CSL 513: Sexual Disorders
Matthew Tiemeyer, MA, LMHC
Fall 2013
For PowerPoint and Word versions: http://www.blueharborcounseling.com/sstp

 “It doesn’t exist”
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Sexologists, for example, see the notion of sex addiction as regressive and anti-sex
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Some assumptions sexologists make regarding the “sex addiction model”:
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It focuses on the "dignified purpose" of sex (no “heat”)
Eliminates responsibility for sexual choices
It encourages people to split (e.g., Jimmy Swaggart)
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Confuses what’s normal with true sexual compulsivity (lumping those who masturbate “too often” with sex offenders and psychosis/personality disorders, etc.)
“(Addictionologists) are missionaries who want to put everyone in the missionary position.”

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“It doesn’t exist” (cont.)
Some clinicians and researchers reject the word “addiction,” saying it applies only to things that activate the brain’s reward system directly
“It’s a nuisance”
Some therapists urge clients engaged in compulsive behavior to do a better job of hiding it
“It’s a lucky break”
Believing that becoming addicted sexually would be a benefit, like “catching a little bit of anorexia” to lose some weight

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Real issue is idolatry
Critiques matter politically, but clients who meet sex addiction criteria are engaged in a level of worship that is profound and crippling.

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Men outnumber women 3 to 1 (3 to 2 online)
 Among addicts…
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70% report severe marital or relationship problems
42% of women reported unwanted pregnancies
58% report severe financial consequences
79% report “serious losses in job productivity”
38% report physical injury from acting out
19% of men and 21% of women were involved in automobile accidents
60% of women were physically abused during sex, and 50% were raped
16% of men reported physical battering

Minimum of 3 (most have 5, over half 7 or more):
1.
Recurrent failure (pattern) to resist impulses to engage in specific sexual behavior
2.
3.
Frequent engaging in those behaviors to a greater extent or over a longer period of time than intended.
Persistent desire or unsuccessful efforts to stop, reduce, or control the behaviors.
4.
5.
Inordinate amount of time spent in obtaining sex, being sexual, or recovering from sexual experience.
Preoccupation with the behavior or preparatory activities.

6.
7.
8.
9.
10.
Frequent engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations.
Continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior.
Need to increase the intensity, frequency, number, or risk of behaviors to achieve the desired effect, or diminished effect with continued behaviors at the same level of intensity, frequency, number, or risk.
Giving up or limiting social, occupational, or recreational activities because of the behavior.
Distress, anxiety, restlessness, or irritability if unable to engage in the behavior.

Minimum of 6 must be met. Patient:
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Has severe consequences because of sexual behavior.
Meets the criteria for depression and it appears related to sexual acting out.
Meets the criteria for depression and it appears related to sexual aversion.
Reports history of sexual abuse.
Reports history of physical abuse.
Reports emotional abuse.
Describes sexual life in self-medicating terms (intoxicating, tensionrelief, pain-reliever, sleeping pills).
Reports persistent pursuit of high risk or self-destructive behavior.
Reports sexual arousal for high risk or self-destructive behavior is extremely high compared to safe sexual behavior.
Meets diagnostic criteria for other addictive disorders.

12.
13.
14.
15.
16.
17.
18.
11.
19.
20.
Simultaneously uses sexual behavior in concert with other addictions (gambling, eating disorders, substance abuse, compulsive spending, etc.) to the extent that desired effect is not achieved without sexual activity and other addiction present.
Has history of deception around sexual behavior.
Reports other members of the family are addicts.
Expresses extreme self-loathing because of sexual behavior.
Has few intimate relationships that are not sexual.
Is in crisis because of sexual matters.
Has history of crisis around sexual matters.
Experiences anhedonia in the form of diminished pleasure for same experiences.
Comes from a "rigid" family.
Comes from a "disengaged" family.

A. Over a period of >= 6 months, recurrent and intense sexual fantasies, urges, and behavior in assoc. with four or more of the following:
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 excessive time consumed by sexual fantasies and urges, and by planning for and engaging in sexual behavior repetitively engaging in these sexual fantasies, urges, and behavior in response to dysphoric mood states (e.g., anxiety, depression, boredom, irritability) repetitively engaging in sexual fantasies, urges, and behavior in response to stressful life events repetitive but unsuccessful efforts to control or significantly reduce these sexual fantasies, urges, and behavior repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to self or others

B. There is clinically significant distress or impairment in social, occupational or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behavior.
C. These sexual fantasies, urges, and behavior are not due to direct physiological effects of exogenous substances (e.g., drugs of abuse or medications), a co-occurring general medical condition or to Manic
Episodes.
D. The individual is at least 18 years of age.

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312.89 Other specified disruptive, impulse-control and conduct disorder: hypersexual disorder
302.9 Unspecified paraphilic disorder – APA says…
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Person must “feel personal distress about their interest, not merely distress resulting from society’s disapproval” OR
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Person must have “a sexual desire or behavior that involves another person’s psychological distress, injury, or death, or a desire for sexual behaviors involving unwilling persons or persons unable to give legal consent”

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Addicts may be any class, gender or age
Shame crushes potential for intimacy
Isolation (and thus loneliness) is highly likely
Multiple addictions are often present (alcohol, eating, drugs, gambling, work, etc.)
A small sample of sexual acting out behaviors includes: obsessive masturbation, sexually explicit images and stories, fantasy, heterosexual and homosexual relationships, prostitution, exhibitionism, voyeurism, visiting strip clubs and massage parlors, indecent phone calls, frotteurism, incest, rape, and child molesting.

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Self-image: I am a flawed and unworthy person
Relationships: If people knew me, they wouldn’t love me
Needs: They will never be met if I have to count on others
Sexuality: Sex is my most important need

Shame
Guilt
Belief
System
Unmanageability Impaired Thinking
Addictive
Cycle
Preoccupation
Despair Ritualization
Compulsive
Behavior
© 2008

 Carnes: Addiction is a developmental disorder
 Schwartz et al. suggest that addiction is an intimacy disorder

From the circumplex model of family systems:
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77% of addicts come from rigid families
87% of addicts come from disengaged families
68% come from families that are both rigid and disengaged

Addicts fall into predominant attachment styles:
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Fearful/Avoidant
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Suppress expression of emotions, even as infants
Lack solutions to their emotional needs
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Attachment figure averse to physical contact?
Preoccupied/Ambivalent
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Anxious about attachment figure’s whereabouts and actions
(unpredictable)
Sometimes exaggerated affect; hard to soothe

Addicts report startling frequencies of past abuse:
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81% report a history of sexual abuse
72% report physical abuse
97% report emotional abuse

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Rigid, disengaged families, leading to… insecure attachment, punctuated by… frequent instances of abuse results in:
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No confidence in relationships or intimacy
Distrust of authority and accountability

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We may pursue different ways of responding to a lack of secure attachment
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Dating/marrying someone like my parent (OR exact opposite)
Isolation
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Positive: Adaptive, active choices designed to heal
One opinion: Acting out may be seen as a misguided attempt to secure attachment at any cost and without risk

Story
Elements
Arousal Template
Acting
Out
Behaviors
Carnes: “(arousal template) … usually contains a scenario based on an abuse experience, a fantasy, or something historical.”

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Voyeurism
Parents could be distant or absorptive; addict gains a sense of power by “knowing” others in more intimate ways than he has known his parents without exposing himself
Exhibitionism
Important figures unwilling to notice client or are impacted by nothing
Bestiality
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May have been comforted by animals more than parents
May have seen animals slaughtered by caregivers

 The incredibly deferential man…
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Early 20s, socially isolated, soft-spoken, extremely aware of the harmful image men have created
Makes sure women are not frightened (or even inconvenienced) by him
Has never dated
Lives at home with parents and brother
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Arousal template:
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Monsters with tentacles violating young girls (anime)
Externalizes his own violence and yet allows him to indulge it
Consider issues with mom and with contempt for his own innocence
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Overt gaming behavior – defending women

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Allender, 2004: Addicts don’t really think that they’re going to get their needs met by acting out yet again
Initial draw and form of acting out likely to be based on attachment needs, but addictive process takes over. Then acting out becomes:
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A way to mock needs
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A way to reconcile circumstances and self-opinion – e.g., “I’m a whore. When I do this it just makes it clear.”

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It takes more energy to follow and enjoy desire fully than it does to mar yourself with it
Evil joins with desire to add momentum, taking it past its target and creating/reinforcing shame
So…aversion therapy not a long-term solution
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Cultivates disengagement, usually executed rigidly
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Encourages a conflicted internal world; i.e, ambivalent preoccupation
Alternative – objectify no one, honor everyone

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Addiction is usually defined as the presence of certain symptoms…so what’s recovery?
The client’s view
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“Just make it stop,” ending symptoms (and killing desire if necessary)
What’s still okay to do?
 What does genuine recovery look like?
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More than what the client believes
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Grief, positive intimacy, healthy desire
A bigger, stronger, deeper story

Lif e becomes unmanageable
Addiction System
1
A journey toward isolation
Fault y belief syst em
Journeying int o life
Another option
2
A journey toward grace & relationship
Balanced belief syst em
Impaired t hinking
Lif e becomes more manageable &
joy f illed
Healt hy t hinking
Preoccupat ion, obsessive t hought s
Awareness of desires, emot ions, needs & want s
Shame, despair, depression, anger
Compulsive behavior
1. Adapted from Patrick Carnes, PhD.
2. Phil Prot hero, MA, MDIV. Redeeming Stories, 2006.
Rit ual behaviors, isolat ion st rat egies
Experience subt ly of emot ion & lif e
Recovery communit y
Act ivit ies t hat f ulf ill lif e & enhance self www.redeemingstories.com
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Redeeming Stories, 2006

1. Break through denial
2. Understand the nature of the illness
3. Surrender to the process
4. Limit damage from behavior
5. Establish sobriety
6. Ensure physical integrity
7. Participate in a culture of support
8. Reduce shame
9. Grieve losses
10. Understand multiple addictions to addictive shame
11. Acknowledge cycles of abuse
12. Bring closure and resolution to addictive shame
13. Restore financial viability
14. Restore meaningful work
15. Create lifestyle balance
16. Build supportive personal relationships
17. Establish healthy exercise and nutrition patterns
18. Restructure relationship with self
19. Resolve original conflicts-wounds
20. Restore healthy sexuality
21. Involve family members in therapy
22. Alter dysfunctional family relationships
23. Commit to recovery for each family member
24. Resolve issues with children
25. Resolve issues with extended family
26. Work through differentiation
27. Recommit/commit to primary relationship
28. Commit to coupleship
29. Succeed in primary intimacy
30. Develop a spiritual life

Stage 1: Intervene in the cyclical compulsive process
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Define the problem
Break denial
End most dangerous/destructive behaviors first
Make 12-step and/or group referral
Stage 2: Initial treatment
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Determine abstinence definition—abstinence list, boundaries list, and sex/relationship plan
Create relapse prevention plan
Ensure group attendance and beginning of 12-step process
Establish period of celibacy
Reduce shame
Assess for trauma and for multiple addictions

Stage 3: Extended treatment (only possible when behavioral change has been in place)
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Address family of origin and developmental issues
Deal with grief (including the loss of acting out)
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Marital and family therapy
Trauma therapy

 Begins to break barriers to intimacy
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Safe place to speak
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Healthier way to approach attachment needs
Possibly even the presence of healthy touch
 Choosing the right group
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Some recommend that a faith-based 12-step program alone will encourage striving for perfection
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SA, SAA, SLAA, SCA, Prodigals, Celebrate Recovery all have strengths and weaknesses

Relapses are usually part of the recovery process
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6 months: Addict’s emotions (and/or those of partner) awaken, destabilizing the process
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Tendency is to flee and pour on self-contempt (fits in with the rigid/disengaged attachment style)
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Shame keeps the addict from entering the healthy sexual cycle
Leaving the shame cycle requires engagement instead of flight…

Strength and tenderness
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Without strength, client won’t believe you can help
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Being willing to confront (and even to end treatment when necessary). Boundaries, though often painful, are likely to increase the client’s internal safety
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Being willing to push through shame to lend dignity to the data
(client’s shame and your own shame)
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Without tenderness, client won’t trust you
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Empathy
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Focusing on the pain created by consequences

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The addict’s brain wiring is not generally receptive to relational matters.
Therapist must be more active, doing more defining, more teaching, more leading.
Style of relating is highly important. But addicts’ behavior is designed to reduce self-awareness, and if behavior is in place, barriers will stay up.
Alternative “back doors” include art therapy / music
/ film

“Wrong Number”…

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Partner can’t distinguish between valid and invalid threats, leading to hypervigilance
Addicts use the spouse’s devotion against them
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Attempt to discredit
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Parallels domestic violence

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96% of addicts have found that disclosure was the proper course in retrospect (60% initially) - Corley and Schneider, 2002
Must be as complete as possible (though perhaps not as detailed as possible)
Partners…
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 want to be empowered to decide how much to be told often wish they had sought/received more support from peers and counselors at disclosure
Disclosing partner needs to be able to have emotions congruent with what’s being disclosed.

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Hard consequences vs. “seventy times seven”
Prime area for conflict between therapists of addict and partner
Leaving should NOT be a threat alone. Partner must be willing to back up whatever is laid out as a consequence for future behavior.
Note: Partner should not be responsible for accountability

 Disclosure Letter – extent of behaviors, as completely as possible
 Clarification Letter – counteracting crazymaking behaviors and confirming the partner’s uneasiness where possible
 Empathy Letter – solidifying alignment with partner

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Some addicts are sex offenders; some aren’t (and vice versa)
A registered sex offender has engaged in sexual behaviors judged illegal by the state:
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Level 1 (vast majority): Low risk of re-offending. May be first time offenders; usually know their victims.
Level 2: Moderate risk of re-offending. Generally multiple victims and abuse may be long term. Usually groom their victims and may use threats to commit their crimes. Crimes may be predatory with the offender using a position of trust to commit them. Typically do not appreciate the damage they have done to their victims.

 A registered sex offender has engaged in sexual behaviors judged illegal by the state:
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Level 3: High risk to re-offend. May have committed prior crimes of violence. May not know their victims. The crimes may show a manifest cruelty to the victims; these offenders usually deny or minimize the crime. Commonly have clear indications of a personality disorder.
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Food for thought: Where does an ego-dystonic sex offender go for help?

Q & A