Clinical Case: Sexual Addiction Compulsivity

Dan, a 29 year old in the high tech industry, requested counselling saying that his wife of two years, Natalie, had discovered his frequenting massage parlours and was threatening to leave the marriage unless he solved his sexual problem. Dan indicated that although sex had beed good during their one year courtship, his interest in marital sex had begun to wane shortly after marriage. In spite of feeling guilty about not satisfying Natalie sexually, he lacked sexual desire for her and placated her by engaging in perfunctory sex every few months.

Dan reported that after the marriage, his frequenting of massage parlours had increased to premarital levels of several times a week. In addition, his masturbation to internet pornography had increased to almost daily. Although Natalie had been aware of his use of pornography with masturbation, she had been unaware of the extent of it. Natalie had had no awareness of his use of massage parlours until money started to go missing. This discovery had precipitated her threats to leave unless he got help.

While asking about Dan's personal history, he described his father as a "man's man" and his mother as "loving". Deeper probing indicated that his dad, a mechanic, had been self-absorbed with outdoor activities, and had shown little interest in Dan. Deeper exploration indicated that his mother, a homemaker, had been depressed much of the time. Through the eyes of himself as little Dan, he couldn't recall his parents showing much affection to him. He remembered how frightened he felt when his dad was angry and out of control. When he felt hurt, afraid, or alone, he didn't recall either of his parents helping him with his feelings.

When asked to describe what his childhood was like, he stated he had had a "normal" childhood. Deeper exploration indicated that he had felt lonely as a child, particularly after his parents separated when he was eight. The event precipitating his parents' separation had been another of his father's affairs. He recalled how painful this had been, how he had blamed himself for the separation, and how no one had helped him with his feelings of guilt, sadness, and fear.

When asked how he spent his time after the separation, he recalled spending a lot of time alone, watching TV and fantasizing about being a famous war hero while playing in his room with a miniature army set. While visiting at his dad's, he had discovered a stash of pornographic magazines. He found viewing pornography highly arousing and pleasureable. By the time he was twelve, he was masturbating to pornographic images on a daily basis. He found that doing so provided instant gratification and relieved uncomfortable feelings such as boredom, anxiety, and loneliness.

An exploration of his childhood experiences, then, indicated the tendency to idealize his parents. This is reflective of the fantasy bond. This exploration also indicated the tendency to take care of his own feelings and to gratify himself internally in fantasy. This is reflective of the defense of inwardness, a self-protective state in which children gratify themselves internally through fantasy
rather than risking reaching out for real gratification that may not be forthcoming from significant others. In an inward state, children have a pseudo independent attitude, in which they perceive they can take care of themselves emotionally.

While exploring his teen years, Dan reported that he lacked the confidence in highschool to date. Instead, he preferred to fantasize about being a famous rock star while playing his guitar, to watch TV and to masturbate to pornography. At the age of 20 he had his first experience of intercourse with a sex trade worker. He recalled the powerful feeling he experienced without the risk of personal involvement. Thereafter, he sought out impersonal, sexual encounters where ever he could, frequenting strip clubs, bars, and massage parlours. Although he experimented with alcohol and pot, he didn't find either appealing. Sex remained his "drug of choice".

It was at a bar that he had met his wife, Natalie. In meeting her, he had experienced the usual rush of excitement and euphoria in pursuing her and her wanting him, but in addition he had felt a certain comfort and "fit". Dating was intense with good sex, and for a time his urges to masturbate to pornography and seek new sexual partners subsided. After about three months, he had resumed his addictive sexual behavior.

Dan listened to a negative thought process that mediated his self-feeding, addictive sexual behavior. He would rationalize his promiscuity by telling himself, "I deserve sexual satisfaction. I'm just being a man. What she doesn't know won't hurt her. Besides, I don't care about the women I sleep with. It's only sex". He would also rationalize his use of pornography: "I've had a hard day. I
deserve some pleasure. Besides, internet pornography is harmless. Every guy does it". The negative voice not only rationalized his self- feeding, sexual behavior, but also left him feeling guilty after engaging in the behavior. After being promiscuous, Dan would berate himself, "I have no self-control. I'm a slut". As he listened to these attacks against himself, he would become sullen and withdrawn, setting the stage for acting out sexually again to numb his emotional pain.

To recap, to some extent, we form psychological defenses that underlie self-destructive behavior such as sexual addiction. We have a negative thought process, the voice, which regulates addictive sexual behavior. If this is the human condition, how do we relinguish our defenses and addictive behavior? It goes without saying that there is no magic bullet, no quick fix. Overcoming sexual addiction is a process, a journey of recovery. Although I will describe the steps of this process in a linear fashion, in actuality they are overlapping and recursive.

The Process of Change

The first step in overcoming sexual addiction is to confront oneself by acknowledging the defenses that underlie the addiction. Through exploration of Dan's early childhood experiences, he confronted himself about having formed a fantasy bond with his mother, his primary care giver. He realized that as a small child he had had legitimate needs to be fed, held, and responded to, and that when his mother had been unresponsive because of her own emotional difficulties, he had imagined she was there attending to his needs. By using his imagination in this way, he had relieved partially his anxiety and tension. He had developed a negative conception of himself, seeing himself as a difficult and demanding child, doubting the legitimacy of his feelings and needs.

Because he had derived a measure of security from an idealized view of his parents and his childhood, Dan found it painful to let go of the fantasy bond with his parents. As he developed a more realistic view of his parents and his childhood, he started to feel better about himself. He realized that his mother's perception of him as difficult was a statement about her and not about himself. As he relinguished the fantasy bond, he began to feel more himself in relation to his parents. He continued to have contact with them, but when he wanted to rather than out of duty or obligation. Dan also confronted himself by recognizing how he had become inward and pseudo
independent as a defense against hurt and disappointment. As a young child, he had learned progressively to take care of himself rather than asking for what he needed and risking rejection. He had learned to look to himself rather than to other people for gratification. As a young child he had learned to feed himself by sucking his thumb, and clinging to his stuffies. As an older child, he fed himself by watching TV, fantasizing about being a war hero, and looking at pornography. As a teen, he fed himself with TV, fantasizing about being a rock star, and masturbating to pornography. Now, as an adult, he fed himself in more sophisticated ways: working long hours, surfing
the net for the perfect pornographic image to turn himself on, and cruising strip clubs, bars, and massage parlours for impersonal sex.

Dan recognized gradually that his excessive work, reliance upon habitual routines such as TV, and in particular, his sexual behavior, were defenses against anxiety and emotional pain. He realized that he had developed an inward approach to sexuality in which he preferred to gratify himself in fantasy rather than experiencing a close, sexual connection with Natalie. He realized that when he
engaged in promiscuity, he was using women as objects to gratify himself rather than experiencing any personal connection.

As Dan confronted himself, he increased his motivation for change. Whereas initially he had been motivated to enter therapy because he was afraid of losing his marriage, now he realized the negative consequences of his sexual behavior and had a genuine desire to shift from an inward to an outward sexuality. Dan desired on a deep level to experience real gratification with Natalie rather than to gratify himself internally in fantasy.

Having begun to confront oneself by acknowledging the defenses that underlie sex addiction, the second step in overcoming sex addiction is to confront the negative thought process or "voice" that regulates one's defenses. The "voice" refers to a well-integrated pattern of hostile thoughts and attitudes about self and others. The voice is construed as a destructive overlay on the healthy self, an alien point of view about the self and others. Because it is internalized at a young age, people experience it as compelling, highly convincing, even comfortable. Because the voice is only partially in awareness, people are often unaware of it or its adverse impact.

Confronting the voice requires separating this destructive thought process out from one's healthy point of view about self and others. What is required is a paradigm shift from listening uncritically to the voice and falling under its influence to separating it out and holding on to one's healthy point of view. Firestone has developed a procedure for doing this. He suggests "saying the voice" in the 2nd person, "You", as if someone else is talking to the person. He also suggests saying the voice in the 2nd person with the affect or emotional tone that it has in one's head. By following this procedure, people have an experience of the voice as a hostile, alien point of view about themselves that is not in their best interest to listen to. Once people separate out the voice, they are encouraged to counter the voice from their healthy point of view in the 1st person singular, "I". The steps in this procedure, then, are: 1) awareness
of the negative voice, 2) separating the voice out by saying it in the 2nd person "You", and 3) affirming one's healthy point of view in the 1st person, "I". Dan learned to say the voices that preceeded and followed his addictive sexual behavior in the 2nd person. Rather than telling himself in the 1st person, "I deserve sexual satisfaction. I'm just being a man. I don't care about the women I sleep with. It's only sex", Dan learned to say as if someone else was addressing him, "You deserve sexual satisfaction. You're just being a man. You don't care about the women you sleep with. It's only sex." When Dan was asked to identify the emotional tone that this voice had in his head, he identified it as matter of fact and convincing. He identified the tone of this voice as belonging to his mother.

Dan also learned to express the voices that followed his sexual behavior in the 2nd person. Rather than telling himself, "I have no self-control. I'm such a slut", Dan learned to say, "You have no self-control. You're such a slut." Dan identified the emotional tone that this voice had in his head as angry and contemptuous toward himself. He identified the tone of this voice as belonging to his
father when he had been most out of control. Realizing that the emotional tone of the voices that preceeded and followed his acting out sexually belonged to his parents, helped him to feel more accepting of himself and to counter the voice from his healthy point of view toward himself in the 1st person. He countered, "I know that acting out sexually is not in my best interest. I want to change this, and will start by being gentle with myself. Beating myself up for slips won't help."

The third step in changing addictive sexual behavior is to act on corrective suggestions for behavior change that counter one's defenses. Dan was encouraged to separate from viewing pornography on the internet by giving his wife the password to the computer at home. He was also encouraged to separate from visiting massage parlours by placing his money under his wife's control temporarily. Although he found it dificult to act on these suggestions, he felt some relief in knowing that these measures protected him from acting impulsively.

As Dan separated himself from pornography/compulsive masturbation and visiting massage parlours, he experienced increased voices and associated anxiety. For example, the voice would say, "Go back to the office and log on to the internet when no one is there. Why not pleasure yourself and feel good?" With the support of the "holding environment" I provided, and the realization that anxiety increases whenever one gives up defenses against anxiety such as addictive sexual behavior, Dan was able to "sweat out" his voice attacks. He did this by separating out the voice in the 2nd person, "You", and soothing himself by affirming his healthy point of view about himself in the Ist person, "I".

For the most part, Dan was able to maintain these changes. When he did "slip" occasionally, these experiences were framed as part of the process of recovery to be learned from rather than as fodder for voice attacks against himself.

At the same time that Dan was giving up gratifying himself in fantasy via addictive, self-feeding sexual behavior, he acted on corrective suggestions to experience more gratification in reality. He was encouraged to be more open with his wife about his thoughts and feelings. Whereas before, when he was feeling bored or empty, he would attempt to numb these feelings by masturbating to
pornography, now he would tell her how he was feeling. He learned to "sweat out" the negative voices that attempted to talk him into withholding communication from his wife (e.g., "She doesn't need to know that. It will only upset her"), and to be open with her. In this way, he pushed through his resistance to being more open and started to experience more emotional intimacy with his wife.

In addition, he was encouraged to engage in positive activities that he found gratifying. For example, although he had had the fantasy of being a rock star as a teen, he hadn't played his guitar in years. He resumed playing and eventually found a small group of musicians whom he could jam with for fun. Although he had played sports until about age 12, now he was inactive physically. He and his wife began walking together and also joined a coed volleyball team.

Finally, Dan was encouraged to join a 12-step group for sex addiction. Dan balked at this suggestion initially, thinking that listening to men talk about their sexual problems would merely fuel his addiction. When it was pointed out that attending such a group would provide him with support as well as a program of recovery from sexual addiction as an adjunct to therapy, he agreed to check it out. Had I not encouraged him to attend a minimum of six meetings before making a decision, Dan might well have stopped attending. By the fifth meeting, Dan reported that he was starting to look forward to attending the 12-step group. What he liked most was the absence of "cross- talk", the ability to speak openly without fear of judgement. Hearing the other men speak about their struggle to maintain sexual " sobriety" also helped him to feel more compassionate toward himself when he "slipped" in the early stages of recovery.

The final and most difficult corrective suggestion for Dan was to move from an inward sexuality to an outward sexuality. Having brought his addictive sexual behavior under control (he had stopped being promiscuous and using pornography when masturbating), he was encouraged to move toward his wife, Natalie, for real sexual gratification characterized by a personal encounter in which both gave and received love. Typically, bringing one's addictive sexual behavior under control does not result in an improvement in the sexual relationship with the partner. This was the case with Dan and Natalie. As much as he felt guilty about not responding to Natalie's sexual requests, he lacked sexual desire for her. He did not find being with her as sexually arousing as gratifying himself in fatasy through pornographic images and prostitutes.

Helping Dan shift from an inward sexuality to an outward sexuality was approached by inviting his wife, Natalie, to participate in couples sex therapy. Initially, therapy focused on helping Dan and Natalie to take responsibility as individuals and as a couple for their sexual relationship in a one-two combination. Dan was encouraged to take responsibility for himself by continuing his recovery
from sexual addiction. He was also encouraged to understand how his sexual addiction had affected Natalie's view of herself and trust in him adversely. Natalie was encouraged to take responsibility for her angry attacks against Dan, which not only stirred up his guilt but
also dampened his sexual desire for her.

As a couple, they were encouraged to see their sexual relationship as a couple problem that would require both of their active participation to resolve. As a first step, emotional intimacy was increased by helping them to talk about the intense feelings - such as bitterness and fear - that had developed in their sex life. Talking helped to diffuse these feelings and to increase their emotional
connection.

As emotional intimacy increased, they were encouraged to show more affection and to experiment with exercises of sensuous touch. At first, both resisted these exercises, citing various reasons such as finding the exercises artificial and lacking in spontaneity. When it was explained that sensuous touch not only forms the basis of healthy marital sexuality, but also is a bridge to sexual desire and arousal, they pushed slowly through their resistance and started to experience the pleasure of touch.

The final step in helping Dan to develop an outward sexuality involved Dan and Natalie experimenting with erotic sexual techniques and scenarios in order to turn each other on sexually. Although they both found it difficult to ask for what turned then on (e.g., fantasies, new positions, and multiple stimulation), doing so slowly resulted in their creating a mutually gratifying sex life.

Outcomes and Duration of Counselling

As Dan experienced gradually more sexual gratification with Natalie, his urges to view pornography and to visit massage parlours diminished in intensity and frequency. The increased sexual gratification in the marriage, coupled with the pleasure Dan derived from positive activities such as music and volleyball, resulted in Dan feeling happier and having a more positive view of himself. He also noticed that although his negative inner voice had not disappeared, it had faded. As result, he felt less conflicted internally and more capable of countering the voice when it attacked him.

The changes Dan experienced are typical of the outcomes clients report. Clients often describe the following outcomes:

1. shifting from an inward to an outward sexuality, characterized by real sexual gratification with a partner,
2. feeling less conflicted internally, with more control over the negative voice,
3. developing a more positive view of self, and
4. deriving more gratification from positive activities and goal-directed behavior.

Conclusion

Recovering from sexual addiction is a process that requires considerable commitment to the process of change. By confronting oneself by acknowledging the defenses that underlie sexual addiction, by confronting the negative voice that maintains the addiction, and by acting
on corrective suggestions to counter the addictive behavior, one gradually shifts from an inward, addictive sexuality to an outward sexuality characterized by real gratification through partner sex.