Eating Disorders and Sexual Addiction James Gerber PhD • • • • • • • Sex and Food Both innate biologically driven motivation Appetite/Desire/Hunger Sensory pleasure Gratification Satiation The same struggles of Anorexia and Bulimia, (over control and under control) manifest in the person’s sexual behavior and attitude. Therefore there are often periods of binging (seeking partners to fill the void) purging (release of orgasm) and restricting (aversion). “In contrast to anorexics who restrict both food and sexual activity, bulimic patients tend to have more sexual involvements…Some bulimic patients will do anything, risk anything, even AIDs to avoid the inner experience of abandonment. What appears to be ploy for sexual fulfillment is really not sexual at all” Zerbe, K. 1993 • Sexual Addiction and Compulsivity • Pattern of out of control sexual behaviors • A person risking or suffering consequences as a result of these behaviors. • An inability to stop despite the consequences. • The use of sexual behaviors or fantasy as a primary way of coping. • A need to heighten the level of stimulation. • An inordinate amount of time engaging in or seeking sexual encounters. • The neglect of other areas of life, such as career, academic, recreational and social. • Levels of Behaviors • Excessive but socially acceptable i.e. masturbation and pornography • “Nuisance” behaviors such as prostitution, voyeurism, phone calls. • Abusive and Dangerous such as child sexual abuse and sexual assault. Dissociation and Objectification Patients often describe that they experience “I”or“me” from the neck up. The body is foreign, disconnected and often held in contempt. “We experience the world through our body selves. ..If I deny my embodiedness I will also minimize the personal significance of the activities I carry on through our body. When my body ceases to be fully personal, my relationships to other body selves are diminished in their personal meanings. The world becomes external and foreign” Nelson J. 1978 Trauma, Attachment and Reenactment Reenactment: The compulsion to repeat as a result of traumatic injury. The experience is overwhelming and cannot fit into existing schemas. The repetition is seen as an attempt to comprehend, and master what was not in the child’s control. It is not only sexual or physical abuse that one may feel compelled to reenact, but also attachment injury. It is proposed that it is through the attachment process (Cyranowski, J. & Andersen B. 1998) that one develops sexual self schemas as part of the internalized model of relating. In this the model is internalized, not just the child’s experience. For example, the child will internalize the hierarchy of the relationship i.e. abuser/abused, humiliator/humiliated. Strong sadomasochistic patterns often emerge from such injury. Later in life the person’s sexual fantasy and pattern of behavior is the window into the person’s internalized model of self and other. The pairing of abuse/attachment injury to arousal is referred to as a trauma bond. Self Concept: The context of the abuse and attachment injury factor in the person’s self concept. In referring to the dilemma of the abused child Fairbairn stated, “Better to be a sinner in heaven than an angel in hell”. This refers to the child’s need to perceive themselves as bad or defective or unlovable because the alternative in intolerable. This would be to acknowledge that the adults who are supposed to love and care for me are incapable or dangerous. There is then a tendency for the person to act from this perception of self and prove that I am unlovable, a slut, deserved to be treated badly. “Even in the impersonal sex what we see is not merely animalistic sexuality but rather desperate lunges, by an ego already torn apart under the pressures of internal conflict, at reestablishing some emotional link to the world…Such eroticism and perversions which to the onlooker and even to the subject may appear anonymous and mechanical are in fact efforts of a shattered ego to salvage something of emotional relationships.” (Nelson, J. 1978.) Treatment of Sexual Addiction • Abstinence and Opening the Channel • Addiction thrives in secrecy. Opening the channel is the process of full disclosure. This includes the discussion of all past and current behaviors, urges and fantasy. It is important that disclosure be treated in a sensitive and non-shaming manner. • Relapse Prevention: • A cognitive-behavioral format is necessary. This includes an education of relapse prevention concepts. The patient is expected to identify individual cognitive distortions that facilitate the behavior, identify risk factors, high risk situations, seemingly unimportant decisions, adaptive coping responses etc. This also includes skills training such as communication, assertiveness and mindfulness. Treatment of Trauma, Attachment and Dissociation • In some situations the injury is dissociated and only known through the reenactment or flashbacks or nightmares. It is also not uncommon for a patient to say, “I don’t need to work on that. I already talked about that”. • Experience can be dissociated in a number of ways. • Cognitive/Memory • Somatic • Emotional The goal is to re-associate what has been dissociated, to release trauma bonds and revise distorted core beliefs formed in the traumatic experience. Evidence of progress is when the person can recount a narrative of the events while emotionally connected but not overwhelmed and able to understand the impact of the experience without reliving it. • Towards these goals it is necessary to use a model (or models) of therapy that allow access to dissociated experience such as, EMDR, IFS, hypnosis, and expressive therapies. • Accessing the traumatic experience is often confused with a goal of catharsis. However, the goal is for the person to reconnect with the trauma with a foot in the world of the past and with a foot in the present. • Revising Beliefs and Behavior • The witnessing allows the person to connect the injury of the past to present behavior. That is to say that it helps the person to understand how and why a particular arousal and relational pattern had been ingrained. A goal is to see this as a natural response to the injury. The patient is able to witness the past experience with an emotional connection and empathy. This helps to associate the event(s) into their life story, feel compassion for oneself and revise distorted beliefs. • This then serves to reduce the intense shame that accompanies the arousal pattern. • As important is that this serves to revise what has been a source of peak arousal to be associated with a destructive injury. • Arousal Reconditioning and Cognitive Restructuring • After the person has been able to witness and process the traumatic event(s) (talking, writing, drawing) the patient works on cognitive restructuring and arousal reconditioning. Cognitive restructuring includes identifying the beliefs formed in the experience of the injury such as, “I could have stopped it”, I must have wanted it”, It was my fault”. This includes an understanding of the context of life in which the trauma occurred. • There are a number of techniques for arousal reconditioning. Satiation exercises are used to pair a negative experience with what had been the peak arousal fantasy. • On the other side healthy fantasy with masturbation has been used to revise the trauma bonded arousal and program in a substitute. Healthy Sexuality • This includes sex education, relationship skills training, intimacy training and revising the relationship with one’s own body. • A goal is to revise, recreate a sexual identity based on one’s authentic values, goals and desires. • This does blend in with other aspects of eating disorder treatment with goals of mindfulness, accepting pleasure, setting boundaries. • Sensate Focus • This is an exercise developed by Masters and Johnson in which the couple is assigned to alternately touch each other for twenty minutes (breasts and genitals excluded). They are instructed to do this unclothed (or as close to this as comfort will allow). Each is asked to explore the other’s body with no goal other than their own sensory and emotional experience. While in itself an exercise in mindfulness, it will evoke the relational or intrapsychic stuck points that are then the subject of therapy.