Q: Sexual addiction is a result of:

A) Overactive libido

B) My partner’s disinterest

C) Cultural permissiveness

D) None of the above

The answer may be obvious to those familiar with the multiple choice trope: D) None of the above. But the point remains true: There are many common misconceptions surrounding sexual addiction. Counselors, with their confidentiality policies and empathic personas, may be the only people to ever hear the true extent of a client’s interior struggle with an addiction to pornography or sexual compulsivity. Positioned on the front lines for educating clients, families and colleagues about this pervasive problem — a problem the Society for the Advancement of Sexual Health conservatively estimates affects 3 to 5 percent of the U.S. population — counselors must know how to identify sexual addiction and formulate appropriate treatment plans and referrals.

But this tremendous responsibility demands one thing that many counselors find difficult: We have to actually talk about sex.

“Professional counselors under-recognize sex addiction,” says Barbara Steffens, an American Counseling Association member and certified clinical sexual addiction specialist in West Chester, Ohio. “Sexual addiction exists in secret and often does not come to the surface until there is a crisis or several negative consequences. Few clinicians are prepared to ask about sexual history or sexually compulsive behaviors when this is rarely the presenting problem in treatment.

“I specialize and work primarily with partners [and] spouses of sex addicts, and they tell me of participating in years of marital therapy where either the issue was not asked about or it was minimized. Partners most often have little to no awareness of the extent of the sexual acting out and so do not know to bring it up in treatment. Often the partner may initiate counseling in response to knowledge of one affair, while additional sexual behaviors remain secret.”

After making the therapeutic space safe to talk about sex, counselors might find that the treatment quickly returns to traditional topics of family history and thought patterns. “Sexual addiction is not about sex,” says Todd Frye, an ACA member and clinical sexual addiction specialist in Olathe, Kan. “Some clinicians assume that sexual addictions are driven by an overly active libido that simply has an abnormal level of craving for sexual images and acts. The bulk of those who present with sexual addiction really have more of an intimacy disorder than a sex disorder.” He explains that sexual addicts might use sexual gratification as a way of creating “metaphoric connections” to serve unmet intimacy needs, while others may use sex to deal with feelings of disconnection and the inability to create relationships with others.

The number of people struggling with sexual addictions is growing daily due to the online availability of sexual material, Frye says, noting that counselors with specified training on the topic are in high demand. “We now have access to a worldwide sexual smörgåsbord,” he says, adding, “I receive referrals often by very competent counselors who feel ill-equipped to work with this addiction.” Although the larger counseling community is more familiar with a generalized approach to addictions treatment, Frye has found that specialized training for sexual addictions is needed to help clients truly achieve recovery.

Jodi Conway, a certified sex addiction therapist and ACA member in private practice with offices in New Jersey and Massachusetts, believes education is necessary to get counselors past preconceived notions about sexual addiction. “There are many [counselors who] don’t believe this is an addiction or think that viewing porn is normal male behavior,” she says. “I think with the increase in high-profile people getting caught in sex scandals and talked about in the media, there is much more awareness that sex addiction exists, but few know what types of treatment options there are or how to find qualified therapists.”

Frye agrees: “Though there is overlap in all addictions work, there are some things that are unique to sexual addictions treatment that are important for the counselor to know in order to work more effectively with the sexual addict.” He points out that traditional addictions treatment focuses on the ingesting of chemicals — taking in alcohol, drugs or food — while sexual addictions are internally based, resulting in chemicals produced inside the body, often through a thought or the sight of an image.

Counselors have many options for obtaining specialized sexual addictions training. The best-known program may be the C-SAT certification program designed by sexual addictions treatment expert Patrick Carnes and administered by the International Institute for Trauma and Addiction Professionals (IITAP). There are also other, faith-based training programs for professionals and laypeople, including a new Sexual Addictions Treatment Provider (SATP) certification at MidAmerica Nazarene University in Olathe, Kan., which, with Frye as co-chair, is set to launch in January.

“Most counselors did not receive specific training in the treatment of sexual addictions in their grad programs or found a one-day seminar to be insufficient to meet their clinical needs in this area,” Frye says. “We wanted to offer them a training opportunity that would equip them to feel adequate in effectively working with the sexual addict and their family. In addition, there has been no university-affiliated and accredited program in the U.S. We wanted to offer an accredited program that draws upon the rigor and resources that a university [can] provide.”

What to expect

Clients coming to counseling for sexual addictions might not have any idea where to start, and for most, the traditional “cold-turkey” abstinence treatment model will not apply. As with food addiction, controlled access to the “risky behavior” is part of human nature and must be considered in the treatment plan.

“The important thing to remember is that the sexually addictive behaviors are a part of the symptom and not the underlying disturbance,” notes Todd Bowman, a counselor and professor who, with Frye, is cochairing MidAmerica Nazarene University’s SATP certification program. Bowman explains that trauma, deficit, conflict and characterological dysfunction are the primary underlying disturbances with most diagnoses. “Without fail, in the lives of individuals struggling with sexually addictive behaviors, I have come to uncover one, if not multiple, of these underlying disturbances that is the drive for their sexual acting out. In addition, it is important to explore the relational dynamics created by the sexual acting out,” he says.

Frye has found that treatment usually starts with working on sobriety from acting-out behaviors such as spending time on pornographic websites. Once some level of sobriety has been achieved, the counselor assists the client in determining the primary function that the acting out behavior played and the relational experiences that helped create the addictive behavior as a coping strategy.

For example, sexual compulsivity provides immediate gratification without risking the vulnerability of having to connect within a true relationship. Sex addicts may be compensating for low self-esteem resulting from an abusive childhood, seeking to avoid unpleasant feelings such as work anxiety, or circumventing the process of having to relate to others in order to have their sexual needs met. Much like addictions to alcohol or food, the compulsivity distracts sex addicts from a reality that feels too difficult to navigate. Counselors can help those struggling with sex addiction to recognize these underlying motivations and stop self-destructive patterns of behavior.

Conway urges counselors never to shame or judge these clients or even to assume a thing about their experiences of sexual addiction. “Most clients have a history of trauma that is underlying their addiction. It is important to explore their acting out behaviors — what are the behaviors, what is their arousal template, what kind of porn are they viewing? The addiction is not to sex, it is to lust, to intensity,” she notes. “Recovery from sexual addiction is about letting go of the fantasies, obsessions, acting out or bottom-line behaviors that were self-defeating and [instead] beginning to have healthy relationships with themselves and others.”

Working with the 12-step model

Many treatment modalities are aimed at sexual addiction, ranging from individual counseling to couples work, anonymous organizations to therapist-led groups. Because the general public is well acquainted with the 12-step model for addiction recovery, the first stop for many individuals struggling with sexual addiction might be a group such as Sex and Love Addicts Anonymous (SLAA) or Sexaholics Anonymous (SA). Counselors often suggest that clients consider these groups because they offer structured accountability and support for new members. However, counselors must be careful when making such referrals because each group (and often each separate meeting) comes with its own norms and expectations. Some groups are not accepting of homosexual relationships. Some groups subscribe to a very strict version of sexual sobriety (for example, no masturbation), while others allow members to define their own abstinence plans that make room for certain behaviors.

“I think the 12-step groups are a great supplement to counseling,” Frye says. “The accountability and support that is included in these groups is fantastic and necessary, particularly toward the beginning of recovery. Getting the sexual addict sober is necessary early on for the counseling to be effective. Groups really assist with this. … Sexual addiction is so complex and powerful that we as counselors need to come with ‘all guns blazing’ and use any resource available to assist in the work we do.”

Bowman describes 12-step groups as “necessary but ultimately insufficient in and of themselves” when it comes to sexual addiction recovery. “Many folks who just go to recovery groups end up white-knuckling it through their addiction,” he says. “Individual counseling is imperative in examining the deeper psychosocial implications and precursors to the addiction … which must be intentionally identified and processed through for freedom to exist at its greatest degree.”

Conway adds that it also can be challenging to get a client to attend regular meetings. “Many are reluctant for obvious reasons, but also because they may have social challenges, or are full of shame, [have a] fear of being recognized or believe that everyone there is ‘bad,’” she says.

Partner preparation

Sexual addiction obviously has an impact on the addict’s family, and on the partner or spouse in particular. Frequently, the client comes to treatment directly because the partner has discovered the behavior. The 12-step approach to family addictions has been applied to this circumstance as well, with S-Anon and COSA (Codependents of Sex Addicts) groups providing support and psychoeducation for the partners of the identified addicts.

But that sort of support might not be enough, and in certain circumstances, may prove even more harmful to the relationship, according to Steffens, coauthor of Your Sexually Addicted Spouse: How Partners Can Cope and Heal.

“The partner or spouse of the person with the addiction is often ignored in treatment or becomes involved only as a support to the treatment of the addict, neglecting the severe stress and trauma experienced by the partner in response to ongoing betrayal, deceit, infidelity and potential abuse in the relationship,” she explains.

Operating from a non-codependency approach, Steffens has developed a “partner trauma model” for working with the partners of sex addicts. “At the time treatment is initiated, most partners are in crisis and in need of their own support and counseling,” she explains. “They are likely displaying traumatic stress symptoms due to the significant deceit, betrayal and threat to their safety brought on by the sex addiction discovery. The partner is assaulted with the reality of repeated infidelity, betrayal, years of deceit, often loss of financial resources, possible infection with sexually transmitted disease and fear for her own safety.” (Note: Steffens sometimes uses “she” and “her” when referring to partners of sexual addicts; she is not insinuating, however, that only men are susceptible to sex addiction or that only women need help recovering from the discovery of a partner’s sex addiction.)

“To ask them to come in to support the person with the addiction is asking a lot early in recovery,” Steffens says. “For many partners, being asked to join sessions to support the addict’s treatment is like being asked to do so for someone who has just assaulted them. The person they love the most has now become the person who has hurt them the worst.” She adds that early in the process, “many partners are reeling with the sudden disclosure of years of sexual acting out and infidelity and are often traumatized by this information.”

In 2006, Steffens performed a study of women whose partners were sexual addicts and found that nearly 70 percent of these women showed symptoms that were akin to those for post-traumatic stress disorder. “For someone with post-traumatic stress, they experienced something that resulted in a sense of horror and helplessness. For many partners of sex addicts, this describes their experience,” she says.

“So, rather than say that a partner of a sexual addict has their own disease or addiction — coaddiction or codependency — I acknowledge and respond to the post-traumatic stress found in those who have had their lives and hopes shattered by the sexual betrayal/infidelity that occurs when the addiction is sex.” Steffens recommends that these partners first find their own support systems and individual counselors, while using couples therapy for crisis management and psychoeducation. “When both individuals have stabilized, more traditional marital work is in order,” she says, while also emphasizing the importance of finding a counselor with specific understanding of sexual addictions.

“I am hearing stories from partners who have gone into … intensive treatment settings only to be told they are ‘just as sick’ as their husbands,” Steffens says. “These partners experience this as retraumatizing and being treated as an appendage of the person with the addiction rather than as an individual with their own mental health needs as a result of the traumatic events they’ve experienced.”

Real recovery

In terms of sexual addiction, the definition of sobriety can vary greatly depending on a client’s specific circumstances and choice of treatment. For some, sobriety is about abstaining from any online content of a sexual nature. For others, it is about limiting sexual contact to a single partner within a committed relationship. Still, one regular theme in recovery is the challenge of finding healthy ways to be in connection with those around them.

“Throughout sexual addiction recovery work, treatment continues to include some element of the counselor assisting the client to engage in current relationships,” Frye says. “Helping the client find healthy, intimate ways of connecting both sexually and nonsexually are put in place to supply the intimacy that most sexual addicts have longed for their entire lives.”

Frye also stresses that counselors must partner with clients to create a sobriety plan or structure that can provide support when the client relapses or feels anxious about relapsing. “A comprehensive plan is necessary so the client can feel equipped to maintain the progress achieved in counseling,” he says.

Conway adds that in recovery, spouses or partners should witness the addicted individual’s defenses going down. “They will have access to their partners’ cell phones, computers, emails, etc.,” she says. “There will be accountability and remorse. Therapists will begin to see the same accountability, vulnerability and willingness to do whatever is required to maintain abstinence. A client’s defenses will lower, and he will get in touch with his feelings.”

Further, real recovery often includes the couple’s relationship changing, not just the addicted person refraining from engaging in acting out behavior. “The person in recovery will be accountable to others in his behaviors and transparent with his partner regarding his life,” Steffens explains. “He actively participates in a treatment program or process. He works to demonstrate consistency. He acknowledges that trust has been violated and begins repair attempts. As the partner is supported in their own restoration following betrayal, they come to watch for and appreciate these signs of deeper change. Recovery is not just behavior cessation or management; recovery becomes an opportunity for holistic change.”

 

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Stacy Notaras Murphy is a licensed professional counselor and certified Imago relationship therapist practicing in Washington, D.C. 

 

Letters to the editor: ct@counseling.org

 

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Supporting partners of sex addicts

For too long, partners of sex addicts have been asked to support the addict’s recovery without having attention paid to their own experience of trauma. In some cases, these partners are even asked to label themselves as “coaddicts” to help frame the addiction within the couple’s relationship. Barbara Steffens is an American Counseling Association member and certified clinical sexual addiction specialist in West Chester, Ohio. She argues that treatment professionals must develop more effective and respectful treatment protocols for partners of sex addicts. To that end, she makes the following recommendations for counselors (Steffens refers generically here to the partner being female, but that is not always the case):

1) Ask her what she needs. Partners have a wealth of wisdom and strength, as well as experience. We need to learn from them.

2) Assess her needs and history. What is unique about this partner, her experience, the relationship, her history? What are her current symptoms? Why is she acting the way she is? Is it safety-seeking behavior that is often viewed as symptomatic of her own disease?

3) Conduct research. We need a more complete understanding of the experiences and needs of those in relationship with sex addicts.

4) See her as a primary patient, a client in her own right, not just as a member of the family who needs information on addiction. She has her own mental health needs as a victim of another person’s infidelity, deception and betrayal.

5) Think safety first. How would you respond to a victim of sexual assault or domestic violence? Help her establish a sense of empowerment. How else can we assist her in finding safety?

6) Join with other treatment providers who specialize in working with partners. There is a growing group of clinicians and sex addiction specialists who are seeking to improve treatment for partners.

7) Consider specializing in helping partners. There are growing numbers of trained specialists in treating sex addiction; we need an array of providers who are educated, experienced and passionate about helping partners recover from betrayal and trauma, and gaining a sense of empowerment.

Steffens adds that partners of sex addicts are struggling with many messages as they seek to heal from their wounding. “In the midst of what most say is the most painful time of their lives, they must attend to their pain, accept the reality of the state of their relationship with the one they love, manage their safety needs [and] consider the needs of family/children, while being told they need to wait and see what recovery looks like before they make any major decisions about severing the relationship/marriage,” she explains. “A counselor can be a lifeline for someone navigating this most difficult time.”

 

— Stacy Notaras Murphy