and the continuation of the behaviour despite significant harmful consequences’
(Goodman 1998: 9).
Kingston and Firestone (2008) cite Goodman as writing that the function
of excessive sexual behaviour is to produce pleasure and provide escape from
pain. Carnes and Wilson (2002) propose that a process would be considered an
­addiction when the behaviours fulfil the following three criteria: 1) loss of control
 2 Sexual addiction

2) continuation in spite of harmful consequences, and 3) obsession/­preoccupation.

Carnes expands this definition by drawing up what he calls the ‘Ten signs of
sexual addiction’:

1A pattern of out-of-control behaviour.

2Severe consequences due to sexual behaviour.
3Inability to stop despite adverse consequences.
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4Persistent pursuit of self-destructive or high risk behaviour.

5Ongoing desire or effort to limit sexual behaviour.
6Sexual obsession and fantasy as a primary coping strategy.
7Increasing amounts of sexual experience because the current level of
activity is no longer sufficient.
8 Severe mood changes around sexual activity.
9 Inordinate amounts of time spent in obtaining sex, being sexual or recov-
ering from sexual experience.
10 Neglect of important social, occupational or recreational activities
because of sexual behaviour.
(1991: 11–12)

According to Carnes, sexual preoccupation becomes an ‘analgesic fix for the sex
addict’ (1991: 21). He asserts that ‘sex addicts use their sexuality as a medica-
tion for sleep, anxiety, pain and family and life problems’ (1991: 23). This self-
medication view of sexual addiction has also been proposed in other forms by
many researchers from different perspectives (Bader 2008; Fenichel 1946,
reprinted 1996; Kahr 2007; Weisse and Mirin, 1997).
I define sexual addiction as a pattern of sexual behaviour that is made up of
four components:

1 It is experienced as out of control and preoccupying.

2 People try to stop but they cannot remain stopped.
3 The sexual behaviour brings with it harmful consequences.
4 It is primarily used to anaesthetise some negative feeling state.

There is increasing information that some people wander into sexual addiction
by experimentation. They opportunistically look at sexual sites and, by the strong
reinforcement provided by arousal and orgasm, find that they become addicted
(Hall 2013). However, in my clinical experience, I am not persuaded that this
is just a matter of opportunity, but rather a case of opportunity meeting a pre-
existing need.

Descriptive examples
It may be useful to illustrate the concept of sexual addiction with a range of
descriptive examples of the behaviours of clients with whom I have worked on
 Sexual addiction 3

an individual basis and in a group setting. Additional material, in the form of two
case studies, is provided at the end of this chapter to further illustrate the concept
of sexual addiction. In each case, both the patient and I have come to the conclu-
sion that the behaviour fits the description of sexual addiction. The cases cited are
composite examples and do not represent any one patient. In my individual work,
I have witnessed the following:
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• A young heterosexual male with a female partner and three children exhibited
‘addictive’ behaviours involving exhibitionist homoerotic masturbation in
showers and changing rooms and other public places.
• A middle-aged married heterosexual male had little control over his use
of internet pornography. He would go online for half an hour and then
compulsively masturbate for much of the night while on the internet.
Sometimes this would go on for several days.
• A young gay man took pictures on his phone, at the gym, of men in the
shower without their permission.
• An extremely able young male medical doctor had ritualised telephone sex
while talking through a fantasy of innocence and seduction. He told me that
he wanted a normal married life and a family.

Each of these patients reported some, or all, of the following harmful conse-
quences: powerlessness, self-contempt, personal danger, health risks, loss of
creative time and career opportunities, financial loss and impaired capacity for
intimate relations with a domestic partner.
Within my group treatment programme, participants have revealed the follow-
ing behaviours: one man having anonymous sex with men in public places, one
masturbating to pornography of women being beaten, another masturbating over a
mixed repertory of images of bondage and domination, two men using sex work-
ers in spite of being committed to fidelity in long-term relationships, and two
others compulsively masturbating over heterosexual pornography. In all but one
case, these men have problems with emotional intimacy and being sexual with
significant others. It is important to emphasise that this is not about heterosexual,
homosexual or solitary behaviours. The issue of concern here is not the type of
behaviour, or the amount of time it consumes, but rather the experience, function
and consequences of that behaviour in the life of the individual.

A historical perspective on sexual addiction

The notion of addiction starts deep in the Judeo-Christian tradition, with the
movement of the Hebrew people out of slavery into the Promised Land. Addic-
tion has overtones of slavery. This theme is taken up in the Christian tradition. In
a chapter referring to slavery, Paul writes: ‘For what I do is not the good I want to
do; no, the evil I do not want to do, this I keep on doing’ (Romans 7:19). This is
the language of addiction.
 4 Sexual addiction

Later in the third century, Augustine writes as follows:

The enemy had my power of willing in his clutches, and from it had forged
a chain to bind me. The truth is that disordered lust springs from a perverted
will; when lust is pandered to, a habit is formed; and when the pattern is
not checked, it hardens into a compulsion. These were the interlinking rings
forming what I have described as a chain, and my harsh servitude used it to
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keep me under duress.

(Translated by Boulding 1997: 192)

Once again, we see the language of slavery and compulsion. It is not an accident
that one of the first self-help group for sex addicts, Sex and Love Addicts Anony-
mous, calls itself the ‘Augustine Fellowship’.
It is evident that the concept of addiction provides us with a way of thinking
about and describing age-old patterns of behaviour that we have always known
about but have not always framed as addictive or compulsive (Butts 1992). In
1812, Benjamin Rush, the Father of American Psychiatry, published (with Sam-
uel Merritt) Medical Inquiries and Observations Upon the Diseases of the Mind.
This book includes a chapter entitled ‘Of the morbid state of the sexual appetite’.
In this chapter, Rush and Merritt give three examples of the sexual appetite that
today we might call ‘sexual addiction’. The interesting thing about this publi-
cation is that some of the remedies they suggest are much the same as modern
interventions: the avoidance of alcohol (which disinhibits) and pornography,
the avoidance of idleness, exercise, the use of music to intercept fantasy, and an
involvement with meaningful and fulfilling pursuits.
In 1886, Krafft-Ebing, an Austro-German psychiatrist, published the Psy-
chopathia Sexualis, a collection of 238 case histories of a variety of sexual pat-
terns. He introduced the term ‘sadism’, from the writings of the Marquis de Sade
and ‘masochism’ after the book, Venus in Furs, by Leopold von Sacher-Masoch.
Krafft-Ebing writes:

Sexual appetite is abnormally increased to such an extent that it permeates all

his thoughts and feelings, allowing of no other aims in life, tumultuous and in
a rut-like fashion demanding gratification without granting the possibility of
moral or righteous counter-presentations, and resolving itself into an impulsive
insatiable succession of sexual enjoyment . . . this pathological sexuality is a
dreadful scourge for its victim, for he is in constant danger of violating the laws
of the state and of morality, of losing his honour, his freedom and even his life.
(Krafft-Ebing 1886: 70)

I often give talks on sexual addiction under the title ‘This dreadful scourge’. This
seems to accurately capture the experience of many.
In 1946, Otto Fenichel published The Psychoanalytic Theory of Neurosis. In
this book there is a chapter entitled ‘Addiction without drugs’. He writes that ‘the
 Sexual addiction 5

mechanisms and symptoms of addiction may also occur without the employment
of any drugs, and thus without the complications brought about by the chemical
effects of drugs’ (Fenichel 1946, reprinted 1996: 381). He also writes of love
addicts and the hypersexual, and notes the connection with paraphilias. He con-
nects hypersexuality to a number of comorbid conditions including anxiety and
depression (Fenichel 1946, reprinted 1996: 384).
The concept of ‘sexual addiction’ became popularised in 1983 when Patrick
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Carnes first published Out of the Shadows. Shortly afterwards, Quadland (1985)
and Coleman (1988) characterised the same syndrome as ‘sexual compulsivity’.
Various researchers label it differently, with each label suggesting a particular
aetiology. Barth and Kinder (1987) described it as ‘sexual impulsivity’, and it has
also been labelled ‘hypersexuality’ (Brotherton 1974). Bancroft and Vukadinovic
(2004) used the term ‘out of control’ sexual behaviour.
For our purposes, suffice it to say that, regardless of the term used to describe
this behaviour, the clinical literature on the topic has been overwhelmingly consist-
ent in the set of symptoms ascribed to the phenomenon (Gold and Heffner 1998).
Zapf et al. (2008) list the features of sexual addiction as recurrent failure to resist,
increased tension prior to the behaviour, pleasure and loss of control, attempts to
curb, not fulfilling obligations, and acting out in spite of harmful consequences. In
clinical observation, we see patients spending a great deal of time pursuing sexual
behaviour or resisting urges to pursue sexual behaviour. We see a repetitious return
to the behaviours with little regard for the consequences. A period of relief is nor-
mally followed by guilt, shame and remorse. We can conclude that the syndrome
remains the same no matter what we call it (Gold and Heffner 1998).

The concept of addiction

The standard medical dictionary defines addiction as ‘the state of being given up
to some habit, especially strong dependence on a drug’ (Jacobs 1997: 170). This
definition specifically includes habit, as well as substance. Griffin-Shelley (1993)
writes that we are now better able to see similarities between addictions to behav-
iours and addictions to substances. He mentions addictions to sex and love, as well
as to food and religion. This is also captured in the definition of an addiction offered
by the American Society of Addiction Medicine in 2011 – namely, ‘a chronic brain
disease that affects the reward, motivation and memory systems and combines both
substance and behavioural addiction under a common umbrella’ (Hilton 2013: 2).
There is increasing evidence that sexual compulsivity is an addiction. That evidence
is multifaceted and based on a growing understanding of the role of neural receptors
in addiction processes (Hilton 2013). This will be explored further in Chapter 3.
I am persuaded of the reality of behavioural addictions, including making
money, exercise, romantic infatuation, pathological gambling, perhaps food,
sometimes ecstatic religion and sex. Many researchers agree that numerous peo-
ple engage in excessive sexual activity that creates problems and interferes with
social and occupational functioning (Lloyd et al. 2007).
 6 Sexual addiction

The principal objection to the term ‘addiction’ is that it provides an excuse for
the behaviour and suggests denial of responsibility. This view continues to circu-
late although it has little foundation. It is not discussed in either our treatment pro-
grammes or in the Twelve Step recovery fellowships. Further information about
recovery fellowships can be found in Chapter 8. However, professionals must
address their distinctive constituencies and the choice of nomenclature is dictated
as much by political and social agendas as by clinical consideration.
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In the literature, it is common to find the terms ‘addictive’ and ‘compulsive’

linked together to describe this behaviour. For example, American specialists
working in this field founded a journal entitled Sexual Addiction and Compulsiv-
ity: The Journal of Treatment and Prevention. In the United Kingdom, the Asso-
ciation for the Treatment of Sexual Addiction and Compulsivity was founded.
The word ‘compulsion’ is normally associated with the relief of painful affect and
the word ‘addiction’ with the production of pleasure. As these behaviours serve
both functions, they are rightly combined.

The medical context

If we consider sexual addiction from a medical perspective, there are two key
frameworks to take into account – namely, the International Classification of
Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and
Statistical Manual of Mental Disorders (DSM-V). In the following section, I focus
primarily on DSM-V for two reasons: first, most of the work on sexual addiction
is American and, second, the DSM is widely used in the United Kingdom as a
guide to diagnosis. While there is general debate about the usefulness of the DSM
(Kutchins and Kirk 1997), it is important and influential in the medical profes-
sion and the professions allied to medicine. Understanding sexual addiction in
relationship to the DSM is therefore important so that practitioners can effectively
communicate across the disciplines.
The International Classification of Diseases (ICD-10) was endorsed by the
43rd World Health Assembly in 1990 and came into use in the World Health
Organization (WHO) member countries in 1994. A current revision is under way
and will be published in 2017. ICD-10 has two classifications relevant to sexual
addiction: ‘F98.8 Behavioural and emotional disorders occurring in childhood and
adolescence’, which designates ‘excessive masturbation’, and ‘F52.7 Excessive
sexual drive’, which includes nymphomania and satyriasis. This does, in fact, give
us a clear identification of sexual addiction/hypersexuality as a medical disorder.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been pub-
lished by the American Psychiatric Association since 1952. The fifth edition, DSM‑V,
was published in 2013. Major efforts were made to have sex addiction, under the
heading of ‘Hypersexual disorder’, included in DSM-V. However, these were unsuc-
cessful, the justification being that ‘at this time there is insufficient peer-reviewed
evidence to establish diagnostic criteria and course descriptions needed to identify
these behaviours as mental disorders’ (American Psychiatric Association 2013: 481).
 Sexual addiction 7

The previous version of the DSM, DSM-IV (American Psychiatric Press 1994),
avoided the use of the word ‘addiction’ altogether. However, DSM-V does use
the term ‘addiction’ and admits to the reality of behavioural addictions, which are
classified under ‘Substance-related and addictive disorders’. This part of DSM-V
includes a section on one behavioural disorder – namely, gambling disorder. The
essential feature of gambling disorder is persistent and recurrent maladaptive
gambling behaviour that disrupts personal, family and/or vocational pursuits. In
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reading through the diagnostic criteria, it is clear that it could, more or less, be
applied to ‘out of control’ sexual behaviour, which is a persistent and recurrent
maladaptive sexual behaviour that disrupts personal, family and/or vocational
pursuits. DSM-V also lists internet gaming disorder as a ‘Condition for further
study’. However, including sexual addiction as a new category of disorder in the
DSM would have wide implications beyond diagnosis, incorporating areas such as
criminal responsibility, wrongful dismissal, insurance liability and issues involv-
ing child custody.
Despite the omission of hypersexual disorder from DSM-V, there are two other
classifications in the manual that are of relevance to the topic of sexual addiction.
The first is sexual dysfunction. This is divided into the following subsets: delayed
ejaculation, erectile disorder, female orgasmic disorder, female sexual interest/
arousal disorder, genito-pelvic pain/penetration disorder, male hypoactive sexual
desire disorder, premature (early) ejaculation, and substance/medication-induced
sexual dysfunction. In working with sexual addiction and compulsivity, it is pos-
sible that one of these disorders might become apparent along with the addiction.
It is important for the practitioner to be aware of this, and to be in a position
either to treat the sexual dysfunction or to refer the client to another qualified
practitioner.
The second DSM-V classification of which we need to be aware is the sec-
tion on paraphilic disorders. DSM-V states that a paraphilia denotes ‘any intense
and persistent sexual interest other than sexual interest in genital stimulation or
preparatory fondling with phenotypically normal, physically mature consenting
human partners’ (American Psychiatric Association 2013: 685). The editors are
careful to state that the term ‘disorder’ can only be used when the paraphilia is
causing distress or impairment; it does not by itself require clinical intervention.
Paraphilic disorders are listed as:

• Voyeurism
• Exhibitionism
• Frotteurism
• Sexual masochism
• Sexual sadism
• Paedophilia
• Fetishism
• Transvestic
(American Psychiatric Association 2013: 685)
 8 Sexual addiction

It is possible that some of these behaviours will present alongside hypersexuality

when working with sexually addicted men. Although they will be explored later in
this book, it is worth noting here that paraphilias are resistant to treatment.

The origins of sexual addiction

Aetiology in narcissistic damage

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The origins of sexual addiction lie in the background and history of each individ-
ual sex addict. Usually, there is a background of attachment disorder and trauma,
which results in poor affect regulation and the need to turn to substances and
behaviours to manage painful affect. Hall (2013) differentiates between attach-
ment-related and trauma-related disorders. However, these seem to me just to be
two forms of trauma. For a comprehensive understanding of aetiology, I would
turn to Goodman (1998), who states that causation lies in narcissistic damage.
Narcissistic damage is a configuration of the self, set up in the family of origin,
which results in two major consequences: the self is experienced painfully and
the self is experienced as unacceptable. By painful, I mean a chronic or pervasive
state of negative affect. By unacceptable, I mean that the self of the person is
experienced as intrinsically flawed in the sight of others and, consequently, the
reality of the self seeks to be hidden and masked. These two themes are combined
in Baumeister’s book, Escaping the Self (1991), which explains addiction as a
flight from the burden of selfhood. The by-products of narcissistic damage are
depression, chronic anger, core loneliness and unremitting shame.
According to the DSM-IV, narcissistic damage can be defined as ‘enduring
affect, cognitive, behavioural, relational patterns in the formation of the self, and
carried into adulthood, that are maladaptive and cause impairment or distress’
(adapted from Goodman 1998). Goodman (1998) further describes narcissistic
damage as ‘impairment in the individual’s system for self-regulation’. This defi-
nition subsumes the effects of both trauma and disordered attachment.
Miller (1987) describes narcissistic damage as a sense of self created in the
family of origin as an accommodation to parental needs, which brings with it a
sense of emptiness, loneliness and anomie, as well as a compulsion to control
and a propensity for grandiosity. Kernberg (1986) suggests a similar symptom
set. According to Kohut and Wolf, the origin of narcissistic damage lies in the
origin of the self and emerges from a ‘faulty interaction between the child and his
selfobjects’ (Kohut and Wolf 1986: 177). Goodman (1998) notes that the litera-
ture indicates that affect regulation, self-care, and self-governance are internalised
from our primary caregivers.
It is important to have a clear understanding of the connection between
addiction and narcissistic damage. Addictions, whether they involve substances,
or processes like sexual compulsivity, are mechanisms for anaesthetising
negative affect and the other consequences of narcissistic damage. Goodman
(1998) attributes the emergence of sexual addiction to the existence of covert
 Sexual addiction 9

sexualisation in the family of origin. He writes that ‘the critical factor seems to
be the relative influence of sexualisation in the individual’s psychic life’ (Good-
man 1998: 136).
Sexual addiction, like any addiction, serves the purpose of anaesthetising rather
than correcting the consequences of narcissistic damage. The principal compo-
nent of narcissistic damage is an endogenous shame that is made more acute by
the shameful consequences of addictive compulsive behaviour.
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The role of shame

Shame is the painful feeling of being unacceptable. It is the core affect of narcissis-
tic damage; it is a driver of the addictive cycle and high levels of shame are often
associated with addictive compulsive behaviour. Lewis links shame with narcis-
sistic damage and describes it as ‘a negative experience of the self’ that involves
‘an implosion or a momentary destruction of the self in acute self-­denigration’
(Lewis 1987: 95). The ‘unto death’ nature of shame is reflected in popular lan-
guage. People say that ‘they were mortified’ or that they were so embarrassed that
they wanted the ‘ground to open up’.
In the literature on addiction, shame and narcissistic damage are interrelated. In
my view, shame is the self experienced as unacceptable. Shame is the oxygen to
the addictive fire. In the treatment programmes that we run, a reduction in shame
coincides with a reduction in acting-out behaviours. Carnes writes that ‘sexual
addiction rests on one key personal assumption: somehow I am not measuring
up’ (1991: 94). The problem is that sexual addiction creates a Catch-22 situa-
tion. While it temporarily creates a tunnel of oblivion, afterwards it contributes to
higher levels of shame.
If the function of shame is to tell us that we are doing something unaccepta-
ble, we recognise that we risk social approbation when we engage in shameful
behaviours. High levels of shame tend to accompany behaviours that take place
outside committed relationships. In evolutionary terms, these behaviours do not
maximally ensure protected childrearing and therefore do not contribute to the
well-being of the species. While socially, cognitively and technologically, we
have moved beyond the need of the primal horde to a place where reproductive
function is no longer a pressing priority, our affect states still operate from an
earlier place in the evolution of humankind.

Sexual addiction and the regulation of affect

Goodman (1998) suggests that addiction grows out of impairment in the affect-
regulatory mechanism of the self, and that it becomes the function of the addic-
tion to manage and modulate the experience of painful affect. Rosen (1997) takes
the same view from a psychoanalytic perspective and Bays and Freeman-Longo
(1989) take a similar view in their explanation of sexual offending. Goodman
clearly states that the addictive process originates in ‘a disorder of self-regulation’
 10 Sexual addiction

(1998: 197). He attributes such disturbance (citing a range of psychotherapeutic

terms all describing the same thing) to the failure of maternal responsiveness,
traumatic disappointments, insufficient maternal availability, faulty patterns of
affective interchange, and a mismatch between the infantile emerging psycho-
biological need and the available environment provision. All these constitute
trauma and/or attachment disorder. To describe sexual addiction as affect regu-
lation is another more psychobiological way of saying that addiction anaesthe-
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tises the twin condition described earlier: the self, experienced painfully and as
unacceptable.
It is important to note that we all use anaesthetising substances and behaviours
to manage painful affect states. In this sense, it is not a disorder but a value judge-
ment about substances and patterns of behaviour. Kahr put this particularly well
in Sex and the Psyche (2007): ‘Sexual fantasies provide respite from our daily
troubles, and they afford instant physical release, as well as psychological release,
when we find ourselves overwhelmed by anxiety, conflict, depression or even fear
of impending breakdown’ (469).
It is easy to see how it is possible to define a particular kind of behaviour or
fantasy that is somewhat non-normative as sexual addiction and compulsivity.
This leads us to consider some of the objections that have been raised to the con-
cept of sexual addiction and compulsivity.

Objections to the concept of sexual addiction

There are a number of objections that are commonly voiced to the concept of
sexual addition. These include the subjectivity of the definitional criteria, the
assumptions that it makes about human purpose, the charge of heuristic predomi-
nance and the implied set of values upon which it is based. These charges will
each be explored in turn in the following section.
Within the theory of sexual addiction, so much is subjective, including three of
the major components – namely, preoccupation, harmful consequences and func-
tion. We need to consider how we define preoccupation. It could be argued that
most men are preoccupied by sex; indeed, looking at the tabloid newspapers, it
would seem that our whole society is preoccupied by sex. If we consider mastur-
bation, for example, some might see masturbating once a week as a p­ reoccupation,
while others might define it as masturbating twice a day. The same question can
be asked when considering the amount of time spent engaging in sexual behav-
iours on the internet. The implication of this is that two people could have exactly
the same behaviour and one would be a sex addict and the other would not. In this
sense, sexual addiction is not a disorder in its own right, but rather it is a subjec-
tive evaluation of a pattern of behaviour. Particularly cogent to this point is an
article written by Levine and Troiden (1988), which argues that sexual addiction
is a stigmatising label and renders a moral judgement on behaviour that diverges
from prevailing erotic standards. Ley (2012) makes similar points in his book The
Myth of Sex Addiction.
 Sexual addiction 11

Addiction treatment and theory bring with it many assumptions about human
purpose. These are often couched in quasi-medical language or in the language of
psychology. ‘Appropriate’ and ‘inappropriate’ have become synonyms for good
and bad. There are many of these assumptions, but the central one is that the
avoidance of behaviours that are defined as ‘addiction’ is a ‘healthy’ life prior-
ity. Balance, relational sexuality, living as a monogamous couple, the pursuit of
intimacy and the ‘perfecting of the self’ are the goals of life. We might like to con-
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sider whether the world would really be a better place without Mother Theresa, or
without the greatness and the contributions of figures such as Gaugin, Escoffier,
Coleridge and Mapplethorpe. We might then question whether it is really better
to live a balanced life.
A further critique of the concept of sexual addiction is that it is subject to
‘heuristic predominance’. This describes a tendency among clinicians who have
a background in addiction recovery (or perhaps to have been married to a sex
addict) to claim special knowledge that automatically invalidates critical argu-
ment. External criticism can be dismissed and rebuffed on the grounds that those
outside this experience cannot know about it and therefore cannot speak with
insight and authority.
Furthermore, beneath most of the American discourse on sexual addiction is
an implied set of conservative values. These can be broken down into two parts:
some are associated with prohibitions against non-procreative sex, while others
rely on the tendency to label ‘too much’ masturbation, sexual use of the internet,
bondage, domination, sadism and masochism all as distortions and perversions of
sexuality under the heading of sex addiction. Equally, gay men may be viewed as
being ‘allowed’ sex as long as it is in the context of a loving relationship. These
are all values and they should be identified as such and not camouflaged in medi-
cal or psychological language.
For all the limitations and inadequacies that apply to the theory of sexual
addiction, and the use of addiction language in relation to sexual behaviour, the
concept of sexual addiction has some distinct advantages. It provides practition-
ers with a systematic model for understanding and classifying a wide range of
sexual behaviours. It also provides practitioners with a systematic approach to
treatment – namely, a treatment programme that is essentially cognitive behav-
ioural. The highly subjective nature of the definitions and diagnostic criteria
for sexual addiction means that the locus of treatment lies not with the medi-
cal establishment or with practitioners but with the individual client. Finally, it
provides a clear and unambiguous response to individual men and women who
experience profound suffering and serious harmful consequences as a result of
their sexual patterns.

Application of theory to practice: two case examples

In the following case studies, the details and other distinguishing features have
been changed to protect the anonymity of the patients.
 12 Sexual addiction

Scott is 34 and is a university-educated accountant working with a large and

prosperous firm in the City. He is middle class and grew up in the suburbs. He
now lives in a fashionable part of London with his wife and child.
About once a fortnight, Scott enters a cycle of compulsive sexual behaviour.
Each cycle has a ritualised sequence. It will begin with Scott browsing the top
shelf of the newsagent during his lunch hour. He will then find phone boxes and
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ring sex workers. This may last 2 or 3 hours. Eventually, he will either end up
with one of the women or, more usually, at a massage parlour.
After orgasm, he goes into a state of profound remorse and regret. He hur-
ries away and heads for home. Thus begins a cycle of repentance, abstinence
and withdrawal, until eventually a sense of need or entitlement brings him back
into another cycle of the same behaviour. He has been ‘locked’ into this cycle
of behaviour for four years. He has been threatened with violence on more than
one occasion from the men who control the sex workers.
He lives his life in fear, anxiety and regret, and loathes himself, both in gen-
eral and in regard to this particular pattern of behaviour. He recognises that it is
out of control, dangerous to his job, his marriage, his family life, his health and
his whole sense of self. However, he goes on doing it.
I use this case study for three reasons: first, it clearly illustrates the chief
characteristics of sexual addiction that have been described in this chapter; sec-
ond, it is a clear example of the ‘cycle of addiction’; and, third, it is the case
study that I use in the treatment programme that I run for sexually compulsive
men.
The immediate treatment priority in working with Scott was to stop the
behaviour. The threat to his marriage and the frequent danger from the men
who controlled the sex workers were all potential examples of harmful con-
sequences. The longer-term treatment priority was to deepen his cognitive
awareness of these harmful consequences and to encourage him to participate
in a cognitive behavioural programme of sexual addiction recovery. It was
clear from his history, which is not given in this case study, that shame was
a major factor in driving the behaviour. In addition, cascading and spiralling
shame was a major outcome of each addictive episode. The aim of treatment
was to help Scott identify his own version of the addictive cycle and to learn
exit strategies and relapse prevention techniques. This involved a much deeper
investigation into the original shame scenarios that underpinned his addictive
patterns. A priority of our work together was the development of cognitive
behavioural techniques for shame reduction and the deliberate construction of
new affective responses. This involved ‘recovery orientated psychotherapy’
(Zweben 1997). The final goal was to help him towards the development of
a capacity for relatedness and self-acceptance, and the development of a way
of living and being that was so fulfilling that he had little need for compulsive
sexual patterns.
 Sexual addiction 13

Kirk is a happily married man with three children. He is a successful lawyer who
has founded a small law practice. He was referred to me by a human resources
specialist because one of his colleagues had, without permission, hacked into
his computer and found quantities of pornographic material in the ‘barely legal’
category.
Kirk’s behaviour began when there were threats to his wife’s health. At the
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same time, full internet access was set up at his legal practice. His history sug-
gested an absent father and a needy, overbearing mother. There was no indica-
tion of any kind of abuse in his family of origin. In my view, his sexual fantasy
and the use of the internet were adult continuations of his earlier childhood
escapes into non-sexual fantasy.
On referral, Kirk immediately joined our treatment programme for sexual
compulsivity. Cognitive behavioural work immediately contributed to change.
He came to me in a state of shock about the size and scale of the consequences
of his actions. At the time of writing, he reports feeling ‘very well’ and has been
continuously free of addictive compulsive behaviours for two years.

This case study illustrates preoccupation, harmful consequences and the process
of recovery. It also illustrates the ‘crisis’ that often necessitates intervention.

Conclusion
This chapter has attempted to define and describe the behaviour of sexually
addicted men. Antecedents to the theory of addiction and sexual addiction have
been noted. The terms ‘addictive’ and ‘compulsive’ have been explained. We
have assigned aetiology to narcissistic damage in the childhood experience of the
individual. Narcissistic damage subsumes both trauma and attachment disorder.
An important function of addiction is the regulation of internal feeling states by
the use of a substance or behaviours. The chapter has concluded with an exami-
nation of the major arguments against applying the language of addiction when
discussing sex. Despite these criticisms, at our clinic, we continue to use the lan-
guage of addiction because no other wording quite conveys the helplessness of the
subject or the repetitious tyranny of the process.
 Chapter 2

Cognitive behavioural therapy

and sexual addiction
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Introduction
The Buddha said that ‘it is better to conquer yourself than to win a thousand
­battles’ (Byrom 2012). The aim of cognitive behavioural therapy (CBT) is to help
the patient to do that, through both cognitive and behavioural change. This chapter
explores how CBT can be used to facilitate change in patients dealing with sexual
addiction. It does not attempt a comprehensive description of CBT, assuming that
the reader is familiar with its core concepts, but rather highlights its specific usage
in this field. The chapter explores the history of CBT and the study of sexuality. It
then sets out the main principles of CBT. It explores the important role that case
formulation plays, with the identification of precipitants, triggers and maintaining
factors. It then considers the tools and techniques available from CBT for working
with sexually addicted patients.

A historical perspective
We tend to think of Freud as the father of the study of sexuality. However, there
were numerous academics and medical specialists who, at the end of the nine-
teenth century, were researching and writing about the complexities of human
sexuality. These included Adolf Patze, a German physician who observed a
strong sexual drive in young children, and Richard Krafft-Ebing, who assem-
bled an exhaustive series of case studies of paraphilic and non-normative behav-
iours. Other important influences were Albert Moll, Havelock Ellis and Magnus
Hirschfield. By the mid-twentieth century, it was generally acknowledged that
specific expressions of sexual behaviour were learned phenomena. This gave rise
to behaviourism becoming the accepted treatment modality for sexual problems
and sexual offenders.
Behaviour therapy was developed by Wolpe (1958) and other practitioners in
the 1950s and 1960s. It focused on helping clients to change unhelpful learned
behaviours. It was based upon learning theory, which looked for general principles
about how people learn new associations between stimuli and responses. Behav-
iour therapy provided solid evidence of efficaciousness and economy of time.
 Cognitive behavioural therapy and sexual addiction 15

CBT is a combination of behaviour therapy and the cognitive approach that

was first developed by Beck and associates in the 1970s. Beck’s contributions are
among the greatest in the history of psychology and psychiatry (Padesky 2004).
He coined the terms ‘automatic thoughts’ and ‘collaborative empiricism’, and rec-
ognised that a mood disorder is primarily a thinking disorder. He realised that our
feelings emerge from our thoughts. He asserted that the aim of therapy was to
enable the patient to become his own therapist, with the long-term goal of making
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the patient ‘both Socrates and the pupil’ (Westbrook et al. 2012: 153).
Over the years since the publication of Beck’s seminal book, Cognitive Therapy
of Depression (Beck et al. 1979), cognitive and behavioural therapy have grown
together. It was recognised that it was important to bring cognitive phenomena into
psychology and therapy. Modern CBT emerged, combining ­behaviour therapy
‘with its emphasis on the importance of behaviour change in overcoming mental
health problems and cognitive therapy, with its emphasis upon understanding and
changing the meaning of events’ (Westbrook et al. 2012: 20).
Sexual addiction is a powerfully reinforced behaviour. Sex is among the most
powerful of reinforcing agents. This can be illustrated by an example of a patient
of mine who goes ‘dogging’ (visiting car parks to see or engage in sexual activ-
ity). He told me that he noticed that he had been out all night in his car and that
the take-away he had bought for supper was still sitting untouched on the car floor
the next morning. Such is the power of sexual addiction. The sexual appetite is
a drive, not just something that people do as an optional behaviour, like taking a
walk in the garden or downloading a film to a tablet. Sex is central to the survival
of the species. This accounts for its strength and its endowment with so much
pleasure. Nature intends sex for procreation and therefore makes the sexual appe-
tite strong and the pleasure great. These features drive it, in spite of all difficulties.
Therapists need to understand the principles of learning that lie behind the
addictive process and the powerful immediate reward that proceeds from the
addictive substance or repetitious behaviour. Learning theory posits two kinds
of conditioning: classical and operant. Under classical conditioning, a neutral
stimulus creates an involuntary response. Ring a bell and the dog will salivate.
The response is outside voluntary control. In operant conditioning, the learner is
actively involved in the process and by his activity receives rewards or punish-
ments. These rewards or punishments increase or diminish the active behaviour
of the learner. Fetch the ball and the dog will get a pat on the head. If the dog does
not fetch the ball, there is no positive reward.
Both these principles can be applied to sexual addiction. Consider the use of
the internet for sexual gratification. There are a series of hand motions, pushing
buttons, moving a mouse and key tapping, which are followed by highly arousing
rewards. This is operant conditioning. At the same time, a double reinforcement
occurs. First, there is relief from the prior negative affect state – for example,
depression, anxiety, loneliness or boredom. Second, an erotic hit follows. Classi-
cal conditioning also operates, because the stimulus creates an involuntary arousal
response. The arousal response, once it starts, becomes increasingly difficult to
 16 Cognitive behavioural therapy and sexual addiction

disengage, partly because it is largely outside voluntary control and partly because
arousal chemistry shuts down the capacity to consider other options. This is fur-
ther explained in Chapter 3.
The power of reinforcement is further enhanced because it takes place on a
variable ratio schedule: it is unpredictably rewarded. For example, a man goes
online in search of sexual stimulation. The appearance of the reward is unpredict-
able. He might look at two pictures before he finds one that matches his erotic
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template; then he might look at twenty more before finding another. The uninspir-
ing pictures are disregarded. It is not possible to predict when the next hit will
come. The pay-out is random and not predetermined. The effect is the same as
a slot machine. Events that are reinforced on a variable ratio schedule are more
adhesive than rewards that are predictable. This makes gambling such a powerful
addictive process: the sequence of pay-outs cannot be foreseen.
Internet pornography is powerful because all these agents contribute to the
process of addiction: operant and classical conditioning, the double reward
(relief from negative affect and its replacement with a highly exciting substitute)
and the unpredictable nature of the arrival of the reward. It is this distinctive
combination of reinforcements that makes internet pornography particularly
addictive.

Overarching principles of cognitive behavioural

therapy
CBT is built around the following principles (Westbrook et al. 2012):

• It is the interpretation of the event that is crucial.

• Behaviour has a powerful influence on our thoughts and feelings.
• Mental health problems are best understood as exaggerations of normal
behaviours.
• It is usually more helpful to focus on the here and now.
• Interacting systems: problems are interactions between thoughts, feelings,
behaviours and physiology.
• Empirical evaluation is important.

Each of these principles is explored in turn in the following sections.

Interpretation of events
As the Stoic philosopher Epictetus (AD55–135) said, ‘Men are disturbed not
by things, but by the principles and notions that they form concerning things’
(Westbrook et al. 2012: 5) This underscores the fact that it is our interpretation of
events that determines the impact that they have upon us, rather than the events
themselves. For example, it is not being made redundant that makes us upset or
angry, but rather the meaning that we place upon it. It might well depend upon
 Cognitive behavioural therapy and sexual addiction 17

the amount of the redundancy payment. It might mean that we finally have the
chance to do something that really interests us. Getting married would normally
be a happy occasion but, once again, it is not the event itself that brings happiness
but rather the way in which we think about it. For example, we might consider a
woman who says to her husband at the wedding reception, “This is the worst mis-
take I have ever made”. Even death itself can be seen as a disaster or a triumph,
a cause for grief or celebration, depending upon the interpretation placed upon it.
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For a member of the Salvation Army, for example, death is being ‘promoted to
glory’.
In working with the sexually compulsive, it is important to understand the
belief system of the individual towards his behaviour. One man who uses sex
workers might feel entirely neutral about his behaviour, while another man might
regard himself as base and immoral. For the second man, the behaviour feeds back
to further impair an already damaged sense of self.

Behaviour influences thoughts and feelings

Behaviour influences thoughts and feelings. This is true with sexual addiction.
The standard pattern is that someone acts out sexually and then has feelings of
self-accusation and remorse. These may be accentuated by a partner finding out
about the behaviour and moving into blame, criticism and rage. The partner’s
accusations confirm and amplify the sense of ‘badness’ in the sexual addict; they
contribute to the sense of profound shame and confirm the core belief of ‘I am a
bad person’. For someone with poor affect control or an impaired self-regulatory
system, these feelings become intolerable and may contribute to further acting
out.
With most sex addicts, the first and highest priority of treatment is to stop
(or greatly reduce) the acting out. This leads to an improved self-image and the
realisation that life is better without the unwanted behaviours. As Westbrook et
al. write, ‘Changing what you do is often a powerful way of changing thoughts
and emotions’ (2012: 5).

Continuum of behaviour
Sexual addiction is best understood as an exaggeration of normal sexual behav-
iour. The ICD-10 (World Health Organization 2011) defines it as ‘Excessive
sexual drive’ (F52.7). We think of sexual behaviours as a continuum. At one end
there is abstinence and at the other there is absence of control. The frequency of
masturbation is an example. There is a point on the continuum of frequency where
one might wonder whether this had moved from being a biological or recreational
pursuit to a pattern of compulsivity. Another example is the use of sex workers.
Visiting one or two sex workers now and again might be seen as recreational
behaviour. However, one might take a different view of a man who visited two
or three sex workers in a 48-hour period. Although this is a value judgement, it
 18 Cognitive behavioural therapy and sexual addiction

would seem that the behaviour had slipped from being recreationally motivated to
a pattern of compulsivity. Sexually compulsive behaviour is an exaggeration of a
natural drive that continues often in spite of harmful consequences.

Working in the present

CBT tends to minimise the historical set-up for a problem. This needs adjustment
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when working with sexually compulsive men. CBT for sexual addiction consid-
ers the present very much in the light of the past. Taking a cue from schema
therapy (Young et al. 2003), we investigate the family of origin to uncover the
set-up for the behaviour and to explore how the present can trigger historic cues.
Because sexual addiction is a response to narcissistic damage (or trauma), it is
important to recognise, and to help the patient understand, that the behaviours are
the legacy of the past, growing out of his biography, and need no longer predomi-
nate in his life. In helping the patient to understand that he did not choose these
behaviours, the therapist contributes to the diminishment of shame. While a per-
son is not ultimately responsible for having these behaviours, they are responsi-
ble for what is done about them. This point is made even at the assessment stage,
so that individuals can begin to get a sense that the behaviour has a function in
their life. At the same time, it is important to recognise that avoidance does not
change the negative feeling state: it only brings temporary relief. Further hard-
ship ensues.

Interconnected systems
CBT visualises individual psychological processes as being made up of a series of
interconnected systems. These are described as cognitive, affect, behavioural and
physiological. Beck developed a useful model for helping clients to understand
the interaction between their thoughts, feelings and behaviours. The so-called
‘ABC model’ focuses on identifying the activating event, or antecedent, which
the client sees as the trigger for his discomfort (A), naming the client’s beliefs
about that event (B) and identifying the emotional and behavioural consequences
(C). For the sexual addict, the antecedent (A) might be being in a hotel room
alone where he has previously acted out on the internet. His belief (B) is that he is
now free to act out once again, and the consequence (C) is that he feels profound
shame. Furthermore, the shame incurred by acting out is then a further set-up to
additional acting out. Loneliness might be the inner cue to the earlier acting out.
CBT works on the ‘behavioural principle’. In other words, if it is possible to
change the behaviour, this will have far-reaching ramifications for thinking, feel-
ing and physiological experience. If sexually compulsive men learn to contain
their sexual behaviour, then this will normally give rise to higher levels of self-
esteem and to lower levels of shame. People become more self-governing. If men
are able to control their sexual behaviour, shame is decreased and well-being is
enhanced.
 Cognitive behavioural therapy and sexual addiction 19

Evidence of effectiveness
CBT is founded on an empirical methodology. Clear evidence regarding the
efficacy of CBT treatment is available for depression, panic, phobias, post-trau-
matic stress disorder and personality disorders. Drawing on the adjacent fields of
substance addiction (Gold and Heffner 1998), internet addiction (Young 2007),
sexual dysfunction (Leiblum 2007), paraphilias (Kruger and Kaplan 2002),
trauma-based disorders (O’Donnell and Cook 2006) and sexual offending
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(Maletzky and Steinhauser 2002), there is ample evidence that CBT is the most
widely used and most effective treatment option. As Westbrook et al. write,
‘CBT is the psychological therapy with the most solid and wide evidence base
for efficacy and effectiveness’ (Westbrook et al. 2012: 13). However, to date,
there are few outcome studies on the efficaciousness of CBT for sexual addic-
tion, although evidence is accumulating. But Vesga-Lopez et al. write, ‘CBT is
currently the psychotherapy with the best documented efficacy for sexual addic-
tion’ (Vesga-Lopez et al. 2007: 153). In the light of the research on themes adja-
cent to sexual addiction, it seems safe to suggest that CBT would also be the most
useful approach for sexual addiction.
When using a cognitive behavioural approach, there should be an initial meas-
urement of the presenting problem during the process of assessment and formu-
lation, in order to give a baseline for evaluating the effectiveness of treatment.
Regular measures throughout the therapeutic process provide for the possibility of
an evaluation of the differing effects of the interventions. It is especially important
to obtain measurements at the end of therapy.
In the use of standardised measurements, validity and reliability must be con-
sidered. ‘Validity’ means that it measures what it aims to measure. ‘Reliability’
suggests that the same results would be shown if the test were repeated in the same
time frame or if administered by another practitioner. In writing about patient-
specific measures, Westbrook et al. (2012) make the point that measurements
should be simple, specific and given with clear instructions. Data should be col-
lected as soon after an event as possible; otherwise, it is likely to be forgotten
or misremembered. Finally, these writers stress that the therapist should show a
genuine interest in the measures. Studies measuring the outcome of our treatment
programme are given in Chapter 8.
There are a number of questionnaires that we use during therapy in order to
gather evidence that our approach is effective in working with the sexually com-
pulsive patient. At the first session we give CORE 34, the Sexual Compulsivity
Scale, the Sexual Symptom Assessment Scale and a simple scale that we devel-
oped, called Sexual Addiction in Routine Evaluation. CORE 34 is widely used
in the United Kingdom to evaluate patient change. It is a patient self-report ques-
tionnaire that measures risk, well-being, symptoms and overall functioning. Its
­composition was informed by feedback from practitioners. It is suitable for meas-
uring outcomes with any psychotherapeutic modality and is pan-diagnostic. Its use
has gathered momentum throughout the European Union and it is now used in
 20 Cognitive behavioural therapy and sexual addiction

the Netherlands, Denmark, Sweden and Portugal (see [Link]

accessed 4 January 2015).
More specific to sexual addiction are the Sexual Symptom Assessment Scale
(Raymond et al. 2007) and the Sexual Compulsivity Scale. Both these are rela-
tively brief and simple to complete. The Sexual Symptom Assessment Scale is
a short questionnaire consisting of ten items, and it is simple and convenient to
administer. There is initial evidence that it is reliable and produces valid results
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(Kalichman et al. 1994). We also use the Sexual Addiction in Routine Evalu-
ation test, which was drawn up some years ago. This measures preoccupation,
intensity, frequency and harmful consequences. This test has not been validated.
It was first used in 2000 before some of the other measures had been developed
(see Appendix 1).
Shortly after we begin therapy, we also give patients a ‘Harmful consequences’
list and ask them to add up all the harmful consequences of their addictive pro-
cesses. This is a sobering experience and the reflective observation, in itself, has
a powerful therapeutic effect (see Appendix 1). In addition, we ask patients, in
the first or second week, to keep a diary of their acting-out behaviour or of their
urge to act out. All these provide a baseline against which to measure progress. In
our groups, we ask participants to fill in these forms at the first session, halfway
through, at the end, and at three-month and six-month follow-ups.
The Sexual Addiction Screening Test, developed by Patrick Carnes in 1983,
is the test most widely used in clinical practice and is easily accessed from a
variety of internet sources. This evaluation tool has equivalents for gay men and
for women. Carnes is a substantial name in the field of sexual addiction in the
United States. This explains why his test is widely used in clinical practice. Apart
from the Sexual Addiction in Routine Evaluation test, all the evaluation tools are
American. Many, if not most, of the therapists working with sexual addiction have
been trained in the Patrick Carnes model for its treatment. It tends to work by
the manual and, in my view, does not take sufficient account of the collaborative
nature of the therapeutic process; it also lacks specificity in its application to the
unique problems of the individual. However, it is a substantial contribution to the
treatment of sexual addiction.
A full account of available measures for evaluation in the field of working with
sex addiction with comments on their usefulness, validity and reliability can be
found in an article by Hook et al. entitled ‘Measuring sexual addiction and com-
pulsivity: a critical review of instruments’ (Hook et al. 2010).

Using cognitive behavioural therapy to work with

the sexually addicted client
This section considers how the practitioner can use CBT to work with the sexu-
ally addicted client. It begins by considering goal setting, then moves on to look
at case formulation; finally it considers the range of CBT tools and techniques
available to the practitioner.
 Cognitive behavioural therapy and sexual addiction 21

The formulation of goals

The formulation of therapeutic goals is an important part of the process of
treatment in CBT. It has a number of features that are useful to therapist and
patient alike. It helps to create a blueprint to prevent therapeutic drift and can
keep the work on target. It helps build up and sustain the therapeutic alliance. It
can instil hope.
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Goals should be collaborative, with a joint focus on the possibility of change.

In our assessment process, we ask patients to complete the following statement:
‘I have come to see you because . . . ’ The function of this question is to crystal-
lise the problem. We then ask the ‘magic wand’ question: ‘If this therapy were to
be successful, what would you like to be different in a year’s time?’ This ques-
tion aims to determine goals. Most men include three points in their answer: they
want to feel better, stop acting out and repair the relationship with their partner.
Sexual acting out brings with it harmful consequences and threatens the partner-
ship. Many men enter recovery to save their relationship.

Formulations
Formulations are diagrammatic explanations of the history and function of a
problematic behaviour. Kuyken et al. in Collaborative Case Conceptualization
describe a formulation as ‘an individual picture that helps us to understand and
explain a client’s problems’ (2009: 37). The benefits of formulation are various.
For the patient and the therapist alike, a formulation helps to bring order into
what would otherwise be chaotic and uncertain. It also helps to apply theory to
practice. Formulations open up new ways of thinking about a problem. Kuyken
et al. (2009) argue that among the additional functions of the formulation are nor-
malisation of the patient’s experience, a promotion of patient engagement and the
simplification of complex problems. Furthermore, the problems of the patient are
clearly addressed. Figures 2.1 and 2.2 show a generic formulation and the usual
formulation of a sexually compulsive man.
In developing a case formulation, it is important to consider precipitants, vul-
nerability factors, triggers and modifiers. Precipitants are factors that cause some-
one to turn to a harmful behaviour. These are often events and circumstances
found in the patient’s general history and which precede the emergence of sexual-
ity itself. One man clearly remembers masturbating at an early age as an escape
strategy from the abuse he experienced. Sometimes it might seem that the behav-
iour emerges from normal sexual exploration, but I do not think that this is the
case unless there is a predisposition for the behaviour.
Triggers are events, circumstances and feeling states that cause one to turn to
the behaviour in the here and now. The most frequently seen precursors are depres-
sion, anxiety, loneliness, shame and hidden dynamics in the relationship with the
partner. Additional triggers or vulnerability factors include low self‑worth and
boredom. Boredom suggests a fundamental alienation from the self.
 22 Cognitive behavioural therapy and sexual addiction

SET-UP
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CORE BELIEFS

When core Selective

beliefs are negative
triggered attention
by a MANAGEMENT TECHNIQUES reinforces
situation core
negative beliefs
attention
occurs
ESCAPE MECHANISMS

SELECTIVE NEGATIVE ATTENTION

DEPRESSION/ANXIETY

To break the cycle, the core beliefs need to change and create more positive ones that
the individual can draw upon when a situation triggers feelings of low self-esteem.

With thanks to Dr. Neema Chudasama.

Figures 2.1 Generic formulation

Sexual acting out is a self-soothing mechanism that the individual uses to manage
these vulnerability factors, but which brings with it harmful consequences. I have
come across cases where men acted out sexually when their wife was in hospital,
or having a baby, pregnant, or not being sexual. The first of these, I surmise, is
connected to the need to sooth worry and anxiety. One patient was being shown
around a vacant property by an estate agent and he reported feeling a sense of
arousal. His thoughts turned to acting out. This event was a trigger because he
had only been in a flat alone with a man in order to have sex. Another patient has
 Cognitive behavioural therapy and sexual addiction 23

SET-UP
Childhood, family, society

CORE BELIEFS
I am worthless
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I am not good enough

When core MANAGEMENT TECHNIQUES Selective

beliefs are negative
If I make money, then I am ok
triggered attention
If I please people, they will like me
by a reinforces
I should have lots of friends
situation core
I must work hard
negative beliefs
attention
occurs

ESCAPE MECHANISMS
Sex addiction, alcohol, drugs, shopping

SELECTIVE NEGATIVE ATTENTION

Focus is on negative thoughts, memories,
intentions and expectations

DEPRESSION/ANXIETY

To break the cycle, the individual needs to change and create more positive ones that
the individual can draw upon when a situation triggers feelings of low self-esteem.

With thanks to Dr. Neema Chudasama.

Figures 2.2 Sex addiction formulation

to avoid a town centre, because his acting-out patterns have historically been in
that location. Yet another patient had to take a different route home from work
because on his previous route he had picked up sex workers. Just driving along
a street can trigger the impulse to act out sexually. Even coming to my office in
Marylebone can be a trigger for some men who have acted out sexually with sex
 24 Cognitive behavioural therapy and sexual addiction

workers in flats near the office. Additionally, poor health, hangovers, conflicts
with a partner, alcohol and recreational drugs can all make a person vulnerable to
sexual acting out.
The severity of the problem faced by the sex addict is rooted in many factors,
which we might refer to as ‘modifiers’. These include early onset, the experienced
levels of shame created by acting out, the overall life satisfaction, the care of a sup-
portive partner, as well as the extent and depth of the environmental stimulus. For
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example, the levels of stress that are experienced in professional life are particu-
larly problematic for male sex addicts. Other modifiers include time, availability
and opportunity. For example, working at home alone allows unfettered computer
access, while travelling increases loneliness and end-of-the-day boredom.
I have observed in the history of sexual addicts that the addictive process waxes
and wanes over the life span. I suspect that it waxes with stress and difficult life
events, and wanes when life events are less troublesome and more fulfilling. For
example, in the early stages of courtship it often wanes. This is because the feel-
ings of oneness with the partner created by the new relationship overshadow the
negative feeling states associated with addiction. There is growing evidence that
the neurochemistry of romantic attraction is akin to the impact of recreational
drugs, particularly cocaine, and has some of the same effects.

Cognitive behavioural therapy tools and techniques

Once we have set clear goals and developed a comprehensive case formulation, we
are in a position to begin to help the sex addict to tackle the addiction. CBT provides
us with a whole variety of tools and techniques, both cognitive and behavioural,
which can be useful in this process. Perhaps, in thinking about the cognitive tools,
it is important to explain that we all have two minds. The first is the mind that is
us being, feeling and doing what we normally do. The other is the part of the mind
that can observe and reflect on being, feeling and doing. In other words, we can
use the reflective part of the mind to examine and explore our history, core beliefs,
assumptions and behaviours. We can use the mind that observes to make changes
in thoughts, feelings and behaviours. What we understand does not govern us in the
same way as what we do not understand. This is conceptualised in Figure 2.3.
There are a number of cognitive techniques that use this reflective part of
the mind and can prove useful when working with sexual addition. These might
include an advantage/disadvantage analysis. Sometimes we also use an ‘empty
chair’ exercise, which can be especially helpful in dealing with shame. The person
who is the cause of the shame is metaphorically placed in the empty chair and,
after a description of the shaming event, the patient is asked to ‘give it back’ to the
person responsible for creating the shame.
The following section explores some of the other key cognitive techniques for
tackling sexual addiction, including Socratic questioning, the downward arrow
technique, challenging cognitive distortions, the hot cross bun technique and
guided reading. We will also consider a range of useful behavioural techniques.
 Cognitive behavioural therapy and sexual addiction 25

Two minds making change

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Mind 1 Mind 2

obsessive-compulsive
sex addiction
disorder

low Mind 2 is the mind that can

self- reflect on Mind 1
esteem

anxiety

Change Mind 1 with Mind 2

1. By increased awareness
2. By involvement in a relationship that
partially reparents
3. Application of CBT tools to the problem

Figure 2.3 Two minds

The Socratic method

We can ask a whole variety of questions in therapy. Some of these can be used to
put the patient at ease, others to clarify what has been heard and yet others to gain
more information. However, it is the ‘Socratic question’ that is central to cogni-
tive therapy (Padesky, 1993). The Socratic method uses questions not to confront
or defend, but rather to elicit new understandings for the patient, helping him to
think about the problem in a new way. The questions might encourage the patient
to take an overview, to see the problem in its wider context and to understand how
it might fit in with a combination of other factors and problems in his life. Some
refer to this as taking the ‘helicopter view’. Socratic questions are always ques-
tions that are within the capacity of the patient to answer. The aim is to encour-
age new combinations, sharpen insight and distinguish patterns. They are used
to help the patient to think in new reflective ways about the issues brought to
therapy. This is what Padesky refers to as ‘guided discovery’ (1993). According
to Padesky (1996), there are four stages to this process: information gathering,
 26 Cognitive behavioural therapy and sexual addiction

empathetic listening, summarising and synthesising. Synthesising encourages the

development of a new way of looking at the problem. In working with the sexu-
ally compulsive, it is particularly important to phrase Socratic questions in a way
that cannot be taken as judgemental.

The downward arrow technique

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The downward arrow technique seeks to reveal and explore negative automatic
thoughts (negative interpretations of our experiences) and the meaning of such
thoughts in the overall context of a person’s life. It can be used to discover the
individual’s core beliefs (the deeply held beliefs the person has about themselves,
others and the world around them), as well as their beliefs about the use of sexual
acting out as a mechanism for self-soothing.
The downward arrow technique involves asking the client a series of questions
that reveal increasingly deeper levels of thinking. Most of the questions follow
the general format of ‘If the thought that you have about yourself is true, what
does it really mean about you?’ It is important that the therapist is supportive and
empathic as the core beliefs are uncovered.
Here is a sample dialogue that combines the guided discovery and downward
arrow techniques:

Therapist: Can we go back to the last time you acted out sexually? Could you
tell me something about it? (Gathering information and empathetic
listening)
Patient: It was last weekend. I went to see three sex workers over a two-day
period.
Therapist: What was happening in the time before you acted out?
Patient: Well, I was just sitting at home. You know, I now live alone. I was
thinking about my ex-girlfriend and how she had left me when she
realised that I used sex workers.
Therapist: Yes, I see. What thoughts went through your mind before you acted
out?
Patient: That I am now alone and I will probably never have a girlfriend.
Therapist: Let’s see if we can make sense of this. So, the situation is sitting at
home alone and ruminating on failure and loss. What did that cause
you to feel?
Patient: I was feeling sad and lonely. I was alone.
Therapist: What did you then do?
Patient: I went onto contact sites on the internet.
Therapist: Were you aware of any body changes?
Patient: Yes, I could feel myself getting sexually excited. The sense of loneli-
ness was replaced by sexual excitement.
Therapist: I wonder if this represents a one-off event or has this combination of
things happened before?
 Cognitive behavioural therapy and sexual addiction 27

Patient: Now to think of it, it does form a pattern. When I have time and I am
alone, my thoughts tend to turn to sex and to sexually acting out.
Therapist: Let me be sure I understand you. You were at home alone, reflecting
on the reality of loss and the possibility that you will always be alone;
there was nothing that you had to do, and then your mind turned to
sex. This was eventually followed up by seeing a sex worker. Is that
right? (Summarising)
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Patient: Yes, I think so.

Therapist: I was just wondering what we might learn from this? (Synthesising)
Patient: Well I can see how my mood state, being lonely and afraid of the
future, caused me to escape into sexual fantasy and the sexual fan-
tasy then caused me to escape into sex itself.
Therapist: What does this information give us that would be useful for the
future? Maybe it could be a good idea to plan the day ahead. Perhaps
the loneliness could be assuaged in another way? What about friends
and family? Maybe if you had left your laptop at work, then the pro-
cess might have been averted? Do you have any ideas about some-
thing that you could do that would be an alternative to loneliness
and, thus, to acting out sexually?

This is guided discovery because the therapist already knows that sexual acting
out is done to relieve intolerable feeling states. The downward arrow technique
can be seen in the use of questions that go towards the root of the problem. Fur-
ther questions, seeking to uncover the negative automatic thought, could then be
asked. For example, ‘What is the meaning to you of the notion that you are alone
and you might forever be alone?’ This might well elicit a response such as, ‘It
means that I am inadequate and a loser’. Once this is established, then it might be
right to use a ‘thought record’ or a ‘critical voice diary’ to challenge this primary
cognition. Another treatment technique would be to have the patient create and
follow an activity schedule for his ‘at risk’ days.

Challenging cognitive distortions

Another important part of treatment is the identification of cognitive distortions
(‘thinking errors’) in sexually addicted men. The most frequent cognitive distor-
tions that come with sexual addiction include statements that shift blame onto the
other person, such as, ‘It really wasn’t my fault. She should not have been wearing
that short skirt’. Another entails the minimisation of the degree of damage done,
such as, ‘Well, no real harm was done’. Another is ‘This is the last time’, or ‘Just
this once’. We find sometimes that acting out increases before the person join-
ing our treatment programme, on the principle that ‘I will start fixing this later
this week’. We ask men in treatment to consider their thinking biases and to give
examples of them in a homework exercise. The concept of cognitive distortions is
considered in more detail in Chapter 6.
 28 Cognitive behavioural therapy and sexual addiction

The hot cross bun technique

The hot cross bun technique illustrates how the cognitive, affect, behavioural and
physiological aspects of the individual are all interlinked. This is illustrated in
Figure 2.4.
This can be illustrated with an example taken from the case study of William.
William came to me with a problem of frequent one-night stands. He had to stop the
behaviour in order to avoid losing his marriage. He genuinely loved his wife and
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his children. His sexual behaviour presented a real problem. Using the hot cross bun
technique, we identified the following components to his sexual acting out:

• Thoughts: I fear I might fail

• Feelings: fear/anxiety
• Behaviour: sexual encounter to manage anxiety
• Physiological responses: fear chemistry giving way to excitement and arousal.

This technique enables us to identify negative automatic thoughts, core beliefs

and dysfunctional assumptions. William’s negative automatic thought was ‘I
might fail’. His core belief was ‘I am not a good person’. His assumptions were
‘If I am successful at work then I am acceptable’ and ‘If I have women then I am
admired’. The primary feeling states that are anaesthetised in the sexual experi-
ence are fear and shame. The problem is that the behaviour creates further shame.
It is not a solution to the underlying fear and the core belief but only a temporary
escape. The means of escape confirms the core belief, which is ‘I might fail’. This
is illustrated in Figure 2.5.
Another example of this technique in action can be seen by looking at Mark,
who came to therapy with the problem of overuse of internet pornography. A
systematic analysis of his situation reads as follows:

Situation

Thoughts

Feelings Behaviours

Physiological changes

Figure 2.4 Generic hot cross bun

Source: Padesky and Mooney 1990
 Cognitive behavioural therapy and sexual addiction 29

Contract negotiation

Thoughts
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‘I might fail’

Feelings Behaviour

Fear Sexual encounter

Fear giving way to arousal

Figure 2.5 ‘I might fail’ hot cross bun

• Thoughts: I am fed up with doing what I am doing

• Feelings: boredom
• Behaviour: sexual use of the internet to relieve boredom
• Physiological responses before use: tension in the legs, restlessness, then arousal.

In each case it is possible to see the interconnection of thoughts, feelings, behav-

iours and bodily changes. This is demonstrated in Figure 2.6, which shows a hot
cross bun for ‘I am fed up’. It is necessary to identify such interconnecting cycles
so that appropriate exit strategies can be constructed.

Guided reading
Reading about sexual addiction, addiction in general, as well as a series of appro-
priate self-help books and articles, keeps recovery in the forefront of the mind.
We offer specialist articles to particular individuals. For example, for men whose
sexual acting out is accompanied by a range of intrusive thoughts, we suggest
readings about the neurobiology of addiction.

Behavioural techniques
We teach a number of behavioural techniques to help men to learn how to control the
urge to act out. These include distraction techniques, such as music, counting back-
wards, reading, studying, noticing all the colours in a room, visualisation of fighting
off the urge, ‘safe place’ visualisation and compassionate mindfulness exercises.
 30 Cognitive behavioural therapy and sexual addiction

Situation

Doing homework
Bored and anxious

Thoughts
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‘I am fed up’

Feelings
Boredom Sexual use of the internet
(empty)

Physiological
Restlessness, tension giving
way to arousal

The feeling of anxious boredom is

replaced with the ecstatic
experience of sexual pleasure

Figure 2.6 ‘I am fed up’ hot cross bun

There is a saying from the programme of Sex Addicts Anonymous (SAA) that
‘nothing is more dangerous to an addict than to have time on his hands’. At our
clinic, we encourage men to plan their off-time to include alternative behaviours
and to fill their time with meaningful activities. We even make activity schedules
for men who are travelling and likely to be away from home. We suggest that men
make flashcards on which helpful quotes and harmful consequences are written,
perhaps accompanied by photos of wife and family.
Additional behavioural techniques that we use include activity monitoring,
behavioural experiments, role play and a recommendation for exercise, nutrition
and good self-care. We also teach relaxation methods and breathing techniques.
Some patients lack social skills, so this work involves the teaching and practice of
effective mechanisms to facilitate their social interaction.

Conclusion
This chapter has been a summary of the principles of CBT as they relate to sexually
compulsive men. We have considered the importance of goal setting and described
the use of formulations in working with this population. We have explored some
of the CBT tools and techniques that can be employed with the sexually addicted
patient, such as the Socratic method and the downward arrow technique. The goal
of treatment is to provide men with freedom from unwanted sexual behaviours.
 Chapter 3

The neuroscience of
sexual addiction
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Introduction
In order for our therapeutic work to be competently informed and well directed,
we need to understand the neuroscience of addiction. While it is not possible to
provide a full description of the topic in this chapter, I shall highlight a number of
specific components that are relevant to therapeutic work.
The chapter begins by considering the genetics of addiction and sex as a bio-
logical drive. There is a biological basis to everything that we think and feel,
and central to this is the impetus to avoid pain and to pursue pleasure. Addiction
brings with it a number of impairments, and compromises the ability to make
healthy choices. It disrupts executive function. The brain chemistry of addiction is
complex. There are four relevant brain chemicals: DeltaFosB, vasopressin, seroto-
nin and dopamine. Pharmacological interventions show promise in the treatment
of sexual addiction. The most significant are the selective serotonin re-uptake
inhibitors (SSRIs). Addiction has its origins in non-optimal attachment, so the
link between the neuroscience of addiction and attachment styles is considered.
The chapter closes with reference to addiction and the ‘loss of self’, and ends with
a quotation from the American Society of Addiction Medicine.

The genetic basis of sexual addiction

There is always a debate over the genetic or environmental determination of
human psychological and biological function, and this is, indeed, the case in the
field of addiction. Ray (2012) takes the view that addictive disorders are signifi-
cantly genetic in origin. Volkow and Li support this, writing that ‘40–60 per cent
of the vulnerability to addiction can be attributed to genetic factors’ (Volkow and
Li 2005: 1429). The American Society of Addiction Medicine asserts that 50 per
cent of the tendency for addiction is genetic (ASAM 2015).
In working with the sexually addicted, it is clear that there is frequently a
family pattern of addiction. Addiction, like well-being, can cascade or ricochet
down through the generations. Some addictions are directly replicated from one
generation to the next – for example, when both father and son are sex addicts.
 32 The neuroscience of sexual addiction

In many cases, patients have begun to masturbate to their father’s pornography.

In other cases, addictions may emerge in different forms in different generations.
For example, the father may be an alcoholic, while the son may be religious, with
religion becoming an addiction equivalent. While there may be debates about
whether addiction is genetically determined, it is clear that addiction, and there-
fore sex addiction, can be an intergenerational process.
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Addiction as a biological drive

Sexual behaviour is part of an inherent drive that is much more than cognitive
thought. It is not a product of logic, but more a product of an emphatic biological
need. In much the same way, the American Society of Addiction Medicine sees
addiction as a ‘chronic disease of brain reward, motivation, memory and related
circuitry’ (ASAM 2015). Ray sees addiction as a brain disease, describing it as ‘a
chronic and relapsing disorder of the brain’ (Ray 2012: 154). Gold and Heffner
(1998) also note that all psychological experiences are chemical experiences in
the brain.
People often discover that it is not easy to try to resist and overcome this pow-
erful biological force. The power of the drive can cause the strongest person to
give in to it. History and current affairs are peopled with those who have lost con-
trol: Bill Clinton, Keith O’Brian and Alan Green, the former Director of Public
Prosecution, who was arrested for kerb crawling near King’s Cross Station. If we
try to resist our biological mandate and find that we are not able to, this brings into
question the nature of volition.
Lord (2008) describes the biological processes that occur in the brain of an
addict, writing that the endogenously produced endorphins create short-term well-
being. As Chou and Narasimhan (2005: 1427) write, ‘This causes plasticity in
neural circuits related to reward and motivation, supporting the idea that addic-
tion is a biological disorder’. The concept of neural plasticity deserves further
exploration.

Neuroplastic learning
Numerous studies over the years have shown that the brain is physically changed
by repetitious learning (Hilton 2013). Addiction represents a powerful but patho-
logical form of learning and memory (Hilton 2013). Ryan (2013) maintains that
psychoactive substances ‘sculpt neural pathways’ and, with repetition, the behav-
iour becomes more driven and automatic. As neuroadaptation occurs, brain struc-
tures develop that allow the behaviour to dominate in the person’s life. As Ryan
writes, ‘Addiction is viewed as an acquired dysfunction of neural reward mecha-
nisms’ (Ryan 2013: 173).
Chemical dependency and sexual compulsivity share many of the same fea-
tures. Ray argues that sex activates the same neural pathways as alcohol and drugs
(Ray 2012). Reynaud and his associates (2010) also maintain that the part of the
 The neuroscience of sexual addiction 33

brain that responds to substance use is the same part of the brain that responds to
internet pornography. In other words, the brain mechanisms and neural circuits
connected to substance use are the same ones that operate with sexual desire and
orgasm; neuroimaging data are cited to support this assertion. Natural drives and
substance-connected longing can both take over the endogenous reward systems.
While alcohol and drugs are exogenous agents in the activation process, sex is an
internally generated chemical response.
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It would be hard to find a more powerful reward system than that provided by
sexual pleasure. By habitually turning to sex to self-soothe, brain organisation
becomes sensitised to sexual stimuli and this heightens, and makes more immedi-
ate, a response to sexual cues. These sexual cues acquire additional relevance to
the sexually addicted individual. The patient who uses internet pornography for
two to three hours every evening would find this usage would sculpting his neural
pathways in the same way as alcohol or other recreation drugs. To search on the
internet and look for the perfect masturbatory image (Hilton 2013) is an exercise
in neuroplastic learning. Internet pornography addiction also has a powerful hold
because it is rewarded on a variable ratio schedule. Sometimes there is a hit and
sometimes there is not. As I have already written, the hits come in a random
sequence, and reinforcements that come on a variable ratio schedule are more
insistent (more addictive) than those that come with predicted regularity (Maltz
and Maltz 2008).
Once these processes are established, they become automatic and acquire a
life of their own. They have the capacity to operate outside controlled processes.
A number of authorities confirm that the triggers for addictive processes can take
place unconsciously (Campbell 2010; Ryan 2013; Volkow and Li 2005; Zeller
2012). Reynaud et al. write that ‘the brain circuitry responds to drug and sexual
cues that are presented outside of awareness’ (Reynaud et al. 2010: 265). This is
not the loss of moral substance but rather an unconscious process. When these
cues are presented, the addict is particularly vulnerable to relapse (Campbell
2010). There is an impairment of volitional mechanisms. The urge to use or act
out is strengthened and inhibition is weakened; in other words, there is more gas
and less brake. Hilton and Watts write:

all addictions create, in addition to chemical changes in the brain, anatomical

and pathological changes which result in various manifestations of cerebral
dysfunction collectively labelled hypofrontal syndromes. In these syndromes,
the underlying defect, reduced to its simplest description, is damage to the
‘braking system’ of the brain.
(Hilton and Watts 2011: 1)

Once the impulse system becomes influential, it is more difficult for the reflective
and cognitive system of the frontal lobes to override it. Campbell (2010) maintains
that even momentary visual triggers (.33 milliseconds) can stimulate the limbic sys-
tem and create addictive urges. These cravings are embodied in the limbic system.
 34 The neuroscience of sexual addiction

They are difficult to access from the frontal cortex, the part of the brain r­ esponsible
for executive decision making. However, Campbell (2010) notes that the recovery
community has not incorporated neuroscientific views that relapse is often pre-
cipitated outside awareness and thus is not fully subject to conscious control or
moral character.
Patients should be made aware of these processes, partly to relieve them of the
shame experienced on relapse and partly to warn them that this process is struc-
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turally built-in and will continue to be present after the behaviour is left behind.
Long-term recovery is normally required to experience the well-being that comes
through abstinence. The concept of neuroplasticity is also relevant in the recov-
ery process, because neuroplastic learning can bring about positive changes in
behaviour. Numerous studies over the years on music, taxi driving, juggling and
intensive study, to name but a few, confirm that the brain is physically changed by
repetitious learning (Hilton 2013).
I will give a personal example of how practice can change brain structure.
When I first decided to learn how to dance, there was no place in my brain that
connected music and movement. I had to repeatedly practise the steps for two
years before they became automatic for me. Seven years on, I can dance without
thinking about it and learn new steps very quickly. I have altered the neural path-
ways in my brain, an example of neuroplasticity. Sex addicts have to do the same,
by repeatedly choosing a different option from sexual acting out. They can then
restructure the brain so that new and different options come into the foreground.

Impaired executive function

Some have argued that addiction is accompanied by impaired executive func-
tion. In a lecture to the 13th International Neuropsychoanalytic Congress, Zeller
(2012) argued that this disrupted function creates impaired insight and interferes
with the recognition of addiction as a disease. This would explain the reluctance
of many people to seek treatment. The frontal lobes are the executive centre of
the brain (Nunn et al. 2008) and are responsible for foresight, anticipation, sus-
tained attention, planning, organising, prioritising, decision making and reflect-
ing. Reef Karim, in a lecture to the 9th International Conference of the Society for
the Advancement of Sexual Health in Los Angeles in 2006, shared this view. He
stated that hypersexual behaviour is associated with executive disorganisation and
emotional dysregulation, and impairs the ability to initiate and plan. Addiction has
been described as ‘disordered salience’ (Hilton 2013). In other words, the addict,
instead of wanting what will bring quality to life and long-term well-being, goes
instead for a short-term gain that brings with it much unhappiness. Our brains
naturally search for novelty (Hilton 2013), and sexuality, especially on the inter-
net, provides almost limitless novelty.
Arousal chemistry overwhelms the cognitive system and disengages it from
the limbic system. Men who have no impaired cognitive function when it comes
to work and day-to-day activities seem to be able to exercise no executive or
 The neuroscience of sexual addiction 35

higher powers of thought when faced with an opportunity to act out sexually.
Thoughts of consequences are abandoned. The mind of the addicted individual
seems not able to function rationally. A course of action is chosen that brings with
it consequences of shame, misery and sometimes harm to others.

The neurochemistry of sexual addiction

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There are four components of the neurochemistry of addiction for us to consider:

DeltaFosB, vasopressin, serotonin and dopamine. DeltaFosB is associated with
the enduring quality of the addictive processes. Vasopressin is responsible for
focus and persistence. Elevated serotonin reduces sexual appetite and dopamine
seems to be, in part, responsible for hypersexual behaviour. I shall examine each
of these in turn.

DeltaFosB
The function of DeltaFosB is best understood with reference to the abuse of
drugs, because it is important in the rewarding action of drugs of abuse. An
over-expression of DeltaFosB in the nucleus accumbens of animals causes them
to prefer drugs like morphine and cocaine. Therefore, it is involved in the medi-
ation of drug-related rewards. Recent work has suggested a connection between
DeltaFosB and natural rewards such as sexual behaviour. Wallace et al. (2008)
have researched this with rats and found that sexual experience significantly
increases the levels of DeltaFosB compared with a control group. This research
suggests that DeltaFosB is not only induced into the nucleus accumbens by
drugs of abuse, but also by natural rewarding stimuli. Additionally, our find-
ings show that chronic exposure to stimuli that induce DeltaFosB in the nucleus
accumbens can increase consumption of other natural rewards (Wallace et al.
2008: 10272). A paper published in 2010 (Pitchers et al. 2010) describes the
effect of sexuality on neuroplasticity and sexual experience. It has been shown
to induce alterations in the nucleus accumbens similar to those seen with drugs
of abuse. Hilton (2013) draws from Nestler (2008) and writes that ‘Supraphysi-
ologic levels of DeltaFosB appear to portend hyperconsumptive states of natural
addiction’. Hilton goes on to write ‘that DeltaFosB is not only a marker but
also a facilitator of hyperconsumptive behaviour (as a neuroplasticity enabler)
has been well demonstrated’ (Hilton 2013: 4). This is reinforced by the Icahn
School of Medicine at Mount Sinai Hospital. Its website asserts that ‘These
DeltaFosB responses are interesting because they provide a molecular mecha-
nism (based on the stability of the protein) by which drugs of abuse, natural
rewards, and stress can induce long-lasting changes in gene expression’ (Icahn
School of Medicine 2013). This suggests that the changes in the brain caused by
repetitious use of internet pornography, or other compulsive sexual behaviour,
establish a rigid and long-lasting vulnerability to act out sexually, long after the
behaviour has been left behind.
 36 The neuroscience of sexual addiction

Vasopressin and oxytocin

The roles of vasopressin and oxytocin in the brain chemistry of sexual behaviour
have not been widely reported. To over-simplify, vasopressin is the brain chem-
istry of focus and persistence, while oxytocin is the brain chemistry of bonding.
Panksepp (1998) suggests that the former affects male behaviour and the latter
female behaviour; vasopressin is predominant in men when they are being sexual,
while oxytocin predominates in women. Panksepp (1998) writes that the abun-
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dance of vasopressin in the male brain mediates male persistence, courtship, ter-
ritory marking and male aggression. He states that vasopressin is elevated in men
during sexual behaviour and peaks at orgasm (Panksepp 2006). Oxytocin is more
related to female sexuality as well as female social responsiveness (Panksepp
1998). Women and men have both components, albeit in different proportions:
for men, oxytocin causes them to be supportive of their offspring and, for women,
vasopressin allows them to protect their offspring from aggressors.
In working with sexually compulsive men, I am aware of the focused nature
and the persistent quality associated with sexual arousal. Interestingly, most of the
men in our clinic are high achieving, goal oriented and successful. We also have
more than our fair share of entrepreneurs. While this might only say something
about the kind of men who are attracted to our treatment programme, it suggests to
me that vasopressin is elevated in these men and that it contributes to their success
as well as to their addictive patterns.

Dopamine
Nunn et al. emphasise that ‘dopamine is the key communicator of the human brain’
(2008: 151). Milkman and Sunderwirth take the view that dopamine is involved
in both drug and behavioural addictions. They define addiction as ‘self-induced
changes (psychology) in neurotransmitters (biology) that results in problem behav-
iours (sociology)’ (Milkman and Sunderwirth 2010: 6). They write that dopamine
increases with virtually every drug of abuse and that it plays a major role in effecting
mood. Dopamine levels increase in a part of the brain, the nucleus accumbens, and
this leads to decreased anxiety and increased levels of reward. A large number of
men at my clinic act out when experiencing stress and anxiety. There is also a con-
nection here between some forms of sexual acting out and risk taking. Many men
have reported that part of the thrill of sexual acting out is the risk that is involved.
Milkman and Sunderwirth write that ‘It is now generally accepted that dopa-
mine is the master chemical of pleasure and that the high from drugs is caused by
increases in dopamine’ (2010: 38). This happens as a result of the use of alcohol,
amphetamines, cocaine, heroin, cannabis and nicotine. Behaviours such as hugs,
gambling, risk taking and sex have a similar impact. Milkman and Sunderwirth
write that ‘addictive drugs and compulsive behaviours share the common effect
of increasing levels of dopamine in the nucleus accumbens’ (2010: 39). This same
 The neuroscience of sexual addiction 37

view is taken by Hull and colleagues (2004) who argue that dopamine facilitates
sexual function, and also Doidge (2007) who asserts that dopamine is released in
sexual excitement, hence the power of pornography.
Maltz and Maltz (2008) state that dopamine is released during sexual arousal
and that it produces a drug-like high, similar to crack cocaine. This overloading of
the brain (2008: 19) reduces the body’s ability to release feel-good chemicals, as
it would under normal circumstances. ‘Even the brief delay between clicking the
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mouse and the picture coming up on the computer screen can release dopamine’
(Maltz and Maltz 2008: 19).
Dominguez and Hull (2005) note that stimulation of the dopamine receptors
on the medial preoptic area of the brain is important for aspects of male sexual
behaviour. They assert that there is strong evidence that the medial preoptic area
of the brain is involved in the enhancement of sexual motivation. If the dopamine
receptors are stimulated, this will, in turn, stimulate male sexual function. If these
receptors are impaired, male sexual function will reduce.
Novelty and excitement elevate dopamine and testosterone (Turnbull 2006).
Some people have lower levels of dopamine (dopermingenic malfunctioning)
(Schmitz 2005) and are less satisfied by natural rewards; they tend to pursue
unnatural highs from thrill seeking and illicit drugs to compensate for genetic
deficiencies. Kingston and Firestone write that ‘several neurotransmitters are
implicated within these reward pathways (e.g. gamma-aminobutyric acid and
opioid peptides) but specifically it is the dopaminergic pathway, referred to as
the mesolimbic dopamine pathway most closely implicated in mediating reward’
(2008: 290).
However, as Nunn et al. write:

This does not mean that the nucleus accumbens always creates pleasure. It
functions to make us want, even when we don’t like. It is possible for a per-
son to come to hate his or her needs, obsessions, addictions or compulsions
but to be unable to stop seeking fulfilment.
(2008: 149)

There is growing research evidence for the role of dopamine in the process of
sexual addiction. Kingston and Firestone maintain that ‘Similarities between
neurological substrates of addiction (e.g. dopamine dysregulation) and sexual
appetitive behaviours have been identified to support the inclusion of sexual
activity as a behavioural manifestation of addiction’ (2008: 291). Part of the
evidence for this comes from the use of dopamine-enhancing drugs in the
treatment of Parkinson’s disease (Dominguez and Hull 2005; Kingston and
Firestone 2008). Case studies of patients with Parkinson’s treated in this way
can show increases in hypersexuality. Vesga-Lopez et al. have noted in their
research that enhanced dopamine facilitates sexual motivation, and that obser-
vation of those with Parkinson’s who undergo dopaminergic therapy ‘suggests
 38 The neuroscience of sexual addiction

that the dopaminergic system via an effect on motivation may play a role in the
­pathophysiology of sexual addiction’ (2007: 150). They assert that dopamine
enhances, or facilitates, sexual motivation and sexual consummation. Kor et al.
(2013) also state clearly that dopamine agonists used to treat Parkinson’s are
associated with hypersexuality.

Serotonin
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The final neurotransmitter of relevance to sexual addiction is serotonin. Serotonin

is involved in reducing the tendency to act out sexually. This information comes
from animal studies, studies with humans and from the effect of SSRIs. Based on
his studies of animal data, Kafka (1997) asserts that decreased serotonin results
in increased appetitive sexual behaviour. He adds that human studies have repeat-
edly demonstrated a connection between serotonin reduction and an increase in
previously suppressed sexual behaviour.
Higher levels of serotonin can be created naturally by physical exercise, sing-
ing, dancing and other meaningful or enjoyable activities. Usefully, serotonin lev-
els are increased in the group process. In our groups for sexually addicted men,
there is much laughter, and laughter too can increase serotonin. The group process
(or sensitive individual therapy) has the capacity to do the same. It is well known
that serotonin enhancement is effective in the treatment of depression and also
that depression can accompany sexual addiction.
SSRIs act by increasing the levels of serotonin in the brain. This medication,
usually given for depression, has an impact on sexual functioning and many peo-
ple report that it decreases libido. It is also given to reduce intrusive and com-
pulsive thoughts. There is emerging evidence that SSRIs are useful in mitigating
sexual compulsivity. Although little research has been done specifically on sexual
addiction and the use of SSRIs, there has been research into their use with peo-
ple with paraphilias and with sexual offenders. It is possible to deduce that this
research provides information that is also useful to an understanding of sexual
addiction. Kafka (1997) was involved in trials involving sertraline and fluoxetine
and found that there was a reduction in the time involved in the pursuit of vari-
ant fantasy or paraphilic masturbation, but that socially conventional behaviour
was left unaltered. Greenberg and Bradford (1997) noted that fluvoxamine elimi-
nated exhibitionist behaviour in one individual. Their study also maintained that
conventional sexuality was unaffected by the treatment and that the problematic
nature of paraphilic urges was reduced. Naficy et al. (2013), in a study of 19
men, found a significant reduction in hypersexual behaviour in those using nal-
trexone. Berlin (2008), in a study of 14 men, found that testosterone-reducing
medication was more reliable and more consistent in reducing ‘out-of-control’
behaviour than SSRIs. However, Greenberg and Bradford (1997) ­recommended
that SSRIs should be the first line of treatment for non-paraphilic sexual addic-
tion, as they had a 50–90 per cent success rate. This same view is supported by
Muench et al. (2011) and by Wainberg et al. (2006), who add that the effect of
 The neuroscience of sexual addiction 39

this medication had no significant effects on partnered sex. They conclude that
their findings s­ uggest that sex drive and partnered sex are mediated by different
processes.
It is clear from these studies that treating some men with an SSRI seems to
reduce the compulsive nature of sexual fantasy and behaviour, and mitigates the
intensity of the drive. In our clinic, we recommend the use of SSRIs when the
sexual addiction is accompanied by the relentless intrusion of sexually oriented
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thoughts. We also use it in situations of extreme behaviour or when the addictive

process is linked to a negatively interpreted paraphilia – for example, coprophilia
or frottage.

Neuroscience and attachment

It is worth considering how neuroscience is linked to our ability to form secure
attachments to other people, as well as exploring the relationship between attach-
ment and sexual addiction. Attachment theory asserts that our childhood attach-
ments to our primary caregivers shape our capacity to self-regulate emotional
mood states. For infants to develop a healthy self-regulating capacity, and a secure
attachment, they must first have an early experience of interactive regulation.
Winnicott (1957) described the ordinary good mother. If individuals do not have
this positive early experience, they are at risk of developing an insecure attach-
ment style that is either avoidant, dependent or disorganised. There is evidence
that damaged attachment patterns are associated with addictive processes.
According to Katehakis (2009), damaged attachment capacities cause internal
dysregulation and also impede cognitive abilities, the use of language, abstract
thinking, weighing decisions, comprehension of ethics and the ability to moni-
tor one’s own activity. She points out that, with maternal deprivation or malign
care-giving, cortisol levels stay chronically high, creating a permanent state of
dysregulated anxiety. This is seen regularly with men in our clinic who act out on
stress and anxiety. Katehakis writes that ‘Habituation of the brain to the opioid-
releasing state of disassociation as its “default mode” of affect regulation predis-
poses the individual to addictive behaviours, including sex addiction’ (Katehakis
2009: 7). The prefrontal cortex is altered, making mood regulation and impulse
control more difficult.
In our experience, there seems to be a particular relationship between an avoid-
ant attachment pattern and sexually compulsive behaviour. A high proportion of
the men in treatment at our clinic have an avoidant attachment style. Hudson-
Allez (2009) notes that avoidant personalities have reduced oxcytocin. A per-
son with insecure attachment has inefficient emotional regulation and cognitive
processes that cannot moderate extreme feelings (Hudson-Allez 2009: 180). The
person looks for external substances or internal behaviours to numb the pain. Kate-
hakis (2009) also confirms the relationship between avoidant attachment styles
and sexual addiction, writing that avoidant personalities seek external sources of
self-regulation creating dopaminergic arousal that temporarily obscures emotional
 40 The neuroscience of sexual addiction

numbness; they are accustomed to doing things in isolation. Katehakis (2009) rec-
ognises that sex addicts easily move into a one-person system, they persist in soli-
tary self-soothing behaviours and rely on opioid release to enter an anesthetised
state facilitating high-risk behaviours that will release dopamine, norepinephrine,
adrenaline and serotonin.
Damaged attachment capacities can often be the result of childhood trauma. In
our clinic, we are aware that there is a relationship between childhood trauma and
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the development of sexual addiction. Hudson-Allez (2009) explains that child-

hood trauma corrupts the formation of the hypothalamic–pituitary–adrenal (HPA)
axis and that this predisposes the child to future addictive disorders. Hudson-
Allez (2009), quoting MacLean (1990), writes that people seem to develop addic-
tions to compensate for the lack of the biochemicals naturally produced through
stimulating relationships. Hudson-Allez (2009) identifies both physiological and
psychological processes with sexual addiction, all connecting with the dopamine
pathways to provide physiological as well as psychological dependency. Creeden
(2004) also states that early stress can produce life-long change in vasopressin
and oxcytocin levels. This could predispose mammals to have increased sexual
arousal, diminished sexual fulfilment and deficient commitment to a single part-
ner. Almost all the men in treatment experience all three of these.
In working with sexually addicted men in our clinic, we review the patient’s
attachment style as part of the analysis of the problem and to inform treatment
interventions. An understanding that dysfunctional regulation was set up in child-
hood care-giving also reduces self-imposed shame. It creates an understanding of
the vulnerability to addictive processes that lie outside the deliberate choice of the
individual. Of course, once this is recognised, there is the choice to accept it or
to deliberately work to change it. We suggest natural ways to integrate mind and
body to effect changes in mood and for the regulation of emotion.

The role of neuroscience in the therapeutic

relationship
While I have written elsewhere about the effect of the therapeutic relationship,
it should be emphasised, at this point, that the therapeutic relationship effects
changes in the brain chemistry of the patient. Schmitz (2005) cites recent stud-
ies that have illustrated that psychotherapy can make changes in neurocircuits
in the same way as pharmacological treatments. In other words, we tend to
become like those with whom we spend time. This is the effect of brain-to-brain
interaction.
It is said that recovering alcoholics have to change their friends. One patient
of mine spends time with Tom. Tom uses alcohol and cocaine. This patient is
influenced by Tom and susceptible to the same pattern. However, by spending
time with recovering sex addicts or recovering alcoholics, a different influence is
exerted. This process is entirely a sociological process or a brain-to-brain biologi-
cal process.
 The neuroscience of sexual addiction 41

The impact of this understanding is clearly seen in the work of recovery groups
for substance abuse and in sexual recovery groups. Hudson-Allez writes that an
affective relationship with the therapist can ‘prompt biological change in the right
hemisphere’ (2009: 276). Drawing from Gedo (1979), she writes that ‘by mak-
ing secure attachments within the security of a therapeutic alliance, interrupted
developmental processes can finally be completed’ (Hudson-Allez 2009: 277).
The insights of neuroscience are built into the insights of recovery-focused treat-
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ment for sexual addiction.

Neuroscience is a complex area, one not always easy to understand. In our
clinic, we refer to it specifically. At the initial assessment, once sexual addiction
has been determined, the patient is reassured that addiction is not a deliberate
choice. It has simply emerged. The neuroscience of addiction is explained. This
brings shame relief. We explain that there is a neurological structure in place that
is the default position when triggered by internal or external cues. This structure
has been created by the repetition of the arousal scenario. It is reinforced and
extended with masturbation. We explain that the arousal chemistry itself shuts
down a person’s ability to consider alternative options, due in part to the presence
of vasopressin. We find that it is important to emphasise to patients that sexual
addiction is not about morality or an inherent failing of character. It is a biological
phenomenon as well as a social and psychological problem. When this is under-
stood, shame is reduced and there is a better prognosis.

Addiction and the sense of self

Baumeister (1991) attributes the origins of the addictive process to an absence
of a sense of self. My clinical experience suggests that most sex addicts have an
impaired sense of self that is experienced as broken. Baumeister (1991) points out
that acute self-awareness inhibits sexuality and the loss of one’s self overcomes
these inhibitions. Sexual behaviour, and sexually addictive behaviour, is about the
loss of self. With the loss of self, there is a loss of inhibition. He points out that
when alcohol is added to this combination, the loss of inhibition is even greater.
Baumeister (1991) states that the man who has been drinking is less able to draw
conclusions, make connections and infer implications. Alcohol prevents us from
thinking about the past or the future, it reduces self-awareness and decreases the
ability to process information relevant to the self, so that there are no thoughts of
implications. Much the same happens when arousal chemistry is released in the
brain.

Conclusion
Similarities between substance-based and behavioural disorders have been iden-
tified and these add weight to the idea that sexual activity can be a behavioural
presentation of an addictive process. This is also supported by the presence of
co-addictions alongside sexual addiction. Having worked with sex addicts for
 42 The neuroscience of sexual addiction

20 years, I have rarely seen sexual addiction in isolation. It usually presents with
one, or several, co-addictions. It frequently sits alongside alcohol overuse, com-
pulsive overeating, recreational drug use, work or fervent religious commitment.
In our clinic, the most frequent co-presentation is escape and loss of self in com-
pulsive work. These co-presentations suggest an underlying addictive process for
behavioural and substance addictions (Kingston and Firestone 2008). They also
suggest a common aetiology, and recent findings support this view (Albrecht et al.
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2007). When an individual has difficulty serving their own best interests, addic-
tion seems to be an apt description (Berlin 2008).
The American Society of Addiction Medicine defines addiction as follows:

Addiction is a primary, chronic disease of brain reward, motivation, memory

and related circuitry. Dysfunction in these circuits leads to characteristic bio-
logical, psychological, social and spiritual manifestations. This is reflected
in an individual pathologically pursuing reward and/or relief by substance
use or other behaviors. Addiction is characterized by inability to consistently
abstain, impairment in behavioral control, craving, diminished recognition
of significant problems with one’s behaviors and interpersonal relationships,
and a dysfunctional emotional response. Like other chronic diseases, addic-
tion often involves cycles of relapse and remission. Without treatment in
recovery activities, addiction is progressive and can result in disability or
premature death.
(ASAM 2015)

This definition includes the pathological pursuit of pain relief and the search for
repeating pleasure. This is equally a definition of sexual addiction. Addiction
alters biology and, at its foundation, addiction is as much about neuronal activity
and neuroplasticity as it is about feelings and behaviour.
 Chapter 4

The therapeutic alliance

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Introduction
The basic textbooks on CBT often start with a reference to the importance of
the therapeutic relationship. This is, for example, the case in An Introduction to
Cognitive Behaviour Therapy, which refers to Rogers’ principles of ‘warmth,
empathy, genuineness, and unconditional positive regard’ (Westbrook et al. 2012:
43). A good early alliance is often viewed as a predictor of successful treatment
(Del Giudice and Kutinsky 2007). While most CBT therapists believe that the
therapeutic relationship is important, it is not believed to be sufficient, in itself, to
effect significant change. This is as true when working with men with addictive
compulsive patterns of sexual behaviours as it is when working with other patient
groups. While acknowledging the necessity of the therapeutic relationship, few
CBT books rarely explore its meaning in practice. This chapter will outline some
of the issues relevant to the therapeutic alliance when using a CBT framework to
work with sexually compulsive patients.
Research has found that sexually compulsive men often feel that the therapist
does not understand the powerful nature of the addictive process (Del Giudice and
Kutinsky 2007). The client normally brings positive expectations to therapy. It is
important, as far as possible, that these expectations are not reduced (Prochaska
and DiClemente 1982). They may be tempered or put into a different time frame.
The expectation of resolution ought to be maintained (unless this is not true). This
can be more difficult to manage when the therapist is presented with a paraphilia.
Kuyken et al., writing in Collaborative Case Conceptualization, stress the impor-
tance of working with the patient’s strengths ‘at every stage in the process of case
conceptualization’ (Kuyken et al. 2008: 28). To talk about something, and to be
understood, allows it not to govern. In this sense, therapy is not the talking cure,
but the ‘communicating cure’ (Schore 2006).
The capacity of the therapist to talk about sex, and to understand sex, is crucial
to working with compulsive men. This chapter will emphasise the need to pay
attention to the shape, nature and function of the therapeutic alliance. It will high-
light the need to understand shame, both for the patient and for the therapist. Sex-
ual addiction, and paraphilias, often grow out of trauma, and we will explore how
 44 The therapeutic alliance

therapists may find themselves experiencing secondary trauma. I will also explain
how it is helpful to have an understanding of attachment theory, as well as explor-
ing the need for ‘limited re-parenting’ and ‘empathetic confrontation’ (Young et
al. 2003). Additional attention will be given to erotic transference and therapeutic
misconduct, and there is a section on modesty of dress. Erotic transference is not
part of CBT theory. However, that does not mean it cannot exist. Therapists need
to be aware of the concept of erotic transference and for this reason I have devoted
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a section of this chapter to the topic.

Self and sexuality

Work with sexually addicted patients is not for everyone. Some are called to it and
some are not. For those who are called to it, it is important to examine and explore
their own sexual issues and templates. Therapists need to be aware of the interplay
between their own schemas and sexual preferences and how these might interact
with those of the patient.
Arousal responses are not voluntary. We do not choose them. We do not decide
for, or against, them. The disgust response is also involuntary. An image or behav-
iour that generates arousal in one person can generate disgust in another. This can
be a source of confusion with one person feeling that something is unnatural and
another person regarding the same act as the apex of sexual pleasure. The thera-
pist must be aware of these differences. We need to be aware of our own history
and our own templates in order to avoid the judgement that can come out of an
involuntary response.
It is also important to agree a common language that therapist and patient can
use to discuss sexual matters. There are two extremes to be avoided – namely,
overly technical language and the use of the vernacular. Some phrases can trig-
ger the patient in their own right. The language must therefore be professional
and appropriate. For example, the term ‘fellatio’ would be too technical, while
the term ‘blow job’ may perhaps act as a trigger for the patient; the term ‘oral
sex’ might be more appropriate. It is also important to avoid euphemisms. For
example, one does not normally ‘sleep’ with a sex worker, one ‘has sex’ with a
sex worker.
It is important to know when a therapist cannot work with a patient, either
for personal reasons or because the patient’s needs exceed the therapist’s com-
petence. In such cases, the patient must be referred on to a more experienced
practitioner, preferably one who has undergone specialist training in this area.
This must be done with great tact. Feelings of shame may be created in the patient.
These patients are acutely sensitive to anything that can be construed as shaming.
Supervision is essential for this work, preferably with a trained psychosex-
ual therapist with knowledge of CBT, or a CBT therapist who has experience of
working with sexually addicted clients and preferably has knowledge of other
therapeutic modalities. The function of supervision is to access additional insights
into the treatment of the sexually addicted. It provides a measure of quality control
 The therapeutic alliance 45

and is important in the resolution of ethical dilemmas. Good supervision can point
out where the patient’s presentation sets off internal problems for the therapist. It
can explicate complex problems, provide emotional support and prevent isolation.
It can help the therapist to know when to refer to another therapist.

Creating the therapeutic alliance

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The first session with a new client might begin with a few social questions to put
patients at their ease (Westbrook et al. 2012). I tend to have a small amount of
social conversation going up the stairs from the waiting room to my consulting
room but, once in the room, quickly turn the focus onto the needs of the patient.
Using a CBT format, it is normal to work to an agreed agenda in each session. This
would tend to include a time for check-in and for bringing the therapist up to date
on developments since the last session, a review of the last session and a follow-up
on homework. One or two items are scheduled as the major focus of treatment for
the session. The session would finish with assigning new homework and asking for
feedback. Feedback is an opportunity to gain information to guide the next stages
of the work. It is important to ascertain what the patient found helpful and what was
not of service to him. The function of the homework is to extend the session into
daily life. Patients who do homework tend to achieve better outcomes than those
who do not. I normally ask patients to record the session and listen to it during the
week. This allows the patient to become a third party to their own responses during
the session. The homework exercises for sexual addiction (which, of course, could
also be undertaken in session) are presented in the following chapters.
Disclosure of personal information is not usually practised in psychodynamic
psychotherapy. However, in CBT there is greater flexibility (Westbrook et al.
2012). Self-disclosure is useful when it is employed in order to aid the patient.
However, it is important to avoid moving the focus away from the patient towards
the therapist unless the self-disclosure is given to create a sense of ‘humanness’ in
the therapist or to illustrate the possibility of change and give hope for the future.
In CBT it is also more acceptable to touch the patient in a non-sexual manner.
After a particularly helpful therapy session of my own, I once shook my star-
tled psychotherapist’s hand, out of enthusiasm. In subsequent sessions, on saying
goodbye, my psychotherapist would literally stand across the room with her hands
behind her back (she was, in fact, a good psychotherapist).
In a survey of CBT therapists (Westbrook et al. 2012), 76 per cent felt that a
handshake was acceptable; 44 per cent said that a hug was acceptable but this was
only practised by 12 per cent of therapists. My own view is that permission should
be asked for any touch apart from a handshake. Decisions on these matters need to
be taken with the gender of the therapist and the sexual orientation of the patient
in mind. Very occasionally, at the conclusion of therapy, I will ask a patient if
he would like a hug. This would be done in the presence of my secretary. In our
group work, we sometimes exchange manly hugs at the end of the programme.
These must still be offered with an awareness of an individual’s response.
 46 The therapeutic alliance

There are a number of important features associated with good-quality

­sychotherapeutic work with sexually addicted men (Griffin-Shelley and
p
­Griffin-Shelley 1993). These include undivided attention, unconditional accept-
ance, shame reduction, the identification of co-morbid problems, cross addic-
tions and the confrontation of defences. Undivided attention suggests the
absence of interruptions and a room that is conducive to calm and respect.
Unconditional acceptance is given without judgement. This is important
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to men who experience great shame because of their sexual addiction. The
absence of judgement and unconditional positive regard are effective mecha-
nisms for lowering shame. Keep in mind the possibility of cross addictions.
Few addicts have just one addiction and the presence of comorbid conditions
must be considered. Comorbid conditions like anxiety and depression respond
well to CBT protocols and pharmacotherapy might be offered when appropri-
ate. In any event, ‘a good working alliance is necessary for a good outcome’
(Westbrook et al. 2012: 41).
Descartes’ cogito ergo sum (I think therefore I am) has been re-written ‘I am
because we are’. Individual identity and self-regard is created by the reflection of
others. This is important in the creation of our internal schemas – in other words, our
view of self, others and the world. Schwartz, in an article entitled ‘Developmental
psychopathological perspectives on sexually compulsive behavior’, writes that ‘the
self comes to exist in the context of others’ (2008: 572). Part of the function of the
therapist is to help the patient increase self-regulation and self-worth. Katehakis
(2009), in her article ‘Affective neuroscience and the treatment of sexual addic-
tion’, writes that sex addicts characteristically demonstrate deficient insight (they
tend to lack secure attachment) and are affected by the interactive regulation of the
therapist. Schwartz makes this clear, writing that ‘sex obsessions serve the purpose
of preserving unaltered these internal models, these need to change, secure attach-
ment begins with an attuned relationship with the therapist’ (2008: 571). Katehakis
further writes that ‘sex addicts characteristically demonstrate deficient insight due
to poor development of the right orbital frontal system’ (2009: 21). In a reference to
sexual offenders, which can be extended to sex addicts, Marshall et al. (1999) write
that a confrontational style is ineffective and can produce negative effects when
compared with less judgemental ways of dealing with the problem.
In writing about effective motivational interviewing, Del Giudice and Kutin-
sky state that the most salient factor in the therapist as an agent of change is ‘the
presence of a personal bond between therapist and client, in which the client views
the therapist as caring, understanding and knowledgeable’ (2007: 304). This idea
is endorsed by CBT therapists Westbrook et al., who write that ‘Your aim is to
communicate warmth, empathy and a non-judgemental attitude, whilst minimiz-
ing client angst and hopelessness, so as to facilitate engagement, lateral think-
ing, creativity and recall’ (2012: 144). Earleywine, in writing about substance
addiction, adds that therapists who are warm and empathetic ‘can produce better
outcomes than other therapists performing the same kind of therapy’ (2009: 40).
 The therapeutic alliance 47

Schwartz also writes that ‘The therapist who focuses on changing the internal
working models is m ­ aximally effective’ (2008: 571). It is clear from this that a
good therapeutic relationship is of great importance. Prochaska and DiClemente
(1982) assert that a warm relationship is a precondition to further work. CBT is an
empirically based therapy. The research literature emphatically supports the view
that empathy, warmth and acceptance are essential to the therapeutic relationship
(Marshall et al. 1999).
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Westbrook et al. write that ‘in cognitive therapy transference is not assumed
to be operating but is a possibility to be explored’ (2012: 357). Let us therefore
explore this possibility further. The client–therapist interaction can uncover sensi-
tive core themes, engaging clients in dealing with profound hopelessness, and in
this way the relationship becomes a mediator of change (Westbrook et al. 2012).
Drawing from schema therapy, Young et al. (2003) pay a great deal of attention
to the therapeutic relationship in two ways. The first is the notion of ‘limited re-
parenting’ and the second is ‘empathetic confrontation’, both of which are now
explored.

Limited re-parenting
The concept of limited re-parenting uses the therapeutic relationship to effect
change in the life of the patient. The aim is to supply, within the bounds of the
relationship, something that the patient needed but never received from his car-
egivers (Young et al. 2003). Young and associates write that, like a good parent,
the therapist tries to ‘partially meet the patient’s emotional needs: secure attach-
ment, autonomy and competence, genuine expression of needs and emotions,
spontaneity and play, as well as the creation of realistic limits and boundaries’
(2003: 43). This begins with a good relationship and appropriately shared emo-
tions. Self-disclosure is accepted for the benefit of the patient. Young et al. go
on to write ‘the goal is for the patient to internalise a Healthy Adult Mode, mod-
elled after the therapist . . . that can fight schemas and inspire healthy behaviour’
(2003: 183).

Empathetic confrontation
The schemas that were useful in childhood often become dysfunctional inter-
nalised working models of the individual’s relationship with the self and oth-
ers. When a distorted or dysfunctional schema arises in therapy, empathetic
confrontation can be used as a way of trying to make this process conscious.
While schemas may have been useful and adaptive in childhood, some are not
helpful in adult life. Young et al. (2003) write that empathetic confrontation
‘acknowledges the past while distinguishing the realities of the past from the
realities of the present’ (2003: 93). Expressions of empathy build up the thera-
peutic alliance.
 48 The therapeutic alliance

Schema therapy and cognitive behavioural therapy

Conceptually the two theoretical models of schema therapy and CBT are closely
aligned (Young et al. 2003). There is not room here to extensively list their differ-
ences. Both CBT and schema therapy stress the role of schemas and modes. They
both include cognition and other features as important to the expression of person-
ality. The differences are ones of emphasis rather than more significant points of
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disagreement. Both encourage collaboration; both encourage the change or modi-

fication of cognitions. They also share many cognitive and behavioural change
techniques. The patient is considered an equal partner in the process of treatment.
A great deal of the work is psycho-educational and homework is important. The
treatment of sexual addiction uses a wide range of cognitive and behavioural strat-
egies. These are located in the context of a restorative relationship. Treatment is
cognitive and behavioural but enhanced and enriched by an emphasis on the thera-
peutic relationship as an additional source of healing. It is this process that makes
group work so effective. Schemas and self-view can be changed by group empa-
thy, awareness of cognitive distortions, awareness of the cycle of addiction, the
repetitive practice of escape strategies and the consistent feedback of the group.
In CBT, the relationship is conceived of as the vehicle for the delivery of appro-
priate interventions. However, when using CBT to work with sexually c­ ompulsive
men, the delivery of appropriate interventions is seen in the context of a relation-
ship that effectively contributes to the process of change. Both the cognitive behav-
ioural interventions and the relationship itself carry weight. Like schema therapy,
which takes longer than straightforward CBT, the treatment of sexual addiction can
take 18 months to 2 years to establish sexual sobriety (Carnes 1991).

Shame
When a patient comes to a therapist for the first time, he might be overwhelmed
by shame. Sex in our society is by its nature shameful, in spite of our social preoc-
cupation with it. The potential for shame is intensified if there is a pattern of ‘out
of control’ behaviour or the patient has non-normative behaviours. The levels
of shame are elevated in revealing the problem to a therapist for the first time.
The therapist must understand the excruciating painfulness of toxic shame. After
spending years doing this work, it is easy to forget how painful it is for new
patients to come to therapy with this problem. The patient is probably speaking
of things he has never told anyone because of shame. As Fenichel writes, ‘I feel
ashamed, I do not want to be seen’ (1946, reprinted 1996: 139).
Higher levels of shame are associated with particular behaviours. Some men
are ashamed of their use of sex workers. Shame may also be experienced by men
who cross-dress or who are involved in bondage. The shame is likely to be com-
pounded when the sexual behaviour is socially stigmatised. In my experience,
men who have sex with men or who have sex with transsexuals are vulnerable to
particularly high levels of shame. Gay men often have high levels of internalised
 The therapeutic alliance 49

self-directed homophobia. High levels of shame can be set up in the family of

origin. The therapeutic relationship needs to be a shame-reducing environment, in
which there is an absence of judgement by the therapist of the patient. Therapists
must therefore avoid any hint of shame, bearing in mind that shame is conta-
gious. It is entirely possible that shame will be projected by the patient into a non-
shaming therapist. Carnes (1983) writes that shame is the principal driver of the
sexually addictive process. My own view is that it is one of a number of drivers
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for the addictive process.

In CBT terms, shame is the affect state associated with the core belief ‘I am
defective’. When asked to put this feeling into their own words, patients will
use terms like ‘flawed’, ‘not up to it’, or a ‘loser’. In schema therapy, shame is
the affect most closely associated with the early maladaptive schemas of defec-
tiveness, failure and social isolation. It is imperative when working with shame,
especially at the assessment and in the early stages of the work, that Rogers’
principles (Westbrook et al. 2012) of empathy, warmth, genuineness and uncon-
ditional positive regard are manifest. When working with sex addicts, I would
also emphasise the importance of compassion. The word ‘compassion’, which is
derived from com and pati (to suffer together), means to be struck with grief and
suffering for the suffering of another. The topic of shame is explored in further
detail in Chapter 5.

Trauma and the patient

Sexual addiction and paraphilias come out of a developmental history that
includes trauma (Birchard 2011). Trauma does not usually come from vicious
one-off events, but like Chinese water torture can be the accumulation of years of
reproof and criticism. Carnes reports a high level of sexual, physical, emotional
and spiritual abuse in his cohort of sexually addicted men (1991). In my own
work, I do not find that sexual and physical abuse are often declared. More often,
I see a history of maternal deprivation. This is often combined with a critical
father, one for whom ‘it is never good enough’. This can be set up in right brain
memory and might not be available for awareness or inspection. Some families
operated ‘don’t tell’ rules that further prevent access to traumatic memory. Some
patients are protected against the recognition of trauma by defending scripts, such
as ‘It did me no harm’, or by self-blame – for example, believing ‘I deserved it’.
Whatever the configuration, it is best to keep in mind that the sexually addicted
man, especially the addicted man with a paraphilia, is most likely to have a devel-
opmental history of abuse or neglect. In this matter, respect for the patient, in the
form of unconditional positive regard, is of great importance.

Extreme cases
From time to time, in working with sexually addicted men, an extreme case
will be presented. Usually, the single most important concern for those working
 50 The therapeutic alliance

with sexually addicted men is the discovery of coercive sexual practice or

­involvements with vulnerable adults or minors. It is important that this is
thought through in advance. Our legal advice is that there is no obligation on
private practitioners to report. However, your notes can be subpoenaed. We
follow the legal guidelines of the General Medical Council – namely, in cases
of threat to self or others (including children), the practitioner may report. Our
practice is to call a case conference and to weigh up the past evidence and the
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future potential for harm. Then we make a decision. We do this with a knowl-
edgeable and experienced outside practitioner. This must be documented so, if
questioned about the decision, it can be shown that a reasonable and prudent
course of action was followed. Another person may not agree with the decision
but it is important to demonstrate that the decision was properly made. In this
regard, the therapeutic contract must be clear. Our contract simply states that, in
cases of possible harm to vulnerable adults or children, it is our decision as to
whether we break confidentiality. The individual can find himself in an impos-
sible position, whereby he cannot get help because of offences and yet without
help he is likely to re-offend. Ward and Connolly (2008) point out that everyone
seems to be entitled to their human rights except offenders or those suspected
of sexual offending.

Secondary trauma
Secondary trauma is trauma created for the therapist in working with difficult or
extreme cases. It would not normally emerge unless the therapist finds a patient’s
script problematic and/or it triggers disgust and distaste. Alternatively, there can
be an accumulation of trauma from dealing with a succession of difficult patients.
Professor Gillian Straker (1993), a CBT therapist involved with victims of trauma
during apartheid in South Africa, recognises that people often enter the helping
profession because they identify with the woundedness of the other. She gives the
following symptoms for secondary trauma: depression, anxiety, psychosomatic
ailments, chronic fatigue, sleep disturbance, survivor guilt, memory impairment,
concentration difficulties, heightened emotions and feelings of helplessness. The
first step in preventing secondary trauma is to recognise the signs (Straker 1993).
Preventative measures involve good supervision and your own process of ther-
apy, as well as attendance at workshops and conferences to prevent professional
isolation.
The following are entries to my journal during the time I was working with
a man who had committed paedophile offences. I give them as an example of
secondary trauma:

Monday 7 January 2002

In typing up the interview with RW I am very aware of his anxiety and a
sense of contagious shame that extends from him to me and I feel that I am
bordering on nothing less than despair.
 The therapeutic alliance 51

Tuesday 8 January 2002

I am experiencing feelings of paranoia and a sense of contamination. I have
been exposed to a culture of fear.
Wednesday 9 January 2002
I keep having dreams of being victimised and at the mercy of predators which
I connect to the nature of the work. I woke up feeling angry and trapped.
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Sunday 13 January 2002

I had two bad dreams last night, one about breaking china and another about
a woman falling to her death on a roller coaster. This feels like it is about an
encounter with evil. This is about a confrontation with evil, the ordinariness
and all pervasiveness of evil in the human condition.
(Birchard 2002: 3)

This experience was secondary trauma. It is unlikely that this level of secondary
trauma would emerge in working with sexually addicted men. However, it has
been placed here as a precaution.

Attachment
Straker (1993) writes that trauma interferes with cognition and brings with it a ten-
dency to dissociate. In men who are sexually addicted, this dissociation is usually
in the form of sexual fantasy or behaviour. One of the primary functions of good
attachment is the downloading of self-regulation from the parent to the child (Good-
man 1998). Without this downloading the child is not able to internally regulate
feeling states. He turns to substances and behaviours to regulate painful affect states.
The relationship with the therapist can promote healing by providing new
opportunities for patients to internalise self-regulatory functions that were not
internalised in childhood (Goodman 2001). Bowlby’s research has given us ‘an
empirically grounded framework for understanding human development as a
relational process’ (1988: 167). Attachment theory suggests that the therapist is
potentially a new attachment figure in relation to whom the patient can develop
fresh patterns of attachment. As Bowlby puts it, ‘the therapist’s role is analogous
to that of a mother who provides her child with a secure base from which to
explore the world’ (1988: 140). As I have written before, it is not the talking cure,
it is the communication cure.

Erotic transference
In working with sex addicts, we cannot afford to ignore the potential for erotic
transference. Erotic transference is the term given to the sexual or romantic trans-
ference of the therapist by the patient. This has only happened to me on two
occasions. Each case involved a gay man with a preference for older men. On
one occasion, I was told by the patient that he wanted to come across the room
 52 The therapeutic alliance

and be sexual with me (not his exact words). I explained that the therapeutic rela-
tionship, while an intimate relationship, was never sexual or romantic and was
not just friendship. It was important not to be shaming. At the following session,
he said that he agreed with me and could see how that for me to respond to his
invitation would do him no good. Keep in mind that such behaviour is part of the
patient’s pathology and it would be more useful to explore the meaning of his
sexualisation. It may be an attempt to render therapy useless, or the patient may
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be triggered by being in a room alone with a therapist. It is important to explore

the reason for the diversion of thoughts away from the content of the session into
sexual interest.

Conduct
In working with sexual addiction, it is imperative that the therapist models appro-
priate boundaries. These include keeping the therapeutic frame, being on time and
the avoidance of cancellation or change. For CBT therapists, these boundaries
tend to be less rigid than with other modalities. Careful attention must be paid
to ensure that the therapist is acting in the benefit of the patient. For this reason,
strict adherence to inflexible boundaries is not always necessary (Westbrook et al.
2012).
There are three areas that are potentially troublesome for the patient/thera-
pist relationship: dual roles, self-disclosure and physical contact (Westbrook
et al. 2012). I have already written about self-disclosure and physical contact.
Dual roles should always be avoided, although in small communities and rural
areas this can be difficult. These kinds of uncertainties should be considered and
resolved with a supervisor.
Sexual contact between therapist and patient re-traumatises the patient. It
opens up a floodgate of negative consequences. Most, if not all, professional asso-
ciations forbid sexual contact between a therapist and a patient. Sexual contact
often begins with boundary violations of a minor nature, such as inappropriate
touching, lifts home, scheduling patients for late appointments, meeting outside
the therapy room, or turning the therapy session into a session that is about the
therapist and not the patient. Most sexual misconduct involves heterosexual male
therapists, usually middle aged, often professionally isolated and frequently with
marital problems. It usually begins by men discussing their own problems with
younger female clients (Westbrook et al. 2012). It is important to remember the
words of the Hippocratic Oath, which states ‘Keep far from all intentional ill-
doings and all seduction and especially from the pleasure of love with women or
men’ (Westbrook et al. 2012: 53).

Modesty of dress
This work calls for modesty of dress. This does not only apply to women thera-
pists. Men also need to be careful about the clothes that are worn. I went to a
 The therapeutic alliance 53

meeting once where a man was asked by a group member not to wear sweat
pants because he found them triggering. While it is not likely that a male therapist
would wear sweat pants to a therapy session, the same rule of dress applies. I had
a patient with sex addiction who had gone to see a psychotherapist who was wear-
ing an outfit that showed her pierced naval. She shamed him for noticing. This
outfit would be inappropriate for therapy. Avoid wearing anything that might be
a possible trigger to a patient. The rule, imparted to me by my own therapist, is to
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wear nothing ‘remarkable’.

Ambivalence
Ambivalence is best addressed in the early stages of assessment and in the early
stages of work. The CBT frameworks offer a secure base within which people
can deal with ambivalence. Almost every sex addict is ambivalent. After all, why
would you want to stop a behaviour that brings so much intense pleasure? The
answer to that question lies in the misery of the aftermath and the general destruc-
tiveness to loved ones and others.

Conclusion
The main focus of this chapter has been to underscore two important principles
underpinning therapeutic work with men with sexually compulsive behaviours.
First, it must be remembered that the therapeutic relationship is a powerful ingre-
dient in the recovery process. While CBT therapists do not concentrate on the
relationship as much as some therapists of other modalities, I believe that
the quality of the relationship is a necessary backdrop to the work. I have explored
the ways that it is necessary and the nature of that necessity. Second, it is impor-
tant to note that the therapeutic relationship alone is not enough to effect long-
term change. As Westbrook et al. (2012) say, it is necessary but not sufficient. In
further chapters, I will explain the tools that need to accompany the relationship in
order to ensure that the therapy is sufficiently effective for lasting change to occur.
 Chapter 5

The primary interventions

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Introduction
At a group programme we run for sexually compulsive men, a very distressed
man cried out at the first meeting, “I just want to be free”. At a first meeting of a
group, there can emerge a line or phrase that encapsulates the ongoing theme of
the group. The theme was ‘freedom’. The following three chapters are about the
interventions that help bring about freedom from addiction to sexual behaviour.
They are about the restoration of choice and the development of a way of life that
is no longer enslaved to sexual rapacity.
These three chapters comprehensively outline the major interventions for sex-
ual addiction. In each case, we draw from a variety of sources about treatment.
These come from general addiction treatment, sex offender treatment, internet and
sexual addiction treatment. We also describe how these are integrated into our
own treatment programme. In summary, the interventions are:

Primary interventions
• Teaching about sexual addiction
• Teaching about neuroscience
• Teaching about shame.

Principal interventions
• Consideration of values
• Understanding supernormal stimuli
• Formulation
• Harmful consequences
• Sex plan
• Family of origin
• Cycle of addiction
• Trigger identification
• Behavioural substitution
 The primary interventions 55

• Cognitive distortions
• Assertiveness training
• Hot seat
• Personal presentation.

Ancillary interventions
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• Relapse prevention
• Health sexuality
• Sexual health.

We begin with teaching about sexual addiction, neuroscience and shame. This
is followed by an investigation into the personal value system of the individual
addict. This value system can be contradicted or compromised by the behaviour.
There is an explanation of supernormal stimuli. We work, in consultation with the
patient, to create a formulation that makes the problem understandable. ‘Harmful
consequences’ brings to the forefront of the mind the harmful outcomes of addic-
tive behaviour. The sex plan teaches an individual to review the patterns in their
sexual behaviour and make decisions about what should be kept and what should
be discarded. There is an extended exercise exploring trauma in the family of
origin. The cycle of addiction is broadly based on the work of Bays and Freeman-
Longo (1989). The principal concern is to identify the triggers for the behaviour
and to substitute alternative behaviours. Cognitive distortions are discussed with
their implications for addictive sexuality. Assertiveness training is followed by
the ‘Hot seat’ exercise and a personal presentation. This concludes with relapse
prevention, healthy sexuality and sexual health. Finally, there is a summary of
useful additional measures that contribute to ending addictive patterns. It is clear
from this overview of treatment that we are working with cognitive behavioural
tools: teaching, formulation, exercises, active involvements, and homework all
play their part in creating awareness of the underlying mechanisms that create
and sustain addictive sexual behaviour. These are effective solutions for recovery.
Milkman and Sunderwirth (2010) draw from antiquity to illustrate that CBT
is not a new way of thinking. They state that the Buddha said, ‘We are what
we think’ (Milkman and Sunderwirth 2010: 306). Plato described ideal forms
as existing within the mind. Marcus Aurelius is reputed to have said, ‘Our life is
what our thoughts make it’ (Milkman and Sunderwirth 2010: 306). Milkman and
Sunderwirth (2010) make reference to Descartes, to Kant and to William James,
the father of American psychology. James wrote, ‘the greatest discovery of my
generation is that a man can alter his life simply by altering his attitude of mind’
(Milkman and Sunderwirth 2010: 306).
Hall (2013) suggests that the treatment objectives are to understand the cycle
of addiction, shame reduction, commitment to recovery, resolution of the underly-
ing issues, prevention of relapse and the development of a healthy lifestyle. Hart-
man et al. (2012) write that the treatment of sexual addiction is, first of all, about
 56 The primary interventions

education. The first part of our group programme and the first part of individual
work is educational. Hartman et al. further write that ‘this is often accomplished
through CBT techniques, which is the most effective psychological treatment for
sexual addiction’ (2012: 291).
Young (2007) did an empirical study of the efficacy of using CBT with internet
addiction. He notes that CBT counselling is effective in reducing the symptoms
of internet addiction. It helps patients to develop healthy lifestyles and includes
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assertiveness training, relaxation training, self-management and the learning of

new social skills. Young further writes (2007) that those who suffer from low self-
esteem and other negative core beliefs are the people most likely to engage with
the internet. He suggests that cognitive restructuring is important to help change
these negative core beliefs, cognitive distortions and rationalisations.
Applicable to group and individual work is the observation by Bandura that
modelling is of importance: ‘Individuals did not need to be reinforced directly for
performing a behavior, in order for that behavior to increase in probability’ (Milk-
man and Sunderwirth 2010: 312). This is from Bandura’s classic work (1969)
Principles of Behavior Modification. It is sufficient to observe another person
modelling behaviour for it to be reinforced. Learning occurs ‘through the observa-
tion of other people’s behaviour and seeing the consequences of such behaviour’
(Milkman and Sunderwirth 2010: 312).
Modelling between group members is a clear process in a therapeutic recovery
group. This principle has been observed many times in the treatment programmes
of our clinic. One person might say, at the beginning of a session, how helpful he
finds the sessions and how much he likes coming to the group. Immediately, this
sets up an atmosphere of well-being in the group. This then, by modelling, sets up
a positive expectation. Another person might talk about a strategy of success that
has been used to overcome his addiction. Others will observe this comment and
incorporate it into their own plans for sexual recovery. While this can be done in
the therapist–patient dyad, it is, we believe, more effective and more comprehen-
sive in group work. Not only are group members on an equal par, they all come
with the same problem. Successful strategies are mirrored and multiplied by the
sheer numbers of potential models available in the group process.

Neuroscience
The neuroscience of sexual addiction is explained to patients at the start of ther-
apy. Men often need a physiological explanation to help them understand the
nature of the problem. This puts a behaviour, which is often misunderstood, on to
a factual basis. It explains that it is not about questions of poor choice or morality.
It is not simply a matter of ‘stop doing it’.
What is the make-up of volition? The brain has been constructed to pursue a par-
ticular pattern of behaviour. This behaviour has emerged from the distinctive history
of the individual. Men often come into recovery in a state of confusion and shame.
An explanation that shifts the focus away from ‘right and wrong’ or ‘good and bad’ is
helpful to calm and reassure. Even at this early stage, it provides a preamble to relapse
 The primary interventions 57

prevention. It helps as an explanation to the continual ­pursuit of the ­behaviour in spite

of harmful outcomes. It helps to answer the question ‘Why did I do it again?’ The
proximate nature of the sexual reward outweighs and obscures the distal aftermath of
remorse that follows. It helps men understand that arousal chemistry is designed by
nature to prevent a consideration of consequences and alternative behaviours. Shame
reduction is a by-product of the teaching on neuroscience.
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Shame
I have three memories from early childhood. These are determining memories.
They shaped all the years ahead. The first: I was taken to the library, probably
before I was three years old, and I took out a book, The Golden Treasury. From
that time, I have read continually and have an enormous library. The second is
being taught the Lord’s Prayer and Psalm 23. I can remember being at my moth-
er’s knee. I knew, even then, that I was dealing with the numinous. The last early
memory was one of intense shame. Even now, years after the event, I still feel
shame. My mother interrupted me (I fear to use the phrase ‘caught me’) in age-
appropriate sexual exploration with another child. I can still remember the look
of horror and the severity of the reprimand. This might be a composite memory
made up of many sex negative messages, but it is the one that I remember with my
narrative mind. It is not by chance that I work with those who experience shame.
As I have said, this was compounded by being the unwanted child of my
father. My brother was his preferred child. I internalised a sense of ‘not being
good enough’ for my dad. I am deeply moved in books and films with scenar-
ios of an affectionate relationship between father and son. These events created
trauma and made an indelible imprint on my sense of identity. It formed my core
belief and drives my automatic thoughts. These can easily be described: ‘I am
fundamentally flawed and intrinsically disordered.’ Similar emotional experi-
ences often underpin the emotional lives of my patients. Sexual addiction is a
short-term answer to the problem of shame.
Reid (2013) proposes that there is evidence that maladaptive shame is a sub-
stantial problem with sexual addiction. This suggests targets for treatment. Mol-
len, writing in Shame and Jealousy, states that ‘sexual fantasies can often be
understood as sexualized narratives about injuries and vulnerabilities in the sense
of self, the core self that must not be violated’ (2002: 41). Mollen further writes,
‘Through the unconscious ingenuity of sexual fantasy the deepest anxiety about
the viability of the psychological bodily self is transformed into the source of
intense personal pleasure’ (2002: 42).
Fossum and Mason, in their book, Facing Shame, describe shame as:

an inner state of being completely diminished or insufficient as a person.

It is the self, judging the self . . . a pervasive sense of shame is the ongoing
experience that one is fundamentally bad, inadequate, defective, unworthy or
not fully valid as a person.
(1986: 5)
 58 The primary interventions

The body language of shame is the bowed head, averted eyes, covered mouth,
the need to hide from the gaze of the other. Yet shame does not require the gaze
of another (Morrison 1987): it can be the eye of the self, looking at the self.
Baumeister, in Escaping the Self, writes that people escape from the self because
‘when you feel stupid, clumsy, inadequate, unloveable, you want to stop thinking
about yourself’ (1991: 22).
A patient took a phone call during a session. It was from his wife saying that a
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tabloid newspaper was at their gates. Another woman, with whom he had a three
year relationship, had sold the story to the newspaper. His wife knew nothing
until the reporters were on their doorstep. I saw the body language of shame. He
took a foetal position in the chair and tried to make himself as small as possible.
It seared my memory.
Will, writing about shame and psychosis, describes shame as follows:

Shame is a painful, unpleasant emotion, experienced as an accompaniment of

some transgression or wrong doing, impropriety, shortcoming or transgression
of behaviour and concepts of what is held to be ‘good’ or ‘right’ or acceptable
within a particular group. It is equated with feelings of disgrace, dishonour,
infamy, humiliation, odium, or the like and may be accompanied by physical
sensations of apprehension, disgust, nausea, and dread. To be ashamed is to
be faced with censure and the possible removal of human support that is felt
necessary to exist with some semblance of comfort.
(1987: 309)

The latter part of this definition, ‘the removal of human support’, is reflected in
the ‘unto death’ nature of the popular expressions describing shame and humili-
ation. I once heard a patient say that he wanted to “fly to the grave”. All these
expressions are references to the need to disappear; they are the language of the
grave.
I do not make any distinction between shame and guilt. Both involve the same
affect system. However, the usual distinction is that guilt is about something you
have done and shame is about who you are. Shame is ontological. It is ‘losing face’
or to disappear. Pattison writes that ‘any experience that induces a sense of per-
sistent inferiority, worthlessness, abandonment, weakness, abjection, unwanted-
ness, violation, defilement, stigmatisation, unloveability, and social exclusion are
likely to be generative of chronic shame’ (2000: 108). It is not a passing thought
but an unending sense of being flawed. Shame requires a cover, often in the
form of religion or overwork that links to acting out. Overwork requires a greater
compensatory behaviour and this behaviour can take the form of sexual conduct.
There are four ways to manage shame (Pattison 2000): withdrawal, attack self,
avoidance or attack other. Withdrawal can be physical or internal. The attack-self
response leads to chronic self-hatred and negative self-labelling. The avoidance
response links into the use of alcohol and drugs of misuse as a way to numb the
 The primary interventions 59

pain of shame. This can be accompanied by perfectionism: ‘I must be excellent in

everything’. The attack-other is blame. The attack-other script explains the inter-
est of the newspaper in my patient with the three-year affair.
Pattison, who was the senior research fellow in practical theology at Cardiff
University, wrote ‘I think I became a clergyman partly to avoid an inner sense of
chaos and worthlessness and to become an acceptable “somebody”’ (2000: 113).
I think I became a clergyman for the same reason. His book, Shame: Theory,
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Therapy, Theology, is an excellent book on the nature of shame. The constant

drive for high achievement brings with it the need for compensatory strategies,
which can be food, alcohol and sexual me-time activities.
Nathanson writes that ‘any attempt to understand shame demands study of
its relationship to sexuality’ (1992: 288). Given our Judeo-Christian culture, it
is hardly surprising that shame should be powerfully attached to sexual practice.
Shame is associated with many belief systems: Evangelical Christianity, Ortho-
dox Judaism and Islam contain profoundly shaming messages about sexuality.
The Roman Catholic Church defines same-sex attraction as ‘intrinsically disor-
dered’. The only acceptable sexual practice is within life-long heterosexual mar-
riage. All these belief systems arose in pre-modern societies and little has been
done to accommodate their sexual ethics to changed circumstances in the modern
social order.
Nathanson (1992) emphasises an intrinsic connection between sex and shame.
It is his contention that the thoughts that accompany arousal are attempts to
reverse shame. Nathanson wrote ‘that the human is so constructed that whenever
the other person so much as falters, so much as a moment, in his willingness or
her willingness to resonate with our arousal and its accompanying positive affect,
we will experience shame’ (1992: 286). This would not be the case with paid sex
workers or, indeed, the internet. With both these sources of sexual pleasure, there
is little possibility of shame created by an unwillingness to respond. Nathanson
adds that ‘sexual activity whether in this solitary form of masturbation or in some
pattern of interpersonal behaviour can provide a wonderfully effective way of
distracting us from negative affect’ (1992: 425). The shame is afterwards.
Stoller intensively studied sexuality and paraphilias. Stoller makes the point
that daydreams, and erotic daydreams in particular, have one function: ‘to ward
off and then undo the effect of humiliations that, striking from any direction, are
defended against by each turn of the daydreams script’ (1987: 295). Nathanson
notes that ‘sexual fantasy is one of the ways we undo shame and reverse life expe-
riences of shame at the hands of others’ (1992: 286).
This discussion about the nature of shame brings us to treatment. There is more
than education. The antidote to shame is, in part, the therapeutic relationship.
Shame begets shame and, according to Mollen, the resolution is in the ‘affec-
tionate response of another person’ (2002: 43). To be heard by a non-shaming
and empathetic advocate can reduce the overwhelming feelings of shame. I think
this is particularly true in the use of CBT. In CBT, there is greater collaboration
 60 The primary interventions

and parity between therapist and patient and a more expansive ‘humanness’,
rather than the unspoken and seldom commenting approach of psychoanalytic or
psychodynamic psychotherapists. The only real cure for shame is the affection
of another. Considerable time is given in the early stages of working with the
sexually addicted to an explanation of shame and the creation of a fruit-bearing
alliance.
Shame can also manifest itself in body dysmorphic disorder. In our assessment
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procedure, we ask the question, ‘Would you describe your genitals as normal
in size, shape and function?’ It is important to note anxiety about too small a
penis. This can represent the presence of body shame. There is much locker-room
humour around the size of the penis. Also exposure to pornography can give men
of average size a feeling of shame. Its meaning is that ‘I am inadequate’. I also
ask ‘Do they work okay?’ to check on erectile dysfunction, early ejaculation or
delayed ejaculation. These disorders are normally about anxiety. I have found that
infertility, for example, can set up major shame about male functioning that can
be defended against by constant sexual conquest.
Time is given to teaching about shame. To recognise that one has a shame
script is different from just feeling shame. Although the feelings of shame do not
easily abate, they do not govern as powerfully as when they are unconscious. An
example: I had my computer stolen from my office just before Christmas. I had
left it in the office kitchen, in my rucksack, because I wanted to use it over the
lunch hour and all the rooms in the clinic were in use. The front door had acci-
dently been left open. Someone came up three flights of stairs and took it from my
rucksack. I felt shame but I realised that my shame response had been activated
and that there was no logical reason for me to feel shame. I did not steal it. Nev-
ertheless, it took four days for the feeling of shame to clear. This was in spite of
frequently doing Padesky’s ‘Thought records’ (Greenberger and Padesky, 1995)
in an effort to put mind over mood.
In CBT, this process of teaching is normally referred to as ‘socialising peo-
ple to the model’. In teaching about sexual addiction, we are giving our patients
information necessary to understand the behaviour. Most men, when they come
into treatment, have very little knowledge about the nature of addiction and less
about sexual addiction. By teaching, we are able to put order into the experience
of chaos. When we teach about neuroscience, we provide an explanation of the
physiological factors that underpin addictive processes. In teaching about shame,
we are providing men with a vocabulary to put feelings into words. They begin to
be able to identify and differentiate feelings. It is important to be able to do this,
as we will see in the next chapter, when we are seeking to help men to identify the
precursors to their cycle of addiction. The reduction of shame is the most impor-
tant function of our early teaching.
 The primary interventions 61

Conclusion
Teaching ‘socialisation to the model’ and providing information all contribute to
the creation of understanding and reduce the shame associated with sexual acting
out. At the start of therapy, shame reduction is soon achieved by these fundamental
interventions. The more that can be done to reduce shame, the better. This infor-
mation, combined with a positive therapeutic experience, can bring great relief.
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Even just talking to someone who is clearly an advocate helps to relieve anxiety
and give hope. Over and over, when I ask for feedback after the initial session, I
hear words and phrases that express relief that someone is trying to understand.
 Chapter 6

The principal interventions

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Introduction
This chapter delineates and explains the principal interventions for the treatment
of sexual addiction. The previous chapter dealt with the early teaching interven-
tions. Most of the following interventions involve the use of practical homework
and experiential exercises. For the past 13 years, we have used most of these inter-
ventions. We have added some more recently. Successive groups have consist-
ently voted the ‘cycle of addiction’ as the most important intervention. Definition
of the cycle is helpful for cognitive understanding. The personal presentation is
the most important intervention for creating change, especially when done within
a cohesive group. The sequence of these interventions is not absolute and can be
changed to better meet the needs of individual patients. I have placed them in the
order that we normally use with patients.

Values clarification
Although a ground-breaking book on addiction and CBT, there is no reference to the
importance of values in Cognitive Therapy of Substance Abuse (Beck et al. 1993).
However, in offender treatment programmes, 69 per cent use ‘values clarification’
as part of their treatment programme (Maletzky and Steinhauser 2002). In a chapter
entitled ‘Motivational interviewing’ in Treating Substance Abuse, there is a reference
to the importance of ‘values clarification’ as part of the treatment process for sub-
stance abusers (Moyers and Waldorf, in Rotgers et al. 2003). Moyers and Waldorf
suggest giving the patient a set of ‘value cards’. These are cards with 80 different
values named one-by-one on each card. The patient is asked to choose his top five val-
ues and to talk about each one in depth. The treatment provider then queries how his
addiction contributes to sustaining that value. These cards are free to download from
[Link] (accessed 4 January 2015). There are also other helpful tools that
can be applied to sexual addiction and can be downloaded free of charge.
Hall in her book, Understanding and Treating Sex Addiction (2013), has a
section on values. She states that ‘values are principles in our life from which we
 The principal interventions 63

derive meaning and fulfilment’ (Hall 2013: 94). As part of her research, Hall did a
survey and asked ‘In what way has your sex addiction contradicted your personal
value system?’ The answers included hypocrisy, bullying, abusing trust, exploita-
tion of women and cheating. She suggests that ‘reclaiming and recommitting’ to
a personal value system is an important part of the recovery process. She includes
a ‘personal values list’ and suggests that patients tick their top ten and then put
them in order of priority.
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Maltz and Maltz in The Porn Trap (2010) include a personal values list similar
to Hall’s. They suggest that ‘you can take time every day to think about your val-
ues and goals, read books on values, ethics, and goal-setting, and discuss what’s
important in your life with a family member, counsellor or a good friend’ (2010:
146). Clarifying values is an important part of the process. They also suggest
a writing exercise entitled ‘What really matters to you?’ and another called ‘I
want to be someone’ to consider how pornography interferes with personal value
systems.
In the book, Why Did I Do It Again? (Bays and Freeman-Longo 1989), there
is also a section on values. It is the authors’ contention that values determine
our choices and actions. It is easiest to see a value system by examining actions.
Bays and Freeman-Longo state that ‘unhealthy, unthinking, selfish behavior
creates your deviant cycle, just as generous, kind, trust worthy moral behavior
creates healthy cycles’ (1989: 32). While they are writing particularly for sexual
offenders, these insights can also apply to sex addicts.
What does it say about a value system that it is possible to spend countless
nights in sexual escapades? What does it say about the view of women (or people
in general) that they can be used as receptacles for sexual gratification? What does
it say about how much a man values himself that he can lose countless hours to
internet pornography? Bays and Freeman-Longo go on to write, ‘the real key to
your hidden values is to look at your behavior’ (1989: 33). The first step in chang-
ing your values is to discover what values you actually have: ‘Three things show
how much you value something: how much you would sacrifice for it, how much
energy and time you give to it; and how you act when your value is under stress’
(Bays and Freeman-Longo 1989: 34). They are clear that the value system can be
changed by practice and repetition.
Hall’s approach and that suggested by Moyers and Waldorf achieve similar
ends. In our practice we use the ‘value cards’ suggested by Moyers and Waldorf
(2003). We find that this is the most helpful approach. The practices associated
with sexual addiction vitiate the claimed system of values. In the long-term recov-
ery plan and in relapse prevention, it is important to return to the issue of life
values along with reflection on the kind of life one would want to be remembered
for. Is it a life filled with sexual acting out, or a life filled with honesty, decency
and of service to others? This is an important consideration when we come to ask
patients, as part of their relapse prevention plan, about the future they want for
themselves and those they love.
 64 The principal interventions

Understanding supernormal stimuli

Barrett’s book, Supernormal Stimuli (2010) provides the basis for the application
of this concept to the world of pornography and sexual addiction. The fundamen-
tal theme is that animals (and humans) respond to artificially produced exaggera-
tions of real and normal phenomena. This is illustrated with a range of examples
from butterflies to birds. When the sexual characteristics are artificially modified,
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the opposite sex prefers an artificial exaggeration to a real mate. Barrett draws on
the research of Tinbergen as a foundation for her ideas. Tinbergen won the Nobel
Prize for his early research with animals. Barrett writes about barn swallows:

Male barn swallows have light brown chests and females choose the ones
with the most intense colour as an indication of fitness. Scientists with a
$5.99 felt tip marker can darken the chest of a scorned male and suddenly the
females line up to mate with him.
(2010: 3)

Another example can be found in the work of Tinbergen, who studied birds that lay
small pale blue eggs. He found that birds preferred to sit on large bright blue eggs
with black polka dots. In other words, ‘the essence of the supernormal stimulus is
that the exaggerated imitation can exert a stronger pull than the real thing’ (Barrett
2010: 3). Barrett applies this to junk food, pornography, propaganda and the media.
It also applies to internet pornography, which is mostly about big-breasted
women, with generously curved backsides, keen on casual sexual encounters. Bar-
rett notes that ‘a growing number of men being treated for sexual addiction have a
problem with pornography rather than with real partners’ (2010: 33). It is a small
step from the animal kingdom to the world of man. These pornographic images are
exaggerated imitations of the real thing. Pornography is an exercise in novel and
neuroplastic learning. Hilton writes: ‘with plastic surgery enhanced breasts serving
the same purpose as . . . artificially enhanced female butterflies; the males of each
species prefer the artificial to the naturally evolved’ (2013: 5). Perhaps this is why
so many men presenting at our clinic with an addiction to internet pornography
have difficulty sustaining sex with a real partner.
Excitement about the artificially enhanced is greater than the excitement of the
reality of the woman. Men with pornography addiction often withdraw sexually
from their partners. The supernormal stimulus is preferred over the reality of the
woman. It is similar with sex workers: they may offer a kind of femaleness that a
partner of 20 or 30 years cannot equal. The stimulus provided by these substitutes
attenuates the attractiveness of the ordinary woman.

Formulation
Westbrook et al. emphasise that ‘the aim of CBT is primarily to arrive at a formu-
lation which is agreed as satisfactory by both client and the therapist’ (2012: 40).
 The principal interventions 65

Its function is to make normal the patient’s experience and to promote involve-
ment, to simplify and to set out the direction for intervention (Kuyken et al. 2009).
To be understood gives rise to hope.
Earle and Crow (1989) in Lonely All the Time, write that the seeds of sexual
addiction are located in negative critical self-talk: ‘I am, in effect, a bad person’.
This is combined with cognitive distortions and other features to set the scene for
the development and continuation of sexual addiction. Young writes that ‘those
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who suffer from negative core beliefs may be the ones most drawn to the anony-
mous interactive capability of the Internet’ (2007: 673). Gold and Heffner (1998)
attribute causation largely to low self-image.
A formulation is simply a diagrammatic outline of a patient’s situation that
describes and makes clear the interconnection of thoughts, feelings and behav-
iours that give rise to the problem. The behaviour usually emerges from dysfunc-
tions and deprivations in the family of origin. This is described in the top part of
the diagram. These deprivations and dysfunctions give rise to a set of core beliefs,
assumptions and compensatory strategies. We re-label ‘assumptions’ as ‘manage-
ment techniques’ and ‘compensatory strategies’ as ‘escape mechanisms’. There is
normally an incident that brings people into therapy. Occasionally it is the accu-
mulation of shame that causes action. The partner might discover the behaviour.
It can be police action that activates an attempt to find help. The problem has
‘maintainers’: these are things that hold the problem in place. With sexual addic-
tion, there is profound pleasure in sexual responsiveness. This alone can hold the
problem in place.
I will outline a typical case of someone who is sexually addicted: someone
who uses sexual behaviour as an escape from intolerable feelings. The set-up
is normally in the family of origin and is almost always closely derived from
the behaviour and characteristics of the principal caregivers. The set-up can also
evolve from other diminishing factors: social stigmatisation in the case of gay
men, or other traumas outside anyone’s control. There was one patient who had
been traumatised by having to learn to sew up wounds at the age of seven. He
and his family had been involved in a war. The set-up can be a disability or an
impediment, like a speech impediment or a stutter. It leads to the creation of a core
belief, which can be described as ‘I am defective’. The sense of diminishment
gives rise to feelings of shame. Alongside the core belief, there are a number of
management techniques that can be formulated as if/then statements. For exam-
ple, ‘If I make money, then I am acceptable’ or ‘If I am good at business, then I am
acceptable’, ‘If I am attractive to women, then I am acceptable’. However, there
are also escape mechanisms that allow times of temporary self-soothing. In this
category we could place all addictions: compulsive over-eating, compulsive exer-
cise, alcohol and sexual behaviour as relief from the overarching power of the felt
core belief. ‘Attentional bias’ means there is selective notice of events and situa-
tions that are relevant to the core belief. Here we find the triggers for an addictive
use of sex as an escape from the painful nature of the core belief. Sexual addic-
tion normally has its own interconnecting cycle: shame gives rise to addiction
 66 The principal interventions

and addiction gives rise to shame. The interruption of this self-perpetuating cycle
gives the individual a sense of self-empowerment.
This is illustrated in the case of Andrew, a multiply addicted gay man. For
Andrew, alcohol and sex were intimately connected. His core belief was ‘I am
defective’. The management techniques were hard work and charm. The escape
mechanisms were alcohol and sex. The maintainer to the sexual addiction was
alcohol. He would become disinhibited and sexually voracious. Other maintainers
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were to have unstructured time and uncontrolled rumination. The goal in treat-
ment was to interrupt the use of alcohol. Once this was done, it removed the
unlimited search for sexual partners.
The formulations differ in detail from patient to patient but, with the addicted,
they all tend to have broadly the same underlying combination of themes: ‘I am
defective and I use sex to escape from this feeling’. Some addicts are not primarily
interested in sex but in female responsiveness. There was one heterosexual patient
who sought the company of transsexuals. They were more female than females –
in essence, a supernormal stimuli. He was attracted by their ‘more than average’
female appearance and, at the same time, they were extremely responsive to him
as a heterosexual man. Other patients just want someone who is glad to see them
and treats them well. I had an elderly friend who used to go to bars used by sex
workers. He said to me, “At least they are glad to see me”.
The formulation makes the hitherto unknown knowable. It brings order out of
chaos. It helps guide the ongoing process of therapeutic work and keeps therapy
on track. It helps the patient to know that someone is trying to understand.

Harmful consequences
Most men who come to our clinic are not in denial. All have suffered harmful
consequences. By far the most men who come to us do so because of the impact
of their behaviour on their relationship. It has come to a crossroads. For many,
the continuation of the partnership is uncertain. Other losses have been suffered:
partners have been given a sexually transmitted disease; one man contracted HIV
through the use of a transsexual sex worker; another has been exposed in the
press; another was arrested for downloading illegal pornography by file sharing;
others fear for these consequences. Sex itself can bring with it unwanted conse-
quences and these are multiplied when the sexual behaviour is out of control.
Early in the therapeutic process we give men a ‘Harmful consequences’ list
(see Appendix 1). This is an aid to reflecting broadly on the harmful consequences
of the individual behaviour. The function of the harmful consequences review is
to break through denial and minimisation. It brings to the forefront the compo-
nents of the situation that are repressed with sexual arousal. It can have a shock
value. It can increase motivation. At the same time, it must be done with care. The
reflection on the harmful consequences is disturbing. We find it more effective
in a group format because the group breaks isolation and this, in itself, reduces
shame.
 The principal interventions 67

We normally begin with the financial consequences of the addiction. For men
who act out with free internet pornography, there are no direct financial conse-
quences. However, if this migrates to the use of paid sites and live webcams, it
can become expensive. For those who use sex workers, the cost can add up over
years of acting out. In one group, we had two men who had spent over £1.5 mil-
lion each on sex workers. This was not just the payment for sex, which can be very
high, but for dinner, gifts, hotels and other sundry expenses. One young man on a
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small salary had spent over £30,000 in 7 years and was relying on payday lenders
to fund his addiction. We had one man who lost a well-paying job for accessing
sexually explicit sites on his work computer. Another young man was in serious
credit card debt. For some men, these are problematic losses. Of course, looking
at the financial consequences will increase the shame but also, at the same time, it
should increase the resolve to end the behaviour.
Another area of harmful consequence is the impact or the fear of sexually
transmitted infections. It is not nice for a man to have to go with a partner to a
sexual health clinic so that she can be tested for an infection that she might well
have caught from him. Several men have given their partners body lice. It would
be hard to imagine a more shaming experience than to give a beloved partner body
lice because of having sex with a – probably desperate and needy – sex worker.
A second problem is that sexual addiction can activate health anxiety. I have
come across men who have been for an AIDS test 10 or 15 times, because act-
ing out has triggered health anxiety. I was recently working with a man who was
rarely sexual outside his relationship. In this case, he had not even touched the
woman or the woman him, but it set up acute health anxiety. He said to me, “I
know that it is not possible to get an HIV infection when you don’t touch some-
one and vice-versa but I am still in a panic that I have HIV”. After a period of
prolonged acting out, men feel unwell because all the body chemistry of arousal is
spent. The effect is much like a hangover. Feeling unwell can activate the need to
act out sexually to escape from the bad feelings of the hangover.
The single most powerful recognition for most men is the countless hours of
lost time. Internet pornography is particularly pernicious as a time distorter. These
are hours that could have been used creatively, in the pursuit of self-improvement,
recreational or sporting activities, or career advancement. There was one patient,
a youngest son. He was a brilliant lawyer. He could have written an important
book if he had spent as much time writing as he did in the aimlessness of sexual
addiction.
Relationships are another area of life that is powerfully affected by sexual
addiction. There is recent research (Griffiths 2012) that suggests that those who
are involved with the internet and internet pornography experience more depres-
sion and anxiety than those who are not so involved. Overuse of the internet harms
the quality of a relationship. Of course, this begs the question of what comes
first: a harmed relationship contributing to the use of the internet or the internet
contributing harm to a relationship. Normally, the use of internet pornography is
done in secret and this too has a negative impact on the quality of the relationship.
 68 The principal interventions

When women are confronted by their partner’s behaviour, they are traumatised as
if coming out of a car crash. They wonder who the man they married actually is.
The sense of betrayal is profound. At our clinic, we have a specialist who works
with female partners of male sex addicts and runs groups for them. Before we did
this, we found that the men were improving in an understanding of the addiction,
and overall in psychological awareness, while their partners were sitting at home
at night without help. Having lost their husbands to sexual addiction, they were
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then losing them to a recovery process in which they were not involved. We estab-
lished the women’s programme to iron out these differences.
Perhaps the most significant loss to the sex addict is that of personal dignity and
the requirement to live a double life. For most men, knowledge of the addiction
is kept a secret. They are caught in a double bind: to tell their wife would cause
her pain, so they keep it a shameful secret. When discovered, often after years of
deception, the women feel an extreme sense of betrayal. Discovery is followed by
anger and reproach, and a whole roller coaster of conflicting emotions. The voice
of the wife amplifies and confirms the core belief of the addict – namely, that he
is a worthless person. This in turn can, unwittingly, contribute to further acting out
to escape the feelings of worthless shame.
Sexual addiction can have far-reaching consequences on those around an
addict. Not only are partners affected but also other family members. Caught up
in the bubble of sexual addiction, men can give little thought to their obligations
as parents. They can miss school plays and sports events, and distance themselves
from the activities of their children. Women need to talk to others about the prob-
lem and so the man’s parents or children, employers or work colleagues can all be
told about the situation. This process, understandable as it is, increases the levels
of insidious shame.
We frequently have men who have lost jobs because of sexual addiction. While
I have not seen figures on this, I wonder how much workplace harassment can
be attributed to sexual addiction. Cooper et al. (2002) state that most internet
pornography is viewed during working hours. Sometimes men come to us after
exposure at work: they have been discovered looking at pornography on the work
computer. These are profoundly disruptive consequences, particularly because
career and working life are fundamental to male identity.
For some men, there are problems or fears of arrest and involvement in the
criminal justice system. These can be actual problems or they can be fears that
continually haunt the addict. One particular problem is that divorce can be com-
plicated by sexual addiction. Women can wonder whether the man is a threat to
the children. We have had several cases in which women have used knowledge of
their husband’s sexual addiction to deny him access to the children. Such suspi-
cions and allegations are then aired in court and open to public scrutiny, as well as
additional expense and lengthy proceedings.
Finally, there is danger from attack and assault. One patient had been robbed
three times and still continued to use sex workers. This is problematic because
danger and sex have been paired in an ‘excitation exchange’. The feelings of
 The principal interventions 69

danger can enhance sexual arousal. The harmful consequences to sexual addiction
are many, varied and manifold. There is not only the reality of a harmful conse-
quence – there is a life lived in fear of a harmful consequence, which is a heavy
burden. Many men tell me that they are relieved to have been found out. They no
longer need to pretend and can now live a life without secrets.

Provisional sex plan

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The provisional sex plan is a simple instrument that allows a man to review his
sexual behaviour and to think through what he feels is compatible with his phi-
losophy of life and his wider value system. In the first column, he writes down
the behaviours that are definitely not okay. In the last column, he writes down the
behaviours that are not a problem for him. In the middle, he writes down behav-
iours of which he is uncertain. Most married men put sex inside marriage in the
‘acceptable’ column and preclude other contact behaviours. The complication is
the placement of internet pornography. The partner might object, but the man does
not see it as a problem. It becomes a problem for him because it is a problem for
her. The same might be true for masturbation. From the stance of recovery from
sexual addiction, it depends on whether masturbation is primarily a biological
function or whether it is the first step in a sequence that leads to full acting out.
This is a more complex exercise for single men than for married men. The
issues are somewhat different. It depends on the nature of their sexual addiction.
For almost all single men, masturbation would be placed in the ‘acceptable’ col-
umn. Some would put the use of internet pornography in the ‘acceptable’ column
and others would not. If the behaviour is frequent one-night stands, we suggest
that a man might make a rule of no sex on the first date or, perhaps, no sex until
three dates. Most men put the use of sex workers in the ‘unacceptable’ column.
This would not be true for all single men.
The process becomes even more complicated when there is a paraphilia.
Depending on the nature of the paraphilia, the extent to which it is either socially
despised or ridiculed will affect its location on the sex plan. In my experience,
most paraphilias are part of an addictive process. Sexual addiction and paraphilia
grow out of an experience of trauma.
The question is more complex with cross-dressing. This might be a matter of
harm reduction; cross-dressing at home alone might be placed in the ‘acceptable’
column but going out cross-dressed placed in the ‘unacceptable’. All the men that
I have worked with who cross-dress have been in partnerships with women. The
difficulty is to find a partner who can understand and tolerate the behaviour.
The same is true of married men who act out with men. This behaviour raises
many questions about the nature of sexual orientation. Sexual addiction can be
gender-blind. For some men, who truly love and value their wife, it can be dif-
ficult to ascertain whether the same-sex connection is just part of an addiction or
whether there is a splitting between love object and sex object. For others, it can
simply represent a heavily repressed same-sex orientation. Alternatively, it might
 70 The principal interventions

represent a genuine bisexual orientation. Sexual behaviour between men can be a

matter of experimentation or necessity (as in prison). It can be a response to pater-
nal deprivation. It might derive from a man’s early experience of comfort from a
male relationship. It also can represent a ‘female-free’ zone when the experience
of women has been threatening or abusive. We take the view expressed by Wilson
and Rahman (2005) that biological same-sex orientation is a normal and stable
variation in the human population caused by the androgen levels in the womb at a
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critical time during pregnancy.

What about bondage and domination? These behaviours tend to be associated
with addictive sexual processes, the common aetiology of which lies in an experi-
ence of trauma. Most of the paraphilias are viewed as transgressive and the social
disapproval becomes shared by the person with the paraphilia. He condemns him-
self. Imagine being 13 or 14 years old, experiencing your first orgasm and at the
same time realising that the behaviour, or fantasy material that accompanies it, is
unacceptable. The more unacceptable the material, the greater the shame.
There are many unanswered questions. There is not space to begin to give
these the attention they deserve. The function of the sex plan is to get men to con-
sider, for themselves, the difference between acceptable and unacceptable behav-
iour. Furthermore, thinking rationally about these patterns will help forearm them
against impulsivity.

Trauma egg and the shame museum

Earle and Earle state that ‘All the sex addicts we have treated have experienced
some type of painful background’ (1995: 14). Understanding past experience
allows a patient to break with the past and not allow the past to continue to operate
in the present. It provides an opportunity for the patient to change for the future
‘by developing transformative skills and tools’ (Earle and Earle 1995: 156). These
skills and tools are largely CBT and include the use of the ‘trauma egg’ (Earle
and Earle 1995: 24–5; see Figure 6.1) and the ‘shame museum’. A version of the
trauma egg given in Sex Addiction: Case Studies and Management (Earle and
Earle 1995) uses this technique but suggests writing in the traumas. We suggest
drawing rather than writing.
The trauma egg helps a man identify the origins of the trauma that gives rise
to his behaviour. It has the function of helping him realise that the patterns of his
behaviour were set up in history and were not chosen. No one chooses a sexual
script. The male sexual template is believed to be formed between the ages of
four and five, and seven and nine (Money and Lamacz 1989). Some would sug-
gest that it takes the form of a bell-shaped curve starting at around four and end-
ing at around thirteen (Friedman and Downey 2002). This is the pattern that we
have observed in the general history, and the sexual and relationship history, of
the addicts who have come to us for treatment. I have consistently found that
all the important information comes from the general history. I am interested in
the men’s experience of school, the attributes of their parents, a history of any
 The principal interventions 71
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By kind permission of th e patient.

Figure 6.1 Trauma egg

life-threatening or chronic sickness, family addictive behaviours, mental illness in

the family, the birth story and the sanctions used to discipline children.
The trauma egg is a large egg-shaped circle (Carnes 1997). My instructions
are to draw smaller circles and within each circle to draw a picture that represents
an experience of trauma, narcissistic wounding, punishment, humiliation, loss or
shame. In the upper-left corner, my instruction is to write the family rules and in
 72 The principal interventions

the right corner to write the family roles. Examples of rules are: ‘Do not spend
money’, ‘Boys do not cry’, ‘Avoid conflict’ and ‘Never speak of sex’. Examples
of family roles are: martyr, princess, the righteous one, clown, rebel and peace-
maker. In the bottom right corner, there is place for the characteristics of the
mother and, in the left, those of the father. Men find this an important exercise.
It encourages reflection and allows them to connect their addiction to life events
unique to them. It helps them understand that the addictive process originates in
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unchosen life events. This too reduces shame. Fuller instructions for the creation
of a trauma egg can be found at [Link] (accessed 4 January
2015).
The shame museum shows the inside of a gallery with a lot of empty plinths.
The person is asked to draw all the shaming experiences that can be remembered
from his early life. We suggest that they put each drawing on a separate sheet of
A4 paper and then create a guidebook to the shame museum. Patients are asked
to talk about the incidents that make up the guidebook. This can be done with just
the therapist or it can be done in group. The process of talking about the shameful
experiences with a sympathetic witness reduces shame and heals trauma. In group
work, I suggest that members pair off and take each other through their guide-
book. This process creates solidarity and exposes the unsaid. The group process
has the added value of the exchange being between two addicts and not between
the addict and the paid professional.
The shame museum is derived from art therapy. There is a rationale behind
using an art therapy format as part of the plan of treatment for men in recovery.
Emotional experience cannot always be put into words. The art therapy exercises
are designed to help explore experiences and feelings previously kept inside, sup-
pressed or acted out in destructive patterns of behaviour. Pictures and images
can express feelings and trigger memory. Images are free from the constraints of
language and logical thought. Pictures can help a person to express many different
layers of an experience and to see it from different perspectives. This is particu-
larly true when addressing addiction.
Both these exercises explore non-nurturing experiences and reveal abuse in the
family of origin. Carnes contends that 97 per cent of sex addicts have experienced
emotional abuse, 81 per cent sexual abuse and 72 per cent physical abuse. Carnes
writes that, ‘simply stated, the more abused you were as a child, the more addic-
tions you are likely to have as an adult’ (1991: 108).
In our clinical practice, we rarely find that our patients have been sexually
abused. Physical abuse is more common; emotional abuse the most common of
all. When I queried this difference in findings with one American specialist in
sexual addiction, he wondered whether I was asking the right question. I always
ask directly about sexual and physical abuse. I am aware that in the sexual and
relationship history there rarely emerge events or facts that would be evidence
of sexual abuse. I am not sure how to account for this difference in our find-
ings, although it may be linked to different child-rearing practices in this country
as opposed to the United States. Most of the cases involving excessive physical
 The principal interventions 73

punishment have been Irish rather than English. I assume a difference of culture.
Most of my patients have been educated since the ban on corporal punishment
in schools. Some of the older men do have memories of caning in school but
these have not been connected (except in one case) to the origins of sexual addic-
tion. Additional tools for family of origin work are suggested by Earle and Earle
(1995). These include genograms, life line, two-chair work, writing (probably not
posting) letters to and from family members, and therapeutic interventions with
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the entire family.

The cycle of addiction

Understanding the cycle of addiction (see Appendix 1) is crucial to the recovery
process. The cycle that we use is based on Bays and Freeman-Longo’s (1989)
cycle of offending. It is seen by men in recovery to be the single most important
intervention. In broad outline, the cycle has four parts: precursors, the process of
acting out, immediate aftermath and reconstitution. We go through the cycle using
an example to illustrate it. From this generic cycle, we ask men to personalise it.
In other words, we ask them to apply it to their own behaviour. The second part
of the exercise is to become familiar with precursors and cues. Avoiding action
should be taken before the cycle even begins. Men are also urged to make lists of
alternative behaviours to substitute for sexual acting out.
The cycle usually starts with a ‘seemingly unimportant’ decision as I will illus-
trate. One man’s seemingly unimportant decision was to go to buy a paper at the
newsagent. He would then be triggered by the top-shelf magazines. The arousal
chemistry would start to build and he would go from phone box to phone box
looking at the cards giving information about sexual services. Under the guise of
getting information, he was actually fuelling his cycle. He would then visit the
doors of sex workers and speak to them directly about their services. Eventually,
usually after several hours, he would reach the point of inevitability and would
hire one of these women or go to a sauna massage parlour where he would be
masturbated. He would live in shame and remorse for a week or two, and then
he would enter the reconstitution phase of the cycle. Eventually, he would come
back to the dormant phase and the cycle would repeat. He had been engaged in
this cycle of behaviour once every 2 or 3 weeks for many years. If he had known
about the cycle or the seemingly unimportant decisions that brought the triggers,
he could have taken avoiding action. Exit strategies are best put in place before the
arousal levels rise to prevent awareness of consequences. Here, too, the proximate
pleasure was so great that it completely overwhelmed thoughts of the massive and
powerful remorse to follow.
When we consider this cycle, it was not just in the 20 minutes or so that this
man had sex with a sex worker. The acting-out scenario began at the newsagents
and continued for several hours until it was accomplished. Each sex addict has a
cycle of this type. For some, it can be very short in building up. For others, the
build-up to the sexual event can be extended over weeks. Some have little remorse
 74 The principal interventions

and some have much. However, in all sexual acting out, the components of the
cycle remain, more or less, in place. One patient would go two or three weeks and
then visit two or three sex workers in one weekend. Another, who lived abroad
separately from his girlfriend, would go on the internet on Friday evening and
stay there almost entirely until the last thing on Sunday night. He would go into
work on Monday morning with the equivalent of a hangover. He would be full
of remorse and regret until the next Friday evening when the cycle would repeat.
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Trigger identification
The precursors can be environmental or internal feeling states. Environmental
factors can be driving down a street where one has acted out previously. There
was a sex addict from Edinburgh who used to be triggered because he drove home
from work through the red-light district. He would then pick up a sex worker. I
said to him, “Drive home a different route”. There are important environmental
factors that are sometimes predictable and sometimes unpredictable.
The same applies to those who use recreational drugs. Just looking down an
alley where one has scored can trigger the urge to use again. The same can be true
of friends: there are those, often in recovery, whom it is good to spend time with.
There are others who contribute to the urge to act out. Permission is given with the
second set of friends. In the case of one man, he had a friend called Wilf. When-
ever he went out with Wilf, they would down seven or eight pints of beer with
shorts and then score cocaine. This led to the use of sex workers either as part of
a continuation of the excitement or as an antidote to a cocaine-inflicted hangover.
The second set of precursors are feeling states that come with automatic
thoughts and have habitually been assuaged through sexual acting out. The most
common feeling states are depression, anxiety, loneliness, boredom and shame.
Recognising that one is in such a feeling state allows a person cognitively to adopt
a different responsive behaviour. For example, loneliness: ‘I am alone, I will act
out on the internet. I deserve this’. Alternatively, ‘I am feeling lonely, this puts me
in a likely position to act out so I will ring someone for a chat instead’. Another
example: ‘I am feeling anxious. I know that anxiety is a precursor to sexual acting
out. I will go for a run instead’. In each case, the precursor to the sexual behaviour
is noted and an alternative solution is chosen. It is probably not possible to choose
something that has as much reinforcing power as sexual pleasure but, with prac-
tice, it is possible to create a much better overall quality of life.

Behavioural substitution
Alternative behaviours must be substituted in place of the acting-out behaviour.
If a man simply stops acting out without a replacement behaviour, he will sim-
ply hurt and open himself up to continued acting out. We give patients lists of
alternative behaviours. These would be self-soothing activities. They are divided
into three categories: emotional self-soothing, physical self-soothing and spiritual
 The principal interventions 75

self-soothing (Hedelius and Freestone 2010). These are not discrete categories.
In the emotional, we recommend playing with the children, helping them with
homework, having a conversation with one’s partner or an old friend, or sitting
quietly alone at a coffee shop. For physical self-soothing, we strongly recom-
mend physical exercise. It could include going for a walk, going out on a bike,
playing cards or singing and dancing. For spiritual self-soothing, we suggest that,
when appropriate, people reconnect with childhood practice, perhaps by going to
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Evensong at St Paul’s, going back to synagogue, or maybe going to a concert on

Sunday morning.
Some people may prefer new activities and we advise them to consider an
alternative spiritual community. Get involved with attractive alternative events.
We encourage men to write out an activity programme for each day. Unstructured
time gives way to addiction. The aim is to assist men to find alternative enriching
activity to replace productively the time spent acting out, and so to interrupt the
cycle of sexual addiction.
It is crucial that the cycle is personalised. This allows for the development of
appropriate exit strategies when there is a recognition of internal feeling states and
external triggers creating the movement towards acting out. It is equally incum-
bent to have in place a set of alternative behaviours that can substitute for the
unwanted sexual behaviour.

Cognitive distortions
Cognitive distortions are also called ‘thinking errors’. They are erroneous ways
of thinking that bring with them strong feelings and can contribute to sexual act-
ing out. Baumeister calls this ‘cognitive deconstruction’ (1991: 62). The thinking
errors associated with sexual addiction tend to be:

• Denial: it did not happen

• Rationalisation: it did happen but it was the last time
• Justification: it did happen but it was not my fault
• Minimisation: it did happen but no real harm was done
• Excuses: it did happen but I was drunk
• Blame: it did happen but she should not dress that way.

Thinking errors are thought patterns that are flawed and distorted. When the
thinking processes are examined, it is plain that there are thinking errors associ-
ated with sexual acting out. Most addictive cycles involve thinking errors. How
many times does one have to say to oneself, ‘That was definitely the last time’ for
it to actually be the last time? Or ‘I will just go on the internet for a few minutes
and that will be all’. Another thinking error that we encounter is ‘I don’t need that
programme, all I need is God’.
Thinking errors come into play after acting out, such as ‘no harm was done’.
This might be the thinking error that would be used after spending half the night
 76 The principal interventions

on the internet and spending a couple of hundred pounds looking at a live sex
worker site. There was real harm done. There was harm because the man was
not in bed with his partner, he was exhausted going into work the next morning
and the money spent could not be truly afforded. In Alcoholics Anonymous, this
is called ‘stinking thinking’. Bays and Freeman-Longo’s book Why Did I Do It
Again? (1989) cites a number of thinking errors taken from work done by Yochel-
son and Samenow (1977). I will cite the ones applicable to sexual addiction:
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• Dominator: ‘she better do what I want’

• Trash City: ‘everything is bad’; ‘no one can be trusted’
• Paranoia: ‘they are talking about me behind my back’
• One track mind: ‘my way or the high way’
• Projecting: ‘if it is true of me it is true of you’
• Not my fault: ‘she did it’
• Denial: ‘I didn’t do anything wrong’
• Blaming: ‘she wanted sex’
• Not so bad: minimising the impact of the behaviour, ‘she will get over it’.
(Bays and Freeman-Longo 1989: 20–1)

Thinking errors can be conceived of in different ways. However, they can all
attach to sexual acting out. They can become so ingrained that they become invis-
ible to immediate recognition
In our practice, we use the following categories of cognitive distortions (drawn
from Sanders and Wills 2005: Figure 1.2). We ask patients to read through the list
and to give personal examples of the distortions that are applicable to them:

• Black and white thinking: seeing things in black and white and
not being able to distinguish shades of grey. For example, ‘I am a
complete fool.’
• Mind reading: concluding without evidence that other people are
thinking in a certain way. For example, ‘People must think that I am
really rude.’
• Gazing into a crystal ball: looking into the future and making generally
negative predictions. For example, ‘This won’t work. Why bother?’
• Mental filter: picking out a single negative feature and dwelling on it
without reference to any good things that might have happened. For
example, ‘It is all too awful.’
• Minimising the positive: rejecting the good in yourself by saying
that it is meaningless. For example: ‘I am a good father but anybody
can do that.’
• Magnification: exaggerating the importance of events. For example,
‘I can’t find my purse, I must be losing my mind.’
 The principal interventions 77

• Emotional reasoning: assuming that a feeling is a fact. For example,

‘I feel like a bad person, so I must be.’
• Unrealistic expectations: using exaggerated performance criteria for
self and others. For example, ‘I should always be kind to others.’
• Name calling: using a highly emotional label. For example, ‘I am so
stupid.’
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• Self-blame: seeing yourself as responsible for a bad event for which

you were not responsible. For example, ‘She is looking upset, it
must be my fault.’
• Catastrophising: predicting the very worst. For example, ‘I have no
future.’

A similar list is given in Treatment Plans and Interventions for Depression and
Anxiety Disorders (Leahy and Holland 2000). We find that the men in treatment
easily identify their distorted thinking.
Marshall et al. (1999) write about the treatment of sex offenders. We find the
same sorts of cognitive distortions with sex addicts. In their book, Cognitive Behav-
ioural Treatment of Sexual Offenders, they give a long list of distortions that include:

• False accusation ‘I did not do it’

• Memory loss ‘It could have happened but I can’t remember’
• Partial denial ‘It was love’
• Denial that it is a problem ‘I will never do it again’
• Minimising the behaviour ‘It happened less often than you think’
• Minimising responsibility ‘I was drunk’
• Denying harm ‘Her problems are not caused by me’
• Denying planning ‘It was on the spur of the moment’
• Denying fantasy ‘I don’t fantasise about it’.
(Marshall et al. 1999: 63)

Almost all these rationalisations can be used by sexual addicts. This is especially
true in the conversation between the man and his offended partner. Sometimes
sex addicts are given to justify the behaviour or to minimise the full extent of
the behaviour to a partner. Sometimes, in my experience, they are given to spare
the partner full knowledge of the degree and frequency of the behaviour. It is not
always about avoiding the truth: some men deny or minimise the behaviour to
spare the partner further anguish, as well as to protect themselves from shame.
Frequently used in a form of CBT known as ‘rational emotive behavioural
therapy’, the ABC model intervenes on the patient’s cognitive distortions (Miller
2010). ‘A’ is the activating event, ‘B’ is the belief and ‘C’ is the consequence.
Cognitive distortions are located in the belief system. Miller (2010: 32) writes that
‘Examining irrational beliefs, doing homework, keeping a record of thought and
 78 The principal interventions

behaviours and role playing are some of the techniques used in this approach’. ‘D’
is the intervention, ‘E’ is the effect of the intervention and ‘F’ is the subsequent
new feeling. Miller further writes that ‘Assisting clients in identifying their com-
monly held irrational beliefs or distortions and identifying their defence mecha-
nisms helps identify a clinical focus and treatment intervention plan’ (2010: 32).
In cognitive therapy, the belief system includes the core belief and assumptions.
Attentional bias and compensatory behaviours derive from these.
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In our clinic, we spend a couple of sessions on identifying a patient’s cognitive

distortions. We simply give them a list of distortions and ask them, as a homework
assignment, to give examples of which ones are most common to them. These are
then considered in further discussion with the therapist. If we are using cognitive
distortions in group work, we ask men to do the homework and then in session to
spend time discussing the results with another group member.

Assertiveness training
This part of the treatment programme gives patients an opportunity to state openly
their needs and wants. Often this is not done in a relationship, an omission that can
cause uncertainty as well as add to cognitive distortions. The process begins with
a ‘yes and no’ exercise. One person says ‘no’ and the other person says ‘yes’ for
30 seconds. For another 30 seconds the process is reversed. This exercise is then
discussed. Which was it easier to say? Did you notice any changes in your voice in
doing the exercise? Did you find yourself becoming angry? Once this is done, we
have a number of role plays. For example, your neighbour is playing the trombone
at two in the morning and you have to ask him to stop. In another, one person is the
employer and the other the employee; the employee is asking for a pay rise and the
employer is refusing. Each of these is examined, along with other role plays, and
comments are made about the content. The evening in a group format is entertain-
ing and there is much laughter. This in itself reduces shame. The major contribu-
tion is that the exercise strengthens cohesiveness in the group process. It could be
done in individual therapy but, I think, with more difficulty and less effect.

The hot seat exercise

This exercise demonstrates that intimacy is established through honest communi-
cation. It can be used individually or in a group process. In the group programme,
each person takes a turn in the hot seat. Other group members stand in front of the
person in the hot seat and tell him three things that they do, or have said, that cause
them to feel distant from him. They then tell him three things that they have done
or said that cause them to feel close to him.
This exercise only takes place once the group has formed and a unifying bond
has developed between the participants. I emphasise that it might well be the only
time they will get honest feedback that comes from people who are on their side.
Careful note should be taken of the feedback. After the exercise, the intimacy in
the group is greatly enhanced. Often men are in tears. It is a marvellous thing to
 The principal interventions 79

be told, perhaps for the first time, the things that you do that bring you closer to
others. For some men, it is the first time they have ever heard anything nice said
about them that they can trust comes from a good and open heart.
I will give an example from our group process:

The three distant experiences:

1 John, when you are late for meetings, I feel distant from you because I do
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not feel respected.

2 John, when you wear shoes that have holes in them, I feel distant from
you because it hurts me that you are not looking after yourself.
3 John, when you were looking out of the window when I was speaking, I
felt distant from you because it triggered my shame.

The three close experiences:

1 John, when you were so kind to Peter, I felt close to you because I can
see that you have a big heart.
2 John, when you speak to me at the pub after the meeting, I feel close to
you because I feel liked and accepted.
3 John, when you spoke so honestly about your relationship with your
wife, I felt close to you because I can see how much you love her. I also
love my wife.

The ‘because’ describes the impact of the behaviour on the other person. Here it is
important to avoid being judgemental – for example, ‘John, I feel distant from you
when you are late for meetings because I think you are just being sloppy’. This is
made clear in the instructions before the exercise. After the exercise, the person is
invited to say ‘what it was like to be in the hot seat’.
This exercise can be done in individual therapy. It can be incorporated at the
end of each session, between patient and therapist, in the form of ‘what things in
the session made you feel distant from me and what things made you feel close
to me’. This can be done over several sessions but only when the therapeutic alli-
ance will bear it. It can be a salutary experience for the therapist as well as for the
patient. The advantage of this exercise is that it demonstrates the achievement of
intimacy through the telling of truth. Interpersonal relationships with partners can
be improved when this approach is adopted.

Personal presentation
This is a crucial part of the treatment process that can be done individually or in a
group. It is the apex of the first part of our sex addiction programme. When I am
working with patients individually, we invite others in recovery to attend. This is
giving service to another and enhances recovery. The guidelines to the personal
presentation are in the Appendix. The session begins with ‘An open letter from
your friends’ (see Appendix 1).
 80 The principal interventions

In this part of the treatment, the man is asked to give his whole history – things
that happened to him in his family of origin, especially instances or experiences
that were shaming, abusive, neglectful or non-nurturing. It includes a sexual
­history and the history of the sexual addiction. It is important to include examples
of powerlessness, preoccupations, rituals and harmful consequences. There might
be a rock-bottom or a crux point that brought the man into treatment. The story
finishes with how he is doing now, what he has learned in treatment as well as
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his hopes and plans for the future. Those who are attending as witnesses have
the following responsibilities: to pay attention, to look for similarities, to be non-
judgemental and to keep in mind how difficult this exercise is. The witnesses will
probably be hearing things that have never been told before, because of shame.
Feedback includes a word of thanks and gratitude, and sharing how the story has
had an emotional effect, how it has given insights into one’s own situation and
what the story has revealed about sex addiction.
The time for feedback is especially important. We find that this is a powerful
emotional experience and that it is essential to the recovery process. It is moving
for the person making their presentation and equally moving to witness a pres-
entation. Each participant signs a confidentiality contract not to repeat any part
of the story to anyone without the express consent of the person giving the story.
This is an important experience of catharsis that reduces shame, keeping in mind
how powerfully sexual addiction is held in place by secrecy.

Conclusion
When we come to the end of the principal interventions, in most cases the group
has become very cohesive. In working individually, the relationship between the
patient and the therapist has deepened greatly. It is the personal presentation done
in group that has the biggest effect on the group participants. Everything in this
programme of treatment is carefully layered. The first few weeks of treatment are
about giving information and building relationships. The principal interventions,
drawn from a variety of sources, have been used by this clinic for many years.
We find that they form an effective combination for the treatment of addictive
compulsive sexual disorders.
 Chapter 7

The ancillary interventions

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Introduction
When we are able to analyse recovery rates in different groups of men, we find
that, if we have ten men in a group, two will recover almost perfectly, six will
get about three-quarters success and two men will not recover at all. In working
with men over 20 years, I am never sure what makes it relatively easy for some
men to withdraw from unwanted behaviours and the reason some men find it so
difficult. There are considerations that might bear upon this question – perhaps
the length of time that the hypersexual behaviour has been in place. Another con-
sideration would be the early onset of the behaviour. Sometimes these behaviours
are in place before adolescence. Another consideration might be the frequency of
use; yet another, the powerful nature of the escaped negative feeling state. I have
sometimes linked unsuccessful recovery to the levels of shame, and sometimes
to the levels of abuse experienced in the family of origin. It could be connected
to different levels of self-control that vary from person to person. While ambiva-
lence is common, some are more ambivalent than others. One factor that might
affect a recovery outcome might well be the importance placed on the intimate
relationship, or some other value held to be more important than sex – for exam-
ple, a deeply held spirituality. I am not sure that any one answer has emerged from
the literature or from outcome studies. So that treatment can be tailored appropri-
ately, more research needs to be done to differentiate the factors that cause some
people to recover easily and others with difficulty.
This chapter is concerned with the final interventions for working with the
sexually addicted. A number of occasional techniques are reviewed that can be
interspersed with the major interventions.

Relapse prevention
Very important to the recent development of the theory of therapeutic change is
work done by Prochaska and DiClemente (1982). This work, ‘Transtheoretical
therapy: toward a more integrative model of change’ is important as a background
to understanding relapse prevention. It was based on a comparative analysis of 18
 82 The ancillary interventions

leading therapy systems. Prochaska and DiClemente write that ‘One of the most
critical preconditions for therapy to proceed is that the client bring positive expec-
tation to treatment’ (1982: 277). Their research shows that there are five stages
to behavioural change: contemplation, determination, action, maintenance and
relapse. If lapse happens, it is crucial that the reasons for the lapse are explored
and understood, and that the patient does not give up or sink back into hopeless-
ness. The return to action must be immediate. It is useful to explain to patients
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that these stages in change exist and that it is important to return to action in the
event of relapse. This provides a cognitive explanation that can then be used to
harness overall change.
In Cognitive Therapy of Substance Abuse (Beck et al. 1993) there is a chapter
entitled ‘Relapse prevention in cognitive therapy for substance abuse’. With little
adaptation, this provides suitable guidance to prepare for the possibility of relapse
with sexual addiction. The addict is vulnerable to high-risk stimuli that can be
internal or external. The internal stimuli are the presence of negative feeling states
including loneliness, boredom, depression, anger, frustration and physical pain.
External stimuli include people, places and things. These activate basic beliefs
about addictive behaviours and these in turn stimulate automatic thoughts and
facilitating beliefs. Facilitating beliefs are a subset of beliefs that give an addict
permission to act out. This brings about the possibility of an actual lapse, and the
actual lapse can turn into a relapse caused by a flow of negative and self-critical
thoughts. The ideal role of the therapist is to help the patient to recognise a lapse
as an opportunity to explore and practise more useful ways of combating sexually
addictive behaviour. The response to lapse should be cognitive and behavioural.
Cognitive strategies include the rehearsal of ‘control beliefs’ that minimise lapse
and relapse. Other cognitive strategies involve the use of distraction techniques.
Behavioural strategies might be the rehearsal of conflict resolution activities
and pro-social activities. For most addicts, this would mean the establishment of
meaningful relationships with non-users or addicts in recovery. Once the addict
has entered into long-term sobriety, it is recommended that, rather than simply
terminating therapy, appointments are reduced to ‘catch-up’ sessions either by
telephone, letter, email or face to face.
Research tells us that relapse is most likely to happen in the first three months
of abstinence-seeking behaviour (Fanning and O’Neill 1996). There are numerous
things that contribute to the achievement of abstinence: a healthy diet, learning
about feelings and how to deal with them, regular exercise, purposeful amend-
ments made to others, better communication and the development of an appro-
priate spirituality (Fanning and O’Neill 1996). While Fanning and O’Neill are
dealing with relapse prevention with problems of substance use, their format fits
equally well for sexual addiction.
All these things contribute to relapse prevention, but Fanning and O’Neill out-
line a more specific five-point relapse prevention plan in The Addiction Workbook
(1996). They specifically list five major steps that, together, constitute an effective
relapse prevention programme. The first is to ‘stop something from happening’.
 The ancillary interventions 83

By this, they mean that each individual must consider their triggers and cues and
avoid them. These are divided into external and internal cues. For example, if a
man’s history of acting out tells him that he is vulnerable when alone at home, he
should therefore avoid being at home alone. If on the positive side, a man knows
that he is tempted to act out on Friday nights, he may consider and put in place
other Friday night activities. An awareness of internal cues is an awareness that
certain feeling states lead into addictive behaviour. For example, ‘I feel lonely’ or
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‘I am anxious’. Recognising these feeling states as precursors to sexual acting out

allow them to be handled in different ways. If a man feels lonely, he may consider
ringing a friend or someone in recovery. Addicts need to keep in mind that addic-
tion can get you ‘when you are up’ and it can get you ‘when you are down’. Both
external and internal cues can be positive or negative, and both types of cues need
to be considered in the creation of a relapse prevention plan.
The second piece of advice Fanning and O’Neill (1996) give about relapse
prevention is ‘to clean up the environment’. In other words, create a situation so
that acting out cannot be immediate. In terms of sexual addiction, this would mean
making certain that there were internet filters on the computers or that all the
telephone contacts had been deleted and appropriate numbers call-barred. They
suggest that it is important to have a list of alternative behaviours on hand for ref-
erence. They also suggest that there are things that can be done at any time: going
for a walk, writing in your journal, practising deep breathing, listening to music
or working on a craft. They continue with physical activities, creative activities,
intellectual and social pursuits and entertainment.
Fanning and O’Neill (1996) also suggest that it is important to be immediately
able to contradict ‘permission-giving’ thoughts and replace them with ‘permis-
sion-denying’ thoughts. Permission-giving thoughts include things like ‘I really
need this’, ‘This is the last time’, ‘No one will know’. It is important that permis-
sion-denying thoughts are readily available. These might include ‘Do you really
need this? You will just feel bad after’, ‘How many times have you said this is the
last time?’ These permission-denying thoughts need to be considered, prepared
and practised until they are as automatic as the permission-giving thoughts.
Fanning and O’Neill (1996) move into the more complex issue of gaining aware-
ness about negative automatic thoughts and replacing these with more functional
and helpful thoughts. They suggest that individuals write down their negative auto-
matic thoughts and alongside write what they call ‘coping thoughts’. By this, they
mean functional alternatives to the negative automatic thoughts about self, the world
and others. An example of this process would look something like this:

• Situation: My wife shouted at me.

• Automatic thought: I am being disrespected.
• Meaning of the automatic thought: I am inherently a person to be
disrespected.
• Alternative thoughts: She is just having a bad day. I am worthy and I am
essentially a good man.
 84 The ancillary interventions

This is in effect a process of changing the negative automatic thoughts with more
functional and less shaming thoughts. While Fanning and O’Neill (1996) suggest
that this can be done without help, I take the view that the process is a much more
complicated one that benefits from therapeutic assistance. Fundamental to CBT
is an understanding that feelings follow thoughts. In my experience, feelings may
be triggered by automatic thoughts but they also have a life of their own. Once
triggered, the feeling state continues even when one realises that the feeling is
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irrational, dysfunctional and the product of one’s individual history rather than an
accurate statement of reality. Learning to change these automatic thoughts requires
regular repetition of more functional thoughts. This can be done by gratitude lists,
rehearsing affirmative thoughts, keeping achievement lists, undertaking service
commitments and the repetitious practice of these new patterns of thinking. This
process is also facilitated by affirmation in the therapeutic relationship and the use
of ‘self-esteem’ tools in the therapeutic process. In our treatment programme, we
use a number of CBT tools. These are cognitive aids and exercises that strengthen
an individual’s sense of self as an efficacious and valuable individual. Their func-
tion is to counter the negative attentional bias.
Fanning and O’Neill (1996) suggest that, once the old core beliefs have been
identified, it is possible to replace them with new core beliefs that are more func-
tional and much less problematic. They suggest that these should be put together
in imagery: pick a high-risk situation, imagine it, visualise it and rehearse it. They
conclude relapse prevention with the following written commitment:

I, ___________, plan never to repeat my addictive behaviour. If I do slip, for

whatever reason, under whatever circumstances, I plan to quit immediately.
When I slip or feel myself about to lapse back into by old behaviour, I will
call ________________. I will go to ___________________ and I will do
____________________.
(Fanning and O’Neill 1996: 148)

Douaihy et al. (2007) recommend seven relapse prevention strategies. Help

the patient to see that relapse is a process and to learn to identify early warning
signs. Help them to identify high-risk situations and to develop coping strategies.
Enhance their communication and interpersonal skills. Help the patient to develop
better management of negative internal emotional states. Work with the patient
to manage cravings and to identify and challenge cognitive distortions. Finally,
consider the use of medication.
Bays and Freeman-Longo write that ‘the essence of relapse prevention is
anticipating and avoiding risk situations and making escape plans to fall back
on (1989: 71). Awareness is fundamental to relapse prevention. This includes an
understanding of how one normally acts in times of stress. Behavioural science
‘has shown that having enough awareness of a behavior reduces the occurrence
of that behavior’ (Bays and Freeman-Longo 1989: 71). Bays and Freeman-Longo
(1989) list a number of relapse prevention techniques, including thought stopping,
 The ancillary interventions 85

sexual arousal conditioning, covert sensitisation, assertiveness training and victim

empathy training. While the latter techniques apply to sexual offenders, they can,
with modification, be applied to paraphilic and non-paraphilic sexual patterns.
Maltz and Maltz (2010), writing specifically about relapse in the use of pornogra-
phy, suggest that relapse is not one event but, in fact, a process extended over time.
They distinguish three levels in pornography relapse: thinking about using pornogra-
phy, accessing pornography and using pornography as a sexual outlet. They recom-
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mend taking the following steps to reverse a relapse: stop, get away, calm yourself,
reach out for support, and reaffirm a commitment to recovery. They note the follow-
ing about relapse: ‘Regardless of how disappointed you may feel about it at the time,
it always has something important to teach you’ (Maltz and Maltz 2010: 208).
Carnes (1991) includes the following components to the make-up of relapse
prevention: identify triggers, reduce stress and build relapse prevention strategies.
Interestingly, he quotes Flannery’s work on ‘stress resistance’ (1989) and cites the
four features of stress resistance formulated by Flannery:

• Stress resistant people actively seek solutions to stress.

• They are committed to meaningful goals.
• They make healthy life choices.
• They seek and use support from others.
(Carnes 1991: 287)

Finally, Carnes (1991) suggests that it is important to build relapse prevention

strategies. He calls these ‘dress rehearsals and fire drills’.
Hall (2013) has made the most comprehensive study of relapse prevention with
application to sexual addiction. She is an exceptionally creative and innovative
writer. In her study, she underscores the neuroscience of sexual addiction and its
application to relapse prevention. She writes about neurogenesis as a process that
can be used to disestablish and create new neural pathways. Drawing on work
done by Matthew Hedelius and Todd Freestone and their programme Cognitive
Neural Restructuring Therapy for the Treatment of Sexually Compulsive Dis-
orders (2010), Hall writes about neurogenesis: ‘Neurogenesis is best achieved
where there is consistency, frequency, intensity and duration’ (Hall 2013: 132).
In other words, practice and repetition are required. She draws on the work by
Hedelius and Freestone on the ‘Twelve Pillars’. She reduces them to ten and has
amended them to make them appropriate for a United Kingdom audience as an
important part of re-wiring the brain. We use the original pillars in our treatment
programme and ask that men recite the pillar of the week three times a day, the
last one being recited out loud. The amended versions are given in Hall’s book
Understanding and Treating Sexual Addiction (2013). The recitation of the pillars
is just one part of the process of neurogenesis.
Hall (2013) goes on to suggest avoiding environmental and emotional trig-
gers, which includes avoiding people and places associated with sexual acting out.
As with other relapse prevention strategies, she suggests the importance of structured
 86 The ancillary interventions

time and the use of pre-planning to avoid unstructured time. In addition, she suggests
strategies to handle emergency situations including the use of the acronym RUN:

Remove yourself from the situation

Un-distort your thinking
Never forget what you have to lose.
(Hall 2013: 140)
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She describes the RUN strategy as ‘the single most important relapse prevention
technique there is’ (Hall 2013: 140). There is no doubt that, while not new in
essence, Hall’s strategy is a distinctly significant contribution to relapse preven-
tion tailored to the needs of the sexually compulsive person.
Milkman and Sunderwirth (2010) suggest other useful ingredients in a long-
term relapse prevention strategy. These might be best seen as the ingredients of
a good life. These are placed alongside what they call ‘natural highs’ as a way of
maintaining long-term sobriety. In one section of their book, Craving for Ecstasy
and Natural Highs (2010), they include cognitive behavioural techniques (which
they call the ‘cognitive behavioural revolution’), the development and mainte-
nance of close and intimate relationships, mindfulness and meditation, nutrition,
exercise and meaningful engagement of talents. These are the components of a
good life. One that is sufficiently good that there is no need to escape into sub-
stances or behaviours.
Our relapse prevention strategy involves explaining the stages of behav-
ioural change and the actions to take if, and when, relapse takes place. We
give patients a ‘Relapse prevention and recovery plan worksheet’, which is an
aid to thinking and planning forward action. This worksheet includes questions
about their cycle of addiction, including the precursors and the cues and triggers
for addictive processes. This is, in effect, a review of previous material and is
placed here again to build upon and consolidate previous learning. It includes
short-term strategies for preventing relapse. This might be putting an internet
filter on the computer or something as simple as turning the computer so that
the screen faces the entrance to the room rather than away from it. There is
then a return to the provisional sex plan for further consideration (see Chapter
6). Individuals are asked to think about and define activities and interests that
are part of wider personal development. These would include cultural pursuits,
academic involvement, leisure and sporting activities. There is a place to list
processes that contribute to acting out – for example, cognitive distortions and
negative self-critical talk.
We caution men to be aware of one particular feature of slips or relapses. This is
the ‘abstinence violation effect’ (Brown 2005), which is likely to lead from a lapse
to a relapse. There seem to be at least four forms this can take: self-­depreciation,
expectation of ongoing failure, the problem of immediate gratification and errone-
ous self-attribution. In other words, the bad feelings caused by a lapse can become
triggers for further lapses until a stage of complete relapse is reached.
 The ancillary interventions 87

We are clear that some people must be avoided and others are good to spend
time with. We had one individual who was addicted to sex and cocaine. He had
a woman called Madeleine on his list of people to avoid. Tragically, he did not
avoid her and wound up brain damaged because he had taken drugs with her and
then choked on his own vomit.
We ask men to consider the value of getting involved in a Twelve Step programme
and, if so, what frequency would be useful to them. Alternatively, they could continue
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with one of our programmes or attend our aftercare programme. They are encouraged
to consider the possibility of ongoing psychotherapy, preferably with someone who is
trained in the treatment of sexual addiction. However, sometimes all that is necessary
is to have a good-hearted (but trained) therapist for further work.
The relapse prevention worksheet starts to close with a section on ­relationships –
how they can be improved. Finally, there is a section on amends. Amends are an
important part of recovery and include making a list of people to whom one owes
amends. Sometimes it is right to make amends in person. At other times it is right
to make symbolic amends. The most useful amends to anyone is the existence of
a lifestyle that is free from damaging and unwanted sexual behaviour. As part of
this process, there is a blank list of proposals that are needed to maintain recovery
on a daily basis, as well as weekly and monthly activities. There is even a place
for annual events – an annual retreat or a recovery convention.
All the material on relapse prevention is much the same. It includes awareness
of acting-out patterns and especially awareness of high-risk situations. It offers
clarity about triggers that can be internal feeling states or external environmental:
people, places and things. The creation and practice of exit strategies are neces-
sary parts of relapse prevention. Most of all, relapse is best prevented by the crea-
tion of a more fulfilling and meaningful quality of life.

Healthy sexuality
When we come to discuss healthy sexuality, we suggest that men return to their
provisional sex plan to consider whether there need to be any changes made.
Often men will have found that some things that were not put in the original plan
now need to be included. Flirting is a good example. Sometimes men did not think
that, for them, flirting was a form of sexual acting out. With an awareness that this
can be a form of acting out, sometimes men will add it to their ‘unacceptable’ col-
umn. Another change might be channel hopping on the television, with an almost
unconscious search for sexually dominant themes in television programmes. At
this stage, the sex plan is renewed, adjusted or confirmed. This process can be
done in individual therapy or in group work.
We give men a paper on healthy sexuality to facilitate discussion. It has an
underlying theme that sex is something done in a loving way between two people.
The paper contains a list of characteristics said to be relevant to healthy sexuality.
These are counsels of perfection and do not make reference to solitary or recrea-
tional sex. They are based on an ideal: that sex is something that is best done in a
 88 The ancillary interventions

monogamous and loving relationship. In this they reflect a set of values currently
prevailing (but not adhered to) in our culture. In fact, every man has to decide
what is right for him. This too, of course, reflects a value system – namely, the
Western cultural notion of individual determination.

Sexual health
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In writing about sexual health and safer sex choices, Zawacki et al. (2005) make
the point that classical cognitive behavioural techniques can be used to challenge
and change beliefs that prevent safe sexual behaviour. These include modelling
of skills, videotapes and instructor demonstrations, discussion of the model and
client rehearsal. Zawacki et al. (2005) go on to quote from Nelson, writing, ‘There
is something different and possibly unique about sexual motivation as compared
with other motivated behaviours that impairs decision making processes’ (Nelson
1995: 204, in Zawacki et al. 2005: 378).
Time should be given to teaching about physical sexual health. This would
include teaching about safe sex practice and the mechanisms of infection for sexu-
ally transmitted diseases. We have a nurse practitioner in sexual health in our
clinic and we ask her to come to explain safe sex and to answer questions about
it. The sorts of questions that emerge are whether it is possible to get HIV through
oral sex either with a woman or man. What are the chances of infection if ejacu-
late is swallowed? What are the dangers of transmission through active anal sex?
Along much the same lines are questions about the safety of condoms as a means
of contraception. This is important in the prevention of unwanted pregnancy. It
would seem in our society that most people would know the answers to these
questions. We find, however, that is not the case, and it is useful to have at least
one session set aside to handle these issues and the questions that arise from them.
If one is working individually with a patient, it is essential that the therapist is
broadly but properly informed so that this information is available. There is a
teaching component with CBT and in working with sex addicts this component
includes information about safe sex. Harm reduction is also part of the aim as well
as cessation from existing behavioural patterns.

Additional components of treatment

In addition to the treatment interventions given earlier in Chapters 5, 6 and 7,
there is a range of additional measures that are incorporated into our programme.
To change such primary behaviours as unwanted sexual behaviours requires an
immersion in a culture of recovery. To facilitate this, we give each group member
a list of the telephone numbers of everyone in the group; then we ask each group
member to ring one other group member each day. We also encourage fellowship
before or after a group meeting. This is to break isolation. Sexual addiction is set
up in an experience of disconnectedness. The use of the phone breaks isolation
and increases connectedness. The same is true with fellowship. If working alone
with a sex addict, this might mean scheduling check-in time with the therapist
 The ancillary interventions 89

between sessions, either by email contact, Skype or a telephone call. Although

this would be unusual with someone trained in psychodynamic modality, it is not
unusual in the practice of CBT. The telephone call is especially useful in breaking
the cycle of addiction. If, when feeling a desire to act out sexually, one makes a
phone call, the desire is almost always eliminated. The same is true after acting
out. If the person is prepared to make a call or check in with the therapist, this can
avoid setting up the abstinence violation effect that has the capacity to turn a lapse
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into a relapse. The telephone is a powerful tool.

We take people through compassionate mindfulness exercises and encour-
age the use of prayer (when appropriate) and meditation as concentration and
self-soothing exercises. Prayer can be considered as a form of self-talk and inner
reflection. When there is a concept or a belief in a God who loves you, this goes
further to answer the need of the sex addict to be loved. It can also relieve shame
when one believes that one is forgiven. The use of a daily meditation book like
Answers in the Heart (Anonymous 1989) is a good way for men to start the day
and it, too, contributes to the immersion process: immersion in recovery. One man
in sexual recovery took a course in mindfulness meditation and found that it gave
him useful tools to help in leaving behind his unwanted sexual behaviours. There
are numerous programmes and teaching events on meditation and relaxation that
men can find helpful. Some of these can be taught in session.
Guided reading is useful. We give patients regular articles to read pertaining to
addiction and recovery. Books are also recommended. Specialist articles are chosen
for particular individuals. There are specialist articles on recovery for clergy and
physicians. These are also chosen with the man’s general location in the recovery
process in mind. They are selected to coincide with the intervention that is being
used at any given time. All this reinforces and amplifies the appropriate intervention.
If treating an individual alone, it is important for that individual to participate in
a group process as well. For this reason, the first important action is to encourage
men to go to a Twelve Step fellowship. We recommend Sex Addicts Anonymous or
Sex and Love Addicts Anonymous. More will be said about these fellowships later.
We sometimes suggest a celibacy or abstinence contract. This is a period of
time that is set aside and involves a commitment to total celibacy. It can be con-
structed differently to meet the particular needs of different patients. The idea of
the celibacy contract is to demonstrate, first of all, that it is possible to live without
being sexual. It also has the effect of clearing the mind of the repetitious images
that are recycled during masturbation. Some authorities are not in favour of the
celibacy contract on the grounds that it sends out a sex-negative message. How-
ever, in our clinic we do suggest it in some instances. We make it clear that it is
offered not because we are sex negative but because it can be a tool to help leave
behind unwanted behaviours. The length of contract is determined with the thera-
pist or, if working in a group, with another group member. We suggest not too
long a c­ ontract but that it can be renewed if the patient finds it helpful. Normally,
we would suggest a couple of weeks or, perhaps, a month. In the case of a mar-
ried man, there needs to be consultation with his partner. Sometimes the celibacy
contract can be amended to include sex with the partner when appropriate.
 90 The ancillary interventions

Couples work can be indicated alongside individual work. We do not think that
it is possible for the same therapist to work with an individual and then to work
with him and his female partner. Brief exceptions can be made to this rule in order
to give the partner information about addiction. She should see a specialist thera-
pist to help her negotiate her way through the trauma caused by the discovery that
her partner is a sex addict. She needs specialist care and her needs should not be
forgotten in the man’s search for recovery.
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There is homework between sessions. This is the same with any application of
CBT to treatment objectives. We also suggest that men keep a journal as part of
their recovery programme. A journal is ‘the portable therapist’. It can be a road-
map to recovery. It is also a way of creating a narrative of experience. We suggest
that it can be used for planning a daily schedule. It gives a voice to the previously
unknown. There are numerous uses for keeping a journal as part of the recovery
process (Thompson 2011).
I have kept a daily journal for the past 25 years. It contains a plan for the day,
a list of important jobs, long-term goals, and a gratitude list (a daily reckoning of
the events, people and circumstances for which I am grateful). Looking back over
the journal, I can chart my own progress. At first, when I started, each day began
with ‘I feel dread’. Slowly this appeared less and less, and was interspersed with
‘feeling good’. Now, almost every day beings with ‘I feel good’. This journal
charts my own way out of addiction and the problems that lay behind it: the linger-
ing impact of trauma and narcissistic damage.

Conclusion
The treatment of sexual addiction involves an interchange between patient and
therapist. It is not the talking cure but the communication cure. The therapeutic
relationship is a key part of the assemblage of interventions, and a good therapeu-
tic relationship is the nest in which all the other interventions lie. It is a process of
immersing the self in a culture of recovery by hearing, reading, seeing and doing.
We get good at what we practise. Here is a note from Confucius (The Analects): ‘I
hear and I forget, I see and I remember, I do and I understand’.
The more a man practises a way of life free, not of sex, but of compulsive
sexual behaviours, the more natural it becomes. I wrote at the beginning of these
chapters on interventions about the man who cried out, “I just want to be free”.
These interventions contribute to the achievement of that freedom.
 Chapter 8

Group work
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Introduction
Having worked with sexually compulsive men for many years, I have come to
the view that group work is an almost essential element in the recovery process.
This does not mean that individual work is ineffective, or not useful, but that an
involvement in a group adds to the effectiveness of the therapeutic interventions.
As our clinic has purposely constructed groups for treatment, we are inclined to
use the group process as an alternative to individual work. Individual work is
scheduled for individuals as preparatory to group work, for people who cannot
find time to do a group and for those deemed likely to benefit more from an indi-
vidualised process. This happens in the case of someone who has a ‘mild’ addic-
tion or a confusing or stigmatising paraphilia. We would also schedule individual
work for those with obsessive–compulsive-type behaviour that needs specialised
attention.
There are important advantages to individual work, and it applies the insight
and skill of the practitioner in a meticulous manner to the needs of the patient. The
advantage of the group process is that there are more models of change and more
sources of individual affirmation.
Writing about the group process involving ‘problematic internet-enabled
behaviour’, Orzack et al. state that ‘one of the most effective treatments for prob-
lematic addictive behaviour is group therapy’ (2006: 250). Line and Cooper take
the same view, stating that group work is ‘the core of almost all programmes of
treatment’ (Line and Cooper 2002: 16). It helps with sexual compulsivity and
paraphilias. It is also cost effective.
Kafka (2007) writes that the best effective long-term outcome is created when
individual work and group work are combined. This is our experience. Alas, there
is expense to be considered and for someone to undertake group and individ-
ual work, at the same time, creates genuine financial strain. This work has not
been widely undertaken by the NHS in the United Kingdom, although there is
hope that this might change. In my experience, group work does far more than
reduce unwanted sexual behaviours; group interactions increase quality of life and
decrease the severity of some comorbid disorders. Orzack et al. (2006) note that,
 92 Group work

in their study, anxiety was the category in which there was most improvement.
Group work has the capacity to require authenticity, and to provide places for skill
building and for creating non-sexual intimate relationships. It is in the words of
Torres and Gore-Felton:

An efficient and cost-effective way of incorporating social interaction and

skill practice into therapy is to provide group interventions. Groups are a
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social microcosm that can provide individuals with the opportunity to practice
social behaviour and interpersonal skills as well as facilitate the generalization
and application of the learned skills to real life in a safe environment.
(2007: 70)

I think that this quotation sums up the usefulness of groups. They do more for
their participants than just reduce or eliminate unwanted behaviour: they improve
quality of life.
We begin by an introduction to our group programme. We explore Yalom and
Leszcz’ understanding of the group process from their book The Theory and Prac-
tice of Group Psychotherapy (2005). This is a helpful and comprehensive study
on group interaction and its benefits to patients. This section is illustrated with
examples drawn from our own course of treatment. We sketch out in detail our
three-part treatment package. This includes an analysis of the data received from
our outcome studies. We examine the role of Twelve Step meetings and their rela-
tionship to Alcoholics Anonymous. Alcoholics Anonymous is the foundation for
all the recovery fellowships. Four of these are examined: Sexaholics Anonymous,
Sex Addicts Anonymous, Sex and Love Addicts Anonymous and Sexual Com-
pulsives Anonymous. We conclude with a brief summary of the chapter.

The contribution of Yalom and Leszcz

Our clinical treatment programme was started in 2001. It is based on a similar out-
patient programme from the United States. It has been revised, updated, extended
and adapted for a British cultural context. We now divide our treatment package
into three parts: primary treatment, intermediate treatment and advanced treat-
ment. The primary treatment arrangement is largely based on an implementa-
tion of the interventions described in Chapter 5 on treatment. The second part
of the treatment is based on art therapy and recapitulates the fundamental issues
behind addiction recovery. The last part of the treatment is the development of
self-esteem. The development of self-esteem is a week-by-week application of
a number of common CBT tools. The group process includes sharing addiction
distress and recovery, as well as systematic teaching, in-session exercises, regular
homework and assigned reading. It has a neuroscience component with an empha-
sis on neurogenesis: that is, the development of new automatic neural pathways
by repetitious practice of alternative behaviours. The groups are between seven
and eleven people.
 Group work 93

To understand the power of the group process, we go to the work of Yalom and
Leszcz (2005). Our groups are not therapy groups as he delineates them, but rather
groups set up with the express purpose of facilitating recovery from unwanted
sexual behaviour and the treatment of comorbid disorders. However, his insights
into the group process are invaluable. In the course of running groups, over 60 to
date, I have witnessed, over and over, the richness of the group process. Yalom
and Leszcz state that groups have the following 11 functions:
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• Installation of hope
• Universality
• Imparting information
• Altruism
• Corrective recapitulation of the family group
• Development of socialising techniques
• Imitative behaviour
• Interpersonal learning
• Group cohesiveness
• Catharsis
• Addressing existential issues
(2005: 1–2)

Groups are a place for the installation of hope. As we have noted in Chapter 4 on
the therapeutic alliance, the creation of hope for recovery is an essential element
in the journey to recovery. The installation of hope, in its own right, is thera-
peutically effective. Yalom and Leszcz (2005) note that a high expectation of a
good outcome before the start of therapy is significantly correlated with a positive
therapeutic outcome. They cite that ‘recent brain imaging studies demonstrate that
the placebo is not inactive but can have a direct physiological effect on the brain’
(2005: 4). This process is seen at the first session of a group. Almost always two
or three men will be positive and hopeful about the outcomes of the programme.
This is a version of what Bandura calls ‘vicarious learning’ (1969: 118): others are
inspired, encouraged and made positive by the positivity of others. The facilitator
of the group also has a role to play in the placement of hope, by words spoken and
by demeanour.
At every first meeting of a group, people remark that they feel ‘no longer
alone’. People come to a group of sex addicts expecting to meet a collection of
the odd and the strange. They are reassured by the fact that these are normal and
successful people. Our groups do not consist of the odd and peculiar but rather the
respectable and the competent: solicitors, policemen, clergymen, architects, bank-
ers, barristers, businessmen, entrepreneurs, as well as students and bartenders. It
is reassuring to realise that all these people have the same problem: out-of-control
sexual behaviour. With this understanding, there is the beginning of an end to
isolation. Yalom and Leszcz (2005: 6) write that ‘a disconfirmation of uniqueness
is a powerful source of relief’. They note (Yalom and Leszcz 2005: 6) that the two
 94 Group work

most common secrets are about personal defectiveness and the secrets of sexuality.
Both these are common presentations in work with the sexually addicted. The
secrets of sexuality are treated in the primary treatment programme and the inter-
mediate programme. The ‘personal defectiveness’ is treated in the advanced
programme.
In our groups, there is a teaching component to most sessions. This is actual
instruction and the systematic provision of knowledge. It is accompanied by
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appropriate reading material. The topics include definitions of sexual addiction,

neuroscience, and information about the role and function of shame. There are
additional brief lectures on harmful consequences, supernormal stimuli, formula-
tion, schemas, trauma, the cycle of addiction and cognitive distortions. Yalom and
Leszcz (2005) note that Recovery Incorporated, the largest American self-help
group for psychiatric patients, is didactic in style. They go on to point out that
many other self-help groups strongly emphasise the importance of the provision
of education. Education is also a routine feature of the Twelve Step programmes.
The provision of service is central to the ideas of Alcoholics Anonymous. It is
important to the recovery programme for addiction to alcohol. Yalom and Leszcz
(2005) make it clear that group members gain through giving. It takes them out-
side themselves and, through altruism, a sense of life ensues. This is seen in our
group process.
Not long ago, a group member said that he needed to say something about
himself to the group. His sexual patterns were an isolated and time-extensive use
of internet pornography. This was a young man with a history of tics, obsessive–
compulsive behaviour and social anxiety. He told the group that they needed to
know about a shameful compulsion. I asked him if he wanted feedback from the
group. He said that he did. This gave every group member an opportunity to show
altruism. Each commented that they all had problems and things that they, too,
were ashamed of. His disclosure made no difference to them. The relief in disclos-
ing his shameful secret, the cause of so much self-hatred, was actually visible in
his face. In his own way, by disclosing the secret, by vicarious modelling, he gave
not only evidence of his own courage but other group members the courage to
disclose secrets that they felt were similarly shameful. At the end of the session,
when he had disclosed social anxiety, his ‘check-out’ remarks were extremely
funny and made the whole group laugh. The man next to him asked, ‘Do you do
best man speeches?’ In this simple exchange, it was possible to see both altruism
and validation and, thus, the reduction in his social anxiety. He knew, from that
simple exchange, that he had been accepted and valued by the group. Yalom and
Leszcz quote Sullivan from Conceptions of Modern Psychiatry, stating, ‘The self
may be said to be made up of reflected appraisals’ (Sullivan 1955: 22, in Yalom
and Leszcz 2005: 65). Change had begun.
The group is also a place where the deprivations of family and early group life
have a place for correction. The group, by validation and cohesiveness, can pro-
vide a new and life-enhancing experience quite different from the experience of
many sex addicts in their original family life. It can also be a place where repairs
 Group work 95

can be made of playground and school experiences. Many sex addicts come from
rigid family environments or from chaotic families; neither are modelled in the
group. The group models good boundaries: order, time keeping and permission
asking. As the groups progress in coherence, there is a much greater place for
relaxation and freedom as well as saying hard things in the context of group affili-
ation. Many of the men in our groups had poor male role models, either through
absence or through the father’s alcoholism or sexual addiction. Men bond differ-
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ently from women or gender-mixed groups. They bond side by side, in the pursuit
of some common purpose. We harness this feature of male bonding towards the
goal of self-defined sexual well-being. One of the goals of the group is to provide
a corrective experience of family life or the experience of the playground. Each
person is tolerated for their idiosyncrasies and valued for their distinctiveness.
Imitative behaviour is a key feature of the group process. People learn not just
from the teacher or facilitator but from the interconnection of all group members.
Men are inspired by the examples of recovery in one person and grieve at the
misfortune of another. The first is a process of learning and the second a process
of altruism and empathic attunement. Every session brings this combination of
responses. Yalom and Leszcz refer back to Bandura and write: ‘In group therapy
it is not uncommon for a member to benefit by observing the therapy of another
member with a similar problem constellation, a phenomena referred to as vicari-
ous learning or spectator therapy’ (2005: 28).
This is exactly the case with recovery groups for sex addicts: they all share,
in some form or another, the same problem constellation, albeit expressed differ-
ently and distinctly, but with a convergence of underlying components.
Because our groups are different in intention from the groups discussed in
Yalom and Leszcz (2005), we are less concerned with the group as a place for
interpersonal learning. This might, in fact, be a weakness in our group process.
As I understand it, interpersonal learning comes about through the inter-group
dynamic involving the impact on the group of individual behaviour. The view is
that patients inevitably show their maladaptive behaviour to other group mem-
bers. For change, group members must receive feedback that they can use to
understand and change their behaviour. Our groups have some of this process but
it is neither the aim nor the goal of the group. Gossip is not allowed outside the
group and cross-talk is not permitted in sessions. Our groups are sharing groups
and there is no place for comment on the behaviour and attitudes of another. We
do this to avoid the creation of further shame. The place for this kind of feedback
is provided in the ‘hot seat’ exercise. There will be more about this exercise later
in this chapter.
While group therapy has similar outcomes to individual therapy (Yalom and
Leszcz 2005), there is evidence that group therapy is particularly important for
stigmatised individuals. Since our groups are made up of highly stigmatised indi-
viduals, it would seem that the group element is an important, perhaps decisive,
element in the goals of sexual recovery. There is the stigma of sexual addic-
tion and, for those with a paraphilia, added stigmatisation brought about by the
 96 Group work

paraphilia. Often there is a highly critical partner whose voice adds to a sense of
profound stigmatisation. Yalom and Leszcz write that ‘the presence of cohesion
early in each session as well as early in the sessions of the group correlates with
positive outcomes’ and ‘group cohesiveness is an important determinant of posi-
tive therapeutic outcome’ (2005: 61). This is plain to see when we compare two
recent treatment groups; the first had high levels of cohesion and all went on to the
intermediate programme. The second did not have the same levels of cohesion.
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This was apparent from the beginning of the group. As facilitator, I was aware of
a deep ambivalence to the requirements of change. In addition, there were three
important early drop-outs who were later revealed to have substance abuse prob-
lems. In the sixty or so groups that I have run, we have had three or four that did not
develop cohesiveness. This may simply be that the combination of personalities
and problems worked against cohesiveness. Another impediment to cohesiveness
might well be the lack of interpersonal feedback in our group process.
The group is a place for catharsis. ‘Catharsis’ is a Greek word meaning ‘to
cleanse’ (Yalom and Leszcz 2005). In our groups, men are encouraged to express
feelings. Feelings give power to thought. We find that sexually addicted men are
not good at recognising or expressing their feelings. Cardinal Newman’s motto
was ‘from the heart to the heart’. We find that, through the expression of emotion
in the presence of others, there is a powerful elicitation of similar emotions in
other group members. In one group, we had an ex-soldier who had seen combat in
Iraq. He spoke about the loss of a friend’s life and began to cry. The group cried
for him and with him, but they were crying for their own losses as well. He had
given them permission to mourn.
Finally, groups are a place for the pursuit of the great existential questions of
life: inescapable suffering and death, a search for purpose and meaning, life is not
fair, bad things happen to good people. While not directly addressing these ques-
tions, the group is a place to find solace and often unspoken answers.
Keeping in mind that a recovery group for sexual addiction is not exactly a
therapeutic group in the sense that Yalom and Leszcz describe, all the factors
operate and all the conditions apply. An understanding of the nature and character
of group therapy informs and enriches the process of recovery in a group situa-
tion. In recovery groups, as with all therapeutic groups, ‘to a large extent, it is the
group that is the agent of change’ (Yalom and Leszcz 2005: 120, italics in the
original).

Marylebone Centre group programme

Primary treatment
Our primary group starts with the filling in of assessment forms. These are com-
pleted again in the middle of the programme and at the end. There are three-month
and six-month follow-ups. I now lay out the sequence of the primary treatment
programme:
 Table 8.1 The primary treatment programme

1. General introduction 8. Cycle of addiction

Share on current status Share on the personalised cycle
Teaching: sex addiction, neuroscience and General share
group process Teaching: triggers and substitute
Homework: reading behaviours
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Homework: triggers and substitute

2. Values clarification
behaviours
Values clarification exercise
9. Cognitive distortions
General share
Teaching: shame and harmful Share on triggers and substitute
consequences behaviours
Homework: harmful consequences General share
3. Harmful consequences Teaching: cognitive distortions
Homework: personalise cognitive
Share on harmful consequences distortions
General share
Teaching: supernormal stimuli and sex 10. Assertiveness
plan Share on cognitive distortions
Homework: sex plan General share
4. Sex plan Assertiveness training and role plays
Share on group process
Share on sex plan Homework: prepare personal
General share presentation
Teaching: formulation and schemas
Homework: Schema Questionnaire and 11. ‘Hot seat’ exercise
formulation 12. Weekend: personal presentations
5. Schema Questionnaire 13. Relapse prevention
Schema Questionnaire explanation Share about the weekend
General share Share relapse prevention plans
Teaching: family of origin General share
Homework: trauma egg Homework: write a review of the most
6. Trauma egg important learning outcomes

Share on trauma egg 14. Healthy sexuality

General share
Share on the homework
Teaching: shame
Share on the nature of healthy sexuality
Homework: shame museum
No homework
7. Shame museum
15. Sexual health
Share on the shame museum
This is in lecture format and involves a
General share
question and answer session
Teaching: cycle of addiction
Homework: personalised cycle 16. Graduation
 98 Group work

Each session lasts two hours and begins with ‘Check in’ and finishes with
‘Check out’. Group business follows immediately on ‘Check in’. ‘Check in’ con-
sists of a brief description of how the individual is feeling and anything important
that has happened during the week. At the first session, the concept of ‘Check in’
is introduced but changed at the first meeting to ‘What were you thinking and
feeling on your way here tonight?’ This is followed by the question, ‘What brings
you here?’ Group business is a brief moment in the session to report apologies and
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to discuss administrative matters affecting the whole group. ‘Check out’ is a brief
report on how the individual is feeling at the end of the session and, perhaps, what
made the biggest impact on him during the session.
The ‘hot seat’ exercise is the nearest we get to Yalom and Leszcz’s (2005) con-
cept of interpersonal learning. As I have described in Chapter 6 on the principal
interventions, in this exercise each person takes it in turns to sit in the hot seat. The
purpose of this exercise is to demonstrate that speaking the truth in love builds up
intimacy. Intimacy is destroyed by pretending that all is well when it is not. This
is followed by a weekend during which each group member is expected to tell his
story. This includes his sexual history and acting-out behaviours. Each member is
given feedback by the group. This is a deeply moving experience. Men are able
to tell their history and get feedback from others in solidarity. Shame is reduced
to nought and a profound bond of attachment is created. This component fulfils
the group function of being a corrective experience of an original disconnected
and sometimes abusive family history. It also fulfils Yalom and Leszcz’s (2005)
concept of interpersonal learning.
We also run an intensive treatment programme. There is an advantage and a
disadvantage to an intensive programme. The advantage is that it really strikes
when men are ready to respond. The disadvantage is that there is no time for
reflection between sessions. On balance, we prefer the 12-week programme and
consider it a more effective option.

Intermediate treatment
The intermediate treatment programme is a 12-week, second-stage recovery pro-
gramme that uses art therapy and creative writing to take individuals further for-
ward in recovery. I am grateful to Francesca Hall who developed this programme
from her experience as an art therapist. The rest of this paragraph is taken from her
introduction to this part of the programme:

It is a sequence of structured exercises to allow for the exploration and

expression of feelings. It is helpful in finding new ways for men to think
about addiction. Emotional experiences cannot always be put into words.
When working with an image, it opens a dialogue from the left to the right
side of the brain. Images are free from the constraints of language. Pictures
can help in the expression of multi-layered and complex emotional states. It
is possible for pictures to provide a different perspective.
(Hall 2012)
 Group work 99

Many of the exercises in our programme offer alternative insights into the ­problem
of addiction. The written options allow the retelling of stories and the creation of
meaningful personal narratives (Thompson 2011). They can give a voice to the
previously unspoken. They can confirm and validate experience. The thoughts
and words of the writer have the capacity to confirm feelings. In our experience,
some men prefer to write and others to draw, but all tend to do both.
The intermediate programme uses the following exercises to continue the pro-
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cess of recovery:

1 Draw a snapshot of when you were happy or describe the scene of your
happiness. The function of this process is to begin to establish that functional
as well as dysfunctional patterns emerged from the family of origin.
2 The grand exhibition of bad feelings: this is a process whereby the feelings of
shame are exposed and shared with the group.
3 The film reel: the object of this exercise is to consider the potential extreme
consequences of the addiction.
4 Saying ‘No’ to your addiction: this is a drawing of a man’s head with various
thought bubbles around it. The task is to write ‘refuse script’ messages in
the thought bubbles. ‘Refuse script’ messages are those that you might give
yourself about not acting out.
5 Message in a bottle: the objective is to identify how it feels to say goodbye
to the addiction. A ‘goodbye’ message is written in the bottle, which is then,
metaphorically, thrown into the sea.
6 Snakes and ladders: in this exercise, we ask men to identify their ladders,
the things that help them get out of addictive situations, and the snakes, the
things that lead them into sexual acting out. The purpose is to further an
understanding of both the cues for addictive processes as well as the tools that
can be used to avoid the behaviour.
7 Wheel of faces: this is an exercise in the development of partner empathy.
8 The gift box: the object is to fill the gift box with amends for the harm done
through the addictive process. This exercise furthers the development of
empathy and allows the individual to begin to let go of some of the guilt and
shame associated with the addiction.
9 The museum of loss: the instructions for this exercise are to draw on
each empty plinth in the museum a symbol of the loss caused by your
addiction.
10 Obituary: the function of this exercise is to write your own obituary, bearing
in mind that it is important to write about the things about yourself that
you are proud of, things for which you would like to be remembered. The
instructions that go with this exercise are: ‘If your internal critic appears, put
its words on a cloud and let them float away’.
11 The hand: in this exercise we think about the future. We encourage men to
think about the ways they can promote their future well-being. It offers a
chance to be proactive rather than reactive. On the hand, write or draw your
imagined future.
 100 Group work

12 The window: here we have created a consideration of the future. The

instructions are to look at your life through the window and write or draw
hopes for the future. The instructions add, ‘Think about what you can do to
increase the probability of your hopes and dreams coming true’.

In the body of the meeting, the group is asked to share their homework in pairs
and then there is a general share on sexual addiction or on matters particularly
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relevant to the homework. Often, there is a time for teaching on some subject
that is brought up by the shares. For example, at a recent session on the ‘snakes
and ladders’ the group felt it was important to discuss the ladders out of addic-
tion rather than the snakes that took them into addictive behaviour. At a session
on the ‘wheel of faces’, one individual gave the feedback that, when he did the
wheel, he could see his partner’s face at every point on the wheel. Each exercise
deepens understanding and the importance of renewing the recovery process on a
day-by-day basis.
The primary treatment programme uses all the principal cognitive behavioural
interventions to bring men to a place of initial recovery. Carnes (1991) writes
that recovery takes 18 months to 3 years to complete. We expect that our pro-
gramme manages the same process on much the same time frame. The intermedi-
ate programme uses art therapy to go deeper into the experience of recovery and
to consolidate the recovery process. The advanced programme is concerned with
rebuilding self-esteem. This is, for many, the building of self-esteem for the first
time, although we subtitle the third part of the recovery course as ‘The restoration
of self-esteem’.

Advanced treatment
As we have shown earlier in this book, most men who present with a problem
with sexual addiction also present with a core belief that they are worthless. This
cognition is accompanied by profound feelings of shame. This combination is
made clear at the start of the advanced programme. The first session is given over
to the formulation and to the completion and interpretation of Young’s Schema
Questionnaire (Young et al. 2003). The first session is followed by 11 sessions.
At each subsequent session there is homework using a different cognitive behav-
ioural strategy. The homework is completed during the week and the main body
of the meeting is to share in pairs on the homework. This is followed by a group
share on sexual addiction in general and relationships in particular, as well as a
general share on the content of the homework.
First, we ask individuals to work on the cognitive conceptualisation diagram
taken from Judith Beck’s book Cognitive Therapy: Basics and Beyond (1995). An
analysis drawn from this useful tool helps men understand the nature of the core
belief. The third session focuses on the completion of a ‘Combating self-­critical
thought diary’. The following sessions include: Positive data log, Checking
 Group work 101

anxious/shaming predictions and Padesky’s old system/new system (available as

a free download from [Link] [accessed 4 January 2015]). Group
members then create an ‘asset list’. The asset list is a list of achievements and
advantages that the men have as individuals. This list is a daily homework assign-
ment. It serves to counteract the negative self-belief. Towards the end of the pro-
gramme, there is the construction of behavioural experiments that are designed to
disprove the negative self-belief. The third part of our recovery programme ends
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with thinking about the nature of the life the men want for themselves, and closes
with a review of the work done over this part of the course.
The total time involved in the whole programme is 36 weeks. This involves
72 hours of group work as well as reading assignments and homework between
sessions. Once the men have completed it, they are encouraged to join our after-
care programme. This programme is a weekly meeting that serves to continue
the process of recovery. The aftercare group follows the same pattern as all our
groups: check in, business, share and check out. With the aftercare group there is
no assigned topic, but it is an ongoing forum to share on the trials and uncertain-
ties of recovery.

Women’s groups
The women’s groups began at the Marylebone Centre in 2005 and have continued
to take place twice a year. They were started in response to a need for informa-
tion and support for female partners of men struggling with sexually compulsive
behaviours, and to assist the potential restoration of the couple relationship. These
groups have been designed by Joy Rosendale, who first worked alone with them
and then with Leigh Brown as co-facilitator.
One of the biggest obstacles has been recruitment. Women often feel this situa-
tion is not their problem, and they are reluctant to talk about the ‘shameful secrets’
with others in a group. However, once enrolled and having met others, sharing
brings tangible relief. The tone is less formal than the men’s programme, at least
for the first six sessions, because the therapeutic input is more about managing
reactions than exploring proactive strategies. As the course progresses, women
are encouraged to moderate the need for external knowledge and control, and
move towards an emerging trust of inner guidance and wisdom. The group usually
has six members and normally runs for twelve sessions of one and a half hours.
Reading and topic lists are given out in advance. Frequently, these women have
partners in the men’s treatment programme.
Aftercare is offered every month initially and then every six weeks. Current
concerns from group members are emailed to one of the facilitators the week
before the group, and the format is similar to the 12-week programme. Generally
the need for ongoing support diminishes after 12–18 months as daily life continues.
The following is a case study provided by Joy Rosendale from the women’s
group.
 102 Group work

Table 8.2 The schedule of the women’s groups

Week 1 Week 6
Welcome to the group Family of origin
Confidentiality/contracts Generational scripts
Introductions Consideration given to the range of
Definitions of sexual addiction addictive behaviours
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Reactions/feelings of the women

Week 7
Should she stay in the relationship or
leave it? Family of origin/family maps discussed
Week 2 Week 8
Mini-meditation – breathing, body scan – Coping strategies/self-care – three-circle
moving to the interior (room and self) exercise
from being vigilant in the environment
Introduction to transactional analysis Week 9
‘parent adult child’ Positive sexuality – how will that be now?
Unconscious couple collusions Lake of desire
Exploration of models: co-dependency,
co-addiction, trauma Week 10

Week 3 Positive sexuality continued – sensuality

exercise
Understanding addiction
How the brain works Week 11
Cycle of addiction/stages of change Coupledom – trust/money/intimacy
Drama triangle
Week 12
Week 4
Ongoing support
Attachment styles – secure, preoccupied Twelve Step fellowships
and avoidant Farewells
Boundaries
Week 5
Boundaries continued
Making your own boundaries clear
Couple recovery contract (see www.
[Link] [accessed 4 January
2015])

Sue (age 41) joined a women’s group two years ago, after learning of her
husband Doug’s (age 50) longstanding addiction to visiting sex workers. Sue
had suspected for some time in their 10-year marriage that ‘all was not well’,
although she could never quite grasp the difficulty. Doug was often absent from
home, without contact, and their sex life had diminished, not helped by Doug’s
frequent erectile unreliability.
 Group work 103

Sue’s life script was conditioned by society and family to nurture and fix
problems for others, and she picked up the mantle of responsibility to solve
the couple’s difficulties. Messages about women performing sexually to keep
men happy were dominant for Sue, and to this end she had breast implants.
Unfortunately, she found Doug’s pornography use still featured ‘well-endowed’
women, despite that offer being available at home.
Sue’s self-esteem was at an all-time low when she had an initial assessment
at the clinic. She had become a full-time detective, tracking all Doug’s technol-
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ogy (‘shopping for pain’, looking for further upsetting information) and was
alternating between a caring and a punitive approach in couple conversations.
She feared she was going crazy and began to suffer anxiety attacks in the car
and supermarket.
An important lesson that Sue heard in the group was that she did not cause
this problem, she could not control it and she could not cure it. Understanding
that Doug’s early ‘set-up’ for his addictive patterns evolved long before she met
him, and learning about the neuroscience of addiction made it more possible for
her to ‘depersonalise’.
Because Sue had a deep fear of abandonment, it was difficult for her to set
appropriate boundaries. She had a lifelong role as the ‘caretaker’. She also had
a ‘please others’ internal script. A tool known as the ‘couple recovery contract’
helped her to separate appropriate responsibilities, to distinguish between those
which were hers and those which were Doug’s. Sue was encouraged to mourn
the loss that the addiction had inevitably brought to the life she had. After years
of emotional isolation, her most important coping strategy was to keep in touch
with the other group members. She decided to discuss with Doug the manage-
ment of the family finances and took on an active role in decision making.
Sue learned that the restoration of trust in Doug’s behaviour was a decision
informed by time and evidence. She negotiated an ‘honesty and accountability
agreement’ and was involved in conversations with Doug: conversations about
the differences between privacy (essential) and secrecy (undesirable).
Sue would never have chosen this situation, but, after two years, she can see
that one of the concepts discussed in the group has begun to happen. She has
started to realise that pain has the potential to enable personal transformation.
As a couple, Sue and Doug are now in counselling and have begun to explore
the difference between individuation and enmeshment.

An outcome study of the Marylebone Centre’s women’s programme was done in

2013. This was not professionally or independently created. Readers should bear
that in mind. The group consisted of seven women and met for ten weeks’ pri-
mary work and subsequently for two aftercare sessions. They completed CORE
10 with an additional section to record the quality of their relationship. CORE
10 (Clinical Outcomes in Routine Evaluation) is a questionnaire that monitors
session-by-session changes in levels of depression and anxiety, as well as overall
functioning. At the start of the programme, the CORE 10 scores ranged from 31
(the highest) down to 10 (the lowest). At the end of the aftercare group sessions,
 104 Group work

the scores of all but one of the members had dropped to mild or low levels as
measured by CORE 10. All the women noticed increased well-being, even if the
relationship showed less improvement. There was an appreciation of the individ-
ual graphs providing feedback on progress during treatment. The group process
provided information. It offered solidarity, shared experience, time for reflection
and became a safe place for all the women involved.
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Tailor-made treatment programmes

The tailor-made treatment is a five-day individual programme that starts on a
Monday with taking a history and finishes on a Friday with telling the story. The
story is told to volunteers from other existing groups. Homework is done in ses-
sion. We use a variety of our associates to deliver therapy. We also combine our
work in the tailor-made treatment with attendance at sexual recovery meetings.
We do not believe that the tailor-made programme is the optimum choice. Most of
the people who choose it are simply not available for anything else. For example,
we had a security worker involved in the military and anything else would have
been impossible. We have to do whatever we can in situations that are genuinely
limited.

Outcome studies for our treatment programme

In this section, we discuss the preliminary outcome studies on the effectiveness of
our primary treatment programme. The figures are based on 37 men involved in
the programme. Their ages ranged from 23–60; most of the men were between 35
and 45. All but three were in a relationship with a female partner. One man was in
a relationship with a male partner.
These outcome studies include CORE 34, the Sexual Compulsivity Scale
(Kalichman et al. 1994), the Sexual Symptom Assessment Scale (Raymond et
al. 2007) and the Sexual Addiction in Routine Evaluation. The last of these is my
own scale made up in 2000 and without empirical evaluation. The former scales
are empirically determined as both valid and reliable. All four measures were
administered at the start and the end of the first part of our treatment programme,
the primary treatment programme. Figure 8.1 shows a substantial decline on
CORE 34. This indicates improvements in symptom reduction, risk reduction and
overall functioning, and increased well-being. Figure 8.2 indicates improvements
(that is, a reduction in unwanted sexual behaviour) using the Sexual Symptom
Assessment Scale. Figure 8.3 shows improvements using the Sexual Compulsiv-
ity Scale. Figure 8.4 shows improvements as measured by my own scale: Sexual
Addiction Outcomes in Routine Evaluation. Finally, Figure 8.5 shows a compos-
ite improvement when all the sexual addiction scales are combined. Please bear
in mind that in each case we are looking for a downward trend. These figures are
limited to before and after completion of the relevant forms and pertain only to the
primary treatment programme. Because the scores are relatively consistent across
 Test: CORE

1.20

1.00
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0.80
Mean Score

0.60

0.40

0.20

0.00
Pre Post
Time

Figure 8.1 Clinical outcomes in routine evaluation

Test: SSAS

25.00

20.00

15.00
Mean Score

10.00

5.00

0.00
Pre Post
Time

Figure 8.2 Sexual symptom assessment scale

 Test: SCS

3.00
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2.00
Mean Score

1.00

0.00
Pre Post

Time

Figure 8.3 Sexual compulsivity scale

TEST:SAORE
2.00

1.50
Mean Score

1.00

0.50

0.00
Pre Post
Time

Figure 8.4 Sexual addiction outcomes in routine evaluation

 Group work 107

9.50

9.00
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8.50

8.00

7.50

7.00

Pre Post
Time

Figure 8.5 Composite sexual addiction recovery scores

the groups, this suggests a standard delivery of the treatment programme. I would
like to thank Daniel Bates for his analysis of the data. Further details about the
analysis can be found in Appendix 1.

Twelve Step groups and Alcoholics Anonymous

Individual practitioners do not normally have access to formal programmes of
group treatment. However, since the group work is powerful, it is suggested that
they consider directing their patients to one of the sexual recovery fellowships.
This would be in addition to individual work. There are three of these operating
in the United Kingdom: Sex Addicts Anonymous (SAA), Sex and Love Addicts
Anonymous (SLAA) and Sexaholics Anonymous (SA). To my knowledge not
meeting in the United Kingdom, Sexual Compulsives Anonymous (SCA) is still
included as part of this review. Although not established here, it is a significant
part of the panoply of sexual recovery fellowships. These programmes are all
based on the principles and traditions of Alcoholics Anonymous (AA). Patient
participation will enlarge and enrich the work of individual practitioners. Built
around the concept of God (Higher Power), these groups are successful in helping
addicts to begin recovery. However, since they are anonymous groups and have
not, to my knowledge, engaged in outcome studies (Kruger and Kaplan 2002), the
evidence about their usefulness comes from their wide establishment.
 108 Group work

Before outlining the work of Twelve Step fellowships, we have to consider a

powerful discrepancy between their philosophy of action and that held by CBT.
This is the question of agency. Primarily, CBT takes the view that the individual is
responsible for recovery through the adoption of a combination of strategies. The
Twelve Step fellowships take the view that the first step to recovery is the admission
of powerlessness and surrender ‘to God as we understand him’. Kingston and Fire-
stone point out that: ‘Another predominant concern with the Twelve Step approach
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pertains to the notion of rejecting personal control. This perspective diametrically

opposes empirically validated cognitive behavioural treatment in general and spe-
cific models of rehabilitation in particular’ (Kingston and Firestone 2008: 293).
This assertion needs further exploration. The predominating effective motifs in
Twelve Step recovery are the group process, the system of personal sponsorship
and the philosophy of life that underpins the fellowship. The question of a Higher
Power needs to be addressed. Parker and Guest take the view that ‘involvement in
12-Step work can often enhance and support the therapeutic process’ (2002: 116).
They point out that, in reality, any form of spiritual belief is acceptable even if it
is a belief in the power of the group as higher than the power of the individual.
This was not the intention of the founders of the Twelve Step programme. Yet
the concept of God (or Higher Power) has an important function in creating relief
from addictive behaviours.
Addiction works in a figure-of-eight cycle. Fossum and Mason (1986) propose
that addictive cycles are alternating cycles of control and release. Sexual behav-
iour is part of the release cycle and abstinence is on the control side of the cycle.
This creates a sequence of interlocking behaviours, rather like bulimia and anorexia.
Unless this cycle is understood and aborted, these apparently antithetical behaviours
contribute to one another. The more a person tries to control a behaviour, the more
they move around the control part of the cycle until a place of need or entitlement is
reached. There is the notion of ‘I need this release’ or ‘I am entitled to it’. This takes
the person into the second part of the cycle, which, in our cases, is sexual acting out.
The individual continues on this cycle until satiation and then returns to control. In
effect, the more a person tries to gain control, the more likely they are to move into
release. It is the acceptance of the paradox of powerlessness at the heart of Twelve
Step recovery that makes it effective in addressing compulsive disorders, effectively
creating a movement off, rather than around, the cycle (Fossum and Mason, 1986).
The cycle is not a moderate process. Fossum and Mason write that:

In the control phase a person will display excesses of control, both in attempts
to control oneself and in efforts to control the responses of others. The release
phase . . . is a breakout, an escape from the pressures of control and shame.
Thus an intense oscillation develops.
(1986: 108)

Fossum and Mason cite Bateson (1972) that AA is so successful with alcoholism
because it confronts this dualism by calling for surrender. This is how the ‘surrender’
 Group work 109

part of the Twelve Step programme works. It works not because there is a Higher
Power (a subject of another discussion) but because it interrupts this alternating
cycle. In fact, even in coming to see a therapist, or going to a group, there is a sense
of coming to a Higher Power. The act constitutes a kind of surrender, or at least a
search, based on the recognition that recovery cannot be achieved alone.
The structure, steps and traditions of AA provide the basis of all the ensu-
ing sexual recovery fellowships. The history of AA has its origins in the Oxford
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Group (Ingle-Gillis 1995). This was a Christian group founded by the evangelist
Frank Buchman. It was never interested in doctrinal matters but more in demon-
strable ethics and social witness. AA dates its foundation to 10 June 1935. Moral
Re-armament, a popular movement in the 1940s, grew out of the Oxford Group.
The founders were Bill Wilson and Dr Bob Smith, known in AA as Bill W. and Dr
Bob. Today AA is a worldwide programme with branches in over 140 countries.
All this began in 1935 with two men.
Here are the Twelve Steps of Alcoholics Anonymous:

1 We admitted we were powerless over alcohol – that our lives had become
unmanageable.
2 Came to believe that a Power greater than ourselves could restore us to
sanity.
3 Made a decision to turn our will and our lives over to the care of God as
we understood him.
4 Made a searching and fearless moral inventory of ourselves.
5 Admitted to God, to ourselves and to another human being the exact
nature of our wrongs.
6 Were entirely ready to have God remove all these defects of character.
7 Humbly asked God to remove our shortcomings.
8 Made a list of all persons we had harmed, and became willing to make
amends to them all.
9 Made direct amends to such people wherever possible, except when to
do so would injure them or others.
10 Continued to take personal inventory and when we were wrong promptly
admitted it.
11 Sought through prayer and meditation to improve our conscious contact
with God as we understood Him, praying only for knowledge of His will
for us and the power to carry that out.
12 Having had a spiritual awakening as the result of these steps, we tried to
carry this message to alcoholics and to practice these principles in all our
affairs.
(Reprinted with kind permission of Alcoholics
Anonymous World Services, Inc.)

In the sexual recovery fellowships, the word ‘alcohol’ is changed to ‘lust’, ‘sexual
addiction’ or ‘sexual compulsivity’. Otherwise the Twelve Steps are the same.
 110 Group work

When the steps are examined, they amount to four: surrender, self-examination,
amendment and ongoing practice. It is clear to see within these steps a fundamental
Christian process without the explicit Christianity. Parker and Guest (2002) point
out that the notion of a Higher Power can be a real problem for some, especially
those who have been damaged or abused by religious organisations and denomi-
nations. In any event, one of the slogans of the movement is ‘take what you want
and leave the rest’. This caveat allows anyone to be able to use the programme and
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to benefit. Because Britain is a secular society, many people baulk at what they
consider to be the religious language of SA, SLAA, SAA and SCA. They may be
helped to avail themselves of the programme by some gentle reasoning: ‘Take
what you want and leave the rest’. We try to explain that they are able to take the
group as the Higher Power and, if possible, explain that the control–release cycle
of addiction is aborted through the notion of surrender. We usually emphasise that
it is largely the group process that makes these fellowships so helpful. Our own
clinical programme is entirely secular but we emphasise the importance of the
cultivation of a personally appropriate spirituality, be it returning to the practice
of one’s youth, going to a concert, walking on the Downs or getting involved in a
personally appropriate spiritual community.
This is an introduction to Alcoholics Anonymous found on their website:

Alcoholics Anonymous is fellowship of men and women who share their

experience, strength and hope with each other that they may solve their
common problem and help others recover from alcoholism. The only
requirement for group membership is a desire to stop drinking. There are
no dues or fees for AA membership; we are self-supporting though our own
contributions. AA is not allied with any sect, denomination or institution;
does not wish to engage in any controversy; neither endorses or opposes
any causes. Our primary purpose is to stay sober and help other alcoholics
achieve sobriety.
(reprinted with permission of AA Grapevine, Inc.)

This same introduction, altered appropriately, would be an introduction to any of

the sexual recovery fellowships.

Sexual recovery fellowships

Sexaholics anonymous
According to a long-sober member of Sexaholics Anonymous (SA), this fellow-
ship was founded in the United States around 1979 by Roy K., who found long-
term relief from his obsession with masturbation and sex workers by focusing
on ‘progressive victory over lust’ as the driving force behind his sex addiction.
Roy K. visited Germany in 1984 at the invitation of Dr Walther Lechler and his
treatment team at Klinik Bad Herrenalb. SA meetings soon spread throughout
 Group work 111

major cities in Germany. In 1992, four former members of Sex and Love Addicts
Anonymous (SLAA) began to meet regularly as an SA group at Hinde Street
Methodist Church in Marylebone. They continue to meet there twice weekly.
There are currently around 40 SA groups in the United Kingdom with a total
membership of approximately 130 people. There are approximately 15,000 SA
members worldwide. Numerically the strongest SA communities today are to be
found in the United States, Germany, Poland, Israel, Ireland and Iran. The group
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member I spoke to made the point that SA seems to prosper in religiously con-
servative countries.
I am told that the sobriety definition, unique among Twelve Step ‘S’ fel-
lowships, was elaborated by the fellowship’s early members, and was recently
confirmed. SA has a shared bottom line of no sex with self or another outside
heterosexual marriage. Although at first sight, this fellowship would not seem to
be appropriate for gay patients, the unmarried, the widowed or any other person
except members of conservative religious groups, I am told, that, in practice,
it is well attended by the above categories, apparently on account of its focus
on progressive victory over lust rather than sexual sobriety alone. It would be
for the individual therapist to decide whether it would be appropriate to make
referrals.

Sex Addicts Anonymous

This fellowship was formed in 1977 (Parker and Guest 2002). The defining differ-
ence between Sex Addicts Anonymous (SAA) and Sexaholics Anonymous (SA)
is that with SAA there is a self-defining definition of abstinence. Therefore, it is
important for referred individuals to have an understanding of the nature of their
problem and the concomitant issues. This recovering community is a welcoming
place for heterosexual, bisexual and gay patients. As the bottom line is self-defin-
ing, the fellowship can embrace a range of individuals.
SAA developed the three-circle model to help individuals determine their
behaviour. This is a technique like the ‘sex plan’, which includes an inner circle
consisting of behaviours that should not be engaged in, an outer circle of allow-
able behaviours and a middle circle of behaviours that might take one into the
inner circle. This helps individuals come to a view about behaviour that is person-
ally acceptable and unacceptable. The SAA fellowship is not anti-sex; rather, it
recognises that sex is a part of human life and only seeks to minimise or remove
problematic sexual behaviours. Having a look at the SAA website, there are 55
meetings in the United Kingdom, 24 in the south-east, 23 in the rest of the coun-
try, 5 in Scotland and 1 in Wales. There are additional meetings in 49 other coun-
tries. However, because meetings are always being added, this figure is open to
change. SAA is a largely male organisation. There are a small number of women
attending and a handful of ‘women only’ meetings. There is one lesbian and gay
meeting in London, but the fellowship is inclusive and there is little evidence that
the needs of gay people are not being met in regular meetings.
 112 Group work

This programme first began to meet in London in 1988 in the disused chapel
of the Hospital for Tropical Diseases in St Pancras Way. The meetings stayed at
between five and seven people for the first three years and then began to grow.
A second meeting was established at Bloomsbury Baptist Church. A number of
meetings were subsequently set up by patients from this clinic, including Guild-
ford and the City of London meetings.
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Sex and Love Addicts Anonymous

This SLAA programme was founded in the United States in 1976 (Parker and
Guest 2002). It was the first programme to envision compulsive sexual and rela-
tionship behaviour as an addiction. Parker and Guest (2002) note that the pro-
gramme differs from other sexual addiction programmes in its focus on love
addiction in addition to sexual addiction. It has a large number of women mem-
bers. Women and men can bring their similar or differing problems. It is a pro-
gramme for those who either avoid or over-engage in sex and romantic intrigue.

Sexual Compulsives Anonymous

According to Parker and Guest, this SCA programme was founded in 1982 ‘par-
ticularly to address the issues of sexually addicted gay men’ (2002: 122). There
are increasing numbers of women and straight men involved in this programme.
The only requirement for membership is a desire to stop having compulsive sex. A
distinctive feature of the programme is the individual sex plan (Parker and Guest
2002). This is divided into three parts: behaviours from which to abstain, high-
risk behaviours and risky feeling states, as well as recovery behaviours. Recovery
behaviours include positive activities that meet one’s needs in a productive and
non-harmful manner. This programme has a list of 14 characteristics of sexu-
ally compulsive people (see [Link] [accessed 4 January 2015]). These
include a foundation of addiction in early life, sex as a drug, romantic obsession,
sex as validation, a search for intensity, compartmentalisation, a fear of abandon-
ment, relationship dependency and increased isolation.
These 14 characteristics are given to patients because they seem to blend the
SAA and SLAA combination into one overall package. We give them to all mem-
bers of our clinical recovery groups. While not all apply to everyone, they make a
useful starting point for recovery. Unfortunately there are, to date, no SCA meet-
ings in the United Kingdom. There are meetings in Belgium, France and other
parts of Europe.

Considerations on referral
In making a referral of a patient to a meeting or fellowship, there are a number of
points to bear in mind. Consider the nature of the fellowship and its appropriate-
ness for the patient. Women can sometimes be overwhelmed in a Sex Addicts
 Group work 113

Anonymous meeting and might feel more comfortable at a Sex and Love Addicts
Anonymous one. It is important to discuss the ‘God language’ with the patient and
possibly give them the 14 characteristics from Sexual Compulsives Anonymous.
You might give them the web addresses of the various programmes and suggest
that they make an internet search. We regularly give meeting lists that we keep
up to date in the office. It is best to talk through with clients what a meeting will
involve, explaining something about the structure and the rituals that are part of
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all programmes. One ritual that may unsettle some people is the tradition, at the
end of a meeting, of everyone joining hands and reciting the Serenity Prayer.
It is important to stress that the meetings are confidential – namely, ‘What you
see here, what you hear here, let it stay here when you leave here’. There is no
requirement to share and only first names are used. Encourage your patient to go
and look for the similarities that might be found in the stories told and the shares
made. It is suggested that one should go to six meetings before making a decision.
In our assessment session, we always give individuals information about these
recovery programmes and tell them that they can make an effective contribution
to recovery. Meetings have the added advantage of being free of charge. All the
programmes have online meetings or telephone meetings, so one is not necessar-
ily bound by time or distance.
There are some limitations to the sexual recovery fellowships. They work on
the ‘disease model’ of addiction. They do not contain as much important infor-
mation as we have laid down in our treatment programme. They do not place
emphasis on the family of origin and have not overtly incorporated neuroscience
concepts into their programmes of recovery. They do not include any work on
the cycle of addiction. Harmful consequences are not explored or enumerated
in a comprehensive fashion. No attention is given to cognitive distortions. How-
ever, we always suggest that individuals supplement their work in our clinic with
attendance at a recovery fellowship. This creates a beneficial immersion in the
recovery process.

Conclusion
In this chapter, we have made comments about the usefulness of group work. There
has been a comprehensive overview of the work of Yalom and Leszcz (2005)
on the effective nature of the group process. This was followed by a descrip-
tion of the various group programmes at this clinic. The contribution of Twelve
Step fellowships was examined with special reference to Alcoholics Anonymous
as the foundation of all subsequent sexual recovery fellowships. Of particular
importance was an explanation of the concept of surrender to a Higher Power as
opposed to the CBT idea of taking personal responsibility. Finally, the four most
relevant sexual recovery fellowships were described, followed by notes to guide
the individual therapist in making an appropriate referral.
 Chapter 9

Paraphilias
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Introduction
I was contacted by a firm of solicitors to give evidence as an expert witness in
a murder trial. I will return to the murder trial at the end of this chapter. The
defendant was found guilty and sentenced to 20 years in jail for murder. Whether
he actually murdered the woman seems to me to be an open question. However,
he did kill her. He confessed to the killing the next day. Murder seems to imply
intention. I do not think that there was an intention to kill her. It was a sexual para-
philia, combined with alcohol intoxication that became a disaster. In working with
men with addiction and a paraphilia, it would be almost impossible to encounter
such a distressing an event. In English law ‘an individual is not able to consent to
receive an act that will cause them serious harm’ (Proulx et al. 2007: 14).
The term ‘paraphilia’ is used to describe strange, unusual or socially uncon-
ventional sexual behaviours (Birchard 2011). Because social convention changes,
so do the designation of these behaviours. As we are familiar, masturbation and
same-sex attraction were originally treated as sexual disorders. Notice the greater
social acceptance of cross-dressing (Grayson Perry) and the social acceptance of
bondage. The latter is witnessed by the availability of handcuffs and fetish gear
in mainline sex shops. Paraphilic behaviours have been recorded in every culture
and throughout the ages. It is known that the Greeks encouraged love between
men and adolescent boys (de Silva 2007). In Buddhism, there are ancient refer-
ences to paraphilic behaviours.
The word paraphilia comes from para and phila. Para means ‘beyond’ or
‘alongside of’, ‘subsidiary to’ or ‘faulty’. Philia comes from philos meaning
‘love’ or ‘dear’. It became a subject of medical interest with the publication of the
Psychopathia Sexualis by Richard Krafft-Ebing in 1886. This book was translated
into English within a decade. It represents the beginning of a medical interest in
sexual variance.
We begin with an examination of the content of DSM-V on paraphilic disorders.
The International Classification of Diseases (ICD-10) also lists paraphilic disor-
ders but labels them ‘disorders of sexual preference’ (World Health Organization
2011). In this section, we will look at the content of DSM-V because there has
 Paraphilias 115

been a change between DSM-IV and DSM-V (American Psychiatric ­Association

1994, 2013). Some authorities object to the description of sadism and masochism
as disorders. Aetiology will be considered. Researchers are divided into those
who write that paraphilias are a multifaceted phenomenon with no single originat-
ing explanation and those who take the view that paraphilias emerge from historic
trauma located in the biography of the individual. Various examples of paraphilias
from clinical practice will be given. Treatment will be considered that includes
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psychotherapy and the use of pharmacological agents. There will be an explo-

ration of extreme behaviours. Reference will be made to the potential dangers
involved in some paraphilic behaviours. The relationship between paraphilias and
sexual addiction will be reviewed.

DSM-V lists the paraphilias as:

• voyeuristic disorder
• exhibitionistic disorder
• frotteuristic disorder
• sexual masochism disorder
• sexual sadism disorder
• paedophilic disorder
• fetishistic disorder
• transvestic disorder
• other specified paraphilic disorders.

ICD-10 lists the disorders of sexual preference as:

• fetishism: inanimate objects or extension of body (like hair);

• fetishistic transvestism: wearing clothes of opposite sex for sexual gratification;
• exhibitionism: exposure of the genitals;
• voyeurism: looking at others engaging in a private activity;
• paedophilia: sex preference for boys or girls under 13, pre-pubertal or early
puberty;
• sadomasochism: involving pain, humiliation or bondage;
• multiple disorders: fetishism, transvestism and sadomasochism (common
combinations); and
• other disorders: phone calls, frottage, animals.

The groupings are roughly similar. DSM-V goes into much greater detail in
descriptions and prevalence rates for each disorder. It states that ‘The term para-
philia denotes any intense and persistent sexual interest other than sexual inter-
est in genital stimulation or preparatory fondling with phenotypically normal,
physically mature consenting human partners’ (American Psychiatric Associa-
tion 2013: 685). They note that the some paraphilias are focused on the activity
and some on the target of the activity. However, they are careful to distinguish
 116 Paraphilias

between a paraphilia and a paraphilic disorder. A paraphilic disorder is one that

is causing distress or impairment to an individual or one whose satisfaction has
entailed risk or harm to another. DSM-V states quite clearly, ‘A paraphilia is a
necessary but not sufficient condition for having a paraphilic disorder, and a para-
philia does not necessarily justify or require clinical intervention’ (American Psy-
chiatric Association 2013: 686).
A voyeuristic disorder is one in which an individual obtains sexual gratification
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by spying on unsuspecting persons who are naked or involved in some sexual act.
This is a common potentially law-breaking activity. Its prevalence is thought to be
roughly two to four per cent of the male population. It occurs in conjunction with
hypersexuality. Exhibitionism is also said to occur in two to four per cent of the
male population and with hypersexuality. Frotteuristic disorder involves touching
or rubbing up against unsuspecting persons. DSM-V states that ‘Approximately
10–14 per cent of adult males seen in outpatient settings for paraphilic disorders
and hypersexuality have a presentation that meets diagnostic criteria for frotteur-
istic disorder’ (American Psychiatric Association 2013: 693). Sexual masochism
involves the act of being humiliated, beaten, bound or otherwise made to suffer.
Sexual sadism is the reverse and involves the act of humiliating another. The use
of pornography is reported in both sexual masochism and sexual sadism. The latter
does not include rape. Rape is considered an act of aggression rather than an act
driven by erotic preference. Sadomasochism is more prevalent in men (Seligman
and Hardenburg 2000) although sexual sadism and sexual masochism are rela-
tively frequent in women but at 20 times less frequency than in men. Paedophilic
disorder is an attraction to children generally aged 13 or younger. It is thought to
affect between three to five per cent of the male population. It is interesting that
in DSM-V all categories of paraphilic behaviour make reference to hypersexuality
except paedophilia. The meaning of this is unclear but it suggests that paedophilia
is not to be thought of in conjunction with an addictive process. I think this is
mistaken. I make this judgement based on the similarity of suggested treatments.
Fetishistic disorders involve a sexual interest in non-living objects (for exam-
ple, underwear, bras and stockings) or non-sexual body parts including feet, hair
and toes. Transvestic disorder is diagnosed when cross-dressing is combined with
sexual arousal and masturbation. Other specified paraphilic disorders include
obscene phone calls, sex with corpses and animals, and sex that involves urine
or faeces. In all these cases, for a diagnosis to be made of a paraphilic disorder
the behaviour must have been engaged in for at least six months and create clini-
cally significant impairment and distress involving social, occupational or other
areas of functioning. A number of paraphilias may co-exist. The most frequent
combination is fetishism, transvestism and sadomasochism (de Silva 2007). In
considering these behaviours, the practitioner should get a sense of whether the
behaviour is essential for sexual functioning or simply adds excitement and inter-
est to sexual functioning.
There is a body of opinion that would not view sadomasochistic behaviours
as a disorder. This has partly been acknowledged in DSM-V with its distinction
 Paraphilias 117

between a behaviour and a disorder. In a letter to the International Society for

Sexual Medicine, Shindel and Moser (2011) state that, after an extensive litera-
ture search, there is no evidence to support the idea that sexual sadism and sexual
masochism are associated with any type of distress. In fact, studies suggest that
‘practicing sadomasochists in the community have shown evidence of good
psychological and social function as measured by higher educational levels,
income and occupational status compared with the general population’ (Critelli
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and Bivona 2008: 352). Baumeister (1991) also writes that masochists are ‘sur-
prisingly normal people’ and that it does not appear to be part of a deviant or
­maladaptive life style. This view is supported by other medical and psychological
authorities (Cross and Matheson 2006).
There are a number of studies about the prevalence of bondage domination
sadomasochistic (BDSM) behaviour. Kinsey et al. (1953) found that 25 per cent
of both sexes responded to being bitten during sexual foreplay. According to
Hucker (1985), Kinsey also found that 12 per cent of women and 22 per cent
of men responded to sadomasochistic narratives. Crepault and Couture (1980)
interviewed 94 ‘normal’ heterosexual men aged between 20 and 45 and found that
masochistic imagery was represented by 45 per cent being raped by a woman, 36.2
per cent being tied up and stimulated, 17.1 per cent undergoing aggression, 11.7
per cent being humiliated and 5.3 per cent being beaten. Hirschfield (1956), based
on other research, found that bondage and domination featured in 17.2 per cent of
all sex magazines. Critelli and Bivona (2008) estimate that between 1 and 5 per
cent of the American and Australian populations are involved in BDSM. Austral-
ian figures published in the Journal of Sexual Medicine suggest that 2.3 per cent
of men and 1.3 per cent of women were involved in some BDSM activity over the
period of 1 year. Detailed British figures are given in Kahr (2007). These were
based on a YouGov survey of 15,000 members. The survey found that 4 per cent
of Britons had fantasies about being violent towards someone and 6 per cent had
fantasies about having violence practised upon them. As Krueger (2010) writes,
these behaviours are common.
In writing about paraphilias, I am deliberately excluding paedophilia. Paedo-
philia is, in itself, a subject that has involved much research and many ­publications.
There is not scope here to give it the rigorous attention it deserves. Furthermore,
while incidentally encountered in work with the sexually addicted, the specific
treatment of paedophilia is a highly specialist area of consideration and lies out-
side the purview of this book.

Aetiology
Researchers are divided in their views about aetiology. Some do not venture more
than a statement that aetiology is complex and uncertain. De Silva writes that
‘theories of aetiology are commented on noting that a multifaceted model is the
most plausible’ (de Silva 2007: 130). Thibaut et al. state that, ‘sexual arousal is
dependent on neural, hormonal, genetic factors and on the complex influence of
 118 Paraphilias

culture and context’ (2010: 610). Various psychological, ­developmental, environ-

mental, genetic and organic factors have been discussed but none of the theories
fully explains paraphilic behaviours.
A second group of researchers and theoreticians locate aetiology in the dis-
tinct biography of the individual. I am in this second group. I take the view that
it is possible to locate the origins of the paraphilia in a distinctive developmen-
tal history. The paraphilia is an outworking of the components of the general
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history that have been automatically eroticised by the brain and incorporated
into the sexual script. This view requires an understanding of the opponent pro-
cess theory of acquired motivation. This theory was first formulated by Richard
Solomon in 1980. It states that the brain automatically changes adverse and
unpleasant situations into acceptable and pleasant ones. For example, jumping
out of aeroplanes is frightening and difficult at first, but it can become addictive
and repeatable. Another example would be a marathon runner who transforms
the pain and difficulty of the run into the runner’s high. To the person who first
takes a sauna, the heat is unbearable but the activity becomes pleasurable and
is repeated. The same is true with lifting weights: the heavier the weight, the
greater the pleasure.
Here is a personal example:

I had an endoscopy without anaesthetic. For 10 minutes I was confined to

a bed with a camera forced down my throat. The doctor said ‘swallow’ and
he pushed the camera across my gag response. For 10 minutes, I was in hor-
rendous discomfort. Afterwards, I found myself fantasising about repeating
the procedure.

This was an example of the opponent process theory of acquired motivation.

According to this theory applied to sexuality, the adverse is changed into the posi-
tive and the pleasurable. According to Money, the ‘opponent process can be dis-
cerned in all paraphilias’ (1993: 38). The brain automatically takes experiences
of narcissistic damage and trauma and reverses them into victories suffused with
sexual pleasure.
The development of a paraphilia is determined by individual life history and
the circumstances that surround the psychological development of the child. It is
laid down in our story and grows out of our individual life experience. Money and
Lamacz write that ‘socially induced pathology, though it has not been absolutely
defined, would appear to be between the ages of four and five years and eight and
nine’ (1989: 202). Friedman and Downey (2002) describe a bell-shaped curve
for the onset of male sexual imprinting beginning at age three or four and peak-
ing at about eight or nine with an upper tail at about age 13. These templates are
activated at puberty. Some psychoanalysts (Friedman and Downey, 2002) believe
that the phase of childhood from birth until the post-oedipal phase, at more or less
age six, is a critical time of sensitivity. During these years, templates are created
that shape future interpersonal interactions.
 Paraphilias 119

Some paraphilic patients experience paraphilic arousal first in childhood.

Friedman and Downey suggest ‘that there is a late childhood critical period
of brain/mind sensitivity to fantasised images that are associated with erotic
arousal’ (2002: 17). Friedman and Downey write as follows: ‘We conjecture
that as the biopsychological processes associated with adrenarche and puberty
begin, they are associated with brain sensitivities leading to the encoding of
erotic fantasies in the mind as if they were etchings’ (2002: 17). This would put
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the development of sexual fantasies and paraphilias a little later than suggested
by other writers.
There is little information on this subject and more research needs to be done.
Given the social taboo on childhood sexuality and the repudiation of sexuality
in childhood by the public, such research is impossible to pursue. Most of the
authorities consulted (Bader 2008; Kahr 2007; Money 1986; Stoller 1975) agree
that fantasy and paraphilia is an encoding of trauma resulting in eroticisation and
triumph. In other words, traumatic events in childhood are reversed and, accord-
ing to opponent process theory, made pleasurable by eroticisation. The outcome:
the painful is made pleasurable, the unbearable made bearable.
Money and Lamacz (1989) list four ways in which juvenile sex and relation-
ship templates are developmentally vulnerable to socially induced pathology:

1 Explicitly neglecting to monitor and reinforce healthy sexual rehearsal play.

2 Punishing or humiliating children for rehearsal play.
3 Prematurely inducting children into sexual rehearsal play.
4 Coercing children into age-discrepant sexual rehearsal play.

It is hypothesised that stimuli that are initially associated with such sexual arousal
acquire greater arousal during masturbation or during other sexually arousing
activity (Leitenberg and Henning 1995). After erotic fantasies have formed, in
most men they tend to rigidly consolidate like ‘crystalline structures or pictures
in a frame’ (Friedman and Downey 2002: 14) and whatever diversity exists is
programmed in such a way that it is contained within a particular person’s frame.
This view is currently being challenged by researchers who maintain that the
use of the internet allows for changes in the earlier scripting. Because the internet
allows one to orgasm to a variety of previously unavailable images, this sets in
motion the possibility of change. This change is then reinforced with the orgasm.
With repeated masturbation, a new set of images is fixed in the sexual template.
We are novelty-seeking creatures and a man might move on from heterosexual
images to images involving domination and submission, to transsexuals or to a
category called ‘barely legal’. It is theorised that this accounts for the movement
to illegal pornography in men who would, otherwise, seek adult men or women. I
suspect that this does not happen unless there is already in place a recessive script
for the behaviour that the internet brings into the foreground.
Person writes that sex and sexual fantasy become ‘the arena in which rela-
tional struggles and issues are played out’ (1999: 221). Arlow (1991) considers
 120 Paraphilias

paraphilias as a defence against and an attempt to repair some traumatic loss that
has not been adequately mourned. Stoller (1975) is more explicit about this pro-
cess. He describes these behaviours as the result of ‘conflicts survived and com-
promise imposed’ (1975: xvii).
The cover of Michael Bader’s (2003) book, Arousal: The Secret Logic of Sex-
ual Fantasies, has a picture of a pearl in an oyster, linking his thinking to Stoller.
The same view is taken by Kahr: ‘trauma functions as a key ingredient in the
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genesis of adult sexual fantasies’ (2007: 507). Kahr goes on to describe the case of
Esme, whose ‘fantasy life permits her to conquer a traumatic early situation with
the added bonus of an orgasm, thus transforming once again pain into pleasure’
(2007: 459).
Money (1993) and Bader (2003), in different ways, describe paraphilias and
link them to psychogenic origins. The import of all these authorities, writing in an
undeveloped field of study, is that paraphilias are the transformation of trauma.
To quote from Kahr, fantasies function as ‘over the counter self-medication pal-
liatives available at any time of day or night without a doctor’s prescription’
(2007: 469).
The paraphilia acts to change trauma into pleasure. Childhood traumas and
humiliations are converted into mastery and triumph. Both are reversal and con-
version. As Money and Ehrharbt observe, ‘the origins of the images that demon-
strate their erotic power at puberty lies earlier in the biography’ (1996: 149). In a
paraphilia, ‘the opponent process cancels the danger or threatened consequences
of a particular experience and makes it sexuoerotically exciting instead’ (Money
and Lamacz 1989: 202).
I will illustrate this process with a case study for which the patient’s permission
has been given. It involves male to female dominance and acts of erotic punish-
ment of the female subject by the male partner.

This patient, named Liam, is a 40-year-old Irish heterosexual male. He is the

middle of three adopted children with one older sister and one younger sister.
He went to a same-sex school secondary school and was a boarder from age 13
to 17. He is currently not in a relationship. Although he did not go to university,
he has done well in business and lives comfortably. He is a recovering alco-
holic and has been in Alcoholics Anonymous for the past six years. He goes
to meetings about five times a week. He has made an excellent recovery from
his abusive use of alcohol. He also uses the gym about five times a week and
is physically fit and slim. He tends to be perfectionist and enjoys things being
neat, clean and tidy. He is an intelligent and capable man with great insight and
a rich spirituality. He has a delightful and understated sense of humour. His
interests are music and opera, especially Wagner. But he says, “I know I am not
right, but I can accept, if I understand.”
Liam was adopted when he was one year old. His birth mother was 15 and from
a poor Irish farming community. Her father threw her out when he learned that she
was pregnant and she was ‘sent to the nuns’. She nursed Liam for about two weeks
 Paraphilias 121

after birth. Presumably, he was bottle-fed after that time. His mother would have
been described as a ‘fallen woman’ and a ‘young slut’. His birth father ran away. It
is unlikely that his mother had any sex education and would have been ignorant of
contraception. He was then adopted by a dangerous and violent woman who was
monstrous in her actions towards him and his adopted sisters. It was the perfect fam-
ily on the outside but this perfection concealed many secrets.
Liam says that “I was adopted for religion. We were told ‘on a daily basis that
we were adopted’.” Of his school years, Liam says “I always felt out of place.” He
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describes his adopting mother as domineering, frightening, vengeful, cold, men-

tal and barbaric. There was nothing positive said about her. There were no good
times. There were constant shouts and constant threats of being hit and beaten.
His adoptive mother used to say, with great frequency, “I will murder you, I will
cut you in two, and I will make you black and blue.” Liam said, “It was malicious,
I can still remember the ringing in my ears.” Everything had to be done fast. She
fell out with everyone and did not attend her own mother’s funeral.
One of Liam’s early memories was his adopting mother teaching him how to
read the time: “She had a clock and if we got the wrong answer she would hit us
across the face. We were threatened with being hit and we were hit all the time.”
He said, “We were hit everywhere with a wooden spoon, arms, legs, across the
face. I still remember the rings on her fingers. It was all to do with her and not let-
ting her down. I wanted her approval and I never got it.” The violence in the family
was random and unpredictable but the threat of violence was constant. Of all of
this he says, “I was kicked and I don’t want to remember it.” Later when he was
older, his mother went to the school to ask the teachers to beat him more. He says
of his entire childhood that “I never understood love, mothers with their children.”
Of his two sisters, the elder one seems to be the more normal of the two,
although she did say that she had been abused by their adopting father. The
younger sister is described as a criminal and a fraudster. Of his adopting father,
Liam says that he was gentle and kind but dominated by the mother. He left the
family home twice during the marriage. This man did nothing to protect the
children from the adopting mother’s onslaughts.
Something should be said about the role of religion in Liam’s life. Contrary
to what is so much in the news about the Irish clergy, Liam was never abused by
any of the clergy. His memories of the Church are good memories. He describes
the church “as a place of peace and safety. The clergy were trying to help me.”
After secondary school, Liam tried his vocation at seminary. He says, “I loved
the church.” It is probable that the church, through its kindness, saved Liam from
even greater damage, by being the only reliable source of safety throughout a
disturbed and violent childhood. The church became the internalised good object.

This patient had an asexual childhood. ‘Sex did not exist’. There are no reported
memories of childhood rehearsal play, sexual experimentation or early masturba-
tion. The three memories that stand out are being terrified at age five or six, going
into his adopting mother’s bedroom and seeing the sheets covered in blood. The
second memory was seeing a girl ‘beautiful and good’ going to school. “I used to
get the train just to see her.” Finally, at secondary school, there was a kind young
 122 Paraphilias

woman who rubbed liniment on his chest when he was sick. There was an absence
of sex education. His adopting parents gave him a book about sex but all the last
part of the book had the pages stapled together.
This patient had had no same-sex experience. Once in seminary, an older pupil
asked him about masturbation (by way of discussion and not as an invitation to
be sexual) but “I did not understand what he was talking about”. He did not mas-
turbate until he was 17. Three things came together at this time: alcohol, mastur-
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bation and the Marquise de Sade. These things have been the centrepiece for his
sexuality ever since. He had his first blackout from alcohol when he was 17.
This patient developed a preference for spanking women. He only had sex
under the influence of alcohol. The woman had to be innocent, slim and blonde.
“There has to be schoolgirl innocence about it. I am extraordinarily aroused by
pure innocence.” Bader wrote that ‘one man I had treated was aroused by the
image of an innocent woman because it negated his normal view of women as
bitter and cynical’ (2003: 26). This search for innocence has not taken Liam into
the realms of the illegal but he is aroused by women in school clothes and school
shoes. There seem to be two parts to this behaviour: pretending that he is punish-
ing them and talking about punishing them. Sometimes he does cane them but the
caning is perfunctory. It is more about “telling her that she has been naughty and
that I have to spank her”. The fantasy is about the threat of violence rather than
the actual violence itself.
Additionally, Liam has a non-paraphilic heterosexual script that is less full of
erotic charge. He also has a history of delayed ejaculation and erectile failure on
penetration. The delay in ejaculation characterises masturbation as well as coitus.
Liam also spoke of self-harm ideation related to knives, scissors and razor blades.
This is particularly strong after masturbation. He said, “I want to cut my balls
off ”. In adult life, Liam has had three prostate infections, one where blood ran
from his penis. He gave as his primary targets:

• to remove the delayed ejaculation

• to remove his thoughts of self-harm
• to remove the murderous rage he feels towards his adopting mother.

He gave as his primary problems:

• the identification of his sexuality and the need to be content with it

• the delayed ejaculation
• the problem of rage he feels towards his adopting mother.

The first priority was to do something to tackle the panic attacks that accompa-
nied Liam’s self-harm ideation. This was of utmost urgency. When he presented
on 26 August 2009, he had a Beck’s Depression Inventory (BDI) score of 15 and
a score on the Beck’s Anxiety Inventory (BAI) of 30. These rapidly diminished
 Paraphilias 123

until the end of September when both his BDI and BAI scores were 6. On the
Panic Rating Scale, he scored at 100 per cent that he was terrified and fearful of
self-harm. On the Generalised Anxiety Disorder Scale, he noted that he was fear-
ful that worry would harm him, that he would lose control and that his worries
and fears were uncontrollable. He also scored high on health anxiety and social
anxiety. We used normal cognitive behavioural processes to help him diminish his
anxiety, including the use of formulation to make the behaviour understandable.
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As the self-harm ideation came after masturbation, we made a list of affirmations

to say before and after masturbation. He has said several times that he has found
these affirmations helpful. On the Young’s Schema Questionnaire, he scored high
for emotional deprivation, mistrust, social isolation, defectiveness, distress about
the future and unremitting high standards. Given his background, all these scores
were understandable.
It is difficult to change a paraphilia. We spent a couple of sessions talking about
the aversion techniques recommended for this process. Fortunately, Liam has the
capacity to be sexual with routine heterosexual images. He has been masturbating
successfully to these images, although he acknowledges that the paraphilic images
continue “to wave at me”. We have not used any of the aversion techniques. To
date he has had good success with keeping the paraphilic imagery at bay. Liam
also joined our treatment programme for men who are sexually addicted. While
the extent to which he was addicted to these paraphilic images was at the time
unclear, I felt that the group experience would be good for him. He is clearly
addicted to alcohol and to some extent to exercise. He can now talk freely about
the paraphilia without creation of further sexual shame. Liam did well in the group
and has continued to work to reduce his desire for paraphilic sexual activity. He
has joined a dating agency and has begun to date, but in a non-sexual context. The
presence of the paraphilia added to his powerful core belief that “I am defective”.
We can easily see how spanking women is a conversion of Liam’s childhood
abuse into an eroticised victory. In his sexual fantasy, Liam is able to get his own
back on the abusive mother figure. I note both that the behaviour is more about
the threat of violence than the actuality of violence, and that the desired object
is innocent and beautiful. This is a total contrast to the adopting mother and, at
the same time, harks back to his experience of kindness from women. It would
seem that the imagery in the self-harm ideation comes from the adopting mother,
threatening to cut him in two and to murder him. It is also a result of the profound
sexual shame that she inculcated in him. The delayed ejaculation is difficult to
treat but we have begun to tackle some of its causes: sexual shame, the need to
be in control, body shame, the need for tidiness and the absence of contaminants.
As Money and Ehrhardt observe, ‘the origins of the images that demonstrate
their erotic power at puberty lies earlier in the biography’ (1996: 149). He says
that the paraphilia continues to “wave at him”. I think that this means that he has
an ongoing experience around the paraphilia, wanting it not to be there, accepting
that it is, learning how to integrate it and learning to accept himself.
 124 Paraphilias

This case study demonstrates the origins of the paraphilia in the history of
the individual. It gives evidence that the paraphilia is located in trauma. The
paraphilia turns trauma into triumph and represents a victorious outcome to the
­historic events that created it. Its function is revenge as well as liberation. In refer-
ence to paraphilia, Money states that ‘it is a mental template in response to neglect
or traumatisation’ (1993: 39).
As Bader would have it, ‘Sexual fantasies undo rejections, turn helplessness
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into power, redeem feelings of unworthiness, and stamp out the slimmest vestiges
of depression’ (2003: 72). He goes on to write:

Whether it is promiscuity or the compulsive use of pornography, sexual activ-

ity has the property of providing a pleasurable, albeit temporary, relief from
self-loathing. A person in the grip of sexual tension and excitement tends not
to feel inadequate, to ruminate about mistakes, or to feel embarrassed about
his or her weight.
(2003: 71)

These actions are the negation of shame staged in the theatre of the mind. Once
again I refer to Bader:

The master rules only with the consent of the slave and this consent is most
powerfully conveyed by the slave’s sexual excitement . . . The master and
slave provide each other with a special kind of attention and recognition that
counteracts an internal sense of being unimportant, invisible and without value.
(2003: 110)

We return to Money and Lamacz:

the pain and humiliation of abuse, discipline and bondage, that become
incorporated into the lovemap, begin by being a tragedy of suffering. Subse-
quently, they metamorphose into a triumph of euphoria . . . That which was
once aversive and avoided changes and becomes attractive and addictive.
(1989: 202)

The main goal of psychotherapy would be to discover and describe the pathogenic
beliefs that lie behind these enactments. It would be to lessen shame and create
higher levels of self-acceptance. The main reason such beliefs and enactments
are difficult to change is that they provide the participants with powerful erotic
pleasure.

Function and comorbid disorders

The literature suggests that paraphilias are usually accompanied by mood disor-
ders and other impairments (Garcia and Thibaut 2011; Seligman and Hardenburg
 Paraphilias 125

2000). According to Garcia and Thibaut (2011), 90 per cent of the cases involve
males and are accompanied by mood disorders, substance abuse problems and
high levels of anxiety. It is not certain whether the paraphilia is the cause of the
disorder or whether the disorder accompanies the paraphilia. Probably both the
disorder and the paraphilia emerge from childhood trauma. When the paraphilia
is socially shamed, this shame is internalised and self-directed. This adds to the
individual’s sense that they are shameful and defective.
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To help us understand the connection with mood disorders is an observation

by Bader:

In my clinical experience, the anxiety underlying addictions often involves

feelings of disconnectedness which the addictive substance is used to allevi-
ate. The addict is ‘filled up’ by the substance, experiencing it as a substitute
for the missing relationship and as a result using it to numb his or her pain.
The Internet provides the perfect addictive solution to the loneliness and dis-
connectedness of the potential addict, namely on-line relationships.
(2003: 244)

According to Seligman and Hardenburg (2000), the paraphilias are a way to man-
age the problems of anxiety and depression, and a mechanism for the expression of
anger and rage. They provide immediate relief from inner discomfort. This is the
role of the paraphilia and sexually compulsive behaviour: to numb the pain of lone-
liness and disconnectedness. It would be helpful to think of it as sexual addiction
with a paraphilic object rather than the paraphilic behaviour that is, in its own right,
associated with mood disorders and other impairments. To quote from Money:

Others regard the eroticization of that activity as completely inappropriate,

react with outrage, contempt, or ridicule. For them it would prevent orgasm,
not build it up . . . a paraphile permits sexuoerotic arousal, genital perfor-
mance, and orgasm to take place, but only under the aegis, in fantasy or live
performance, of the special substitute imagery of the paraphilia. Herein lay
the seeds of shame, the same shame that is relieved and disavowed by the
process of sexual fantasy and sexual behaviour.
(1993: 38–9)

The relationship between sexual addiction and comorbid disorders is more exten-
sively discussed in Chapter 12.
In clinical practice, paraphilias are rarely, if ever, encountered outside an
addictive process. However, because many paraphilias are socially ridiculed or
create disgust, this increases the cycle: sexual addiction causes shame, the shame
is increased in paraphilic behaviour and this, in turn, further contributes to the
cycle of addiction.
The assessment procedure that we use is the normal assessment procedure to
be used with sexual addiction. However, particular attention is paid to the nature
 126 Paraphilias

of the paraphilia with specific questioning to determine how significant it is

within the overall sexual template. In other words, is the paraphilic fantasy or
behaviour essential for sexual functioning or does it enhance sexual functioning?
We try to link the paraphilic behaviour to the individual history. We take men
though the neuroscience of sexual addiction and teach on the nature of shame.
The other interventions, given in the chapters on interventions, are used along
with special reference to the paraphilia. We ask about the role of the fantasy in
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masturbatory fantasy. We endeavour to come up with a commitment to shared

goals in treatment.
Below are a number of paraphilic behaviours encountered in clinical work.

John was preoccupied by fantasies of spanking young women. His fantasy life
was contained to the internet. His wife was aware of this and uncomfortable
with his paraphilic behaviour. He and his wife were both committed Evangelical
Christians and this behaviour seemed to run contrary to the content of their faith
and to the lifestyle to which they were publicly committed. In John’s develop-
mental history, there was a punishing and disapproving mother. This was reversed
in the paraphilia where John became the punisher and the woman the punished.
William, also a committed Christian, had fantasies of women urinating on
him. This caused him to feel great shame. It seemed to be an eroticisation of his
shame: “I am worth nothing”. He was therefore degraded by this act, which was
automatically sexualised and provided intense pleasure.
Richard used to engage in multiple acts of self-degradation. He was a het-
erosexual man but he would fellate up to ten men a night at a nearby public
toilet. Richard once said to me, “I am addicted to sex that degrades”. Richard
was a successful businessman and, last heard of, was living with his girlfriend
in Holland.
Thomas was preoccupied with seeing his wife have sex with other men. In
addition to this paraphilic script, there was a functioning heterosexual script.
Sometimes the wife would engage in this behaviour. There were usually para-
philic conjugal fantasies during intercourse. These seemed to be about the sub-
stitution of another more potent person who could better serve the wife than
could Thomas. It was about his uncertainty about potency and therefore the
eroticisation of a substitute. There were no homosexual connotations in his
behaviour.
Robert always wanted to be sexual with his wife and another woman simul-
taneously. This seemed to me to be about a dilution of femaleness rather than an
increase of femaleness. Two can mean less than one, just as well as twice one.
He had a belief about vagina dentate. He thought that his penis could become
trapped in his wife’s vagina. This seemed to me to be a fear of female engulf-
ment that was reduced with two women rather than increased.
Adam came to me and said that he liked having sex that was “wet and
muddy”. I mistakenly assumed that this meant urine and faeces. However, it
turned out that he liked having sex in puddles.
 Paraphilias 127

Treatment
Garcia and Thibaut (2011) write that the ideal treatment would diminish or a­ bolish
the paraphilia. There would be a significant reduction in anxiety and distress.
There would be the availability of a non-paraphilic normative pattern of sexual
behaviour. There would be no side effects from the treatment. If the paraphilia
involved the desire to harm others, this would be entirely abolished. As they add,
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this is currently unavailable and ‘the treatment of men with a paraphilia is dif-
ficult’ (Garcia and Thibaut 2011: 772). The difficulty seems to relate to little
understanding that the paraphilia can be treated like a sexual addiction with a
non-normative direction of interest.
Most people do not seek treatment for a paraphilia. This is the result of a combi-
nation of the pleasure derived from the paraphilia and the shame experienced from
it. It is only when the behaviour creates significant distress that men come into treat-
ment. The most frequent presentation is that the paraphilia has been discovered. The
presence of a sexual addiction can be shocking to a partner. This is amplified when
the sexual behaviours are of an unusual and, from the point of view of the partner,
a repellent nature. De Silva (2007) takes the view that it is a legitimate objective to
seek to incorporate the paraphilia into partnered sex, when it can be tolerated by the
partner. He writes that ‘in clinical work with fetishists, the approach of incorporat-
ing the paraphilia in a controlled way has met with success’ (de Silva 2007: 133).
Some authorities suggest the use of aversion therapy with disruptive para-
philias. Other authorities take the view that these approaches are ineffective. Here
are the three main aversion techniques suggested by de Silva (2007: 132):

• Covert aversion: this procedure is to ask the patient to fantasise the paraphilic
fantasy and at the moment of orgasmic inevitability to switch to a powerful
aversive scene.
• Orgasmic reconditioning: the patient is directed to use the paraphilic fantasy
to the point of inevitability and then switch to a more conventional fantasy.
• Saturation therapy: masturbate to the paraphilic fantasy and then continue
after orgasm to verbalise the fantasy during the refractory period for at least
20 minutes.

Some additional aversive techniques are listed (Abel and Osborn 1997):

• Olfactory aversion: antecedents to the behaviour are paired with a noxious

odour – for example, ammonia or rotting meat.
• Thematic shift: masturbation to the point of inevitability to a variant fantasy
and then a shift to a non-variant fantasy at the point of orgasm. With repetition,
the shift is introduced earlier and earlier.
• Directed masturbation: masturbation to a non-variant fantasy.
• Exposure: the use of non-variant explicit imagery to increase these sexual
experiences and fantasies.
 128 Paraphilias

All these behavioural mechanisms are intrusive. The exercises are basically only
recommended to reduce offending behaviour. They can, with adaptation, be used
with difficult and problematic paraphilic behaviours. However, Marshall et al.
(1999) take the view that aversion therapy does not create long-lasting changes.
They also raise ethical problems. For example, one treatment suggested for
exhibitionism: the subject exhibits himself in front of hospital staff who do not
react. Another version of this is to ask the exhibitionist to exhibit himself in front
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of a video camera with the scene played back to the therapist (or group members)
for feedback. In our experience in working with paraphilias, these adverse tech-
niques are difficult to implement. We have tried ammonia aversion. Once with
an exhibitionist, this proved helpful in preventing the move from anticipation to
actual exposure. The second was with a man with coprophagia. This did not prove
helpful. The addictive hold of the behaviour was so powerful that, every time,
it overwhelmed the attempt at aversion. I have listed these aversive techniques
earlier for therapeutic consideration, keeping in mind that authorities disagree on
the effectiveness of treatment.
The aims of treatment need to be carefully considered, and the therapist and
patient need to arrive at agreed goals. In practice, any treatment that attempts to
get rid of the paraphilia must also work on enhancing other outlets for sexual
expression. We normally suggest to paraphilic patients that they join our treat-
ment programme for the treatment of sexual addiction. We find that to be able to
talk about the nature of the paraphilia diminishes shame. The young man cited
earlier who had women urinate upon him was so nervous telling his story that he
was literally shaking. Once he had told his story, he was given feedback from the
group. The feedback was ‘So what?’ It made no difference to the group. They
were not perturbed by this revelation. It was possible to watch the shame diminish
with the feedback. So, when we are working with a paraphilia, we integrate these
men into our overall treatment programme. A paraphilia is the distinctive object
of an addictive process.
In North America (Thibaut et al. 2010), CBT is the usual treatment for para-
philics who are not at risk of harming others through their variant sexual interests.
The content of the treatment (Abel and Osborn 1997; de Silva 2007; Garcia and
Thibaut 2011; Seligman and Hardenburg 2000; Thibaut et al. 2010) is the same
as the treatment for sexually addicted patients. It usually includes identifying the
cues for the behaviour and learning to manage the feeling state in a more accept-
able manner. Learning about the cycle of the behaviour is crucial so that exit
strategies can be developed and implemented. Cognitive distortions are explored
and recognised. Social skills and sexual social skills are taught when necessary.
There is an emphasis on relapse prevention. In fact, all the components relevant
to working with addicted clients are used to work with paraphilias. Treatment is
multifaceted and can involve individual therapy, group work, family counselling,
psycho-education and a commitment to self-help groups. Seligman and Harden-
burg write about self-esteem, sexual knowledge and positive recreational outlets,
that ‘improvements in these areas of functioning can lead to reduction of the
 Paraphilias 129

paraphilic preoccupation which in turn can enhance other areas of life’ (Seligman
and Hardenburg 2000: 111). Added to this is victim empathy work. In working
with sexual addicts, this work normally involves the development of empathy for
partners and family.

Pharmacological and psychotherapeutic combined

treatments
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The authorities tend to agree that the most effective treatment of paraphilias is
a combination of pharmacotherapy and psychotherapy. Thibaut et al. write that
‘whilst a biological approach is probably essential in the treatment of patients with
severe paraphilia, a psychotherapeutic context to treatment is equally necessary’
(2010: 606). Thibaut et al. (2010) comment that the ‘optimum formula for treat-
ment of paraphilia may well be a combination of cognitive behavioural therapy
and anti-libido medication in a dynamic psychotherapeutic framework’ (606) The
general view is that a combined therapy approach is more effective than either
therapeutic approach used alone. Abel and Osborne write that ‘serotonin reup-
take inhibitors such as sertraline, fluoxetine and paroxetine have been added as a
first step on drug intervention’ (1997: 388). The use of pharmacological agents
has been discussed in Chapter 3 on neuroscience. In working as an independent
practitioner, it would be well to have on hand a knowledgeable medical doctor
who would be able to prescribe accordingly. This would need to be a doctor who
would be able to work sympathetically with the therapist in creating an outcome
with maximum effect. The prognosis is best with early treatment, a strong sense
of self, high levels of motivation and a substantial part of the sexual template that
includes normal sexual experience.

Extreme cases
From time to time, in working with sexual addiction, men present with a para-
philia that is dangerous. These include two especially dangerous paraphilic
interests: knife play and hypoxyphilia, otherwise known as auto-asphyxiation.
Hypoxyphilia is a potentially lethal practice of sexual arousal that is produced
while reducing oxygen to the brain. It is usually a solitary sexual activity. Among
the more common forms are self-hanging, strangulation, and techniques to restrict
breathing movements (Hucker 2012). The disorder is frequently found alongside
depression and an SSRI is reported to be an effective pharmacological agent that
has the dual benefit of relieving concurrent depression and reducing sexual impul-
sivity. Hazelwood et al. write that ‘of all sexual risk taking nothing results in more
deaths than asphyxia’ (1983: 6).
Knife play is another dangerous paraphilia. Knife play involves the use of a
knife on the body of the partner. Often a knife is produced and seen by the partici-
pant. Those who write about such activity always urge great caution: no alcohol
or recreational drugs, scenarios are planned in advance, safe words are agreed and
 130 Paraphilias

all equipment must be sterile. The website Master Sam’s Knife Play Resources
is very clear about the dangers involved in knife play, stating, ‘you cannot get
around the fact that a knife is defined as a deadly weapon’ ([Link]/
a14/knife_lessons/[Link] [accessed 9 January 2012, but no longer available]).
Both knife play and breath play are dangerous. Breath play is more likely to
end in tragedy for the lone participant. Knife play is more likely to end up with a
partner injured or killed. These are rarely encountered in working with the sexu-
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ally addicted. In over 20 years of work, I have only once knowingly encountered
auto-asphyxiation. In my work with this man, I pointed out the dangers involved
in the practice and worked to improve the safety measures to be as certain as pos-
sible that he would not come to harm.

Connection between sexual addiction and the

paraphilias
I have noted the connection between sexual addiction and the paraphilias through-
out the chapter. DSM-V alludes to this connection by listing that all paraphilias,
with the exception of paedophilia, might occur in the context of hypersexuality.
There is uncertainty in the literature about the relationship between sexually com-
pulsive behaviour and a paraphilia. It is clear that sexually compulsive behaviour
may not involve a paraphilia. However, the two are linked in the following way.
Both are driven by shame and both produce shame. They were established in the
family of origin as a means of self-soothing. They are both responses to narcis-
sistic damage or trauma in the family of origin. Both are a means of affect man-
agement and self-regulation. They wax and wane over time. Both can bring with
them harmful consequences. Sexual addiction is a response to childhood trauma
and to negative affect states and their replacement with eroticised intensity. A
paraphilia is similarly a response to childhood trauma, a turning of trauma into
eroticised triumph.

Conclusion
I will finish by returning to the murder trial. In this case, both were drunk. Both
enjoyed ‘rough sex’ and she apparently asked him for knife play. He had lost all
control and was disinhibited and discoordinated by a large amount of alcohol. He
applied the knife to her neck. His hand slipped. He then fell asleep for about 8
hours. He did not fall asleep, he blacked out.
 Chapter 10

Internet pornography
addiction
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Introduction
When I first started the clinic, a young man came to me in great distress. This was
his story. He was a self-employed designer. He owned his flat. He lived a relaxed
lifestyle. He would get up in the morning, go to the computer. He would spend
the next four to five hours searching for sex. Eventually he would find someone
for sex. This happened regularly. He was doing little work because he spent so
much time in pursuit of sexual engagement that there was little motivation to
do anything else. He had remortgaged his flat to maintain his financial position.
This man had no structure in his day and little self-discipline; he was caught up
in a vortex. He was addicted to the internet and, through the internet, to offline
encounters. This had been continuing for many years. As Greenfield notes in an
early book on internet addiction, Virtual Addiction, ‘It is an attractive and easy
way to immediately alter your reality’ (1999: 35). Greenfield also writes that ‘it
creates power, exhilaration and intensity’ (1999: 27). It can also create disaster.
The internet has many useful contributions to make to human sexuality. It is a
helpful resource for those living in isolated communities to find information about
sexual behaviour and, in particular, the transmission of sexually communicated
infections. It is useful for disabled people, and those who are house bound or
transgendered. It is helpful to sexual minorities in providing a sense of commu-
nity, that they are not alone.
Griffiths (2011) recognises the positive impact of the internet on women and
those who are sexually marginalised. It can provide a ‘safe place’ for sexual
exploration and access to a social community. Of particular interest, the website
[Link] (accessed 4 January 2015) provides gay men with
a range of proposals and opportunities to develop away from their self-directed
homophobia and resolve the trauma that often comes from living as a gay man in
a straight world. There are many websites dedicated to helping young gay men,
older men and lesbians move forward together as a community and end their
individual isolation.
The same would be true for those interested in bondage or who have a specific
fetish. ‘Fetlife’, a bondage site, states that it has nearly three million members in
 132 Internet pornography addiction

a forum where people accept you as you are. It advertises that the site includes
­pictures, videos, discussion groups and blogs. ‘Informed Consent’ now largely
closed, claimed to have hundreds of thousands of members (editor’s note: this
website has been closed or reduced since the time of writing). These sites, and
other similar ones, not only provide for specialised sexual interests but also help
break the isolation that can accompany such an interest. In this there is a paradox:
to expand your world on the internet, you have to isolate yourself in doing so.
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Pornography literally means ‘writing about harlots’ ([Link]

[accessed 4 August 2014]). Keeping up to date on factual information on the
development of the internet and the prevalence of internet pornography is impos-
sible simply because of the rapid day-by-day changes and developments in the
industry. However a brief overview of prevalence of pornography on the internet
will give some sense of the extent of the issue.
Pornography is defined as ‘sexual content for the purpose of autoerotic stimula-
tion’ (Zitzman and Butler 2009: 212). Griffiths (2011) notes that men tend to use
websites and search for unusual sex, whereas women tend to use chat rooms. He
also makes the observation that women are more likely than men to go from online
to offline affairs. This view is shared by Young (2007). It seems to reflect the
difference in male and female sexuality. Women are more interested in an actual
relationship while male sexual desire seems to be less relationship orientated.
Greenfield also noted that ‘One of the biggest problems with computers and the
internet is that people can become highly compulsive and addictive in their use.
Internet and computer addiction poses serious social implications for a world glued
to computer screens’ (1999: 8). Given what we know about the expansion of the
internet and pornography on it, this remark shows considerable foresight.
Carnes et al. (2001) stated that in January 1999 there were 19,542,710 unique visi-
tors to pornography pay sites. Two hundred sex-related websites were being set up
per day and sex was the third largest internet economy. They noted that 70 per cent of
all traffic occurred during office hours. It is not clear whether they were writing about
American sites and using American statistics. Four years later, Yoder et al. (2005)
made the following observations: average age of first exposure was 11; the largest
consumer group was between 12 and 17 years of age. In a report in 2002, 80 per cent
of companies reported internet abuse by employees. Their report showed a correlation
between internet usage and increased depression and relationship problems. Yoder et
al. used the following definition of pornography: ‘Sexually explicit pictures, writings
or other material whose primary purpose is to cause sexual arousal’ (2005: 23) They
claimed that, in 1999, 30 million people logged on to such websites and that the busi-
ness was worth $57 billion per year of which $12 billion was earned in the United
States. Southern (2008) refers back to 2001 and states that 60 per cent of all business
on the internet was related to sex, 70 per cent of e-porn was used during working hours
and that sex was the third largest business on the internet.
Writing in 2009, Twohig et al.’s first mention estimated that internet
­pornography made up 12 per cent of all internet traffic and that 13 per cent of the
American population viewed pornography on a regular basis. Seventy-five per
 Internet pornography addiction 133

cent of these were men and 17 per cent met the criteria for sexual addiction. In
2010, Twohig and Crosby noted that 12 per cent of the internet was made up of
pornography, 13 per cent of Americans viewed it regularly and 17 per cent of users
met the criteria for sexual compulsivity. Twohig and Crosby (2010) wrote that
there seemed to be a correlation between problematic internet use and depression,
social isolation, damaged relationships, financial consequences and decreased
productivity. Maltz and Maltz, writing in the Porn Trap (2010), stated that there
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were 400 million pages of pornography on the internet. They also noted that 25
per cent of daily internet searches were for pornography. Of particular interest
was their observation that American matrimonial lawyers had reported that por-
nography had played a significant role in divorces, and that half of those cases
had involved disputes over the compulsive use of internet pornography. This rein-
forced the concern expressed by Twohig and Crosby (2010) about the impact of
internet pornography on the partnered relationship. Muench et al. (2011) observed
that pornography had grown dramatically and was generating $13 billion in 2011.
The pornography industry is growing so quickly that it is impossible to keep
the figures accurate between the date of writing and the date of publication. How-
ever, the following figures were obtained on 9 April 2014:

• 68 million daily searches for pornography in the United States

• In 2010, 13 per cent of all global web searches were pornography
• 10 per cent of adults admit to having an addiction to online pornography
• 70 per cent of all access to pornography is during workdays.
([Link] [accessed 7 August 2014])

The website goes on to say that pornography sites have larger revenues than the
top technology companies (Microsoft, Google, Amazon, eBay, Yahoo, Apple and
Netflix) combined. All these figures are confusing. There are rapid changes in
the technology so what is true one day will be changed or increased the next day.
Young writes in ‘Cognitive behavior therapy with internet addicts’: ‘Research
over the past decade has identified Internet addiction as a new and often unrec-
ognized clinical disorder that impacts a user’s ability to control on-line use to the
extent it causes relational, occupational and social problems’ (2007: 671). Here
we have a twin addiction with a number of consequences. There is an addiction to
the internet combined with an addiction to internet pornography. This combina-
tion is reinforced at every level and has far-reaching consequences for individuals
caught up in this multifaceted process.
Naomi Wolf, described as a third-generation feminist, begins an article in the
New York Magazine with the following quote: ‘In the end, porn doesn’t whet
men’s appetites, it turns them off of the real thing’ (New York Magazine: n.d.).
She goes on to write: ‘The onslaught of porn is responsible for deadening male
libido in relation to real women, and leading men to see fewer and fewer women
as porn worthy’ (New York Magazine: n.d.). This is the effect of supernormal
stimuli.
 134 Internet pornography addiction

Eoin Stephens, writing in a Christmas letter as President of the Personal

­ ounselling Institute (PCI) College in Dublin, makes the following point about
C
supernormal stimuli. He says that by this term we mean artificially enhanced
stimuli. This creates hard-to-resist responses at all levels, in our thinking, our
emotions, our physiological reactions and our behaviour. The supernormal stimuli
do this by subverting and hijacking evolved appetitive instincts and motivational
systems, and by over-stimulating their associated neural pathways.
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Hilton, writing about pornography, makes the point that this addictive effect
‘may be amplified by the accelerated novelty and the supranormal stimulus factor
afforded by Internet pornography’ (2013: 1). He further writes:

Indeed, it is illustrative of Tinbergen’s concept of supranormal stimulus, with

plastic surgery enhanced breasts presented in limitless novelty in humans
serving the same purpose as Tinbergen’s and Magnus’s artificially enhanced
female butterfly models, the males of each species prefer the artificial to the
naturally evolved.
(2013: 5)

Maltz and Maltz (2008: 35) say that the average size of a man’s erect penis is 5.8
inches, the average size of a male porn star’s erect penis is 8 inches and 85 per cent
of female porn stars have breast implants (source: from Men’s Health magazine,
March 2004 and The Smart Girls Guide to Porn). Supernormal stimuli illustrated
from the world of pornography. Naomi Wolf writes in the same article mentioned
earlier, ‘Today, real naked women are just bad porn’ (New York Magazine).

Internet pornography
Pornography works by using the brain’s system of mirror neurons. The brain’s
mirror system ‘resonates with the motivational state of the individuals depicted’
(Hilton 2013: 6). These mirror neurons help us to establish empathy with others.
If I see a girl crying on a tube train, I feel concern for her upset. I am upset that
she is upset. This happens similarly when I watch a film. These neurons help us to
feel what another is feeling. In doing psychotherapy, I am aware that these are in
constant use so that I have some sense of what is happening for the patient. These
mirror neurons create arousal when we see arousal on the screen, just as we can
experience sorrow at sorrowful occasions and joy at happy occasions.
The internet helps us to avoid life problems. It provides a refuge from stress,
other negative experiences and difficult-to-tolerate emotions with the added
bonus of powerful sexual pleasure. Griffiths (2011) refers to the ACE model of
problematic internet use: Availability, Convenience and Escape. He describes the
internet as a place of refuge from the everyday stressors of life. Young takes the
same view – that it is a relief from moments of mental tension and ‘a tool to cope
with life’s problems’ (2007: 672). Southern notes that it can be ‘an attempt to
manage stress, reduce anxiety, ward off boredom, loneliness, depression, express
 Internet pornography addiction 135

frustration or anger, and bolster a fragile ego’ (2008: 672). It avoids rather than
solves problems.
In our clinical work, we see this happening. In its own right, it is not really a
problem. We all do something to manage tension and to cope with life’s prob-
lems: going on holiday, a glass of wine, fretwork, solitaire, or saying the rosary.
It is on a continuum. The problem occurs when the activity or behaviour domi-
nates life to the extent that it interferes with other more important occupational or
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economic goals. It can also bring to the forefront and interconnect with existing
psychopathologies. It can be escapism ‘entangled with comorbid problems’ (van
Rooij et al. 2012: 176). Research done by Ceyhan and Ceyhan (2008) among
Turkish students found that previously existing psychopathologies provoked the
development of problematic internet behaviours. Loneliness was the most impor-
tant. This research suggests that the comorbid problems are exacerbated by the
internet but not essentially caused by the internet.
One of the main problems with overuse of the internet is that it increases indi-
vidual isolation. Chaney and Chang (2005) are clear that frequent internet users
have fewer friends and lack social support. Griffiths (2011) found that excessive
internet use increased social and self-alienation. He noted research on students:
those who did not use the internet for sexual entertainment were more content
than those who did. Maltz and Maltz claim that the nine most negative conse-
quences of the overuse of internet pornography are:

• Individuals become easily bored and irritated

• Isolation from others
• Objectifying others
• Neglecting important areas of life
• Making partner unhappy
• Feeling bad about self
• Engaging in risky behaviours
• Having problems with sex
• Becoming addicted to sex.
(2008: 72)

I am not persuaded that internet use causes these ‘consequences’ but that most
of these are already present, and drive, internet behaviour. In the same way that
sexual addiction, in general, is driven by negative affect states, so is internet por-
nography (a type of sexual addiction) driven by difficult and painful feeling states.
However, I accept that the overuse of internet pornography contributes to both
negative affect states and negative downward spirals.
Another feature of the internet is that the diversity of the material, and the
ease of access, allows the sexual template to be modified. Escalation can increase
in two ways. It can escalate in the amount of time used in the pursuit of sexual
gratification, and it can escalate in the variety of material that is seen. Given that
novelty seeking is a feature of human life, there is endless novelty on the internet.
 136 Internet pornography addiction

Overuse of the internet can create boredom with what is, and this can lead to
searches for new and different scenarios. Keeping in mind that arousal chemistry
shuts down a man’s awareness of consequences, he might venture into the illegal.
An orgasm with a new scenario would reinforce the use of that scenario. This may
allow variations and changes to the sexual template. I do not think this would hap-
pen unless there was already in place a propensity for this to take place. In other
words, an existing but recessive sexual script might become more dominant by
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the use of the internet.

According to Young (2007), overuse of the internet causes changes in offline sex-
ual behaviour. We have worked with a number of men who have reported changes
in their sexual patterns and sexual interests, something called ‘porn-induced sexual
dysfunction’. For the most part, this is a loss of libidinal interest in the sexual partner.
Young (2007) writes that men experience decreased interest in sex with partners, 75
per cent report sexual problems and 85 per cent report relationship problems. The
nature of the sexual or relationship problems are not specified.
The fact that these two things occur together does not mean that the first causes
the second. However, it is clear that intimacy with the supernormal stimuli pre-
sented on the internet could reduce the desire for intimacy with a real person. We
have also had cases where sexual uncertainty with a real partner is magnified by
sexual activity online where genuine intimacy is avoided. For example, men with
early or delayed ejaculation rarely have this problem when they are masturbating
alone. The use of the internet might abet the problem although probably not cause it.
A number of consequences have been reported about the effect of internet
addiction and internet pornography on a individual’s circumstances and life. Cey-
han and Ceyhan (2008) report loneliness and depression. Yen et al. (2007) report
that, for young people, depression is associated with internet addiction. Young
(2007) reports that academic and marital problems are associated with internet
sexual addiction. Van Rooij and colleagues (2012) report that the consequences
of internet addiction are a severely unbalanced lifestyle, missed opportunities and
negative long-term consequences, including excessive expenditure, lack of self-
care and social problems.
Ge and colleagues, in writing about CBT for internet addiction, state that ‘recent
neuropsychological studies indicate that cognitive deficits may be involved not
only in substance abuse but also in IAD (Internet Addiction Disorder)’ (2011:
2037). They go on to state that this finding is thought to reflect working memory
and/or attentional operations or cognitive processes. If this is substantiated, it
would explain how often poor choices are made and poor objectives pursued. In
other words, internet addiction is similar in its effect and aetiology to the use of
drugs of abuse. Yoder et al. (2005) consider that pornography releases chemicals
that act on the body in much the same way as cocaine. Ge et al. (2011) recom-
mend short-term CBT as an effective intervention.
Internet addiction and internet sexual addiction have a substantial impact not
just on individuals but also on individuals in relationships. Zitzman and Butler
(2009) have written an important article on pornography use and its impact on
 Internet pornography addiction 137

the attachment relationship. Pornography disconnects sexual experience from

­relationships and it detaches sexual experience from attachment. Zitzman and But-
ler write: ‘Our findings support the development of a model linking husband’s
pornography use and concomitant deception to significant attachment injury and
trauma-like experience and symptomology for the pair-bond’ (2009: 227).
The impact of this is not only on the partner in the relationship but also on
the pornography addict. In all the groups that we run, the men are overwhelmed
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with grief caused by their partner’s distress. There is injury to the attachment
partner and therefore a significant threat to the attachment relationship. This
threat also destabilises the sex addict and affects the relationship, often by with-
drawal of the soothing support of the partner. The aggrieved partner experiences
a catastrophic loss of trust. Zitman and Butler state that ‘the sexuality and scripts
of pornography are inherently attachment-attacking’ (2009: 214). The use of
pornography affects trust in the relationship. Trust is the foundation of secure
attachment, and pornography contributes to deterioration in the relationship and
has an impact on family life. Pornography contributes to the loss of an embodied
sexual relationship.
Greenfield acknowledges that the internet can be a problem and suggests a
number of strategies to help you ‘reclaim your life’ (1999: 69). These include
taking a technology holiday, developing other interests, taking more exercise,
watching less television and shortening internet sessions. He also suggests
psychotherapy and support groups. All these suggestions can be integrated
into the psycho-educational component of therapeutic work with internet sex-
ual addiction. In addition, it is possible to suggest putting a timer by the com-
puter or setting an alarm clock. A very simple technique is to ask the pornog-
raphy addict to rearrange the location of his computer – either by putting it in
the family room or by positioning the screen so that it faces the entrance to the
room. We normally advise the installation of security software to prevent the
downloading of pornographic material. We recommend that the password is
set by a trusted friend rather than the partner. If the partner sets the password,
it renders her the adult and him the child. We also suggest that an effort is made
to cultivate new friends and increase face-to-face social interaction. Carnes et
al., in In the Shadows of the Net (2001), suggest all the same arrangements
to decrease computer use but, in addition, an accountability partner and/or an
online sponsor. Maltz and Maltz (2008) suggest setting goals, reading books,
sympathetic discussion, lifestyle changes and values clarification as effective
components of treatment.
It is not feasible to suggest that people abstain entirely from the use of the
internet. Our lives are inextricably bound up with it. As Young suggests, ‘moder-
ated and controlled use of the Internet is the most appropriate form of treatment’
(2007: 673). A cognitive and behavioural treatment programme seems to provide
the most important ingredients in any programme of response. Griffiths (2011)
writes that CBT may prove beneficial in alleviating the symptoms of online sexual
addiction. Dutch research (Van Rooij et al. 2012) makes the same suggestion.
 138 Internet pornography addiction

The Dutch researchers used an existing CBT-based treatment ­ programme

‘­Lifestyle training’ combined with motivational interviewing. ­Southern (2008)
recommends a comprehensive treatment programme that addresses the major
functions of the behaviour and includes intimacy enhancement, love map recon-
struction, dissociative states therapy, arousal reconditioning, skills training and
relapse prevention. On the subject of CBT and the treatment of internet addiction
and internet pornography addiction, Young (2007) writes that behaviour therapy
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is used to moderate problematic internet activity. He suggests that those who suf-
fer from negative core beliefs are the ones most likely to be attracted to the inter-
net. Young (2007) recommends cognitive restructuring to address the negative
core beliefs and the cognitive distortions.
It is clear from the chapters on intervention that almost all the interventions
for sexual addiction are, in fact, cognitive behavioural. I have made it clear that
whether those using these techniques and interventions realise that they are cogni-
tive behavioural techniques is another matter. In our group treatment programmes,
about one-third of the participants are there because of their addiction to inter-
net pornography. As has been demonstrated in Chapter 10, there are effective
treatment mechanisms. However, because of the immediacy and speed of access,
internet addiction is a more difficult addictive process to treat. In many ways, it
is easier to stop using sex workers. Sex workers require planning, phone calls,
access to cash, often driving and then searching for a flat or house number. In this
process, a lot of time can be required and this gives many more opportunities for
the individual to intercept the behaviour. With the computer, a couple of clicks
and the person is transported to oblivion.

Dissociation and internet use

It is useful to consider the overuse of internet pornography to be similar to a dis-
sociative condition. Lost in the internet is to be largely lost to the world. As I have
noted already, there can be huge time distortion. Greenfield (1999) notes that time
distortion is a universally agreed feature of dissociation. Over and over in our
groups, we hear stories of men who have lost all sense of time in their involve-
ment with the internet. In fact, when we ask men to write a list of all the harmful
consequences of their internet addiction, the most common response is the loss
of time.
While the use of the internet would not meet the DSM-V criteria for a dis-
sociative disorder, the connections and similarities should be noted. The criteria
for dissociative trance are described thus in the DSM-V: ‘this condition is char-
acterized by an acute narrowing or complete loss of awareness of immediate
surroundings that manifests as profound unresponsiveness or insensitivity to
environmental stimuli’ (American Psychiatric Association 2013: 307). We had a
man in one of our groups who said that he was so lost in masturbating to internet
pornography that he did not hear his wife and children come home. According to
the DSM-V, ‘This unresponsiveness may be accompanied by minor stereotypical
 Internet pornography addiction 139

behaviours (e.g. finger movements) of which the individual is unaware’ (Ameri-

can Psychiatric Association 2013: 307) I think of the unconscious finger move-
ments on the mouse, or otherwise at the computer, searching for objects of intense
erotic stimulation. Another feature that links sexual and internet sexual addiction
to a dissociative condition is the ‘addict self’, which we often hear people talk
about as though it were a separate personality. People will say, ‘The addict took
over’ or ‘It was not me, it was my addict’. There is a sense that the addict is a sub-
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personality that from time to time takes control and has a will of its own. There
is a marked relationship between stress or other significant emotional difficul-
ties and the use of the computer for sexual arousal and gratification. To quote
from DSM-V, ‘Dissociative disorders are characterized by disruption of and/or
discontinuity in the normal integration of consciousness, memory, identity, emo-
tion, perception, body representation, motor control and behaviour’ (American
Psychiatric Association 2013: 307). Chaney and Chang (2005) describe in their
research that the research participants described symptoms of dissociation and
depersonalisation when engaged in online sex. These involved disturbances in
consciousness, memory, identity and perception.
There are those who argue that there is an important link between sexual
offending and the use of internet pornography, and others who would not take this
view. Bensimon (2007) suggests that long-term exposure to pornography disin-
hibits the individual and can contribute to the normalisation of illegal or danger-
ous behaviours. It is likely that the use of pornography normalises and enables
the rehearsing of scenarios that may eventually be acted out in real life. It would
also be possible to argue that the provision of the activities and events in a virtual
world act as a substitute for the action in reality. This debate is set to continue.
In the preceding chapter, we considered the positive contributions of the inter-
net to human sexual life. Internet pornography is expanding exponentially both
in terms of prevalence and in terms of earned income. I have set out the major
negative correlations. This chapter has some tips on how best to help yourself out
of internet pornography addiction as well as notes on treatment. It has concluded
with some thoughts on the relationship between internet pornography use and dis-
sociative conditions.
Addiction to internet pornography is simply a form of sexual addiction. All the
interventions for use with sexual addiction apply to compulsive use of the inter-
net for sexual expression. The difference is that it is not possible, in the modern
world, to remain abstinent from the internet. In our treatment programmes, we
are able to reduce internet usage to a non-problematic level, but we have not been
able to create complete freedom from such usage. There is ease of access. Internet
pornography is only a click away and the shift from the real world to the virtual
world so quick that there is rarely time for executive thought. The last word can
go to Griffiths: ‘Similarly, if the cybersex user experiences clinically significant
distress or impairment because of their engagement in sexual behaviours on the
Internet, it appears safe to claim that s/he suffers from Internet sex addiction’
(2011: 120).
 Chapter 11

Trauma and attachment

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Introduction
Attachment disorders are the adult consequences of childhood trauma. We often
think of trauma as a one-off catastrophic event, but a repetitious experience of
neglect or harm also creates the after-effects of trauma, which include problematic
affect regulation (Flores 2004). According to Allen, for some individuals, ‘attach-
ment trauma undermines their ability to self-regulate’ (2005: 29). Attachment dis-
orders and trauma are on a continuum of severity, from mild to severe. Substances
of abuse and behavioural addictions are used as ways to self-­anaesthetise and to
self-regulate the negative emotional states left behind by childhood experiences
of indifference, incompetence, abuse, abandonment or neglect. Flores writes that
‘difficulty overcoming ineffective attachment states can leave certain individu-
als vulnerable to addictive compulsions as compensatory strategies’ (2004: 43).
Some individuals learn to use sexual fantasy and sexual behaviour as compensa-
tory strategies.
Sexual addiction can therefore be understood, in part, as a dysfunctional
response to early traumatic attachment patterns. The use of sexual fantasy, over-
frequent masturbation and the excessive use of internet for sexual purposes all
represent efforts to regulate or escape from painful affect. The negative affect state
is left behind and replaced with erotic oblivion, hence there is double reinforce-
ment. There is an impaired ability to otherwise self-soothe. I call these attachment
patterns ‘traumatic attachment patterns’ because they are created by subtle, and
not so subtle, deficits in the relationship between the child and his caregiver. They
give rise to an uncertain and empty sense of self, unusually high levels of shame
and general dysphoria. These are often defended against by outward confidence,
academic excellence, zealous work, pursuing respected professions, winning pub-
lic office and seeking celebrity. In the treatment of sexual addiction, it is important
that these patterns, left over from impaired attachment, are reflected in the treat-
ment goals and objectives.
 Trauma and attachment 141

Content
This chapter presents the following propositions:

• Aetiology of traumatic attachment: attachment trauma gives rise to pervasive

negative feeling states with few internalised management techniques. Thus,
patients come to rely upon substances or behaviours to regulate their internal
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feeling states, one of which is sexual behaviour.

• Treatment of traumatic attachment: the creation of a stable alliance between
the patient and the therapist is essential for the establishment of safety.
The traumatic events are retold with an experience of the original affect.
This is done in the context of a safe place and with a safe person. There
follows a narrative reconstruction of the events and the teaching of affect
self-management techniques. This combination of treatment components
contributes to resolution.

This chapter also considers examples from clinical practice. It reviews the con-
cept of attachment, explores the sequelae of traumatic attachment and introduces
appropriate treatment strategies. Group therapy for trauma is discussed. The chap-
ter draws upon attachment theory and the application of cognitive behavioural
techniques to the process of analysis and treatment.

Traumatic attachment
In clinical experience, almost every sex addict with whom I have worked has a
history of traumatic attachment. Here are some examples.

Robert compulsively used internet pornography to manage anxiety. He did this

at work and subsequently lost a well-paying job. He described his father as
‘very strict’ and his mother as ‘selfish’. They were not a close family and there
were no close bonds. He began masturbation and told me that he “perpetually
did it”. He was an American and, under British law, the severity of the beatings
from his father would constitute child abuse.
Saul was an aeronautic engineer. His father created a mini-friend relation-
ship with his son and did not fulfil the responsibilities that come with father-
hood. His mother divorced his father and remarried a man who treated Saul
harshly. There was considerable cruelty. He describes his mother as emotion-
ally and physically distant. He had many different childminders. He witnessed
a great deal of violence in the relationship between his mother and stepfather.
Saul, although married with a son, was obsessed by pornography and had fre-
quent sexual encounters with random women.

(continued)
 142 Trauma and attachment

(continued)

Roger describes his mother’s face as either one of extreme panic or, alterna-
tively, expressionless. This is a reminder of the ‘still face experiment’ conducted
by Dr Edward Tronick at the University of Massachusetts ([Link]/
watch?v=apzXGEbZht0 [accessed 8 May 2014]). In his experiment, after a
period of play, the child is presented with the mother’s still face. This causes the
child great distress. Roger’s mother was both hostile and seductive. He yearned
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for a genuine mother and became greatly attached to an aunt. He was bullied at
school. He had a lifetime of serial relationships, preferring women in fantasy.
Cross-dressing was part of his sexual repertoire.

As therapists, in all these cases and in countless others, we are not just called to
end the compulsivity of sex but also to treat the traumatic foundations of resorting
to addictive substances and behaviours. In reviewing my case material, there are
repeated examples of abuse and neglect. One patient described his childhood as a
‘concentration camp’. These examples are commonplace in the life stories of the
sexually addicted. Sexual addiction can be a solution to the painful feeling states
caused by disturbed attachment and traumatic injury.
Often there is little self-recognition among clients of their own history of trau-
matic attachment. Some simply disbelieve that the past has anything to do with
the present. Others are obeying unconscious family rules, such as ‘never speak ill
of your parents’. Most blame themselves. To be with Roger and others like him is
to be in the presence of toxic and self-borne shame. Carnes (2001) suggests that
shame is the most powerful driver of the addictive process. It is the invariable
outcome of traumatic patterns of attachment. A full analysis of the role of shame
in sexual addiction can be found elsewhere in Chapter 5.

Attachment
Attachment styles continue throughout the lifespan. They can be adjusted by
the intake of new information – in particular, by the replacement of the original
attachment relationship with a new corrective attachment experience. Such an
experience can come through new and different relationships. The therapeutic
relationship can provide a place of stability. The cohesive group can be a safe
haven. Alternative methods of self-soothing can be learned to replace the addic-
tive soothing processes.
Addictive processes emerge from an impairment of the self-regulatory sys-
tem, which occurs as a result of traumatic attachment. Goodman writes that
‘impaired internal regulation of their subjective states leads individuals to
depend upon external actions to regulate their subjective states and to cope
with the subjective consequences of internal dysregulation’ (1998: 175). He
continues:
 Trauma and attachment 143

Impaired affect regulation involves 1) affect regression tendencies 2) deficient

ability to utilise anxiety and other affects as signals; and 3) impaired tolerance
of painful affect. To the extent that affect regulation is impaired, emotional
states tend to be unstable, intense and disorganising.
(1998: 176)

In effect, this means that the patient turns to addictive substances or processes to
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manage unruly, overwhelming and painful affect states. Sexual behaviour is one
means of temporarily accomplishing this goal.

Traumatic disappointment
The insecurely attached individual has few inbuilt management techniques to han-
dle negative emotion. These affect states are frequently set up by patterns of trau-
matic attachment. Sexual preoccupation is often used to manage anxiety. Follette
and Pistorella write that ‘many people who have been traumatised experience
depression, sadness or loss of meaning in life’ (2007: 20). Briere and Scott (2013)
also considers depression as an outcome of traumatic disappointment, writing
that ‘exposure to traumatic events can produce a range of depressive symptoms’
(2013: 25).
We frequently witness a correlation between high levels of anxiety and sex-
ually compulsive behaviour. Allen (2005) writes about the 90–10 proposition:
when we experience a powerful emotion (especially fear), 90 per cent is based on
the past and 10 per cent relates to the current presentation. The past includes our
history of disturbed and traumatic attachment experiences. Van der Kolk makes
the point that ‘chronic physiological hyper-arousal to stimuli reminiscent of the
trauma is a cardinal feature of the traumatic response’ (1989: 349). He goes on
to write:
When the persons who are supposed to be sources of safety and nurturance
become simultaneously the sources of danger against which protection is
needed, children manoeuvre to re-establish some sense of safety. Instead of
turning on their caregivers and thereby losing hope of protection, they blame
themselves.
(1989: 344)

This gives rise to the twin conditions of anxiety and shame. Van der Kolk writes,
‘Childhood abuse and neglect may cause a long-term vulnerability to be hyper-
aroused expressed on a social level as decreased ability to modulate strong affect
states’ (1989: 359). Briere and Scott are even more explicit, asserting that ‘the
degree to which we can regulate ourselves is determined by the length and strength
of our earliest attachment experience’ (2013: 54).
In every group that we run, at least two out of ten men act out on loneliness.
There is an existential sense of loneliness accompanied by fears of abandonment.
 144 Trauma and attachment

In clinical observation, this is associated with maternal deprivation. It manifests

itself in an addictive pattern that is predicated on female responsiveness. How-
ever, one response is never enough. This addictive process shows itself in webcam
behaviour, text messaging and the exchange of sexually explicit photographs.
The behaviours that emerge from traumatic attachment are the behaviours of
addiction: substance abuse, alcohol misuse, sexual addiction, gambling, com-
pulsive shopping and spending. Flores tells us that ‘there is a high correlation
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among a variety of dysfunctional, destructive behaviours including sexual com-

pulsion/addiction, paraphilia, addictive relationships, kleptomania, compulsive
spending, embezzlement, gambling and self-injury’ (2004: 6). He adds, ‘Indi-
viduals who have difficulty establishing emotionally regulating attachments are
more inclined to substitute drugs and alcohol for their deficiency in intimacy’
(2004: 7). These behaviours, in their addictive form, are used to manage negative
affect. The solution then becomes the problem. With sexual addiction, the prob-
lem emerges from the potential and real harmful consequences. The behaviour
suspends the problem but provides no lasting cure. Many substance abusers are
survivors of traumatic attachment and have ‘diminished affect regulation skills’
(Briere and Scott 2013: 163). Briere and Scott go on to write that trauma creates
‘feeling states that are easily triggered and hard to accommodate and survivors
are forced to rely on emotional avoidance strategies such as dissociation, sub-
stance abuse or external tension reduction activities’ (2013: 111).

Unmet developmental needs

Walant (1995) views addiction as a way of coping with the traumatic effects of
unmet developmental needs. From Walant’s perspective, addiction is a ‘disease
of isolation’ (Flores 2004: 148). Affiliation is an important mechanism for self-
soothing. This explains the power of the therapeutic relationship or the group
process in the regulation of negative affect states. These new patterns of affili-
ation can repair some of the deficits created by non-optimal caregiving. These
patterns are underpinned by observations from neuroscience. Flores writes that
‘During critical times of development, if children have been provided a poor
attachment experience, their brain shows less opiate receptor density. Con-
sequently, it is more difficult for them to regulate their affect and self-sooth’
(2004: 123). Van der Kolk is more explicit, stating: ‘people who were neglected
or abused as children may require much higher external stimulation of the endog-
enous opioid system for soothing than those whose endogenous opioids can be
more easily activated by conditioned responses based on early caregiving experi-
ence’ (1989: 359).
Van der Kolk (1989) ties three important factors together: sub-optimal attach-
ment patterns in the family of origin, neuroscientific information and addictive
behaviour. We find that sex addicts use sexual behaviour as a way of regulating
uncontrollable and hard-to-endure feeling states.
 Trauma and attachment 145

The effects of disturbed attachment have consequences for the individual’s

ability to manage and sustain long-term meaningful relationships. We find in our
treatment programme that some men have a lifetime of successive relationships:
some have married and remarried, some develop non-sexual relationships with
partners and some endure profoundly abusive relationships. Briere and Scott write
that ‘formerly abused or neglected individuals may find themselves in conflictual
or chaotic relationships later in life’ (2013: 176). They may have problems form-
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ing intimate relationships and may behave in a manner that harms or threatens
close relationships. In our experience, sexual addiction is frequently accompanied
by the fading of the sexual relationship with an intimate partner. Once the sexual
addiction is disclosed, the partner is traumatised. It may cause the relationship to
falter and eventually fail. Failure of such relationships will not just cause hard-
ship to both concerned, but will also render consequences for the children of the
relationship.
Shame is another outcome of traumatic attachments. Allen writes that ‘shame
is a common facet of trauma . . . trauma events render you helpless, the very core
of shame’ (2005: 7). The sex addict uses sexual behaviour to alleviate an experi-
ence of shame. The behaviour itself causes more shame in a never-ending cycle of
repetition, which is combined with self-blame.
While the outcomes of the treatment of trauma are under-researched, most
research on the effectiveness of treatment for post-traumatic stress disorder has
focused on the use of cognitive behavioural therapeutic approaches. These tech-
niques have the advantage of having undergone the most research (Allen 2005).
The treatment plan that follows is drawn from CBT and therapeutic approaches to
the treatment of trauma. Cognitive interventions include a detailed verbal explora-
tion of the traumatic event that allows the patient to hear assumptions, beliefs and
perceptions (Briere and Scott 2013). These then become available for modifica-
tion. Research supports the notion that CBT induces change in the self and world
schemas. These help people to realise that they are competent and that the world
is not inherently dangerous. Foa writes, ‘As is apparent from the data, cognitive
behavioural therapy corrects evaluations of oneself and of the world’ (2006: 421).

Cognitive behavioural therapy for trauma

The central tenets of cognitive behavioural treatment for trauma can be summa-
rised as:

• Creation of the alliance and establishment of safety

• Grounding exercises
• Re-experiencing of the trauma in a counter-activated environment
• Construction of a coherent narrative
• Cognitive restructuring and core belief modification
• Reconnection to life.
 146 Trauma and attachment

These interventions provide an approach to working with victims of trauma. They

are of relevance to working with sex addiction because, as we have seen, trau-
matic injury grows out of disordered attachment.
As noted in previous chapters, CBT has not emphasised the importance of the
therapeutic relationship. I suggested in Chapter 4 on the therapeutic alliance that,
in working with the sexually addicted, it is important to recognise the efficacious
nature of a good therapeutic alliance. In this work with the traumatised, the nature
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and safety of the relationship becomes the foundation of all other applications
and interventions. According to Briere and Scott, ‘Bowlby described the essence
of healing from trauma as ‘exploring painful feelings with a trusted companion’
(2013: 30). Briere states that ‘the core of trauma treatment comes down to talk-
ing about the traumatic experience in a trusting relationship, mentalizing in the
context of secure attachment’ (Briere and Scott 2013: 249). In this sense, the
role of the therapist is to become a ‘good enough’ attachment figure. Allen also
emphasises that ‘secure attachment is the antidote to trauma’ (2005: 35). This is
a concept shared with Young et al. (2003) and fits with the concept of ‘limited
re-parenting’.
The attachment provided by the therapeutic relationship, or by a cohesive
group process, provides self-soothing and self-regulation. Attachment theory sug-
gests that substance abusers remain vulnerable to relapse until they are able to
establish mutually satisfying relationships (Flores 2004). It is further emphasised
that there is a neurobiological basis underpinning this process (Briere and Scott
2013). The therapist becomes an attachment figure for the patient. In order for this
to happen, the therapist needs to display high levels of congruency, compassion
and sustained empathetic presence. In this context, the cognitive and behavioural
processes of treatment can then be applied. Without this attachment, there is little
hope of working effectively with the interventions for trauma repair. This applies
both to individual therapy and to group work, although, in the latter, the group
itself provides a variety of attachment opportunities. These new attachments pro-
vide an experience that can correct the older disturbed patterns of attachment.
They also provide a soothing of discordant affect states through human contact.

Patient safety and autonomy

The first priority in treatment is to establish the safety of the patient. This includes
‘site safety’, which extends to the consulting room and to the waiting area. Differ-
ent therapists will have different ideas about how this would look in practice, but
it is important for these areas to be comfortable, clean and tidy, without excessive
noise or interruption. The second condition for safety involves handing control
for the pace of the therapy to the patient. People who have suffered from trauma
or from traumatic attachment must be allowed to move forward according to their
own judgement. At the basis of trauma is the absence of control; this is exactly
the experience of a child growing up in abusive or neglectful families, and the
therapeutic process needs to provide the opposite experience.
 Trauma and attachment 147

Grounding
In the process of establishing safety, it is vital to provide the patient with grounding
techniques. These are techniques that can be used to bring the patient gently back to
the present. They prevent the patient from becoming locked into a traumatic mem-
ory. We teach these methods of self-soothing to sexual addicts, most of whom lack
internalised methods of emotional self-care. These techniques include compassion-
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ate mindfulness exercises, meditation, breathing training, diaphragmatic breath-

ing, visualisation exercises and progressive muscle relaxation. We also encourage
yoga and, when appropriate, we encourage prayer, particularly the rosary. This
form of prayer is rhythmical and gives the person something to hold. It also uses
finger movements that are in themselves relaxing. We take people through a ‘safe
place’ exercise, which consists of visualising a safe place, describing it in detail,
considering its colours, sounds and smells, and considering who might be there.
One patient described his safe place as “sitting alone on a rock in Cornwall looking
out at St Michael’s Mount”. In effect, this exercise creates a portable form of ‘site
attachment’ (Allen 2005). All, or any, of these grounding techniques are taught to
recovering sex addicts to help them manage unwieldy emotional states.

Safe place
There are two approaches to mastering fear (Allen 2005): calming techniques and
the exposure to fear in a safe environment. In the latter, the experience of fear is
paired with a safe place, leading to the extinction of the fear. This process involves
exposure to stimuli that are reminiscent of the trauma, triggering memories and
activating the original emotional content (Briere and Scott 2013). This is done in a
safe place and with a safe person, thus creating counter-activation. In other words,
going through the trauma in a safe place with a safe person connects the traumatic
memory to the opposite emotional experience to the initial trauma, leading to the
extinction of the original affect state. In order for this to happen, the original fear
state has to be invoked; otherwise it is not available for attenuation. This also
gives a patient the opportunity to challenge some of the cognitive distortions that
might be held around the traumatic incident, particularly the attribution of respon-
sibility, and to reflect upon more realistic or hopeful perspectives.

Reattribution of responsibility
In working with traumatic attachment, the reattribution of responsibility is important.
Children are indeed helpless and must configure themselves to their environment to
maintain connection with the caregiver. The responsibility lies with the caregiver.
Over and over, I work with people who have internalised a malignant sense of self.
As a child, it is not possible to attribute error to the caregiver, and consequently the
self is made the mistake. To be in the presence of a new reparative attachment figure
makes a difference, but, when this is combined with an exploration of the original
 148 Trauma and attachment

issues, the effect is enhanced. In this, and in other components of trauma therapy,
well-phrased and gentle Socratic questioning is useful in creating new perspectives
on the original attachment uncertainties. As Briere and Scott write, ‘open-ended
questions . . . allow the client to progressively examine the assumptions and inter-
pretations made about the victimization experience’ (2013: 128). ‘Victimization’
may seem, at first glance, too strong a word, but in my experience those who have
experienced traumatic attachment patterns are victims of trauma. The only differ-
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ence is the time frame: they have been raised in a family that constantly led them to
believe that they were worthless. This is an experience of trauma in which they are
helpless and without means of escape.
Traumatic memories are remembered in fragments. Foa makes the following
point:
Clinical observations suggest that trauma narratives recounted by clients with
chronic PTSD [post-traumatic stress disorder] are characterised by speech
fillers, repetitions, and incomplete sentences; time and space in these narratives
are disconnected, and thought utterances reflect confusion. Foa and Riggs
hypothesized that the natural process of recovery involves organising and
streamlining of traumatic memory. They further suggest that individuals who
fail to organise this narrative would exhibit more trauma related disturbances.
(2006: 414)

Both Foa (2006) and Briere and Scott (2013) take the view that increased coherence
in the provision of the narrative is effective in the reduction of symptoms. In indi-
vidual therapy and in the group process, this is achieved by working on the ‘trauma
egg’ (details of which can be found in Chapter 6 on the principal interventions), as
well as in the preparation of the personal presentation. Both these mechanisms are
done in the presence of supportive others. The advantage of the group process is that
there are more insights and that these come from peers rather than professionals.

Cognitive restructuring
Cognitive restructuring is the development of the ability to mentalise, and there-
fore the development of a reflective self. Through Socratic questioning and sensi-
tive contributions by the therapist to a patient’s reflections, the patient is able to
expand the part of their mind that can observe the mind. Another term for this is
‘metacognitive awareness’. It is one thing to be afraid; it is another to know that
your fear schema has been activated. Even this basic understanding changes the
nature of the process. Allen writes that:
Negative views about the self-promote feelings of helplessness and guilt, and
unrealistic beliefs about the dangerousness of the world contribute to a feeling of
on-going threat, fuelling worry, anxiety and dread. Any therapy for trauma will
address these beliefs, but cognitive restructuring makes them a primary focus.
(2005: 263)
 Trauma and attachment 149

This allows the patient to begin to understand that these are internal processes of
the mind and not necessarily reality. CBT allows for the cognitive reconsideration
of inaccurate thoughts about the self, others and the world. Foa writes that ‘the
three psychological factors involved in the successful processing of a traumatic
event are: emotional engagement with the traumatic memory, organisation and
articulation of the traumatic narrative, and modification of basic core beliefs about
the world and one’s self’ (2006: 422). Each of these is transferable to working with
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traumatic attachment. Additional behavioural techniques may include improving

self-care, social skills, reconnection with others, journal writing, assertiveness
training, communication skills, stress management, problem solving, nutrition,
exercise and an encouragement to join self-help groups (Sanderson 1995). It is
worth noting that, in the case of trauma, medications do not mend the problem and
have less impact than psychological therapy (Briere and Scott 2013).
At our clinic, we use group work to facilitate recovery from sexual addic-
tion. Briere and Scott write that ‘although systematic research on the effective-
ness of group therapy for trauma survivors lags behind research on individual
therapy, the studies that have been reported are encouraging’ (2013: 265). It seems
to me that, to some degree, our groups provide trauma repair, in the sense of
focusing on attachment trauma. Group affiliation itself has been shown to further
self-soothing. This seems not to be without a neurobiological base. Van der Kolk
writes that ‘there is now considerable evidence that human attachment is, in part,
mediated by the endogenous opiate system’ (1989: 356). He continues, ‘in recent
years knowledge about the brain circuits involved in the maintenance of affilia-
tive behaviour are precisely those endowed with opioid receptors’ (Van der Kolk
1989: 357). The ‘trauma egg’, mentioned earlier, explores traumatic attachment
issues and the personal presentation, used in individual and group work, creates
a coherent narrative. Although incidental to trauma work in their construction, it
is clear that these represent aspects of trauma treatment. The group process cre-
ates an end to isolation, and is thus of substantial benefit to those with attachment
trauma. At each session, there is ‘check in’ and additional time for sharing. Often
these shares are either about current distress or historic attachment trauma. The
groups also seriously consider alternatives to sexual acting out in the development
of rewarding and meaningful activities, and social contacts. In doing this, they
further the process of recovery, not just from sexual addiction but also from the
long-term effects of attachment trauma.

Conclusion
While it would not be possible, without further training, to do trauma recovery
work per se with those in recovery for sexual addiction, it is possible to note the
character of trauma work and integrate aspects into the overall treatment package.
Grounding exercises, repetition of the trauma with the accompanying affects and
the creation of a narrative, aid recovery by attending to the sequelae of causation.
 Chapter 12

Cross addictions and comorbid

disorders
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Introduction
Cross addictions and comorbid disorders come in all sizes, shapes and
­combinations. Sex addiction is often preceded by alcohol use, alcohol being the
gateway drug into addictive sexual behaviour. Frequently, alcohol and cocaine
are combined into a cocktail and used before, or alongside, sex. Some people use
food as a primary self-soother. For others, their patterns involve highly exciting
and challenging occupations and pastimes. Sex is an exciting alternative to a life
experienced as boring. Comorbid disorders often accompany sexual addiction.
For ease of classification, the problems that accompany sexual addiction are sepa-
rated into two categories: cross addictions and comorbid disorders.

Cross addiction
There is a clear relationship between sexual addiction and the problematic use of
alcohol and drugs (Albrecht et al. 2007; Garcia and Thibaut 2010; Hudson-Allez
2009; Schwartz 2008). According to Hartman et al. (2012), 40–60 per cent of
sex addicts have a substance use disorder as well. We frequently have men in
our treatment programme for sexual addiction who have made a good recovery
from drugs and alcohol but cannot overcome ‘out-of-control’ sexual behaviour.
The high prevalence of substance use co-presenting with ‘out-of-control’ sexual
behaviours suggests a shared aetiology (Albrecht et al. 2007). The aetiology for
most addiction, to behaviours and substances, is in disturbances in the family of
origin that give rise to poor affect regulation. The impairment of affect regulation
steers a person in the direction of substances and addictive behaviours.
Behavioural addictions are different from ingested substances. With an ingested
substance, once the top is on the bottle, the body eventually becomes accustomed
to the absence of the substance. With behavioural addictions, the reward mecha-
nisms are internally generated. This is particularly relevant when considering the
neurochemistry of sexual addiction. The body is biologically programmed to be
sexual, and this programming needs to be considered when attempting to deal
with addictive urges. For many, it is unclear whether an urge is just a response
to a naturally implanted drive or whether it is a response to an addictive trigger.
 Cross addictions and comorbid disorders 151

It is more difficult for men with addictive patterns of sexual behaviour to be

definitively clear about the distinction between the addictive urge and the biologi-
cal mandate. In sexual addiction, sexual behaviour is used to self-medicate nega-
tive affect states (Wolf 1988). The use of alcohol and drugs has the same purpose:
to medicate or anaesthetise negative affect states.
Addictions do not present in a side-by-side way but rather they interact to
‘become a package’ (Hartman et al. 2012: 290). Addiction specialists have recog-
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nised that addictions are characteristically interconnected. These interconnections

have been described as follows:

• Switching: Suspending one compulsive behaviour but initiating a new one.

• Masking: One addiction masks or excuses another.
• Fusion: More than one addiction needs to be present for the other to work.
• Ritualizing: One addiction is part of the ritual for another.
• Numbing: Shame about one addiction is numbed by another addiction.
• Disinhibition: One addiction lowers inhibitions for another addiction.
• Alternating: An ingrained pattern of alternating from one addiction to
another.
• Intensification: Mutual addictions intensify each other.
(Flores 2004: 8)

I suggest that underneath all addictive processes are the implications of narcissistic
damage: the self experienced as deficient and unacceptable. Flores writes that ‘sub-
stance abusers continue to substitute one compulsive, potentially addictive behav-
iour for another until they are forced to face the gnawing emptiness and intolerable
anxieties that drive their substance use’ (2004: 11). Gnawing emptiness and intoler-
able anxiety are by-products of narcissistic damage and attachment trauma.
When sexual addiction presents with another addiction, it is difficult to decide
the first thing to treat. How do you prioritise the interventions and order their
sequence? In my experience, when there is seriously mood-changing use of sub-
stances of abuse, this must be dealt with before the sexual addiction. The sub-
stances so alter consciousness and disinhibit that further work is not possible.
We have had men in our recovery groups who are multiply addicted, usually to
alcohol and cocaine, but the recovery results are very disappointing. We get bet-
ter results when the co-addiction is limited to alcohol but, when alcohol and sex
are fused, the combination becomes more problematic. I would suggest that the
patient needs to have made a reasonable recovery from alcohol and recreational
drugs before embarking on sexual addiction recovery. This is not always true and
the circumstances of each patient must be considered. It is, in the final analysis, a
matter for clinical judgement.

Comorbid disorders
The presence of particular comorbid conditions suggests that these are related
to addictive processes. The negative affect states created by comorbid disorders
 152 Cross addictions and comorbid disorders

are experienced as intolerable. The relief is delivered by substances or ­addictive

behaviours. However, the presence of these disorders also suggests that they,
along with the addiction, emerge from a common origin. Shame is an example.
The sexual behaviour is used to anaesthetise feelings of shame but also cause
feelings of shame. In my view, the shame precedes the sexual behaviours and
is, in the first place, independent of it. In all these combinations (sexual addic-
tion and comorbid disorders), the sexual addiction is used to manage the pain-
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ful feeling that is created by the comorbid condition. Sexual addiction (Schwartz
2008) becomes a mechanism for the management and control of negative internal
feeling states. Hudson-Allez asks the question, ‘And why are we surprised when
insecure, lonely, stressed or depressed individuals use sex as a way of trying to
change how they feel about themselves?’ (2009: 181).
Kafka writes that sexual addiction can be conceptualised as a ‘sexual dysregu-
lation disorder in comorbid association with a mood disorder’ (1991: 63). Trauma
theory would assign childhood trauma as a causative factor in the development of
sexually compulsive behaviours (Chaney and Chang 2005). Such sexual behav-
iours are seen as ways in which there is regulation of the internal feeling states
(Schwartz 2008). Internet addicts find that the internet is a ‘tool to cope with
life’s problems’ (Young 2007: 672). Bancroft and Vukadinovic (2004) write that
there is a negative mood and increased arousal in men with ‘out-of-control’ sex-
ual behaviour. There is considerable evidence (Carpenter et al. 2013; Hall 2013;
Naficy et al. 2013; Young 2007) that one of the functions of sexual addiction is to
regulate the painful feeling states associated with comorbid disorders.
High levels of anxiety and depression are commonly reported, generally,
within addicted populations. Vesga-Lopez et al. (2007) write that studies consist-
ently document the following comorbid issues in addicted populations: dysthy-
mia, depression, anxiety disorders, phobias, generalised anxiety disorder, adult
attention deficit disorder and substance abuse. Raviv (1993), writing about sexual
addicts and pathological gamblers, notes that research, from 12 sources, cites that
addicts have elevated levels of anxiety, depression, obsessive compulsiveness and
interpersonal sensitivity than do non-addicted groups. Problematic sexual behav-
iour is an attempt to ‘manage stress, reduce anxiety, ward off boredom, loneliness,
depression, express frustration and bolster a fragile ego’ (Southern 2008: 705).
Ceyhan and Ceyhan (2008), in their research with students on problematic inter-
net use, take the view that previously existing psychopathologies of individuals
could provoke the development of excessive internet behaviours. I hypothesise
that in all cases, in effect, the psychopathology precedes the sexually addictive
behaviour.
Research has linked sex addiction to loneliness, depression, anxiety, psycho-
somatic illness, unhappiness and feelings of emptiness (Torres and Gore-Felton
2007). In our clinical work, we find that the most common comorbid disorders are
depression, loneliness, anxiety disorders, boredom proneness and the shame that
results from chronic low self-worth. Boredom, shame and loneliness are not medi-
cal disorders although all are debilitating. In each case, we find that the distinctive
 Cross addictions and comorbid disorders 153

feature of sexual addiction is its function. It is the use of sex primarily to relieve
a negative feeling state rather than sex in the service of recreation or procreation.

Depression
When depression is comorbid with sexual addiction, it is important to treat the
depression as a priority before the sex addiction, simply because depression robs
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the will to recover. Comorbid depression is a ‘block to recovery’ (Hall 2013: 178).
The reduced activity characteristic of depression leads to hopelessness, and hope-
lessness makes it impossible to build recovery. In clinical practice, it is possible
to work on sexual addiction and depression at the same time, but in such cases
the sexual addiction is treated in group and the depression in individual psycho-
therapy. It is also important to treat the problem identified by the patient as the
most significant. The therapist should be guided by the patient’s priorities. The
mechanisms for working with depression will be familiar to cognitive behaviour
therapists: behavioural activation and cognitive restructuring.

Loneliness
In every recovery group of sex addicts, there are usually two or three who act out
on loneliness. This is an existential experience. In taking the initial history, we
look in particular for their sense of themselves at school, looking out for words
like ‘outsider’, ‘did not fit in’, and ‘loner’ to describe the school experience. We
also try to get a sense of the attachment style, looking particularly for avoidant and
ambivalent attachment styles.
There is evidence that loneliness accompanies and is increased by internet
usage. Research done by Yoder et al. on the use of internet pornography showed
a ‘significant association between Internet pornography usage and loneliness’
(2005: 19). Ceyhan and Ceyhan (2008) showed that loneliness was a significant
predictor of problematic internet use. Griffiths in another study on internet sexual
addiction noted that those students who did not use the internet for sexual pur-
poses were ‘more content with their lives’ (2011: 119). The Stanford Institute for
the Quantitative Study of Society found that the internet could lead to loneliness
and a decrease in social relatedness (Young 2007). In a survey of 396 online
addicts, Young found that social isolation was present in 56 per cent of those
surveyed.
Loneliness and isolation are approached in CBT using social skills training,
encouragement of social interaction, group work and through the therapeutic
relationship. When the loneliness gives way to social anxiety, standard cogni-
tive behavioural protocols can be used. This would include guided discovery,
a case conceptualisation and formulation to make the problem understandable,
working to change negative automatic thoughts and creating a hierarchy of
safety behaviours to be dropped incrementally. Behavioural experiments can be
used. In some cases, we video the patient and, in advance, ask him to rate the
 154 Cross addictions and comorbid disorders

quality of his anticipated performance. We then show him the tape of his actual
­performance in the feared situation (i.e. public speaking, signing a cheque,
standing and making small talk).This process provides evidence that discon-
firms the self-perception.

Anxiety
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A large number of patients in our programme present with comorbid anxiety dis-
orders. CBT generally sees features of human behaviour on a continuum rather
than as binary categories of order and disorder. The following illustrates the links
between anxiety and sexual addiction: one patient realised that he acted out sexu-
ally in direct response to situations and circumstances that created high levels of
anxiety. This was particularly acute when his wife threatened to leave him. This
particular patient had an anxious–ambivalent attachment style and scored high
on Young’s Schema Questionnaire in the ‘fear of abandonment’ category (2003).
One of the tasks in treatment was to treat the anxiety that triggered the addictive
behaviour.
In a survey of German sex therapists, Briken and colleagues (2007) found that
sexual addiction was accompanied by a ‘high rate’ of psychiatric disorders: 40 per
cent anxiety, 70 per cent mood disorders and 30–50 per cent substance abuse dis-
orders. Raymond et al. (2003) in a small-scale research project (23 participants)
assessed the prevalence of psychiatric disorders in people with compulsive sexual
behaviours and found a high percentage with Axis I disorders (acute symptoms
that need treatment) and Axis II disorders (predominantly personality disorders
or intellectual disabilities): 33 per cent mood disorder, 42 per cent anxiety and 39
per cent with cluster C personality disorders. Lifetime prevalence of an anxiety
disorder was high at 96 per cent. Raymond et al. (2003) note that treating concur-
rent Axis I disorders, such as depression and anxiety disorders, with medications
does not, in their clinical experience, eliminate sexual acting out. However, it
is difficult to eliminate sexual acting out ‘without treating the Axis I disorders’
(Raymond et al. 2003: 375). Although a small study, it suggests that there are high
levels of anxiety associated with compulsive behaviour, and that both the addic-
tion and the anxiety disorder need to be treated. However, the anxiety is manifest,
be it in generalised anxiety disorder, worry about worry, social anxiety or health
anxiety, and it is effectively treated using routine cognitive behavioural protocols.
A common anxiety presentation with sexual addiction is a preoccupation
with sexual health. This usually comes as a fear of HIV/AIDS. Three men were
recently in treatment, all with a debilitating fear of HIV/AIDS. In each case,
they recognised that the fear was unwarranted and irrational. One man had
kissed a woman and another had been masturbated. Their safety behaviours
were to seek reassurance and to be tested. If their health anxiety were effec-
tively treated, it would ease their personal distress and end their unnecessary
repetitive testing.
 Cross addictions and comorbid disorders 155

Boredom proneness
There is a class of sex addict in which the addiction to sex is combined with a prefer-
ence for high adrenaline activities – for example, sky diving, para-sailing, helicopter
skiing, racing cars. These men often turn up at the practice on motorcycles. There is
one patient who heads off to the continent at the weekend travelling by motorcycle
and certainly driving at 100 miles per hour. It is as though the volume control on the
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routine in life is turned down low. They seem to need higher levels of excitement
to make life worthwhile. For some, the excitement of fear has become fused with
sexual behaviour. Chaney and Chang (2005), drawing on Mikulas and Vodanovich
(1993), describe boredom as a state of minimal arousal and dissatisfaction. A num-
ber of other researchers ‘found significant relationships between boredom prone-
ness and depression, anxiety, hopelessness and hostility’ (Chaney and Chang 2005:
6). Whatever the cause, the individual turns to sexual behaviour and fantasy.
Chaney and Chang (2005) make the connection between the alleviation of
boredom and the provision of excitement. In a study of men who have sex with
men, they note the importance of boredom proneness. They assert that the bore-
dom prone are more likely to use alcohol, drugs and engage with pathological
gambling. Boredom is the outworking of an alienation from the self. The self is
experienced as impoverished and demeaned and, therefore, there must be distrac-
tion. Sexual behaviour operates as an effective distraction that not only distracts
but, at the same time, gives a powerful reward. Pascal wrote in the Pensees (1669)
that all humanity’s problems stem from man’s inability to sit quietly in a room
alone. I take this to mean that it is our own internal alienation that does not allow
us to sit quietly. It demands that we escape from the self, and the conflicts of the
self, into internet pornography or some other addictive behaviour.

Low self-esteem
Low self-esteem is the one common feature that appears and reappears in work-
ing with the sexually addicted. Baumeister (1991) points out that many forms of
addiction are associated with low self-worth. He writes ‘that for a brief moment
they leave behind a painful lonely existence and are transformed by their acting
out’ (Baumeister 1991: 27). Kor et al. (2013) conclude that the most common
ensuing behaviours are masturbation, compulsive use of pornography, cruising
and multiple relationships. The outworking of low self-esteem is the experience
of shame. I have written extensively elsewhere about the nature of shame. Shame
is reduced in a non-judgemental and good-quality therapeutic relationship. It is
particularly reduced in the process of group work. In addition, there is a range of
cognitive behavioural tools available for the restoration of self-worth. In this prac-
tice, we use asset lists, ‘catch the critical’ voice worksheets, anxious predictions
and thought records among other tools for working with low self-esteem. The
single most important way to raise self-esteem is to stop acting out. The process
 156 Cross addictions and comorbid disorders

of endless repetitive episodes of acting out eventually wipes out even a vestige
of self-esteem. Creating a situation where men begin to leave behind unwanted
sexual behaviours makes a powerful contribution to the emergence of nascent
self-worth.

Cognitive behavioural therapy

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Cognitive behavioural therapists are well placed to treat sexual addiction. The
interventions for sexual addiction are cognitive and behavioural. There is an abil-
ity to work with cross addiction and comorbid disorders. For example, people
with negative core beliefs are the ones most drawn to the use of the internet for
sexual purposes (Young 2007). Cognitive restructuring should be used to address
negative core beliefs and cognitive distortions (Young 2007).
Young (2007) asserts that CBT is effective with substance abuse and emo-
tional disorders. She writes that ‘researchers have suggested cognitive behaviour
therapy as the treatment of choice for Internet addiction and addiction recovery in
general has utilized cognitive behavioural therapy as part of treatment planning’
(2007: 671). It is my view that CBT is the modality of choice in the treatment of
all forms of sexual addiction and the accompanying cross addiction and comorbid
disorders.

Conclusion
This chapter has looked at cross addictions and comorbid disorders. The prob-
lems that have been chosen for discussion in this chapter are those that have fre-
quently presented in our clinic. Comorbid disorders might be better described as
co-­occurring negative feeling states. What makes a disorder a disorder? There
is an experience of painful affect combined with a subjective impairment. All
comorbid disorders and cross addictions grow out of narcissistic wounding and
attachment trauma. Therefore, I hypothesise that all have a common aetiology.
 Chapter 13

Conclusion
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There are three things on my mind as I come to the end of this book. These three
things are not especially connected but neither are they completely separate. The
first thing that has worried me for some time is the pathologising of male sexu-
ality. This is the tendency to see the a particular attribute of male sexuality as a
disorder or, indeed, something worthy of disapproving investigation. The second
is that, by writing about the treatment of sexual addiction, this will be taken to
mean that I am joining forces with those who would attempt to define acceptable
and unacceptable sexual patterns. That would be completely wrong. I regularly
say to patients ‘it is only a problem if it is a problem’. Finally, we are in the middle
of a paradigm shift. There is a change in thinking about the nature of addiction.
This has shifted from substances only and now includes the concept of addic-
tion to behaviours. This is largely driven by the new work in the neuroscience of
addiction.

Male sexuality: a pathology?

My first observation is that there is a tendency to make male sexuality a pathol-
ogy. Male sexuality is, by its nature, linear and goal orientated. In our species,
women attract and men are attracted. Women know this intuitively and this is why
they dye their hair, wear short skirts, have breast enhancements, paint their nails
and wear perfume. This is why men look, stare, wolf-whistle, follow, approach
and try to obtain a telephone number. This is just the way it is.
There is also great power to the sexual drive. Little in the human experience
is so powerfully reinforced. As I wrote in Chapter 3 on neuroscience, addiction
raises questions about the nature of volition. If with repetition, a man’s neuropath-
ways are predisposed to sexual behaviour, this raises questions about the nature of
choice. Arousal chemistry shuts down other considerations and allows no appeal
to higher-order values. The behaviour is powerfully reinforced. These are impor-
tant questions about the nature of will and freedom of choice.
Male sexuality is picture driven and interested in body parts. This is the appeal
of pornography, manufactured almost entirely for men. There is the question of
age. Most men are attracted by younger women. The sexual template is formed
 158 Conclusion

in the brain before one becomes sexually active. The image in the brain stays the
same age as the person ages. In the coital fantasy a man, when he is 60, is presum-
ably not running a fantasy of a 60-year-old woman in his head. Most likely he is
running the fantasy of a woman in her early 20s. Coital fantasy is a way of allow-
ing people in long-term relationships to go on being sexual when their bodies are
no longer attractive.
Internet offences abound with many men becoming criminalised and put on
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the sex offenders’ register when such action is unnecessary. It is an offence to

download an illegal image even if you do so unintentionally. A man does not
know what is likely to come up on his computer when he is viewing internet por-
nography. Yet he has committed an offence even though he had no idea what was
about to come through. This is particularly problematic with file-sharing; a man
could be sent anything or things labelled in misleading ways. To be designated a
sex offender, in our society, is to join the living dead.
Finally, there is the question of consent in relationships. What is consent? Can
you actually give legitimate consent after two glasses of wine? At what point is it
possible to change your mind? Alcohol reduces judgement and eliminates fear. It
also prevents us from properly considering the consequences of our actions. Short
of signing an agreement before every sexual act, the nature of informed consent
is very difficult to judge. Even if you did sign an agreement giving consent before
every sexual act, you could change your mind between agreeing consent and the
act taking place. The nature of informed consent is difficult to determine both for
the initiator and the receiver in sexual activity.

Controlling sexuality
In every society and every age, there have been attempts to control the sexuality
of others. The eminent feminist and anthropologist, Gayle Rubin, has written well
about this tendency to place sexual preferences in a hierarchy of acceptability. She
writes that ‘a radical theory of sex must identify, describe, explain and denounce
erotic injustice and social oppression’ (1984: 267). Arguing from Foucault (1984),
Rubin takes the view that human sexuality should be seen in its historical context.
Rubin goes on to write, ‘sexuality in Western societies has been structured within
an extremely punitive social framework and has been subjected to very real for-
mal and informal controls’ (1984: 277). It is Rubin’s argument (1984) that sexual
behaviours are placed in a hierarchy of acceptability with married heterosexuals
at the top of the hierarchy and the sexually irregular placed in the tier below. The
bottom of the pyramid would include transsexuals, transvestites and sex workers.
Masturbation has an ambiguous location as deemed to be somewhat less accept-
able than partnered sex.
The control of sexuality has come, over time, from many sources: religious
organisations, elite social groups, legal and judicial organisations, the press and
even the armed forces. I had one young man who, while at an army college, was
pressed into marrying his pregnant girlfriend because it was his ‘duty’ to do so.
 Conclusion 159

At the end of the nineteenth century, medical professionals began to join in

this process by designating non-normative sexual behaviours as medical disor-
ders. This is clearly reflected in DSM-V (American Psychiatric Association 2013)
although somewhat diminished by their distinction between a pattern of behaviour
and a disorder (American Psychiatric Association 2013: 685). The whole litera-
ture on sexual addiction could be seen as part of this narrative, as another attempt
to place sexual behaviours into a hierarchy of acceptability. The American lit-
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erature does this with little reflection. Poorly trained sex addiction therapists and
psychotherapists do this as well. Too much sex, or sex of the wrong kind, is to
be modified, rectified and corrected by a technology of the self. The goal of life
becomes the correction of the self rather than the integration of the shadow. In
my therapeutic practice, acceptable and unacceptable templates are not subject
to judgement. Our sexual template is not a matter of choice but grows out of our
history. Sometimes it is right to help the patient come to terms with his sexual
template. At other times, it is right to help him learn how to control it and to free
himself from the potential harm that it may cause him and others. In each case, a
clinical judgement must be made. The work must proceed carefully.

Paradigm shift
We are in the midst of a paradigm shift in scientific thinking about addiction from
the purely behavioural to an understanding that addiction is not just about behav-
iour, but also about physiological changes in the brain. Kuhn noted ‘that when an
established paradigm is challenged by anomalies, scientists tend to defend the sta-
tus quo until it becomes apparent that emerging evidence and theory have rendered
the status quo obsolete’ (2013). This precipitates a paradigm shift (Hilton 2013).
Such shifts involve controversy in the movement from one paradigm to another. I
believe that we are witnessing such a shift in our thinking about addiction. Previ-
ously confined to substances, the understanding of addiction in terms of neurosci-
ence is gaining ascendency. With this comes an understanding not just of substance
addictions but behavioural addictions. Drawing from Kuhn (2012), Hilton (2013)
stresses that we are witnessing a ‘paradigm crisis’ with neuroscience developing
a parallel paradigm with the introduction of behavioural addictions. Hilton writes:

an increased knowledge of cellular mechanisms allows us to understand

that addiction involves and alters biology at a synaptic level, which then
affects subsequent behaviour. Addiction neuroscience is now as much about
neuronal receptor reactivity, modulation and subsequent plasticity as it is
about destructive and repetitive behaviour.
(2013: 3)

This paradigm shift is illustrated by the definition of addiction given by the Amer-
ican Society of Addiction Medicine quoted in full at the end of Chapter 3 on
neuroscience.
 160 Conclusion

If we look at the early critiques of the concept of sexual addiction, we can

see the beginning of the conflict. Barth and Kinder (1987) reject the appellation
because it is not in DSM-IV (American Psychiatric Association 1994) and Levine
and Troiden (1988) reject the concept on the grounds that, in their view, by defini-
tion, addiction is about a substance. With the development of a neuroscience of
addiction, it becomes clear that the psychological and the physiological are tied
together and that it is unhelpful to speak of them separately. As I have already
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written, Goodman writes ‘to speak of dependence or distress that is psychological

but not physiological is meaningless’ (1998: 25).
We can chart the progress of this paradigm shift if we make a comparison
between DSM-IV-TR (Diagnostic and Statistical Manual of Mental Disorders,
text revised, 4th edition) (American Psychiatric Association 2000) and DSM-V.
Here it is possible to see the beginning of an introduction of the concept of behav-
ioural addiction. DSM-IV-TR does not use the word ‘addiction’. In reference to
drugs of abuse, the word ‘dependency’ is used – for example, alcohol depend-
ence, cocaine dependence, cannabis dependence. Gambling is cited as ‘pathologi-
cal gambling’. The general description given is the same one that we would give
for any behavioural addiction. In DSM-V, gambling is listed as a ‘non-substance
related disorder’. There is a note after the diagnostic criteria: ‘Although some
behavioural conditions that do not involve ingestion of substances have similari-
ties to substance-related disorders, only one disorder – gambling disorder – has
sufficient data to be included in this section’ (American Psychiatric Association
2013: 586). Alongside this, under ‘Conditions for further study’ is the category
‘internet gaming disorder’. Further in this section is a reference to ‘internet addic-
tion’. In the section of DSM-V that refers to paraphilias, all paraphilias, with the
exception of paedophilia, may present with hypersexuality. This is another term
for sexual addiction. I also note that DSM-V has a chapter entitled ‘Substance-
related and addictive disorders’ (American Psychiatric Association 2013: 481).
There is an incipient recognition of the underlying role of neuroscience in under-
standing these disorders. DSM-V states:

Thus groups of repetitive behaviours which some term behavioural addictions,

with such categories as ‘sex addiction’, ‘exercise addiction’, or ‘shopping
addiction’ are not included because at this time there is insufficient peer-
reviewed evidence to establish the diagnostic criteria and course descriptions
needed to identify these behaviours as mental disorders.
(American Psychiatric Association 2013: 481)

We can see the emergence of the paradigm shift from identifying addiction as
entirely related to substances to a recognition that behavioural addictions exist,
even if the acknowledgement is tentative and guarded. The only point of going
into so much detail about DSM-IV and DSM-V is to demonstrate the progress of
understanding and the process of a shift of paradigm. Once addiction was seen as
only related to substances. There is awareness now, largely through accumulating
 Conclusion 161

neuroscientific evidence, that the word ‘addiction’ can equally relate to learned
repetitious behaviours.
We shall finish with the Bible. The mythology of Genesis tells a great truth.
It points to one aspect of the human condition that there is, in the human condi-
tion, a fundamental tragedy. In Genesis, this tragedy is connected to the fall of
Adam and Eve. They were sent out of Eden and their return was prevented by
a cherubim with a fiery sword. This is juxtaposed against The Song of Songs, a
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celebration of sexual and romantic passion. The song is clearly a celebration of

human passion and it is right that it found its way into the corpus of scripture. It
is a celebration of the sexual encounter and, in particular, the ardour of the yet to
be married. It is a celebration of the sexual intensity, in this case, between a man
and a woman. Together these two books, or parts of them, catch this double aspect
of the human sexual experience, one pointing to tragedy and the other to ecstasy.
Genesis points to the tragedy of loss, The Song of Songs points to the ecstasy of
anticipated fulfilment.
At the end of every Twelve Step sexual recovery meeting, people stand, join
hands and recite ‘the Serenity Prayer’. This is an appropriate way to conclude this
book:

The Serenity Prayer

God grant me the serenity to accept the things I cannot change, the courage to
change the things I can, and the wisdom to know the difference.
(Reinhold Niebuhr 1892–1971)
 Case studies
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Introduction
The case studies listed here illustrate a number of important facts. Sexual ­addiction
often goes back into childhood and gathers momentum with adolescence. There
is often a profound attachment disorder at the root of the problem. The behaviour
escalates and grows in complexity. It becomes increasingly ‘out of control’. As
with almost all addictions, the behaviour is a response to one or more negative
feeling states. The behaviour is hidden because of shame and the greater the dan-
gerous or negative feeling state, the more difficult it is to clear the slate. Marriage
can be fraught with problems. Some of these can relate to sexual functioning
while others normally emerge from inherent problems of incapacity for genuine
intimacy. This is usually set up in the family of origin by difficulties connecting
to caregivers, or by never actually seeing intimacy in the family of origin and
therefore never internalising the components of intimacy. I write not to shock but
to portray the unhappiness that can be visited upon men with these ‘out-of-control
sexual behaviours’. These are composite cases; every effort has been made to
protect the identity of any given person and any similarity is incidental. The con-
fidentiality of patients has been respected at all times.

William

Introduction
William used sex workers. He used them two or three at a time and he did so
frequently. He had been doing this for some years. He had stolen money to pay
for this addiction.

History
How did this come about? What were the antecedents to the behaviour? Ethel Per-
son, in her book The Sexual Century (1999), makes the point that these behaviours
grow out of an individual’s biography. In other words, the behaviour emerges
 Case studies 163

(it is not chosen) from the particular patterns of childhood. In this case, how did
this destructive behaviour come to be?
The first thing to bear in mind is severe disturbance to the attachment relation-
ship between William and his mother. It was an extremely difficult and stressful
pregnancy. His mother was in hospital after his birth. He was born not breathing
and had to be resuscitated. He was sent away to school when he was quite young.
He went on to a rigid and formal school. The family was ‘rigid and disengaged’,
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a combination said to characterise some families of sexually addicted people

(Carnes 1989: 129).
Maternal deprivation gave rise to the endless yearning for the female. The sex
workers William chose were always nice. The marriage seems to have gone rea-
sonably well it but had no effect on his use of sex workers. The wife was appalled
and distressed when William was arrested. The sexual content of their marriage
had deteriorated and virtually ended.
William had been a moral and law-abiding professional. What would have
caused this reliance on sex workers and the related theft of money to pay for the
compulsion? An explanation would lie in the notion of sexual addiction. In my
view, the compulsion overwhelmed and overpowered his ability to think straight.
It also overwhelmed his internal inhibiting mechanisms. William has described
the events as a response to stress. Each time he got away with it, the shame and
fear would subside.

Treatment
When William came into treatment (of his own volition and self-paying), he was
a man in pain and felt destroyed as a person. He did well in our treatment pro-
gramme and completed it without relapse. The court had no alternative but to give
him a prison sentence for his theft.
It is William’s face that I remember best of all: it had the look of someone so
haunted and unhappy that these feelings and experiences had etched their way into
his physical being. A pattern of lifelong searching had created the face. This man
had reaped the whirlwind. He suffered dire consequences. It is hard to imagine
circumstances that were so dangerous and at the same time so ignored. His actions
seem inexplicable.

Robin

Introduction
Robin approached me by email from the United States. He was coming to England
for six weeks on business. He was planning to be here for the summer holiday. He
came to the office on his first day of arrival. He was outgoing and jovial, a delight
to meet and to know.
 164 Case studies

This patient was an exhibitionist. In the years of this behaviour, he had only
been seen a handful of times. This ‘not being seen’ might have been the result of
an internal braking system or it might have been part of the acting-out behaviour.
The most recent and perhaps most dangerous example of his acting out was at a
hotel.

History
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Robin’s father was described as dignified and able. He was a solicitor. Robin
described him as incredibly loving, quite private, stoic and one who loved the
good things in life. He also described him as stubborn and self-assured. The fam-
ily avoided conflict. The mother was described as loving and caring. However,
there seemed to be a bond between the parents that excluded the children.
The atmosphere in the house was sexual. Although never abused or involved
in the sexual behaviours of his parents, he knew of parties. I wonder whether, as a
child, he was ever properly noticed. His parent’s exclusive relationship could well
have set up a sense of needing to be seen. The acting-out behaviours are about
‘see me’ in my power and as an attractive person. The best way to understand a
paraphilia is simply to take the sex out of it. It is entirely about ‘see me’. I would
conclude from this, working backward, that he was never seen.
There are numerous early memories of the beginning of the behaviour. Most
of these were of exhibitionism. He went to school where he described himself as
‘the leader’. Once again we have the theme of ‘being seen as potent’. It is inter-
esting that there was an intense focus on his penis as an object of attention, even
adoration.
He does not use pornography excessively but sometimes turns to it as an alter-
native to self-exhibition. He says that the use of pornography began before nine
years of age. He looks at pornography for two to three hours at a time. There are
no same-sex experiences.

Treatment
The early treatment involved taking a detailed history, then working on harmful
consequences, an exploration of his family of origin and the cycle of addiction.
Robin prepared his life story and the story of his sexual development and his sexual
addiction. A group of men in recovery from sexual addiction were gathered to hear
his story and give feedback. This would have been the first time he had stopped
living the double life and surrendered to the power of a group process. Finally,
the reality of Robin was known and he was still accepted as a person of value and
worth. He was prescribed an SSRI. He was encouraged to attend online meetings
of Sex Addicts Anonymous or to attend a sexual recovery group in the States.
I have rarely come across such a dangerous paraphilia. The literature (Rosen
1997) suggests that exhibitionism is the most common of the paraphilias.
 Case studies 165

We were aware of the great responsibility placed upon us to help him. This man
was enslaved to a repetitious pattern of behaviour that would ultimately bring
harmful consequences, threatening everything he had built up, including his fam-
ily, his business and his freedom. If he were arrested, not only would he lose
everything, so would the people who work for him. It was not just him who was
threatened, but the security of their families.
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Wright

Introduction
I have seen Wright for years. He came to me some time ago looking for treat-
ment for his sexual addiction. The last time I saw him he became furious and
outraged at the memories of his profound humiliation. I listened with interest and
compassion. I could feel the rage that he felt towards himself for creating his own
downfall.
Wright is addicted to sex and one particular female sex worker. He acts out
with recreational drugs. He uses them less and less now. When Wright acts out, he
uses internet pornography. Once the binge is over, he becomes fearful.
He came to me overwhelmed with self-disgust. The other precipitating factor
that brought Wright to therapy was a diagnosis of a critical illness. He was quite
clear that he felt as though he had brought this upon himself.

History
Wright’s father was an important barrister. The man apparently hated Wright.
Neither parent had the means to give Wright proper nurturance. He hated himself.
However, he was also clever and became a solicitor.

Treatment
Wright had been to Twelve Step recovery groups for sexual addiction. He has
subsequently been though our treatment programme. He still relapses. In spite of
this, he lives a functioning life and has made advances in a number of areas.
What do I make of this man? I have much respect for him. I know of no one
who has battled so long and hard against an addiction. He goes on battling with
the implications of his illness. He is intelligent, witty, learned, ironic and wry.
There is about him a kind of humility and self-deprecation. I have rarely met
anyone whose life has been plundered by so much self-hatred and shame. Why
does he continue to see me? Probably because I am the only one who really
knows him and respects the courage and determination that is, in fact, part of the
overall character of his life. This is a life made tragic by addiction and noble by
the struggle.
 166 Case studies

He had once given me the privilege of seeing in him the most profound
e­ xpression of everything that was driving the addiction, and always had driven
the addiction – namely, rage and self-hatred.

Russell

Introduction
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Russell is a successful medical doctor. He was in his mid-thirties when he first

came to see me. I found him a thoughtful, low-key and sensitive man. He was not
just any medical doctor, but an orthopaedic surgeon. There was no room for error
in his work. He had achieved a considerable place in society. He was the son of a
medical doctor and grew up in the West Indies. He became the top scholar before
going to read medicine in the United States.
Over time, Russell’s sexual behaviour had receded and eventually was all but
extinguished. He came to see me because he felt overwhelming shame and guilt.
His sexual patterns were to use the internet to chat to women. There was no inter-
est in internet pornography and infrequent masturbation. He was disturbed by
these patterns of sexual behaviour and wanted to leave them behind. It was clear
that he wanted to change these behaviours for himself and not just in response to
his wife’s distress. He lived in profound shame and unhappiness. His evaluation
assessment form indicated high levels of anxiety, absence of enthusiasm, tearful-
ness, self-blame and deep unhappiness.

History
At an early age, Russell had learned to escape from intolerable feelings through
masturbation. He would masturbate in his room. He described these earlier sexual
behaviours, along with all his early sexual encounters, as shameful. He could not
get solace from his mother or his father and thus sought it in himself.
He described his mother as having no negative traits. He described his father as
one who never took ‘no’ for an answer. His father was an alcoholic. From child-
hood Russell said that he was frequently hit by his father.

Treatment
Russell did well in our treatment programme and left the behaviours entirely
behind. The tendency to lapse will probably be always with him especially in
times of emotional distress and threats of spousal rejection.
We soon established that Russell acts out sexually in response to stress. It
was also clear that he had a very negative sense of self. This inner rejection of
the self would have been set up by a father who always said ‘no’ and who was
so consistently brutal. The combination is easy to see: sex forms an escape from
early trauma, then is established as a lifelong pattern repetitious of emotional
 Case studies 167

management. A formulation for Russell looks like this: low self-esteem gives rise
to shame which, when combined with anxiety, leads to sexual acting out. Sexual
acting out in turn confirms the core belief that he is not good. Repeated anxiety
becomes the immediate trigger to the behaviour.

Ricardo
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Introduction
I met Ricardo three years ago. He was involved in architecture and design, and
had been very successful. He was good-looking and powerfully built. He had great
charm. He had pushed through a terribly difficult background and had eventually
moved from Italy to Britain where he took a year off to do a post-graduate degree
relevant to his field of work. He was clearly distraught, and highly agitated, when
he came to my office.
The presenting problem was sexual addiction represented by continuous
sexual thoughts and fantasies, multiple partners and frequent masturbation
with the use of the internet. It was clear to Ricardo that these were attempts to
relieve intolerable feeling states. He was consumed by sexual fantasy. Along-
side the sexual addiction was an addiction to adrenaline that motivated his
working life. These behaviours made up a frantic life lived in escape of the
mundane.

History
Ricardo has the adult legacy of an appalling disrupted and abusive childhood.
He began life in trauma. He said that he was born a ‘blue baby’ and a number
of attempts at resuscitation were required for him to live. He describes himself
at school as ‘odd’. His father travelled with his work. Further descriptions of
his father are ‘tough’ and ‘not there’. He describes his father now as an addict
who does not work. His mother is more ambivalently described. There were other
problems referred to on his father’s side of the family.
Ricardo began to use pornography when he was very young. He would bor-
row his dad’s collection of pornographic videos and would look at pornographic
magazines. A similar pattern continues. Ricardo also experienced a number of
incidents that we would consider abuse. Eventually the family disintegrated.

Treatment
Ricardo joined our clinic’s treatment programme for men with compulsive behav-
iours. In our treatment programme, he did extraordinarily well and often spoke
with rare insight and thoughtfulness. The presenting reason for coming to see
me was that he could not sustain a standard monogamous relationship. Although
he had been in long-term relationships, he said that he had never had a sustained
 168 Case studies

relationship without frequent cheating on his partner. The addictive patterns were
overwhelmingly intrusive.
It strikes me that Ricardo has an anxious-avoidant attachment style. He stays
in relationships with women that are not fulfilling because the fear of being alone
is a greater distress than the relationship itself. He is avoidant in style and the use
of pornography; his multiple sexual involvements suggest this, along with his
obvious capacity to take care of his ‘needs and wants’ himself. His sexual addic-
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tion, such as it is, is clearly a long-established method of self-soothing, and acts

to provide the excitement in the face of annihilation. In this story, we can clearly
see that sexual addiction became a solution to the historic traumas of life. Ricardo
is a good man and I hope that he will be able to find freedom from the tyranny of
the past. I hope that he will learn to be able to be in the monogamous relationship
for which he yearns.

Mason

Introduction
Mason spoke a great deal and with a loud voice, as though he needed to be heard
and had not been heard before. He spoke at length as if it were not really him
speaking. There was something about him that caused one to suspect that all was
not as it seemed. He was successful as an educator. His domestic life had been
less successful. He had met a woman whom he had now fallen in love with and
came to me for help with his sexual addiction. He developed a good amount of
psychological awareness over the course of treatment.
Mason’s sexual patterns involved a series of sexual relationships with a number
of women. He used the internet to meet women. Sometimes this involved online
sex with women, sometimes he would meet women for real-time sex. There was
a minimal use of internet pornography, which had never been an important com-
ponent of his sexual behaviour. His patterns of masturbation were normal for a
man of his age. He was not aware of the triggers for his sexual behaviour. He had
a small cache of sexually explicit material. He would either have telephone sex or
online sex or, if the occasion presented itself, he would meet women for real-time
sex. The woman he had fallen in love with became aware of these sexual patterns.

History
Mason did not have a good start in life. There were problems around his birth.
He was placed for adoption. He said that he was not sure where he fitted in.
He was adopted by a not very well-off family. He has always tried to offset
this and began to earn his own money. Success as an educator has given him
worth and substance. There was one incident of genital trauma in childhood and
another as a young adult. There was one disturbing and traumatic incident in
young adulthood.
 Case studies 169

Treatment
Mason has been through our treatment programme twice. To date, he is doing
well. He has transcended the deprivations of his background, although not without
scars.

Matthew
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Introduction
Matthew was a tall and handsome man. He was addicted to making money and
having sex. I am not sure which was the more powerful of the two processes. His
concern was extramarital sex. He presented with the following objectives: to have
a clear understanding of who he was and to be at peace with himself. He was a
man who combined great drive with an enormous set of problems. His business
was ‘doing deals’ and he described himself as a ‘networker’. He continually trav-
elled for business.
Once having just come back from Australia, where he had closed a big deal, he
was ecstatic. Later it was revealed in therapy that his primary sexual interest was
receiving oral sex and being masturbated. He has been involved in swingers’ par-
ties, threesomes, and frequently masturbates to internet pornography.
Money and sex seem to be his primary addictions. However, he had a period
of a couple of years using recreational drugs. He collects antique cars, old books
and maps. He experiences some erectile dysfunction when having sex with his
partners but none with one-night stands or sex workers. This man is a curious
combination of narcissism and vulnerability.

History

Matthew was an unwanted child in a disturbed family. His father’s parents wanted
him to be aborted. He is avoidant. He frequently talks about being trapped in a
relationship. The presence of multiple partners suggests this as well. With multi-
ple partners, there is a dilution effect so that no partner gets very close. If that hap-
pens, one just moves on to another and then, when that gets too close, back again.
He speaks with disgust about his parents, especially his dad. There have been
constant money problems in the family and his dad seems to have sunk into
depression. The mother lives in the family accommodation. The provenance of
this accommodation is unknown. He distrusts all women and is preoccupied about
whether they are willing and able to take care of themselves.

Treatment
Matthew was in individual psychotherapy for several years. This was not CBT
but more general psychotherapy of an explorative kind. I was never told what
 170 Case studies

he actually did for a living. Underneath the mask of invulnerability, it was clear
that he was struggling and hurt. I think I was the good father that he never had. I
always liked him and so this part of the process came easy. Matthew joined our
treatment programme. His participation in the group was good. He was always
‘larger than life’, but the group accepted him as he was. This is the saddest part of
this story: Matthew only wanted to be loved.
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Timothy

Introduction
Timothy made an appointment to see me after a discreet phone call. He had just
come back from a South African treatment programme for sexual addiction. He
had found the process unhelpful. He was a well-dressed, distinguished man. He
was a man of substance, keenly intelligent, observing, articulate and powerful.
His goals in therapy were to stop using sex workers and to save his marriage.
When I saw him, he had already retired and was living most of the year in Malaga.
There was little use of pornography. He was on a series of medications that were
causing a loss of libido and created unreliable erection functioning. He became
aware that the precursors for sexual acting out were anxiety and boredom. His
wife, whom I did not meet, was described as non-sexual and controlling. Part of
the problem was associated with aging and its many losses. Also, since retiring,
there were few challenges. In a sense, everything that gave life meaning was now
in the past.

History
It was clear in his history that Timothy’s mother regarded children as a nuisance.
He was absent to both his parents. He noted that parents made decisions for their
children without taking their needs into account. He grew up an isolated child,
holidays were lonely and, as he grew further, he never became a team player. He
was uncomfortable and shy around girls. He is a heterosexual man with no ambi-
guity about his sexuality.

Treatment
Because he lived in Malaga, it was not possible for Timothy to attend our group
treatment programme. I went through the interventions for sexual addiction in
individual psychotherapy. He had considerable success in leaving behind the
unwanted behaviours. After treatment, we continued to meet on an occasional
basis to help maintain sobriety.
At one point, Timothy said he wanted space and not to be controlled. Further-
more, he had split sexual object and love object. In other words, he enjoyed being
sexual with people with whom he had no relationship. He had had a limitless
 Case studies 171

career. There was a sexual outworking of limitlessness. I suspect that his success
was a defence against feelings of low self-worth. He once said that you can always
do more. This was taken, and cultivated, in his sexual life as it was in the rest of
his life. He always had to be doing to feel okay.

Charles
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The following case study is a genuine case and, while some of the details have
been changed, it is published with explicit patient consent. I would like to thank
this patient for agreeing to its publication.

Introduction
Charles came into our recovery programme last summer. He did an intensive five-
day treatment package. It was a small group of five men. One member of the
group, older than the other men, wore a distinctive yellow anorak. At the last
meeting, I noticed that a change had come over Charles. He was surreptitiously
glancing at his mobile telephone. He left the building and did not go with the other
men for fellowship. As it happened, he had a call from a dominatrix and this had
triggered an overwhelming urge to act out. He went to his car and drove to north
London. I will continue this story at the end.
Charles’ pattern is to pay dominatrices to abuse and humiliate him. He is
addicted, as another patient of mine put it, ‘to sex that degrades’. Much time is
spent on the internet looking at pictures of degradation. After every ‘acting-out’
session, he is filled with shame and remorse and becomes suicidal. There is so
much self-hatred that he simply wishes no longer to be.

History
Charles is 35 years old. He is a white male of middle-class origins. He is single
and desperate to have a girlfriend and, ultimately, a wife and family. He is a keen
football supporter and remembers that the happy times in childhood were going
on the coach, with his dad, to follow their team. He said that this was the only time
he could remember that his dad was nice, joking with the other men and boys and
drawing him into the camaraderie. To this day, he follows the same team. There
is great affection for his grandmother who lives close by. She was, and is, clearly
a person of great kindness and features much in his conversation. His mother is a
shadowy figure and, like with his dad, I have no real idea of who she is or what
she is like. It is important to note that his father was not his genetic father. Charles
was conceived by donor under medical auspices.
Let us keep in mind that people are much more than their sexuality, no mat-
ter how oppressive and troublesome that might be. Charles is good-looking, well
built and has a great smile. Underneath the exterior, there is astonishing resil-
ience and an impressive capacity to make changes and to endure. He is a man
 172 Case studies

of high intelligence, great kindness and considerable personal charm. The thing
that strikes me most about Charles is his determination to change. He is an unu-
sual person to counter so much experienced adversity with so much formidable
resolution.
Afflicted with a terrible speech impediment since childhood, the shame was
compounded by disfiguring acne. His dad used to say when he stuttered, as he told
me many times, ‘spit it out, boy’. He used to dread being called upon to read aloud
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at school. When he went to university, he had to write his name down so that his
room-mate could read it. He could not say his own name. It was not until he found
a speech therapy programme, about four years ago, that he began to control the
stammer. He now has about 85 per cent of his speech in his control. The stammer
meant that he was a source of constant ridicule all though school. This sense of
being ‘less than nothing’ was automatically sexualised and created the patterns for
his sexual acting out (Birchard 2011).
There are other patterns that reflect his diminished and hated sense of self. His
self-care has been poor and he finds it difficult to manage his clothes and to keep
his room tidy. He used to go out with unhelpful friends on Saturday night and
then would use alcohol and become another person, who was overly generous,
belligerent and confrontational. He has driven his car after these evenings and
become a danger to himself and others. He needs glasses but has not managed to
get to an optician. His financial affairs are completely out of control. His family
have bailed him out many times. He spends money that he does not have on domi-
natrices. He borrows from payday lenders. There is little awareness of this deadly
cycle: I am not worth looking after and therefore I do not look after myself. This
gives way to increased feelings of worthlessness and decreased self-care.
There are a number of cues that trigger his sexual behaviour: going to the town
centre on a Saturday night, the bad feelings of the hangover the next day, and
certain old friends. The behaviour is triggered by feelings of rejection, as well
as intense loneliness. Just the presence of his laptop can trigger him to go on to
sexually explicit sites, and these take him to the explicit sites of women offering
degrading services.

Treatment
Since the initial treatment programme, Charles has completed another 12-week
programme. He is also in individual therapy. He has begun treatment with an
SSRI and this has given him some relief. We have been working on the identifica-
tion, in advance, of his triggers so that he can take avoiding action. The arousal
chemistry shuts down the capacity to consider consequences. The short-term gain
from acting out is so powerful that the long-term losses cannot be considered.
These after-feelings of shame and remorse are inaccessible to him during the
intensity of the arousal. All sense of personal volition is lost.
Charles attends Sex Addicts Anonymous. These meetings supplement the
work of our clinic. The strategy is to increase his self-worth through positive
 Case studies 173

feedback and through a series of CBT exercises to change his inner schema. He
has been encouraged to go to other groups where he can mix socially with young
women without the use of alcohol. This he is doing with some success. He has met
a number of young women and taken them out. The goal has been to increase his
social skills and improve his relationships so that his loneliness can be changed
and his sense of self moved from self-hatred to self-acceptance. There is a need
to increase his sexual repertoire so that he can begin to reinstate his primary het-
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erosexual script away from the paraphilia and towards more normative patterns
of sexual behaviour. He has recently had his first girlfriend. There were very few
sexual social skills and these had to be taught, including a lecture on female sexual
anatomy.
To pick up the story that I started with, Charles was on his way to see a domi-
natrix. He had gone to three cash points. None were dispensing money. He headed
for a fourth cash point that was just next to a tube station. The moment he was
passing the tube station, the man from the group in the distinctive yellow anorak
walked out of the station and met Charles heading for the cash point. They had
a cup of tea and Charles told this man what was happening. Charles went home
and went for a run instead. He shared in the group that a strange sense of peace
had come over him in bed that night. The next day he said that he got a lot done.
In London, there are 270 tube stations. What are the chances that, at that exact
moment, these two people should accidentally meet? It has persuaded Charles that
maybe there is, after all, a Higher Power.
 Appendix 1

Marylebone Centre therapeutic

tools
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Sexual Addiction in Routine Evaluation

Important: please read first.
This form has four statements about how you have been over the PAST WEEK.
Please read each statement, think about how things have been over the past week
and circle the statement that is closest to how things have been.

1 I have been preoccupied by my sexually addictive behaviour

Not at all 0
Only occasionally 1
Sometimes 2
Often 3
Most or all of the time 4
2 I have felt the intensity of my sexually addictive behaviour
Not at all 0
Only occasionally 1
Sometimes 2
Often 3
Most or all of the time 4
3 I have acted out my sexually addictive behaviour
Not at all 0
Only occasionally 1
Sometimes 2
Often 3
Most or all of the time 4
4 I have had real or potential harmful consequences from my sexually addictive behaviour
Not at all 0
Only occasionally 1
Sometimes 2
Often 3
Most or all of the time 4
Total score: Mean score:

Thank you for taking the time to fill out this form.
 Appendices 175

Harmful consequences
Please identify any harmful consequences caused by your addictive compulsive
behaviour. Please list actual situations and circumstances. Try to write out the
total cost of your addiction and the potential future costs if you do not get it sorted
out.
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Financial
Money spent on escorts or sexual services

• Costs of websites and webcams

• Taking people to dinner/gifts of money/expensive presents
• Subscription costs for telephone and websites
• The cost of alcohol and entertaining in pursuit of sexual adventure
• Lost promotions at work that have meant a smaller salary
• Not fulfilling your work potential, and therefore less income
• Less money to spend on your partner or children

Health
Stress due to acting out or recovering from acting out

• Risk of body lice

• HIV exposure
• Other sexually transmitted infections
• Activation of health worries
• 
Personal development: not meeting important occupational or recreational
goals because of acting out
• Not fulfilling your potential
• Huge amounts of wasted time that could have been put to better use
• Damaged self-image

Relationships
Impaired parenting/being involved in sexual pursuits and neglecting family
commitments

• A serious impact on your partner

• Your partner leaves you
• S/he cannot bear it any longer
• Divorce
• Loss of friendships
• Disinterest in friendships
 176 Appendices

Self-image
You feel bad about yourself

• You feel guilty much or most of the time

• You experience yourself as bad and worthless
• You contemplate of suicide as a way out
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Legal and social consequences

You are arrested or fearful of being arrested

• You get picked up for kerb crawling

• You are afraid that you are going to end up in the papers
• You fear that you will lose your position in society
• Potential loss of respect if others knew
• 
Lawsuits and divorce made more complex by knowledge of your sexual
behaviour

Physical dangers
Getting knocked over the head

• Getting mixed up with a dangerous man or woman

• Taking great personal risks

Other harmful consequences

Downloaded by [University of California, San Diego] at 13:02 12 May 2017

Cycle of addiction
ACTING OUT

Inevitability

p
Trigger ld u
Bui Remorse
SUDS Regret
Daily life Disappointment
Dormant
Seemingly
unimportant
Anxiety decisions
Core loneliness
Shame
Habit
Anger
Boredom
Reconstitution
Roughly based on Bayes Adapted by ‘Try harder’
and Freeman-Longo Thaddeus Birchard

Figure A.1 Cycle of addiction

With particular thanks to Joy Rosendale.

 178 Appendices

Guidelines for telling your story

This is an opportunity to share your story with other members of the group. It is
seen as an important part of the recovery process. For many, telling their story is
the start of real momentum in recovery and a powerful tool in decreasing shame. It
is equally important for the others who hear your story. Without giving advice or
judging you. They will provide you with feedback about what they have learned
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from you, how they have identified with your experience and what stands out for
them from your story about the development of the addiction. There will be about
40 minutes for your story with the remaining time set aside for feedback.

Telling the story

It is best to tell it and not to read it.

• It is not a performance or an exercise in public speaking.

• We need to hear you speaking.
• It is a good idea to prepare in advance. What is it that you want to say?
• What happened? How did it affect you and those around you?
• Some people find brief notes or an outline helps.
• 
It is important to be specific about your behaviours but to avoid naming
specific places or people.

The story might consist of the following

What happened to you in your family of origin, especially situations or events that
were shaming, abusive, neglectful or non-nurturing? (Sometimes people take up
most of their time telling their early story and regret not having enough time to tell
the story of their addiction itself).

• The history of your sexuality and sexual addiction. How was it set up?
• How did it develop? What were the acting-out behaviours?
• 
Examples of powerlessness, preoccupation rituals, double life and
harmful consequences.
• 
Any particular rock bottoms and the crux point that led to your seeking
help.
• What has been different since coming on the programme?
• How is your recovery going now?
• Your hopes and plans for the future.

Those who are listening have the following responsibilities

• To remain silent, pay attention and be respectfully present.
• To look for similarities rather than differences.
• To be non-judgemental.
 Appendices 179

• 
To keep in mind throughout how demanding this exercise is – and how what
they are hearing may well have never been told before because of shame.

Feedback normally takes the following form

A word of thanks and gratitude.
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• No advice or trying to make it better.

• Sharing how hearing you tell your story has affected them emotionally.
•  Sharing what stands out for them from the story and in what ways they
can identify with it.
• Sharing how the story has given insight into their own recovery process.
• Sharing what the story has told them about the addiction.
•  As always, but especially when someone has told their story, the
fellowship and support of the group is an important process for everyone.
With thanks to Alex Smith.

An open letter from your friends

____________________ (name), you have chosen today to tell us your story.
We welcome you into that process and assure you of our support and
encouragement.
This normally involves telling us what happened to you in your family of
origin, especially situations or events that were shaming, abusive, neglectful or
non-nurturing.
It also involves telling us the history of your sexuality and your sexual
­addiction – how it was set up, how it developed, how it manifested itself, exam-
ples of powerlessness and harmful consequences, any particular rock bottom or
crux point that might have caused you to come here, what has been different
since coming here, how your recovery is going now, and your hopes and plans
for the future.
There is no right way or wrong way to do this. All we want is to hear you
speaking honestly and openly. Please do not name particular acting-out places or
particular websites so that this can remain a safe place for all of us. We respect
your courage and dignity in taking this step.
Those of us who are your witnesses have the following responsibilities:

• To pay attention and to be respectfully present at all times.

• To look for similarities rather than differences.
• To be non-judgemental.
• To respect your anonymity and confidentiality and not to refer to the story,
even anonymously, to any outside this group without your express consent.
• To keep in mind throughout how demanding this exercise is, and how we are
hearing what has probably never been told before because of shame.
 180 Appendices

One of the facilitators will let you know when you are coming to the end of time.
It is important for all of us, and for you, that there is time for feedback.
Feedback normally takes the following form:

• A word of thanks and gratitude.

• No advice and no caretaking.
• It is not an excuse for us to talk about ourselves but rather for us to share how
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the story has illuminated our own life, how it has benefited those of us who
have heard it.

_______________ (name), one of the slogans of sexual recovery is ‘from shame

to grace’. May you experience the reality of that today. May this be for you, and
for all us together, a journey from shame to grace.

Statistical information

57 Mean (SD) 58 Mean (SD) 60 Mean (SD)

SSAS Pre 23.00 (8.09) SSAS Pre 23.88 (8.92) SSAS Pre 23.83 (9.95)
Post 14.00 (10.04) Post 17.88 (7.64) Post 21.83 (5.95)
SCS Pre 2.85 (0.53) SCS Pre 2.96 (0.84) SCS Pre 3.06 (0.65)
Post 1.89 (0.66) Post 2.11 (0.66) Post 2.43 (0.68)
SAORE Pre 1.45 (1.02) SAORE Pre 1.50 (0.94) SAORE Pre 2.00 (0.88)
Post 1.02 (0.85) Post 1.06 (0.87) Post 1.38 (0.79)
CORE Pre 1.05 (0.60) CORE Pre 1.37 (0.38) CORE Pre 0.97 (0.74)
Post 0.56 (0.32) Post 0.99 (0.30) Post 1.07 (0.39)

Figure A.2 Descriptive statistics

Sample characteristics: A series of Shapiro-Wilk Tests (mean p-value = 0.454) (Shapiro and
Wilk 1967, Razali and Wa 2011) and visual inspection of histograms, normal Q-Q plots and box
plots showed that all but one set of scores for pre- and post-treatment assessment scales were
approximately normally distributed, with standardised scores for skewness and kurtosis falling
within –1.96 and 1.96. One set of group scores for the SCS had a significant Shapiro-Wilk score
(p = 0.013) and a skewness statistic that suggests a slight negative skew (z = 2.1250). Given the
relatively small sample size and the general trend of the rest of the rest of the data, further analysis
was conducted with normality assumed.
 Appendix 2

Resources
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General
Anonymous (1989) Answers in the Heart: Daily Meditations for Men and Women
Recovering from Sex Addiction, Center City, MN: Hazelden Meditations.
Carnes, P. (1991) Don’t Call It Love, New York: Bantam Books.
Carnes, P. (2001) Out of the Shadows: Understanding Sexual Addiction (3rd edition),
Center City, MN: Hazelden Meditations.
Hall, P. (2013) Understanding and Treating Sex Addiction, Hove: Routledge.
Penix Sbraga, T. and O’Donohue, W. (2003) The Sex Addiction Workbook: Proven
Strategies to Help You Regain Control of Your Life, Oakland, CA: New Harbinger.
The Kick Start Recovery Programme: [Link] (accessed 4 January
2015).

Online pornography
Carnes, P., Delmonico, D. and Griffin, E. (2001) In the Shadows of the Net: Breaking Free
of Compulsive Online Sexual Behaviour, Center City, MN: Hazelden Meditations.
Maltz, W. and Maltz, L. (2010) The Porn Trap: The Essential Guide to Overcoming
Problems Caused by Pornography, New York: Harper.
Weiss, R. and Schneider, J. Untangling the Web: Sex, Porn and Fantasy Obsession in the
Internet Age, New York: Alyson Books.
Your Brain on Porn: [Link] (accessed 4 January 2015).

Paraphilias
Bader, M. (2008) Arousal: The Secret Logic of Sexual Fantasies, London: Virgin Books.
Fogel, G. and Myers, W. (eds) (1991) Perversions and Near-Perversions in Clinical
Practice: New Psychoanalytic Perspectives, New Haven, CT: Yale University Press.
Kahr, B. (2007) Sex and the Psyche: The Truth About Our Most Secret Fantasies, London:
Allen Lane.
Money, J. (1986) Lovemaps: Clinical Concepts of Sexual/Erotic Health and Pathology,
Paraphilia and Gender Transposition in Childhood, Adolescence and Maturity, New
York: Irvington.
 182 Appendices

Women and sex addiction

Carnes, S. (2009) Mending a Shattered Heart, Center City, MN: Hazelden Meditations.
Collins, C. and Collins, G. (2012) A Couple’s Guide to Sexual Addiction, Avon: Adams
Media.
Davis Kasl, C., (1989) Women, Sex, and Addiction, New York: Ticknor and Fields.
Mellody, P. (2003) Facing Codependence, San Francisco, CA: Harper.
Norwood, R. (2000) Meditations for Women Who Love Too Much, London: Arrow Books.
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Weiss, D. (2000) She Has a Secret, Colorado Springs, CO: Discovery Press.

Love addiction
Mellody, P., Wells Miller, A. and Miller, K. (1992) Facing Love Addiction: Giving Yourself
the Power to Change the Way You Are, San Francisco, CA: Harper.
Norwood, R. (2008) Women Who Love Too Much, London: Arrow Books.
Wilson Schaef, A. (1989) Escape from Intimacy: The Pseudo-Relationship Addictions, San
Francisco, CA: Harper.

Gay men and sex addiction

Weiss, R. (2013) Cruise Control: Understanding Sex Addiction in Gay Men, New York,
Alyson Publications.

Sex addiction and the clergy

Thoburn, J. and Baker, R. (eds) (2011) Clergy Sexual Misconduct: A Systems Approach to
Prevention, Intervention and Oversight, Carefree, AZ: Gentle Path Press.

Resources for partners of sex addicts

Carnes, S. (ed.) (2011) Mending a Shattered Heart: A Guide for Partners of Sex Addicts,
Carefree, AZ: Gentle Path Press.
Collins, C. and Collins, G. (2012) A Couples Guide to Sexual Addiction, Avon: Adams
Media.

Cognitive behavioural therapy

Beck, J. S. (1995) Cognitive Therapy: Basics and Beyond, New York: Guilford Press.
Mitcheson, L., Maslin, J, Meynen, T., Morrison, T., Hill, R. and Wanigaratne, S. (2010)
Applied Cognitive and Behavioural Approaches to the Treatment of Addiction: A
Practical Treatment Guide, Chichester: Wiley-Blackwell.
Trower, P., Jones, J., Dryden, W. and Casey, A. (2011) Cognitive Behavioural Therapy in
Action, London: Sage.
Westbrook, D., Kennerley, H. and Kirk, J. (2012) An Introduction to Cognitive Behaviour
Therapy: Skills and Applications, Los Angeles, CA: Sage.
 Appendices 183

Working with groups

Bieling, P., McCabe, R. and Antony, M. (2006) Cognitive Behavioural Therapy for
Groups, New York: Guilford Press.
Yalom, I. and Leszcz, M. (2005) The Theory and Practice of Group Psychotherapy, New
York: Basic Books.
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Twelve Step programmes

Sex Addicts Anonymous (SAA): [Link] (accessed 4 January 2015).
Sex and Love Addicts Anonymous (SLAA): [Link] (accessed 4 January 2015).
Sexaholics Anonymous (SA): [Link] (accessed 4 January 2015).
Sexual Compulsives Anonymous (SCA): [Link] (accessed 4 January
2015).

Sex addiction recovery services

Association for the Treatment of Sexual Addiction and Compulsivity (ATSAC): www.
[Link] (accessed 4 January 2015).
College of Sexual and Relationship Therapists: [Link] (accessed 4 January
2015).
International Institute for Trauma and Addiction Professionals (IITAP): [Link]
(accessed 4 January 2015).
Hudson Centre: [Link] (accessed 4 January 2015).
Life Works: [Link] (accessed 4 January 2015).
Marylebone Centre for Psychological Therapies: [Link] (accessed
4 January 2015).
Paula Hall and Associates: [Link] (accessed 4 January 2015).
Relate: [Link] (accessed 4 January 2015).
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 Index
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ABC model 18, 77 affiliation 144, 149

Abel, G. 129 age 157–8
abstinence 34, 82, 86, 89, 111 agenda setting 45
abuse 49, 72–3, 121, 123; traumatic alcohol 4, 40, 42, 66; avoidance of shame
attachment 140–1, 142, 143, 145; 58–9; brain mechanisms 32–3; case
unsuccessful recovery 81 studies 120, 122, 123, 172; cross
acceptability of sexual behaviours 158–9 addictions 150–1; dopamine 36; impact
ACE model of problematic internet use on judgement 158; loss of inhibition
134 41; murder case 114, 130; traumatic
acting out xvii, 5, 17, 22–4, 36, 68; ABC attachment 144
model 18; anxiety disorders 154; Alcoholics Anonymous (AA) 76, 94, 107,
assessment of 20; case studies 164, 108–9, 110, 120
167, 172; checking in with therapist to Allen, J. 140, 143, 145, 147
prevent 89; cycle of addiction 73–4, altruism 94
108, 177; downward arrow technique ambivalence 53, 81
26, 27; facilitating beliefs 82; goals amends 87, 109
of therapy 21; guided reading 29; low American Psychiatric Association (APA)
self-esteem 155–6; relapse prevention 6–7, 115, 116, 138–9, 160
83, 85, 87; thinking errors 76; trigger American Society of Addiction Medicine
identification 74 5, 31, 32, 42, 159
activity scheduling 27, 30 ancillary interventions 55, 81–90
addiction: author’s own experience of xiv, anger 8, 82, 125, 134–5, 177
xv; as a biological drive 31, 32; concept anxiety: boredom proneness 155; case
of 5–6; cross addictions xvii, 41–2, studies 123, 166, 167, 170; comorbidity
150–1, 156; cycle of 55, 62, 65–6, 73–4, 5, 46, 125, 152, 154; cycle of addiction
89, 97, 102, 108, 125, 177; definitions 177; formulations 22, 23; group
of 1, 5, 42, 159; historical perspective work 91–2; health anxiety 67, 154;
3–5; internet 132, 133, 136, 139, 152; healthy sexuality 87–8; impaired affect
paradigm shift in understanding of xvii, regulation 143; internet pornography
157, 159–61; traumatic attachment 140; 67, 134, 141; Marylebone Centre for
see also sexual addiction Psychological Therapies xiii; narcissistic
advanced treatment 92, 100–1 damage 151; neurochemistry 36;
advantage/disadvantage analysis 24 paraphilias 125; relieving 61; secondary
affect regulation 9–10, 142–3, 150; see trauma 50; sexual dysfunctions 60;
also self-regulation sexual fantasies as respite from 10;
 196 Index

social anxiety 94, 123, 153, 154; behaviour: ABC model 18; continuum of
spouses 103; traumatic attachment 143; 17–18; hot cross bun technique 28–9,
as trigger for sexual behaviour 21, 74 30; influence on thoughts and feelings
Arlow, J. 119–20 17
arousal 2, 117–18; childhood 119; classical behaviour therapy 14, 15, 138
conditioning 15–16; cycle of addiction behavioural activation 153
73; ‘excitation exchange’ 68–9; internet behavioural experiments 153
pornography 136; involuntary nature of behavioural substitution 73, 74–5
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44; mirror neurons 134; neurochemistry behavioural techniques 29–30

34, 36, 37, 41, 57, 157; ‘out-of-control’ beliefs: ABC model 18, 77; cognitive
152; shame and 59 restructuring 148–9; control 82;
art therapy 72, 98, 99 downward arrow technique 26;
assertiveness training 55, 56, 78, 85, 97, facilitating 82; formulations 22, 23;
149 irrational 77–8; negative 17, 56, 65,
assessment 19–20, 125–6 100–1, 138, 156; paraphilias 124;
‘asset lists’ 101, 155 relapse prevention 84; trauma 145
Association for the Treatment of Sexual Bensimon, P. 139
Addiction and Compulsivity xii–xiii, 6 Berlin, F. 38
attachment 31, 39–40, 44, 51, 102; Bible 161
attachment disorder 8, 10; case studies Birchard, T. 50–1
163, 168; internet pornography impact bisexuality 69–70
on 136–7; loneliness 153; traumatic Bivona, J. 117
xvii, 40, 140–9, 151, 156; unmet black and white thinking 76
developmental needs 144–5 blame 59, 75
attention deficit disorder 152 body dysmorphic disorder 60
attentional bias 65, 78, 84 bondage 3, 48, 70, 115, 124; conservative
Augustine 4 values 11; prevalence 117; social
auto-asphyxiation 129, 130 acceptance of 114; websites 131–2
aversion therapy 127–8 boredom 24, 29, 152, 155; case studies
avoidance 58–9, 144, 168 170; cycle of addiction 177; internet
avoidant attachment style 39–40 pornography 134, 136; relapse
prevention 82; as trigger for sexual
Bader, Michael 120, 122, 124, 125 behaviour 21, 74
Bancroft, J. 5, 152 boundaries 52, 95, 102, 103
Bandura, A. 56, 93 Bowlby, J. 51, 146
Barrett, D. 64 Bradford, J. 38
Barth, R. 5, 160 brain 31, 32–4, 35, 56; affiliative
Bates, Daniel 107 behaviour 149; attachment
Bateson, G. 108 39–40; dopamine 36–7; impact of
Baumeister, R. 8, 41, 58, 75, 117, 155 psychotherapy on 40; mirror neurons
Bays, L. 9, 55, 63, 73, 76, 84–5 134; sexual template 157–8; traumatic
BDSM activity 117, 132; see also attachment 144; see also neuroscience
bondage; domination; masochism; breath play 129, 130
sadism Briere, J. 143, 144, 145, 146, 148, 149
Beck, A. 15, 18 Briken, P. 154
Beck, Judith 100 Brown, Leigh 101
Beck Anxiety Inventory (BAI) 122–3 Buchman, Frank 109
Beck Depression Inventory (BDI) 122–3 Butler, M.H. 136–7
 Index 197

Campbell, N. 33–4 compulsion 6

career impacts 3 conditioning 15–16
Carnes, Patrick 1–2, 5, 9, 20, 49, 72, 85, conduct of therapist 52
100, 132, 137, 142 confidentiality 50, 80, 102, 113
case studies 11–13, 120–3, 162–73 Confucius 90
catastrophising 77 Connolly, M. 50
catharsis 96 consent 158
celibacy 89–90 conservative values 11
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Ceyhan, A. 135, 136, 152, 153 continuum of behaviour 17–18

Ceyhan, E. 135, 136, 152, 153 control beliefs 82
Chaney, M. 135, 139, 155 control over sexuality 157, 158–9
Chang, C. 135, 139, 155 Cooper, A. xiii, 68, 91
childhood 118–19 coping strategies 84, 102
choice 157 coping thoughts 83–4
Chou, I. 32 coprophagia 128
Christianity xii, 3, 59, 110, 121 coprophilia 39
classical conditioning 15–16 CORE 10 questionnaire 103–4
clergy xiii, 59, 121 CORE 34 questionnaire 19–20, 104, 105
Clinton, Bill 32 cortisol 39
coercive sexual practices 50 ‘couple recovery contract’ 102, 103
cognitive behavioural therapy (CBT) xvi, couple work 90
14–30; continuum of behaviour 17–18; Couture, M. 117
cross addictions and comorbidity 156; Creeden, K. 40
education 56; evidence of effectiveness Crepault, E. 117
19–20; feelings and thoughts 17, Critelli, J. 117
84; formulations 21–4, 64–6; goals critical voice diaries 27
21; historical perspective 14–16; Crosby, J. 133
interconnected systems 18; internet cross addictions xvii, 41–2, 150–1, 156
addiction 136, 137–8; interpretation cross-dressing 48, 69, 114, 116, 142
of events 16–17; paraphilias 128; Crow, G. 65
primary interventions 55; schema crystal ball 76
therapy compared with 48; therapeutic cues 83, 172
relationship 43, 45, 47, 59–60; tools culture of recovery 88, 90
and techniques 24–30; trauma 145–9; cycle of addiction 55, 62, 65–6, 73–4, 89,
Twelve Steps compared with 108; 97, 102, 108, 125, 177
working in the present 18
cognitive distortions 27, 48, 55, 65, 75–8; danger 3, 68–9, 176
cognitive restructuring 56, 138, 156; daydreams 59
group work 78, 97; paraphilias 128; De Silva, P. 117, 127
relapse prevention 84, 86; trauma 147 Del Giudice, M.J. 46
cognitive restructuring 56, 138, 148–9, DeltaFosB 35
153, 156 denial 75, 76, 77
cognitive therapy 15 depression: author’s own experience of xv;
Coleman, E. 5 boredom proneness 155; comorbidity 5,
comorbidity xvii, 5, 150, 151–6; group 46, 152, 153; effectiveness of CBT 19;
work 91; identification of 46; internet formulations 22, 23; hypoxyphilia 129;
pornography 135; paraphilias 124–6 internet pornography 67, 133, 134, 136;
compassion 49 Marylebone Centre for Psychological
 198 Index

Therapies xiii; narcissistic damage 8; empathy 46–7, 129, 134

paraphilias 125; relapse prevention ‘empty chair’ exercise 24
82; secondary trauma 50; serotonin Epictetus 16
enhancement 38; sexual fantasies erotic transference 44, 51–2
as respite from 10, 124; traumatic escape mechanisms 22, 23, 65, 66, 134–5
disappointment 143; as trigger for evaluation of treatment 19
sexual behaviour 21, 74 ‘excitation exchange’ 68–9
developmental histories 49, 118–19; see excuses 75
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also family background executive function 34–5

developmental needs, unmet 144–5 exercise 82, 86, 149
Diagnostic and Statistical Manual of exhibitionism 3, 7, 38, 115, 116, 128,
Mental Disorders (DSM-IV) 7, 8, 164–5
114–15, 160 existential issues 96
Diagnostic and Statistical Manual of exit strategies 12, 73, 75, 87
Mental Disorders (DSM-V) xvi, 6–7, expectations: of therapy 43, 82; unrealistic
114–17, 138–9, 159, 160 77
DiClemente, C.C. 47, 81–2 exposure 127
directed masturbation 127 extreme cases 49–50, 129–30
dissociation 39, 51, 138–9
distraction techniques 29–30, 82 family background 8–9, 18; author’s
divorce 68, 133 own xv; case studies 121, 163–4,
dogging 15 166–72; formulation 65; group work
Doidge, N. 37 94–5; intergenerational transmission
domination 3, 11, 70, 117, 171, 173 of addictive behaviour 31–2; personal
Dominguez, J. 37 presentations 79–80; shame 57; tools
dopamine 35, 36–8, 40 for family of origin work 73; ‘trauma
Douaihy, A. 84 egg’ 70–2; traumatic 49; see also
double reward 15, 16 developmental histories
Downey, J. 118–19 Fanning, P. 82–4
downward arrow technique 26–7 fantasies 10, 51, 57, 124; case studies
dress, modesty of 52–3 13, 167; childhood 119; coital 158;
dual roles 52 paraphilias 126; shame 59; trauma 120,
dysphoria 140 140
feedback: group work 94, 95, 96, 178, 179,
Earle, M. 70, 73 180; ‘hot seat’ exercise 78, 98; personal
Earle, R. 65, 70, 73 presentations 80; therapeutic alliance 45
Earleywine, M. 46–7 feelings: ABC model 18; automatic
education 55–6, 94 thoughts 84; catharsis in group work 96;
Ehrhardt, A. 120, 123 group work 99; hot cross bun technique
Ellis, Havelock 14 28–9, 30; influence of behaviour on 17;
emotional abuse 72 see also emotions
emotional reasoning 76 fellowships 107, 110–13
emotional self-soothing 74–5 Fenichel, Otto 4–5, 48
emotions: ABC model 18; impaired affect fetishism 7, 114, 115, 116, 127, 131–2
regulation 143; influence of behaviour financial loss 3, 67, 175
on 17; regulation of 39, 40; secondary Firestone, P. 1, 37, 108
trauma 50; see also feelings Flannery, R. 85
empathetic confrontation 47 flirting 87
 Index 199

Flores, P. 140, 144, 151 cognitive distortions 78; connectedness

Foa, E. 145, 148, 149 88–9; harmful consequences 66;
focus 36 ‘hot seat’ exercise 55, 78–9, 95, 97,
Follette, V. 143 98; intermediate treatment 98–100;
formulations 21–4, 64–6, 153 internet pornography 138; modelling
Fossum, M. 57, 108 56; outcome studies 104–7; personal
Foucault, M. 158 presentations 79–80; primary treatment
free choice 157 96–8; referrals 112–13; sexual recovery
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freedom 54, 90 fellowships 107, 110–13; shame

Freeman-Longo, R. 9, 55, 63, 73, 76, 84–5 museum 72; tailor-made treatment
Freestone, Todd 85 programmes 104; trauma survivors 149;
Freud, Sigmund 14 Twelve Steps 107–10; women’s groups
Friedman, R 118–19 xiii, 101–4; Yalom and Leszcz 92–6
frontal cortex 33–4, 46 Guest, D. 108, 110, 112
frotteurism 7, 39, 115, 116 guided discovery 25–6, 27, 153
guided reading 29, 89
gambling 7, 16, 144, 152, 160 guilt 5, 50, 58, 148, 166; see also shame
Garcia, F. 125, 127
gay men 3, 66, 69–70, 114; author’s own Hall, Francesca 98
experience xv; boredom proneness Hall, P. 8, 55, 62–3, 85–6, 153
155; conservative values 11; erotic ‘hand’ exercise 99
transference 51–2; internalised handshakes 45
homophobia 48–9; sexual recovery happiness 99
fellowships 111, 112; social Hardenburg, S. 125, 128–9
stigmatisation 65; websites for 131 harmful consequences 10, 55, 97;
Ge, X. 136 assessment of 20; case studies 12;
Gedo, J. 41 internet pornography 138; paraphilias
General Medical Council 50 130; principal interventions 66–9;
generalised anxiety disorder 152, 154 Sexual Addiction in Routine Evaluation
Generalised Anxiety Disorder Scale 123 test 175–6; ten signs of sexual addiction
genetics 31–2 2; thinking errors 75–6, 77
‘gift box’ 99 Hartman, L. 55–6, 150, 151
goals 21 Hazelwood, R. 129
God 89, 107, 108, 109, 161 health anxiety 67, 154
Gold, S. 32, 65 health risks 3, 175
Goodman, A. 1, 8–10, 142–3, 160 healthy sexuality 55, 87–8, 97
Gore-Felton, C. 92 Hedelius, Matthew 85
Green, Alan 32 Heffner, C. 32, 65
Greenberg, D. 38 helplessness 13, 50, 124, 148
Greenfield, D. 131, 132, 137, 138 ‘heuristic predominance’ 11
Griffin-Shelley, E. 5 Higher Power 107, 108, 109, 110, 173
Griffiths, M. 131, 132, 134, 139, 153 Hilton, D. 5, 33, 35, 64, 134, 159
grounding 147 Hippocratic Oath 52
group cohesiveness 96 Hirschfield, Magnus 14, 117
group work xvi, 48, 54, 91–113, HIV/AIDS 67, 154
178–80; advanced treatment 100–1; homework 45, 55, 78, 90, 100–1, 104
assertiveness training 78; attachment homophobia, internalised 48–9
opportunities 146; case studies 164; homosexuality see gay men
 200 Index

Hook, J.N. 20 journals 90

hope 93 Judaism 59
hopelessness 153, 155 justification 75, 77
hot cross bun technique 28–9, 30
‘hot seat’ exercise 55, 78–9, 95, 97, 98 Kafka, M. 38, 91, 152
Hucker, S. 117 Kahr, B. 10, 117, 120
Hudson-Allez, G. 39, 40, 41, 152 Karim, Reef 34
Hull, E.M. 37 Katehakis, A. 39–40, 46
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hypersexuality 5, 116, 160; see also sexual Kernberg, O. 8

addiction Keshet-Orr, Judi xii
hypofrontal syndromes 33 Kinder, B. 5, 160
hypoxyphilia 129, 130 Kingston, D. 1, 37, 108
Kinsey, A.C. 117
Icahn School of Medicine 35 knife play 129–30
imitative behaviour 95 Kohut, H. 8
interconnected systems 18 Kor, A. 38, 155
intergenerational transmission of addictive Krafft-Ebing, Richard 4, 14, 114
behaviour 31–2 Krueger, R.B. 117
intermediate treatment 92, 98–100 Kuhn, T. 159
International Classification of Diseases Kutinsky, J. 46
(ICD-10) 6, 17, 114 Kuyken, W. 21, 43
International Society for Sexual Medicine
117 Lamacz, M. 119, 120, 124
Internet Addiction Disorder (IAD) 136 language issues 44
internet use xvi–xvii, 3, 131–9, 152, learning 14, 15, 34, 56, 93, 95
160; ABC model 18; case studies 13, Lechler, Walther 110–11
165, 166, 168, 169; comorbidity 152; legal issues 50, 176
conservative values 11; cross addictions Leszcz, M. 92–6, 98
156; cycle of addiction 74; dissociation Levine, M. 10, 160
138–9; effectiveness of CBT 19, 56, Lewis, H. 9
156; harmful consequences 66, 67; Ley, D. 10
hot cross bun technique 28–9; impact Li, T-K. 31
on relationships 67–8; loneliness libido 38, 129, 133, 136, 170
153; negative core beliefs 65; neural limbic system 33
plasticity 32–3, 35; novelty 119; on-line limited re-parenting 47, 146
relationships 125; provisional sex plan Line, B. 91
69; reinforcement processes 15–16; loneliness xv, xvii, 18, 24, 125, 143–4;
relapse prevention 86; sexual offending case studies 172; comorbidity 152,
158; shame 59; supernormal stimuli 64; 153–4; cycle of addiction 177; internet
traumatic attachment 140, 141; see also pornography 134, 135, 136; narcissistic
pornography damage 8; relapse prevention 82; as
intimacy 3, 136, 162 trigger for sexual behaviour 21, 74
intrusive thoughts 29, 38, 39 Lord, W. 32
Islam 59
isolation 135, 153 MacLean, P. 40
magnification 76
Jacobs, D. 5 maintainers 65, 66
James, William 55 male sexuality 157–8
 Index 201

Maltz, C. 37, 63, 85, 133, 134, 137 Muench, F. 38–9, 133
Maltz, W. 37, 63, 85, 133, 134, 137 multiple partners 126
management techniques 22, 23, 65, 66 murder case 114, 130
marriage xiii, 17, 162 ‘museum of loss’ 99
Marshall, W. 46, 77, 127
Marylebone Centre for Psychological Naficy, H. 38
Therapies xii, xiii, xiv, 96–107 name calling 77
masochism 4, 7, 11, 115, 116–17 Narasimhan, K. 32
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Mason, M. 57, 108 narcissistic damage 8–9, 18, 118, 130, 151,
masturbation 3, 89, 114; acceptability 156
of 158; arousal during 119; aversion Nathanson, D. 59
techniques 127; case studies 122, 123, negative affect 135
166, 167, 168, 169; conservative values negative automatic thoughts 26, 27,
11; continuum of behaviour 17; ICD- 83–4
10 6; internet pornography 136, 141; negative core beliefs 17, 56, 65, 100–1,
low self-esteem 155; neuroscience 138, 156
41; precipitants 21; preoccupation 10; Nelson, R. 88
provisional sex plan 69; shame 59; Nestler, E. 35
SSRIs used in treatment 38; neurogenesis 85, 92
transvestic disorder 116; traumatic neuroscience 31–42; addiction as a
attachment 140 biological drive 32; affiliative behaviour
maternal deprivation 10, 39, 49, 144, 163 149; attachment 39–40; executive
meditation 86, 89, 102, 109, 147 function 34–5; genetic basis of sexual
memories, traumatic 148 addiction 31–2; group treatment
mental filters 76 programme 92; neural plasticity
Merritt, Samuel 4 32–4, 35, 42; neurochemistry of sexual
‘message in a bottle’ 99 addiction 35–9, 150, 157; paradigm
metacognitive awareness 148 shift in understanding addiction 157,
Mikulas, W. 155 159, 160–1; relapse prevention 85;
Milkman, H. 36–7, 55, 56, 86 teaching about 55, 56–7, 60; therapeutic
Miller, A. 8 relationship 40–1; traumatic attachment
Miller, G. 77–8 144
mind reading 76 Niebuhr, Reinhold 161
mindfulness 29, 86, 89, 147 novelty 34, 37, 119, 135–6
minimisation 75, 76, 77 Nunn, K. 37
mirror neurons 134 nymphomania 6
modelling 56, 88, 94
modesty of dress 52–3 ‘obituary’ 99
modifiers 21, 24 O’Brian, Keith 32
Moll, Albert 14 obsessive compulsive disorder xiii, 91
Mollen, P. 57, 59 olfactory aversion 127
Money, J. 118, 119, 120, 123, 124, 125 O’Neill, J. 82–4
mood 2, 15, 36, 40, 152 operant conditioning 15
mood disorders 124–5, 154 opponent process theory of acquired
Moser, C. 117 motivation 118, 119
motivation, opponent process theory of orgasmic reconditioning 127
acquired 118, 119 Orzack, M.H. 91–2
Moyers, 62, 63 Osborne, C. 129
 202 Index

outcome studies 104–7 pornography 3, 4, 131–9; case studies

Oxford Group 109 164, 165, 167, 168, 169; definition of
oxytocin 36, 39, 40 132; dissociation 138–9; dopamine 37;
harmful consequences 66, 67; impact on
Padesky, C.A. 25–6, 60, 100, 101 relationships 67–8; loneliness 153; low
paedophilia 7, 50–1, 115, 116, 117 self-esteem 155; neural plasticity 32–3,
panic 19 35; novelty 119; provisional sex plan
Panic Rating Scale 123 69; reinforcement processes 16; relapse
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Panksepp, J. 36 prevention 85; sadism and masochism

paraphilias xvi, 5, 114–30, 160; aetiology 116; shame 60; supernormal stimuli
117–24; case studies 164; comorbidity 64; traumatic attachment 141; see also
124–6; effectiveness of CBT 19; internet use
expectations of therapy 43; extreme post-traumatic stress disorder (PTSD) 19,
cases 129–30; individual therapy 145, 148
91; provisional sex plan 69; relapse potency 126
prevention 85; social disapproval powerlessness 3, 108, 109
70; SSRIs used in treatment 38, 39; prayer 89, 109, 113, 147, 161
stigmatisation 95; traumatic background precipitants 21
49, 144; treatment 127–9 preoccupation 2, 10, 20
paraphilic disorders 115–16 presentations 62, 79–80, 97, 178–80
Parker, J. 108, 110, 112 primary interventions 54–61, 92, 96–8;
Parkinson’s disease 37–8 teaching about neuroscience 56–7;
Pascal, B. 155 teaching about sexual addiction 55–6;
pathology, male sexuality as a 157–8 teaching about shame 57–60
patient safety 146 principal interventions 54–5, 62–80;
Pattison, S. 58, 59 assertiveness training 78; behavioural
Patze, Adolf 14 substitution 74–5; cognitive distortions
penis size 60 75–8; cycle of addiction 73–4; formulation
perfectionism 59 64–6; harmful consequences 66–9; ‘hot
permission-giving and permission-denying seat’ exercise 78–9; personal presentations
thoughts 83 79–80; provisional sex plan 69–70; shame
persistence 36 museum 72; supernormal stimuli 64;
Person, Ethel 119, 162 ‘trauma egg’ 70–2; trigger identification
personal presentations 62, 79–80, 97, 74; values clarification 62–3
178–80 Prochaska, J.O. 47, 81–2
personality disorders 19, 154 prostitutes see sex workers
pharmacological treatments 129 Proulx, J. 114
phobias 19, 152 provisional sex plan 69–70, 86, 87, 97
physical abuse 49, 72–3, 121, 123, 141 psychiatric disorders 154
physical self-soothing 74–5 psychogenic sexual disorders xiii
physiological responses 28–9, 30 puberty 118, 119, 120
Pistorella, J. 143 puddles, sex in 126
Plato 55
pleasure: cycle of addiction 73; dopamine Quadland, M. 5
36; as a ‘maintainer’ 65; opponent questionnaires 19–20, 97, 100
process theory of acquired motivation
118, 119; paraphilias 120, 124, 127; Rahman, Q. 70
sexual fantasy 57 rape 116
 Index 203

rational emotive behavioural therapy 77 Schwartz, M.F. 46, 47

rationalisation 75, 77 Scott, C. 143, 144, 145, 146, 148, 149
Raviv, M. 152 scripting 119, 126
Ray, L. 31, 32 secondary trauma 50–1
Raymond, N. 154 secrecy 68, 69, 103
reattribution of responsibility 147–8 selective negative attention 22, 23
recovery groups see group work selective serotonin re-uptake inhibitors
Recovery Incorporated 94 (SSRIs) 31, 38–9, 129, 164, 172
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recovery oriented psychotherapy 12, 41 self 10, 41, 42, 58; boredom proneness
recovery rates 81 155; correction of the 159; narcissistic
‘refuse script’ messages 99 damage 8, 151; sexual fantasies 57;
Reid, R. 57 traumatic attachment 140
reinforcement 15–16 self-acceptance 12, 124, 173
relapse prevention 12, 55, 56–7, 63, 81–7, self-blame 49, 77, 145, 166
97 self-contempt xv, 3
relatedness xv, 12 self-control 81
relationships 67–8, 87, 133, 136–7, 145, self-degradation 126, 171
175 self-destructive behaviour 2
relaxation 30, 56, 147 self-disclosure xiv, 45, 47
reliability 19 self-esteem xiii, 18, 56, 84, 100; case
religion 59, 121; see also Christianity; God studies 167; formulations 22, 23; group
remorse 5, 12, 17, 171, 172; see also guilt; treatment programme 92; low 155–6;
shame paraphilias 128–9; spouses 103
responsibility 18, 147–8 self-harm 122, 123
Reynaud, M. 32–3 self-management 56
Riggs, D.S. 148 self-medication 2, 120
risk taking 2, 36, 40, 129, 135 self-regulation 8, 9–10; attachment theory
Rogers, Carl 43, 49 39–40, 51; paraphilias 130; therapeutic
Rosen, I. 9 relationship 46, 146; traumatic
Rosendale, Joy xiii, 101 attachment xvii, 140, 141, 142–3; see
Rubin, Gayle 158 also affect regulation
RUN 86 self-soothing 22, 32–3, 40, 65; alternative
Rush, Benjamin 4 methods of 142; behavioural substitution
Ryan, F. 32 74–5; case studies 168; downward arrow
technique 26; grounding techniques 147;
sadism 4, 7, 11, 115, 116–17 group affiliation 149; impaired ability
sadomasochism 115, 116–17 for 140, 144; paraphilias 130; prayer and
‘safe place’ 141, 147 meditation 89; therapeutic relationship
safe sex 88 146
safety 146 self-talk, negative 65, 86
Samenow, S. 76 Seligman, L. 125, 128–9
Sanders, D. 76 serotonin 35, 38–9, 40
saturation therapy 127 Sex Addicts Anonymous (SAA) xiv, 30,
satyriasis 6 89, 107, 110, 111–13, 164, 172–3
Schema Questionnaire 97, 100, 123, 154 Sex and Love Addicts Anonymous
schema therapy 18, 47, 48, 49 (SLAA) 89, 107, 110, 111, 112
schemas 44, 46, 47, 48, 97, 145 sex workers 3, 23–4, 44, 102, 138; case
Schmitz, J. 40 studies 12, 162–3, 165, 169, 170;
 204 Index

continuum of behaviour 17; cycle of 171, 172; comorbidity 152; cycle of

addiction 73; harmful consequences 66, addiction 65–6, 73, 177; definition of
67, 68; hierarchy of acceptability 158; 58; diminishment of 18; ‘empty chair’
shame 48, 59; trigger identification 74 exercise 24; group work 94, 98, 100;
Sexaholics Anonymous (SA) 107, 110–11 hot cross bun technique 28; impaired
sexual abuse 49, 72–3; see also abuse executive function 35; low self-esteem
sexual addiction xiii, xv–xvi, 1–13; 155; modifiers 24; narcissistic damage
aetiology in narcissistic damage 8–9; 8; negative core beliefs 65; paraphilias
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affect regulation 9–10; as a biological 70, 124, 125, 126, 130; partner’s
drive 31, 32; case studies 2–3, 11–13, accusations contributing to 17; relief
162–73; cognitive behavioural therapy from 41; sexual behaviours preceded by
and 14–30; comorbidity 151–6; 152; shame museum 72, 97; teaching
concept of addiction 5–6, 160–1; cross about 55, 57–60, 61; therapeutic
addictions xvii, 41–2, 150–1, 156; relationship 44; ‘trauma egg’ 71, 72;
definitions of 1–2; formulation 65; traumatic attachment 140, 142, 143,
historical perspective 3–5; internet 145; as trigger for sexual behaviour 21,
pornography 139; medical context 6–8; 74; unsuccessful recovery 81
neuroscience of 31–42; objections to Shindel, A. 117
concept of 10–11; paraphilias 130; role ‘site safety’ 146
of shame 9; teaching about 55–6, 60; ten Smith, Bob 109
signs of 2; traumatic attachment 140, ‘snakes and ladders’ 99, 100
142, 144 social anxiety 94, 123, 153, 154
Sexual Addiction in Routine Evaluation social skills 30, 56, 92, 128, 149, 153,
test 19, 20, 104, 106, 174–6 173
Sexual Addiction Screening Test 20 ‘socialisation to the model’ 60, 61
Sexual Compulsives Anonymous (SCA) Socratic method 25–6, 148
107, 110, 112, 113 Solomon, Richard 118
Sexual Compulsivity Scale 19, 20, 104, Southern, S. 132, 134–5, 138
106 spanking 122, 123, 126
sexual contact 52 speech impediments 172
sexual dysfunction 7, 19, 60, 122, 136 spiritual self-soothing 74–5
sexual health 55, 88, 97, 154 Stephens, Eoin 134
sexual offending: affect regulation stigmatisation 65, 95–6
9; behaviour therapy 14; cognitive ‘still face experiment’ 142
distortions 77; effectiveness of CBT 19; Stoller, R. 59, 120
internet pornography 139, 158; relapse Straker, Gillian 50, 51
prevention 85; SSRIs used in treatment stress 24, 36, 84; case studies 163, 166;
38; therapist’s decision to report 50 early 40; internet pornography 134;
sexual recovery fellowships 107, 110–13 stress resistance 85
Sexual Symptom Assessment Scale 19, 20, substance use 10, 42, 87, 160; attachment
104, 105 theory 146; avoidance of shame 58–9;
sexualisation 8–9 brain mechanisms 32–3; comorbidity
sexuality xvii, 157–8 125, 152, 154; cross addictions
sexually transmitted infections (STIs) 67 150–1; DeltaFosB 35; dopamine 36;
shame xvii, 5, 9, 40, 48–9, 68, 162; effectiveness of CBT 19, 156; impaired
ABC model 18; assertiveness training affect regulation 143; recovery groups
78; author’s own experience of xv; 41; traumatic attachment xvii, 140, 141,
case studies 12, 123, 165, 166, 167, 144; trigger identification 74
 Index 205

Sunderwirth, S. 36–7, 55, 56, 86 triggers 21–4, 44, 53, 55, 65; case studies
supernormal stimuli 64, 133–4, 136 172; cycle of addiction 73, 177;
supervision 44–5, 50 identification of 74; relapse prevention
surrender 108–9, 110 83, 85
symptoms 5 Troiden, R. 10, 160
systems approach 18 Tronick, Edward 142
trust 137
tailor-made treatment programmes 104 Twelve Steps xiv, 6, 87, 89, 94, 107–10,
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telephone calls 3, 88–9, 115, 116, 168 111, 161

testosterone 37, 38 two minds 24, 25
thematic shift 127 Twohig, M. 132–3
therapeutic contract 50
therapeutic relationship xvi, 43–53, unconditional acceptance 46
90; affiliation 144; ambivalence 53; unconditional positive regard 49
attachment 51, 141, 146; conduct 52; undivided attention 46
creating the therapeutic alliance 45–7; universality 93–4
empathetic confrontation 47; erotic unmet developmental needs 144–5
transference 51–2; extreme cases 49–50; unpredictability 16
limited re-parenting 47; modesty of unrealistic expectations 77
dress 52–3; role of neuroscience 40–1; urges 150–1
schema therapy 48; secondary 50–1; self urination, paraphilia for 126, 128
and sexuality 44–5; shame 48–9, 59–60;
stability 142; traumatic developmental validity 19
histories 49 values 11, 55, 88
Thibaut, F. 117–18, 125, 127, 129 values clarification 62–3, 97, 137
thinking errors 27, 75–8; see also cognitive Van der Kolk, B. 143, 144, 149
distortions Van Rooij, A.J. 136, 137–8
thought records 27, 60, 155 vasopressin 35, 36, 40, 41
thoughts: ABC model 18; coping 83–4; hot Vesga-Lopez, O. 19, 37–8, 152
cross bun technique 28–9, 30; influence video work 153–4
of behaviour on 17; negative automatic Vodanovich, S. 155
26, 27, 83–4; permission-giving and Volkow, N. 31
permission-denying 83 voyeurism 7, 115, 116
time, lost 3, 67, 138 Vukadinovic, Z. 5, 152
Tinbergen, J. 64, 134 vulnerability factors 21–4, 40
Torres, H. 92
transference 44, 47, 51–2 Wainberg, M. 38–9
transsexuals 48, 66, 158 Walant, K. 144
transvestites 7, 115, 116, 158 Waldorf, 62, 63
trauma 8, 43–4, 49, 118, 152; attachment Wallace, D. 35
xvii, 40, 140–9, 151, 156; case studies Ward, T. 50
167, 168; CBT for 145–9; effectiveness Watts, C. 33
of CBT 19; Marylebone Centre for websites 131–2; see also internet use
Psychological Therapies xiii; paraphilias Westbrook, D. 15, 17, 19, 46, 47, 52, 53,
120, 124, 130; secondary 50–1; 64–5
traumatic disappointment 10, 143–4; ‘wheel of faces’ 99, 100
unmet developmental needs 144–5 Will, D. 58
‘trauma egg’ 70–2, 97, 149 Wills, F. 76
 206 Index

Wilson, Bill 109 World Health Organization (WHO) 6

Wilson, G. 70 worthlesness 100
Wilson, M. 1–2
‘window’ exercise 100 Yalom, I. 92–6, 98
Winnicott, D. 39 Yen, J. 136
withdrawal 58 Yochelson, S. 76
Wolf, E. 8 Yoder, V. 132, 136
Wolf, Naomi 133, 134 Young, J. 47, 100, 146, 154
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Wolpe, J. 14 Young, K. 56, 65, 132, 133, 136, 137–8, 156

women: internet use by 132; Sex Addicts
Anonymous 111; Sex and Love Addicts Zapf, J. 5
Anonymous 112, 113; women’s groups Zawacki, T. 88
xiii, 101–4 Zeller, M. 34
work 68 Zitzman, S.T. 136–7