Creating Intimacy with the Self

Posted by on Dec 15, 2017 in Articles, Healing Intimacy Disorders, Love | 0 comments

Creating Intimacy with the Self

Creating Intimacy with the Self:

A New Approach to Relational-Marital Therapies

When I was trained as a marital-relational therapist, the focus was on the interpersonal relationship, that is, the interaction between two individuals.  This included enhancing communication, the quality of intimacy, looking at time spent together and apart as well as the explicit and implicit contracts, anger and conflict management, problem-solving skills, and parenting and negotiation. This work was necessary, but not always sufficient.  Sometimes each person required additional individual therapy to work on developmental trauma, neglect, or the impact of parental attunements or lack thereof. The approach could be effective, but when seeing one of the partners separately, the partner may be open and self-disclosing to the therapist at the expense of critical sharing with their partner, or the couple becomes polarized as they separately tell their version of recent interactions, complain ot the therapist or want them to validate the other partner’s perceived misdeeds. This frequently makes the relationship more complex and difficult, since hearing one side of a disagreement can lead to incorrect insights and hence advice from the therapist.

Intrapersonal-Relational Therapy

Eventually a third, more useful approach to relationships emerged:  intrapersonal-relational therapy focused on strengthening one’s relationship with self.  Many clients present with internal core beliefs of self-hate, perfectionism, depersonalization or feeling “object-like,” or carry shame, believing they are “damaged goods,” which influences their choice of partner and what they are willing to accept and expect in the relationship. Two people in a destructive relationship can actively – and unconsciously — recreate patterns from their childhood.  A person who feels defective and undeserving will often recreate neglect or abuse. If the male partner, for example, hates himself, he could fear true intimacy and reject it, and for example escape into illicit affairs, online pornography, workaholism, or discharge out-of-control anger to prove to his partner that he is “bad” or unworthy. In other couples, one person becomes so over adequate to earn the partner’s affection, that their partner feels unnecessary, has no defined job role with the house, garden, kids or chores, and the foundation of the actual partnership is undermined and subsequently threatened.

In intrapersonal-relational therapy, the couple is seen by the therapist and the focus is on each partner learning self-compassion and care, and developing the capacity to receive the partner’s mirroring of adoration, affection, understanding and appreciation. This is done by having each individual identify the angry, lonely, sad, disconnected and scared parts of them self that manifests their outwardly expressed thoughts, feelings, and behaviors. Next, the partners learn to form an internal (within the self) intimate relationship with these adverse parts of self, similar to the connections we form with our children or good friends. When the parts of the self that are sad or lonely shows up, the partners listen compassionately and accept these parts (feelings), knowing that their feelings are likely amplified by the unfinished business— unprocessed emotions — from their past.

When we are mistreated as a child or bullied by peers, the injured parts of self can become disconnected, particularly if no one helps us process these feelings, allowing us to make sense of why others can be cruel or neglectful. The mistreated child might falsely conclude that it is he or she that is bad, rather than understand the behavior or maltreatment in context, i.e. the bullies picked on him because he looked vulnerable, which is because his dad exploded angrily at home, which has led him to withdrawing more and unable to pay attention in class. Oftentimes, there is a domino effect with one problem creating the next, until the victim concludes they were chosen by the bullies to be picked on because of being defective, bad or sick, and they feel shame.

Healing the Core Self

Self-compassion and nurturing can heal those injuries to the core self.  When clients feel the anxiety or hears the self-talk that attempts to cover the deeply felt shame, they instead learn to actively re-parent themselves or engage their partner to assist them to receive kindness and self-compassion and “correct” the formerly adverse emotional experience.  When they make a mistake, or don’t know how to do something effectively, the partner or self can reason gently and reflect, “That’s ok. No big deal. We can learn and are learning, to do it differently.”

The new revolution in mindfulness teaching is to teach individuals that their minds are often reactively stuck in the past, full of fault-finding or the debilitating recounting of “what they should have done,” or are anxiously playing out the future, full of “What If?” fears.  To increase self-control, problem-solving capacity, and to enable the generation of more positive experiences in the present moment, we must allow ourselves (and our clients) to learn from emotional loss, psychological pain and suffering, mistakes they’ve made and the conflicts they need to face in order to achieve the wisdom that comes from self-growth and that eventually leads to far more personal happiness.

Intrapsychic Therapy

Today’s intrapersonal-relational therapy often adds the component of “Ontrapsychic Therapy.” In this approach, one partner is the focus of a therapy session while the other partner silently witnesses their partner work through the angry, sad, lonely and disconnected parts of self with the therapist. This provides greater clarity and compassion in the witnessing partner, allowing them to understand why their partner may act in ways that upsets them.  As a wife watches her husband deal with the memories of his father beating him for a minor infraction as a child, she can then feel genuinely sad for him. She might better understand what prompts her husband to be critical with her and/or their children. This knowledge can then help to motivate her to reach out and help him learn greater patience and gentleness with both himself and his family members. The husband recognizes that he is repeating a destructive pattern. He mindfully notices that his out-of-control, angry part is fueling negative voices that say of his daughter, “She doesn’t respect me. That child needs to be punished.” Instead, he learns to calm himself, take a time-out, and find a more compassionate, constructive intervention. At that point, therapeutic help, that which develops interpersonal and parenting skills, can prove very useful.

Critical Development of Self-empathy

When individuals develop self-empathy, their relationships with others will begin to change and improve. These subtle changes lead to positive feedback and more positive mirroring from others, which increases the individual’s self-esteem and self-cohesion and creates more self-empathy. This continuously regenerating, upward spiral is the primary goal of relational and intrapersonal-relational therapy.

Once one partner begins to do deeper work, often their personality begins to shift from defensive, angry, avoidant, or dismissive, to being more open, “response flexible,” and vulnerable. Their partner then begins to shift in response, and typically, requests to do similar work themselves. As each partner changes and evolves, they feel more positive and hopeful, which motivates more change. Often, the tools for interpersonal interaction — improved communications and collaborative solutions-focused problem-solving — are maximally deployed and become highly effective.

Sexual Trauma in Context with Inescapable Stressors

Posted by on Aug 7, 2017 in Addiction, Articles, Attachment, Childhood Trauma, Healing Intimacy Disorders, Intimacy Disorders, Love, Masters and Johnsons, Trauma | 0 comments

Sexual Trauma Within the Context of Traumatic and Inescapable Stress, Neglect, and Poisonous Pedagogy


by Mark F. Schwartz, Lori D. Galperin, and William H. Masters


Post-traumatic Stress

The Diagnostic Statistical Manual-III (DSM-III) defines posttraumatic stress disorder (PTSD) as the result of a recognizable stressor that would evoke significant symptoms of distress in almost anyone (American Psychiatric Association, 1987, p. 236). The implication of this terminology is that the natural response to such trauma is PTSD — that the response is not an “illness” and that any person experiencing an event of that magnitude is likely to be similarly affected. Thus, rather than stigmatizing trauma victims by assigning to them a mental disorder, it might be more reasonable to categorize the adaptive and maladaptive survival strategies, describe such individuals as “survivors” and then label the “pathological intensifications” (Horowitz,1986) of such strategies as a mental disorder.

Because a child’s natural defenses include dissociation — even amnesia — the cycling of numbing and intrusion responses that predictably occur following posttraumatic stress (Horowitz, 1986) may continue to cycle indefinitely. The numbing portion of the cycle involves a person feeling like an object, treating others like objects, and responding objectively without the use of emotions to guide actions and without the capacity for genuine caring and compassion for self or others. Therefore, the numbing results in restrictive, self-punitive responses, as well as constriction, isolation, and disconnection from others.

Intrusion is the breaking through or flooding in of cognition or affect that overwhelms the individual. Typically, it is coded as anxiety, depression, or some other generalized distress, such as somatic complaints. Ritualized or compulsive behavior is often used to cope with this distress or to numb out further, which adds to the individual’s disability. Specifically, when the intrusion phase begins, compulsive behavior may function as a vehicle for the re-creation of numbness. When the numbing becomes intolerable (i.e., when the person feels so removed, inhuman, or unreal that all connection to self, others, and physical reality feels lost), compulsive behavior or rituals are then used to reestablish feeling.

It is likely that without external guidance and support from caregivers, the result of early trauma will be pathological intensification or mental disorder. Thus, the impact of trauma can be measured only by assessing both event and context (i.e., the presence or absence of nurturing and support from the caregivers). With sufficient support, the trauma may be “finished,” “worked through,” or resolved without any resulting pathological intensifications.

Disorders of Extreme Stress (DES)

Whenever a person experiences severe and chronic stress that is inescapable for prolonged periods, the resulting syndrome is predictably different from that of a posttraumatic stress, which consists of an overwhelming acute event that has a termination point. There is also a vast literature reviewed by van der Kolk (1989) that suggests that the physiologic concomitants of chronic, inescapable stress are different from those for acute stress. For many children who experience PTSD, there is a backdrop of stress in the day-to-day atmosphere of abuse, neglect, and danger to which some children are subjected both in and out of their homes. Whenever children are afraid to walk inside their homes because of chaotic, unprovoked, and inconsistent rage and hostility randomly projected onto family members, the environment can be considered similar to inescapable stress (DES).

Children who are chronically traumatized by their caretakers may have experiences similar to those of torture victims.

For such children, witnessing molestation, seeing one parent beaten or raped by the other parent, being locked in hot cars on summer days, or almost being drowned in bathtubs culminates in a pervasive sense of unpredictability, danger, and terror. Whenever such episodic posttraumatic stress occurs in the context of this pervasive, overwhelming, chronic stress, the long-term effects will be much more devastating. Judith Hennan (1992) and Bessel van der Kolk (1993) have recently reviewed the existing literature and suggested that the distorted survival strategies that result from inescapable stress in humans include, predictably, depression and anxiety; somatic symptoms; dissociative symptoms; compulsive reenactment; susceptibility to revictimization; intimacy and relationship disorders; and some personality adaptation in the borderline, narcissistic, antisocial, or schizoid realm.

Children who are chronically traumatized by caretakers in an environment of endemic family stress may have experiences similar to those of torture victims, which include the creation of dependency, intimidation, disorientation, and isolation (Suedfeld, 1990) Children, by definition, are dependent on caretakers. Abusive parents further engender torturous dependency by withholding basic care and opportunity. When children are forced to submit and obey as the price for being allowed cleanliness, food, clothing, access to friends, or just momentary respite from abuse, they are made into slaves. Their fates become entirely contingent on the whims of the captors/parents, and their realities reshape to fit the rules of the game, The name of the game is the subjugation of vulnerable, trusting, and ultimately desperate children by adults who are often powerless everywhere else in the world.

If children believe that they are in mortal danger and that the threat is embodied by the people on whom they are most reliant, the result is a feeling of such profound powerlessness that any will to continue is totally eradicated. Therefore, resilient children bounce back through an instinctive reframing of their environments that restores hope: They conclude that they are bad and have caused their own suffering, that their caregivers truly love them, and that if they can only try harder — or be better — everything will change. To wit: They are not without love and need only perfecting to be truly deserving.

The shame and isolation of “the secret” often compounds and reinforces these dynamics. When the secret is sexual abuse, children often have been told an array of confusing lies: “I love you best of all.” “This is our little secret.” “If your mother knew, she wouldn’t love you, she would know you’re a bad little girl,” and so on. These confusional techniques occur together with the disorientation of overwhelming, incomprehensible stimulation, which is often accompanied by excruciating physical pain. The mood of the torturer changes radically from one moment to the next: A kiss on the cheek follows a pillow over the face that nearly ends life. The isolating shame and secrecy further reinforce dependency on the torturer: “You’re my special one.” “If anyone else knew, they would hate you, but you’ll always have me.”

The longer the abuse continues, the more bound to the abusers the children feel and the more removed they become from other potential connections. The longer the abuse continues with no intervention, the more certain children become that they are not worth saving. Our culture is one in which adults are deemed more aware and knowledgeable than children. Mothers in particular seem to know things magically that children think are unknown. Likewise, the God of Western culture is considered to be all-knowing — even Santa Claus has inside information and knows if you’ve been bad or good. Amid all of these mythologies and belief systems, how can children imagine that no one notices? When intact, a parent’s position is in some measure a buffer or insulator between the child and the dangers of the world. A child being abused by his or her father can have one of two beliefs about his or her mother:

“She knows but I’m not worth saving” or, “She doesn’t know and I have absolutely no one capable of protecting me.” Again, it becomes more acceptable to feel bad and unworthy than at the mercy of all the world’s dangers. The net effect of the required adaptations to this array of implicit double binds is comparable, in essence, to those arising from intentional brainwashing. The process is the same: Bonds are severed, disorientation is engendered by deprivation or overstimulation, confusion is engendered by double messages and contradictions without resolution, and dependency on the torturer for cessation of the suffering is implicit.

This result may be intended or merely a by-product of domestic cycles of ABUSE! and neglect, but the damage is of atleast comparable and perhaps greater magnitude in domestic circumstances because the children’s/prisoners’ ego formation is still unfolding and parents’ access to the children is total. Virulency of trauma is increased by factors such as premeditation, maliciousness, and the possibility of recurrence.

For child victims, chronic, learned helplessness often renders them targets for further victimization throughout life.

For natural disaster and kidnap victims, as well as POWs, there is the hope that one day the experience will end. There may be the remembrance of a time of normalcy or happiness. However, for the child victim of domestic violence, this is reality as far as the eye can see — both backward and forward. For child victims, even when the abuse stops, the cycle often does not because the chronic, learned helplessness still renders them targets for further victimization throughout life. Their capacity to say “No” seems to be permanently injured. Initially, there are cycles of protest, despair, and apathy (Bowlby, 1969) until apathy finally becomes a relatively constant state and the individual succumbs.


Alice Miller (1983, 1986) has written about the hidden cruelties of our philosophy and practice of child rearing as a society — what she calls poisonous pedagogy. Underlying such philosophies is a belief that children are impulsive, out-of control creatures who require discipline to rein them in and civilize them. Instead of recognizing their acting-out behavior as the result of not feeling loved, attended to, and nurtured, parents assume that the behavior is a result of “badness.” Therefore, they feel entitled to punish, deprive, neglect, scream at, or threaten to or actually abandon such “bad” children. In so doing, they believe that they are acting in the best interests of the children.

Children learn not to question such disciplinary tactics for fear that worse will follow. When the children respond with anger to being treated unfairly, they are often punished more and told by the angry and sometimes out-of­control parents (ironically) that anger is not permitted, i.e., “Don’t you talk back to me, young lady” or “If you cry, I’ll give you something to cry about”— a compelling indication that no emotional response is permissible. Therefore, children learn to suppress their natural responses to abuse, which creates a broadening of psychopathology. Paradoxically, health care workers can co-conspire with families when acting-out children are scapegoated and taken to professionals to get “treated” or to be made “well.”

It is only against the backdrop of poisonous pedagogy that the devastating impact of sexual and physical abuse, both acute and chronic, can be fully comprehended. To fully assess the extent of injury and the necessary and sufficient components of rehabilitation for the victims, we must consider the acute PTSD; the chronic, extreme stress that constitutes the context of the trauma and the neglect — and societal response. Children are totally dependent on adults for life itself, and society’s attitude commonly has been one of ownership, that is, that parents have the right to bring up their children any way they wish. Within this pedagogical context, children assume that sexual abuse, for example, is a form of punishment, something they deserve for being bad—something being done” for their own good” by adults who know what’s best. In addition to the indigenous poisonous pedagogy, there is in our culture’s conceptualization of childrearing a very poor articulation of what all children require to thrive. The result is that parents, children, professionals, and state agencies cannot define neglect adequately.

Neglect is the absence of what all children need to thrive, but of what does that consist? When children are neglected, they feel unlovable. Typically, it does not occur to them to think that their caregivers are imperfect, incompetent, incapable of loving, or, at the worst, sadistic. To define a standard of comparison, one might simply ask: What is the impact on a child of having two parents, each of whom is tremendously selfish and self-absorbed, each of whom puts his or her needs above those of everyone else, 100% of the time? What is the damage, even though no overt abuse occurred? In some ways, neglect may be more pernicious than abuse, but because the two often occur together, it becomes quite difficult to determine which is most injurious or exactly where the damage of one ends and the other begins.

All children need respect, consistency, attention, support, role models, praise, protection, loving touch, assurance, and play as much as they need food and shelter. Children need opportunities to learn and make mistakes without pressure or punishment. They need to be accepted as unique, not considered replicas of their parents or older siblings, and they should be encouraged in self-expression, even when their opinions are different from those of their parents and teachers. They need to be let in on the secret that adults are imperfect, and that sometimes children are right and caretakers are not. They need to be provided with developmentally appropriate challenges and choices so that they develop the ability to evaluate, learn, and, most of all, trust themselves. Finally, as children mature neuromuscularly, they must gradually separate from caregivers and establish a sense of autonomy to operate effectively in a constantly changing environment.

Too often, the aims of child rearing are discipline and submission rather than guidance and appropriate limits. The tactics used are reflective of the underlying goal and rely heavily on shame induction (Bad boy! Bad girl!); threats of abandonment and the withdrawal of love; obedience, conformity, and never questioning authority; and the suppression of what is natural, spontaneous, and unique. If socialized properly, children are supposed to collude with ease and never say, “The emperor has no clothes!” Hence, they must disqualify their own sensory experiences and not see or be aware of everyday discrepancies and injustices; in a modern technological society, the problems become compounded.

In 20th Century Western culture, children get material possessions, but have few opportunities to develop their creativity: Emphasis is placed on meeting needs externally rather than developing internal capacities.

Values become imposed or imbibed from the outside rather than cultivated from within. Often, there is the hypocrisy of “do as I say, not as I do,” and achievement and attainment are worshipped as the new twin gods of modem existence. Children quickly learn that achievement equals desirability, and self-image becomes linked to what they have, do, and can get, rather than any durable sense of intrinsic worth.

As they get older, they lack the ability for introspection or simple enjoyment and instead feel increasingly driven to attain and acquire more and more in order to escape the feeling of inner emptiness. There is confusion as to what exactly is important and when it becomes enough, and all play becomes impossible unless it is linked to achievement. Because so many children today grow up with deficits of this type, there are high levels of endemic societal distress that, being so widespread, go unlabeled as dysfunctional. Children who lack basic internal resources are even less equipped to contend with the additional and extreme demands that acute and/or chronic stress generate. They have nowhere to tum, either externally or internally.

The sexually traumatized individual, particularly the victim of incest, is typically dealing with post-traumatic stress, DES, neglect, and poisonous pedagogy simultaneously. For this reason, therapy rarely can be focused only on the multiple rapes. Instead, individuals must eventually recognize both what they deserved to get but did not and what they got that they did not deserve, and grieve these multiple losses within the context of a nurturing therapeutic relationship. Then, they need to be given the opportunity and guidance to be able to learn new habits and skills that are different from those derived within the original abusive, neglectful environment.

Encapsulation Syndromes

Even if children are counseled soon after being raped, they are often unable to disclose or remember the details verbally. They can reenact the abuse with dolls or recreate the details through drawings, but there seems to be impairment in cognitive verbal articulation. This phenomenon is reflective of dissociation, which is the separation or non-integration of trauma-related emotions, thoughts, sensations, or behaviors.

(Braun, 1988), DSM-III defines dissociation as a disturbance or alteration in the normally integrative function of identity, memory, or consciousness (American Psychiatric Association, 1987, p. 253). For abused children, dissociation is an automatic survival strategy. It enables children to deflect traumatic experiences into a separate consciousness, making daily functioning possible. Thus, a child who is raped by his or her father before going to school in the morning is still able to go to school, participate in class, and interact with peers two hours later. Through disassociation, the child is able to believe that “it didn’t happen.” “It didn’t happen to me,” or, “It happened to someone else.” The cost of such rigid compartmentalization is that the child’s development is fixated or impaired with each traumatic experience. Each experience provides a new block of unintegrated material and a further break in the continuity of experience and consciousness. Summit (1983) describes the child as encapsulated within a bubble and feeling dirty, bad, damaged, or defective.

Although the individual continues to age developmentally and acquire new skills and life experiences, this part of the self does not seem to age. New experiences do not penetrate the semipermeable membrane, leaving the individual with the original core beliefs of defectiveness unaltered and, therefore, regardless of achievements, feeling like an imposter. It is as though the adult has developed a functional persona as an overlay, but the core “defective child” remains unintegrated. To many adults, the lack of integration may be experienced as an absence or a void — the empty, unfillable hole in their abdomen — that they attempt to assuage with addictive consuming.

By dissociating, the individual is prevented from registering the pain that would shatter functioning, but is likewise prevented from expression of the strong feelings and grieving necessary for completion of the stress-response cycle. This unexpressed emotion that the encapsulated bubble contains periodically intrudes as rage, which is either acted out or directed inward.

Dissociated aspects of trauma may leak back into consciousness, causing cycles of intrusion and numbing.

Deprived of any memories of the traumatic events in which these feelings originate, and with a distorted perception caused by the parents’ destructive parenting behavior, the child, and ultimately the adult, is left feeling defective, bad, ashamed, and isolated, which affects how he or she relates to others.

Dissociated aspects of trauma also may leak back into consciousness; causing cycles of intrusion and numbing and result in feelings of terror, powerlessness, and rage. Flashbacks to more specific elements of the original trauma or conflict may also occur. Emerging in this out-of-context manner, they typically cause the individual to feel “crazy” or hopelessly out of control of his or her mind and body, Identity, esteem, body image, sense of personal power, effectiveness, trust, and intimacy are so damaged that personal relationships become unstable and tumultuous. These traits have traditionally been labeled as “borderline,” but would be better characterized as “accommodations syndromes,” to emphasize that individuals’ perceptions are reasonable within the context of their trauma-engendered accommodations to the perceived developmental events.


Horowitz (1986), who has studied the adaptations to severe stressors in childhood and adulthood, has suggested that the common, “natural” result of severe trauma is repetition, which consists of flashbacks, intrusions and reenactment, until there is completion or mastery of the original, overwhelming stress. Such mastery requires that individuals relive their experiences, revising the age-specific cognitive confusion and releasing the intense emotions. If the stress response cycle is not successfully completed, individuals may reenact disguised repetitions with accompanying numbing and intrusions throughout their lives. (For example, some battered children and battered monkey infants grow up to batter their children; see Table1.1 for more examples.) As has already been noted, the most potent coping strategy for childhood trauma is dissociation, and the dissociative process by definition interferes with completion of, mastery of, or working through the trauma. The result is that most victims of childhood trauma are left to repeat in disguised form, ad infinitum, the events that are too terrifying to remember.

Table 1.1 lists clinical examples of reenactment. These compulsive reenactments — often revolving around themes of self-punishment, self­cutting, hypersexuality, workaholism, binge or purge eating, or thematically repetitive, destructive relational attachments — become ritualized expressions of unresolved trauma. The habitual behaviors serve as a regulatory mechanism and thereby contain “unmetabolized” trauma as previously described, mediating the cycle of intrusion to cause numbing, and the cycle of numbing to create the capacity to feel. Compounding the problem, these reenactments may also become part of addictive cycles due to the “high” from endorphin release triggered by the flash­back of the original trauma (van der Kolk, 1989). Likewise, the pleasure and stress release of the habituated act further perpetuates the habit. Thus, the factors that maintain destructive behavior may become independent of the factors that originally caused them.

These reenactments can become a distraction from the emptiness and isolation that have resulted from trauma and dissociation, giving the individual the illusion of connectedness, power, and control, as well as brief, illusory relief from chronic loneliness and dysphoria. In this context, compulsions serve as clues, or windows, to the original abuse in and out of the family, and they maintain survival in what feels like a situation of potential annihilation. More and more it becomes clear that an essential component in alleviating compulsion is identifying its original source and understanding both its original and continuing functions.

When mental health professionals confront destructive acting out without knowledge of its origins, they may, paradoxically, increase the level of shame generated from individuals’ inability to change a pattern of behavior they have honestly and mightily struggled to control.

TABLE 1.1 –  Clinical Examples of Reenactment of Trauma

  1. Marrying a “second” alcoholic or someone else who is rejecting.
  2. Physically abusing one’s own child after one has been abused.
  3. Finding oneself in a dangerous situation, such as outside a porn shop in a car alone.
  4. Finding oneself getting romantically involved with a priest again or with someone who is married.
  5. A woman marrying a man who molests her daughter and then remembering her own incestuous relationship with her own father.
  6. Finding work in the emergency room of an inner-city hospital and repeating the chronic and severe chaotic terror in one’s childhood.
  7. Having chronic affairs with strangers, combined with sexual inhibitions with one’s own husband or wife.
  8. Repeating the rape by one’s father or brother through compulsive “tricks” with strangers.
  9. Needing to be beaten or humiliated while having sexual interactions.
  10. Using traumatic sexual fantasies to be aroused or to enable orgasm with a loving partner.

Changing the individuals’ behavior and self-perceptions can be useful even in the absence of knowledge of the past, in some cases. However, the rigid belief that one is always responsible for one’s actions can be, in some instances, extremely inaccurate and potentially destructive. Unconscious reenactments, based on distorted survival strategies, sometimes result in destructive behavior beyond conscious control. Self­ responsibility is possible in such cases following effective psychotherapy that optimally allows the individual to recognize the original function of the symptom and to achieve resolution of the original trauma that had been fueling the prior unconscious enactments.

Physiologic Parallels

The tendency to form repetitive behavior patterns as a result of trauma is more than psychological. Van der Kolk (1989) has reviewed an accumulation of animal and human research, indicating that traumatic stress results in changes in the brain and autonomic nervous system that may mediate and exacerbate a variety of cognitive and behavioral symptoms.

With deregulation of the autonomic nervous system, trauma survivors are incapable of enacting the fight-or-flight response as part of Selye’s (1956) General Alarm System, which leaves them vulnerable to dangerous situations. In addition, they seem to have chronic excessive sympathetic activity, which explains why they often respond to non­emergency situations as if there were a crisis, and indeed sometimes seem to be “crisis generating.” Such research helps explain why medications that block adrenaline, such as clonidine or propranolol, seem to be effective in calming the trauma victim. Van der Kolk (1989) also draws a parallel between trauma victims and the Rhesus monkeys who were stressed experimentally, in early life. Such monkeys later respond violently to amphetamines and chronically drink more alcohol, suggesting a neurobiological link between early trauma and vulnerability to addiction.

Van der Kolk (l989) also has reviewed changes in the central nervous system — in the hyperarousal system — due to chronic alteration in the central neurotransmitter systems. Using the paradigm of response to inescapable shock in animals, he notes that catecholamine depletion is the result of traumatic stress in both humans and animals. This also leads to rational pharmacologic solutions to the use of pharmacologic agents that alter norepinephrine metabolism, such as tricyclics and MAO inhibitors in selected trauma victims. The noradrenergic tracks emanating from the locus coeruleus to the hippocampus and amygdala also play a role in facilitating memory retrieval, which may implicate this system in flashbacks and nightmares of individuals with a history of post-traumatic stress.

Finally, prolonged stress causes analgesia in mice and rats, and similar effects clinically in some trauma victims. This response can be inhibited by the opiate receptor blocker naloxone. This suggests that the analgesic effect of trauma occurring clinically with many veterans and sexual abuse survivors is certainly opiate-mediated. Prolonged stress activities anesthetize receptors in the brain in a manner similar to injection of exogenous opiates such as morphine (Christie & Chester, 1990). Therefore, the self-cutting and other anesthesia frequently demonstrated in survivors can be blocked with opioid antagonists (Braun, personal communication, 1992, and in our own clinical experience) and show cross-tolerance with morphine. It is likely that after exposure to severe stress, re-exposure to traumatic situations in humans can evoke an endogenous opioid response, producing the same effect as a narcotic. Thus it may be possible that such individuals may develop physiologic masochism and may actually become addicted to stress to relieve depression and pain.

Trauma Coding

Trauma coding refers to the control that trauma maintains over survivors, shaping their lives as victims. Primary drives such as the need for nurturance, affection, and genital eroticism are paired with severe abuse and torture, leading to strong and complex double binds that make it difficult to let go of the trauma. Some survivors believe that acknowledging that their caregivers hurt them requires that they have to hate their caregivers and dismiss all positive child memories as distortion. Some survivors need to hold on to their hate because it keeps them bonded tightly to their abusers. Working through the trauma requires that individuals eventually break the trauma coding and free themselves from the rage and hatred that bind them to the people who hurt them in order to be free to create lives that are not organized around the abuse and abusers.

Acknowledging the losses and illusions replete within childhoods filled with neglect and abuse may be more difficult than processing the overt trauma.

On the other hand, many trauma survivors need to hold on to illusions that someone, usually the non-perpetrating parents, really loved them. Otherwise, they become overwhelmed with affect and cognitions that suggest that their lives have been all bad, that they are alone, that any good moments were lies, and that they might as well die. For this reason, they initially attempt to rigidly defend the non-molesting parents as though the parents were the children and they the responsible adults on the scene. Acknowledging the losses and illusions replete within childhoods filled with neglect and abuse maybe more difficult than processing the overt trauma by a given perpetrator.

Table 1.2 lists the components of breaking the trauma coding. Breaking the coding requires accurate, non-distorted memory of childhood and accurate attribution of responsibility for abuse and neglect to those responsible. Adults reexamine and revise their childhood perceptions of the abuse. The core beliefs that derived rationally from the childhood experiences are then reexamined. Finally, the affects that were inhibited or suppressed as children are encouraged and facilitated as a focused process. The result is that adults work through their experiences sufficiently to allow themselves to need neither parental acceptance nor revenge.  Only then are the skills for adult relationships able to be developed and at last, unburdened by transference, emanating from past relationships.

TABLE 1.2  – Breaking the Trauma Coding: Re-empowerment

Breaking the trauma bond requires:

  1. Accurate memory of childhood traumas.
  2. Not distorting the events.
  3. Placing responsibility for abuse and neglect and those responsible.
  4. Using the adult’s reasoning capacity to reexamine and revise the child’s perceptions.
  5. Examining the core belief systems that were established on the basis of the childhood events and making them reality-based with regard to the new perceptions.
  6. Expressing the emotions never expressed as a child.
  7. Expressing the adult emotions of sadness and anger directed at the perpetrators.
  8. Working through the strong emotions to point where one does not want either revenge nor parental acceptance.
  9. Reestablishing a relationship with one’s inner child, on the basis of survivorship and compassion.
  10. Establishing and redefining relationships with adults that are not reactive or similar to early relationships.
  11. Establishing boundaries with others in a non-victim stance, which is based on mutual respect, compassion, and egalitarianism.
  12. Learning tools for healthy expression of intimacy, sensuality, and sexuality.
  13. A female survivor once described several repetitions, including having had her tubes tied at the age 18 for fear of one day, molesting her own child.

As a child, I would lock myself in the bathroom and play with dolls the way I had been touched. One would be in bed, the other would fondle him or her. l couldn’t understand why I did that or where it came from. I was ashamed of this awareness but couldn’t help acting it out. I thought the shame belonged inside me, that the awareness was created solely from me. During my teenage years, I turned to boys to duplicate some of those feelings — of f being cared for or loved. I knew I was fooling myself. I felt the emptiness I was left with after my liaisons with boys, but it was all I had. I was desperate to feel loved. My need for affections was so great, I couldn’t say no to many people and I rarely did.

Do you want to know why I had my tubes tied at age 18? Because whenever I thought of myself around my child, a mental image would always appear. The image was clear, and I believed in its certainty. I saw myself not being able to control the thing that lived in me from you. I saw myself fondling sexually my own infant!

This illustration poignantly conveys the profound fear in adults of internalizing their persecutors and becoming perpetrators themselves. It is frightening to trauma survivors to hear themselves, saying the same abusive phrases said to them to feel themselves capable of the same neglect or abuse that rendered their own childhood a living hell. Some survivors do eventually victimize themselves and/or others in a manner similar to that of their perpetrators. Many survivors’ worst nightmare is that part of the pattern of re-victimization and of trauma coding culminates in their abusing or neglecting their own children.

Silverman, Steele, Droegenuelle, and Silver (1962) noted several decades ago that 100% of batterers were battered in childhood. This repetition is difficult to comprehend without understanding the unconscious reenactment resulting from trauma coding. Some trauma victims also reenact these perpetrations in their sexual fantasies, cementing the erotic, violent connection. Some actually reenact the perpetration outwardly and become victimizers of themselves or others. The result of such shame-producing repetitions is the double-bind belief that they cannot be angry at their aggressors because they are equally bad and have also hurt others. It is imperative that the re-victimization process end, that the victims make amends, and that they learn compassion and self-forgiveness.


All children learn by modeling adults, particularly their parents. Abused children are being told continually that their parents’ affection is conditioned on their performance, which is never sufficient. This creates perfectionistic, self-critical inner voices that berate and criticizes children’s actions; these are the voices of the abusive parents, which have been introjected. Typically, there has been minimal reinforcement for good performance, much less any “unconditional positive regard,” and therefore the self-nurturing and self-appreciating internal messages are nonexistent. When others attempt to provide the latter, there seems to be no internal system to accept such accolades, and therefore individuals tend to avoid or to not hear such strokes and to sabotage their achievements.

This can be a feature of, or coexist with, an even more insidious phenomenon — identification with the aggressor. The abused child can identify with either the aggressive, powerful perpetrator or the weak passive, but usually equally angry partner. Living in a home with continual passive and active rage, the child is like a sponge, absorbing the high levels of resentment. The child will tend to identify with the powerful aggressor, as if to say, “l’ll become like him or her so no one can ever hurt me again. In addition, the child tends to rebel against internalization of the weak parent, who is despised for not protecting the child. The result is the development of thoughts and behaviors similar to the perpetrator, whom the child supposedly hates. One survivor, who was molested in infancy by her father, writes the following to her mother:

“And there is a big part of you in me now. I’m struggling to get rid of it; it is a lot like exorcising a demon — except that the you in me is like an implosion of blackness more than an explosion of rage. Oh yes, when your personality surfaces in me, I become punitive, paranoid, critical, and blaming. All I feel is hate and fear. But when that passes, I’m left with a black hole, devoid of feeling. I’m empty, an emptiness that is palpable and painful. It’s a blackness l can’t describe. It is as if my knowledge and duplication of your horror is robbing me of who I really am. I, the real person, the person who’s been lost for so long, is missing. And sometimes it feels that if I can’t rescue her soon from that void, she’’ll be lost forever.”

In this quote, she is able to articulate powerfully the core of her self-hatred. She despises her mother and despises herself for internalizing and absorbing aspects of her mother.

Recovery from Sexual Compulsivity

Posted by on Aug 5, 2017 in Academic Papers, Addiction, Articles, Attachment, Childhood Trauma, Dual Diagnosis Co-occurring Disorder, Healing Intimacy Disorders, Intimacy Disorders, Love, Trauma | 0 comments

Recovery from Sexual Compulsivity
by Dr. Mark Schwartz



One male client has obsessive thoughts, spending hours looking at pornography on his computer, scrolling for hours rather than spending the evening with his girlfriend. Another compulsively seeks oral sex with men having large penises, but has no romantic attraction to men. A third is obsessively aroused by images of children, while a fourth pays prostitutes to demean him through physical abuse before going home to his family. Such complex deviations signify why it can be difficult to delineate a rational etiology, and why these clients are often unresponsive to cognitive-behavioral “relapse prevention,” arousal reconditioning, social skill and empathy retraining or exposure-based therapies.

The premise of this paper is that sexual compulsivity is a developmental disorder, and an effective psychotherapy treatment plan requires a comprehensive understanding of the contributing factors. In this age of video games and electronics, when children can easily be exposed to pornography, early hardwiring can set the stage for objectifying self and others. The sexual activity becomes a means to avoid, withdraw, and disconnect from relationships and challenging life interactions. As the therapist chronicles the child’s response to critical life events, these unique sexual behaviors can be seen as rational “survival strategies.” These can then be altered by revisiting and revising the events the child avoided feeling and the child’s conclusions by using affect-based psychotherapies such as Gestalt, psychodrama, Internal Family Systems, Schema Therapy, Eye Movement Desensitization and Reprocessing (EMDR) and many others. Frequently, the client also needs to change the way he or she interacts with people, focus on the quality of intimate relationships, and create a balanced life.

A second premise of this presentation is that sexual problems often overlap with disorders of intimacy. Effective treatment involves creating what Mary Main (1995) has called “earned-secure attachment,” that is, the individual has a history of disorganized attachment and becomes more securely attached with treatment. We add in this paper that the individual has also to establish “earned secure attachment with self,” which requires self-compassion, self-soothing, self-efficacy, and self-cohesion.

The third premise is that sexual compulsivity is commonly related to trauma and neglect reenactments, so-called “trauma work.” Horowitz (1986), having studied adaption to severe stressors in childhood, has suggested that the common “natural” result of severe trauma is repetition, which consists of flashbacks, intrusions, and reenactments until there is “completion.” That is, if the stress response cycle is not successfully completed, erroneous schema become ingrained into the working model of self. In psychoanalytic terms, Stoller (1988) writes, “The individual’s life is dedicated to repeating the trauma in disguised form “to cope with contradictions such as a nurturing parent having chronic affairs or a priest who molests, for example.” The client may dissociate, and one part of self believes the mother is “good,” another believes she is “bad,” resulting is the inability to integrate, and the two opposite conclusions cannot be consolidated into narrative memory. Thus a “trauma-bond” is established, which can result in unconscious reenactments of “templates of interpersonal relatedness” (Cloitre, 2016).

The fourth premise is that for many individuals, the result of the foregoing premises is the creation of an obsessive-compulsive spectrum disorder, amplified by anxiety and created by difficulties in affect-regulation. Judith Herman (1992) writes, “Abused children discover they can produce release through emotions becoming dysregulated and the child is unable to find a consistent strategy for establishing comfort and security under stress.” Such individuals become more likely to exhibit self-destructive behavior: “acting in or acting out.’” These individuals are impaired in their capacity to reflect upon their own feelings and those of others. Compulsive sexual behavior can then become a vehicle whereby abused children regulate their internal state. The individual survives by suppressing affect and then is compulsively driven to act out for release. Emotions like sadness, fear, loneliness and anxiety are numbed, medicated and avoided through compulsive activity. Tension reduction affords self-soothing, anesthesia from pain, and restoration of affective control.

The fifth premise of treatment is that all the above-mentioned components are necessary, but not sufficient, for a full recovery. Often during childhood and adolescence, the individual is withdrawn or disassociated such that they miss critical life experiences such as dating, which become more difficult as they age. In the absence of certain critical capacities in negotiating the outside world, described by Greenspan (1977) as “structural abilities,” the client may be unable to negotiate expectations of complex day-to-day interactions. Such structural abilities might include managing social interactions, understanding boundaries, as well as the ability to play, experience pleasure, and demonstrate gestures such as showing another person you like them by smiling, laughing, and picking up on reciprocal responsiveness. Similarly, there are most often deficits in metacognitive processing due to developmentally missed opportunities and guidance. Metacognition is the ability to reflect on and make meaning of one’s mental states (I’m irritable because I didn’t sleep well) or elaborating a theory of the other’s mind (Mommy’s irritable because she is fighting with Daddy), and decentralize, (suffering is universal rather than being something only self-endured) thereby establishing a sense of mastery, meaning-making, and personal efficacy.

Thus, recovery needs to be mapped as a daily process, requiring discipline, practice, and time to learn more healthy adaptations and cognitive reprocessing. It requires a combination of a therapist, 12-step meetings, a sober-coach, and ideally a healthy partner capable of secure attachments. The client is taught basic Buddhist principles of self-discipline in order to set “intentions” for change by not avoiding anxiety-inducing exposures, and then to check out conclusions and interpretations of experiences. This will be discussed in more depth.

Developmental Disorders

Sroufe (1988) followed 240 individuals from birth to adulthood longitudinally and tested them and their families exhaustively each year after recording their attachment patterns using the “strange-situation” paradigm. His results were extraordinary and revolutionized our understanding of the development of psychopathology. It transforms the existing paradigm that psychopathology is mainly due to genetic influences on the brain to a greater focus on postnatal events shaping behavior.

Sroufe (1988) states: “Caregiver psychological unavailability, physical abuse, sexual abuse, and serious distortions in the infant-caregiver relationship were strong predictions of adult psychopathology. Emotional problems are developmental outcomes; that is, they derive from a process of successive transactions of the child and the environment. Disturbance is created by the interplay of multiple factors operating over time, and links between antecedent conditions and disturbance are probabilities and nonlinear. The same process that governs continuity and change in normal adaptors governs the development of disturbance.”

A history of childhood abuse was virtually never related to a positive outcome and frequently led to a fragmented self and disassociation in adulthood.

The praxis to understanding compulsive sexual behavior is that there is not a “cause” for a sexual deviation; rather, there are developmental trajectories for the unique symptoms. Critical life events precipitate other mitigating, positive or negative life experiences, thereby increasing or decreasing the resulting degree of disability, and the likelihood of symptom emergence. Adaptation continually unfolds within an ever-changing context, allowing for developmental deviation or for amelioration as an ontogenetic process. Sexually compulsive behaviors can result from different developmental pathways, which, as Sroufe documents, are probabilistically related to disturbance. Individuals beginning on similar paths may diverge, manifesting different symptoms of deviation. A statement such as the most common contributing factor to pedophilia is a history of sexual abuse seems reasonable based on research data, but can also be misleading, since most individuals molested do not develop pedophilic sexual arousal. Any simplistic “cause seeking” model needs to be discarded to understand how certain critical events in a person’s development can become pernicious enough to cause divergence in sexual unfolding.

For paraphilias, the specific expression of sexual arousal has a biographical basis. For example, persons aroused by auto-erotic asphyxiation may have certain critical events in their trajectory in common, such as molestation with a pillow over their face. Identifying such critical developmental events is crucial to the therapy process in our model of treatment. A corollary of this is that understanding non-deviant sexual arousal that is typically culturally established is quite likely equally complex. The current prevalent use of computers and phones by adolescents likely has a significant influence on this process, especially with certain subtypes of adolescents, and more than likely greatly amplifies the risk of objectification of self and others.

We use narrative-based therapies to help clients establish a cohesive-coherent narrative of their life events. We involve family members and friends in this process and use expressive therapies to access unsuppressed or suppressed affect related to unintegrated memories, such as a sibling being favored or a child being unwanted at birth. The unsuppressed affect can result in cognitive-affective distortions, which become eroticized. For example, unsuppressed affect can activate an adolescent male’s desire for attractive girls who are mean and rejecting, then activate prior resentment of early rejection from the mother. The rage can somehow be transposed into forced sex imagery as the brain struggles with contradictory emotions of moving toward and away and needing someone they fear.

Many clients have enormous difficulty knowing what they are feeling and instead are flooded with anxiety. If they experience the onset of a negative emotion, it becomes intolerable and they impulsively move into sexual activity to avoid and escape. Working with affect tolerance (Linehan, 2000) followed by exposures to emotions without acting on them is then practiced daily.

Attachment and Sexual Compulsivity

Secure attachment in intimate relationships refers to the capacity to turn to caretakers for a secure base, feelings of safety and security, and the experience of being seen and known and valued (Brown and Elliot, 2016.) Secure attachment creates a means of effective affect regulation. The secure base allows children freedom to explore their environment and interact with others, establishing a core sense of self and identity, as well as self-efficacy and mastery. When there is a lack of attunement with the caretaker or abuse or neglect, the child sometimes role-reverses and inhibits the expression of neediness (insecure avoidant style), while other children may amplify their expression of neediness, activating the attachment system in an effort to capture the mother’s unpredictable attention (insecure preoccupied style). By over-focusing on the unreliable caretaker, the child fails to explore his or her environment and develop self-agency, self-awareness, and self-cohesion. The resulting anxiety, as they get older without core skills, can be expressed as a hypersexual fantasy. In one scenario, the individual maintains loyalty to the caretaker by becoming a compulsive caretaker (codependent), at the cost of the developing self (Lyons Ruth et al., 1993). They use pornography as a safe way to allow sexuality without anticipated rejection or abandonment — and without threat to the primary bond.

Sroufe (1988) found that insecure avoidant boys were likely to bully, lie, cheat, destroy things, brag, act cruelly, disrupt the class, swear, tease, threaten, argue, and throw temper tantrums. On the other hand, insecure avoidant girls became depressed and blamed themselves. This quite likely is the source of increased aggression in males sexually acting-out, in contrast to females. As avoidant children reach adolescence (Gillath and Schachner, 2006), they tend to engage in sex, to feel similar to their peers, but claim it is not enjoyable or that they feel very little. This suggests they may require the additional stimulation of illicitness to feel even minimal arousal since their bodies are numb and unresponsive to touch and affection. Being held and touched is necessary for children to establish somatosensory responsivity. For this reason, hypersexual individuals in recovery almost always become hyposexual if they find a partner and are unresponsive to their partners in sex. Sensate focus, pioneered by Masters and Johnson, and mindfulness exercises are critical to increase responsivity.

The intimacy disorder therefore originates in the child feeling unloved and unsafe, thus fearing closeness with others. Later, it becomes too difficult to rehearse sexual activities with self or with a romantic partner, so distance is created by masturbating to pornographic or paraphiliac images. Objectifying the other’s body seems to provide enough reactive distance to get affection without activating the pain of rejection or enmeshment. In John Money’s terms (1986), the love-map or template for self and others becomes objectified, such that sexual arousal diverts from the natural trajectory and is blocked, allowing the unusual to bizarre to intrude or displace (paraphilia). The behavior can create an addictive cycle as it becomes a functional means of self-soothing and modulating intense emotions. The individual responds to stress by escaping into fantasy or copes with distress by numbing and escaping into an “illusion of intimacy.” The problem is that the connection is temporary and quickly followed by emptiness, requiring more sexual activity to escape feeling even worse.

Even individuals with enough social capital to marry or date often describe feelings of emptiness and loneliness. Like a hormone unable to bind to a receptor site, other people are available, but clients cannot connect with them to assuage their inner emptiness. This emptiness seems to be related to the absence of a core sense of an integrated self. They verbalize that they feel like an impostor, filled with self-hatred and shame. They remain internally in a state of self-conflict with polarized parts of self continually in battle. They achieve, but remain perfectionistically driven to more. They can sometimes find partners, but become quickly bored or engaged in conflict, successfully pushing them away. Their hypersexual behavior may be temporarily suspended by a new encounter, but once the early stage of exploration and discovery declines, they cannot bond.

We therefore believe that it is requisite in treatment for clients to form a compassionate relationship with the neglected and injured parts of self, disowned in childhood, and make reparations. Cognitive therapies are used to stop negative self-statements. As described earlier, we teach daily mindfulness to re-associate the body’s sensations, and to recognize and tolerate emotional states, using Dialectical Behavior Therapy (Linehan, 1993). If there is PTSD trauma, we seek resolution with cognitive reprocessing therapies to develop a cohesive sense of self. Often destructive prior relationships need to be terminated and family work is essential to repair damaging, destructive cycles and establish healthy boundaries. Choosing a partner with secure attachment is critical, so clients are taught to recognize characteristics of avoidant, preoccupied, and disorganized partners.

To repair the attachment system, a person’s internal working model requires a “template” that often does not exist when there is severe neglect. Brown and Elliot (2016) have developed a technique to remap attachment representations using the “Ideal Parent.” See Table I. They ask the client to imagine a different set of parents, ideally suited to their nature. They then support the client’s recognition of parents who are present, reliable, consistent and interested in the child, facilitating the child’s growth through safety and exploration. The technique is often astounding to clients as they recognize the degree of absence they originally experienced. When resistance emerges, it too is useful in working with aspects of minimization, denial, and loyalty to the family system. A “love map” with clearer expectations of self and other is “written-in,” practiced, and then further differentiated in rehearsals with the therapeutic community, friendships, and dating. Table I lists components of Ideal Parent work.

Trauma, Neglect, and Sexual Compulsion

When a child encounters sexualization prematurely, it is, as novelist John Fowles says, “Like a ship sent out to sea without a rudder.” Thus, a loving father having chronic affairs or a nurturing mother who is highly seductive and brings different men home to sleep, leaves the child with contradictions that are difficult to integrate, particularly if the brain is not fully mature. The result is internal splits, i.e., good mom does bad things because she is driven by her “bad sexuality;” dissociative templates then are engrained into the child’s developing sense of self. Hendrix in his IMAGO therapy suggests that positive and negative attributes of caretakers are involved in mate selection. One solution to dealing with unintegrated parts of self might be, for example, to find a wife who is the Madonna, but the husband can experience sexual arousal only in affairs with the temptress on dating sites. Conceptualizing parts with polarized templates lends itself to Gestalt-like interventions.

A critical component of trauma is implicit in Freud’s writing on repetition-compulsion. Freud wrote, “The patient remembers nothing of what is forgotten,” but he expresses it in action in an attempt to achieve mastery over the traumatic situation. Reenactments may be understood as arising from templates set in place through affective behavior. Cloitre suggests, “templates of interpersonal relativeness” are formed on the basis of past experiences with others and guide future behavior. Thus, if the priest comes to dinner and then molests the child in the child’s own bedroom while the parents are in the living room, the experience may be impossible to integrate because of the dramatic contradictions. The memories may then become unavailable for long-term memory, but are enacted first in doll play or drawings of sexual activity, on sexual websites, then by sexual acting-out. These repetitions result in dissociation; one part of self acts out while another part of self has rigid integrity. We use Resick’s cognitive-reprocessing therapy, Internal Family Systems, and EMDR, all with the same client to get to very different material in the cognitive reprocessing.

The obvious treatment consists of first establishing control over the out-of-control behavior, followed by increasing ability to remember the truth about, and experience emotions of past trauma. This is done with one foot in the past and one in the present to allow the adult self to correct cognitive distortions and provide internal safety and reassurance. Unconscious repetitions are then made explicit with behavioral suggestions to write about the destructive past enactments. Metacognitive work (described later) then becomes critical.

Obsessive-Compulsive Spectrum Disorder

The fourth component of the treatment model is the obsessive-compulsive spectrum nature of sexual enactment. In some cases of paraphilia, prescribing a drug such as Nardil or Anafranil (monoamine oxidase inhibitor and tricyclic) will quickly bring the behavior under control. This suggests that in some individuals, brain changes are involved in the anxiety driven, compulsive nature of deviant sexual arousal. When events in childhood seem chaotic and out of control, and the caregivers cannot be trusted to provide comfort or safety, some children cope by developing repetitive action patterns such as checking that the door is locked or washing their hands repetitiously. The fear is channeled into an illusion of safety by distracting oneself with repetitive acts. The brain seems to “hardwire” such repetitions, and the individual avoids and protects him or herself by feeling in control through these useless enactments. It seems reasonable to assume that for some individuals, sexual fantasy, pornography or paraphilia would become eroticized compulsive rituals.

Assuming there is an OCD component to some sexual deviations, the treatment of choice is exposure therapy with response prevention. This entails the repeated enacting of the ritual so that: (1) the arousal no longer creates release or relief; (2) the behavior is not under the client’s control; (3) the client is unable to use the arousal to escape stress or reduce anxiety. To do this, we use fantasy satiation, dictating the enactment every morning at 7 a.m. by therapist mandate and recording the enactment for 20 minutes, or we use covert sensitization in which the fantasy is dictated for three minutes, followed by adverse consequences for three minutes, three times for a total of 18 minutes daily. The sense of control and illicitness is thereby extinguished. We encourage the patient to develop more insight and become more aware of the cognitive process. We teach the client to identify daily stressors and deal with them directly through problem solving. Meanwhile, we encourage the development of non-deviant arousal and fantasy, and regular rehearsals.

For those engaged in chronic affairs or hook-ups, we ask the client to identify five alternative ways that can be used early in the cycle to deal with the urge to relapse, and use “buddies” as an alternative form of self-soothing. We also do a great deal of work around developing empathy for the other person (and self) so that instead of that person being an “object,” the desired individual becomes a person resembling their “friends” in group.

Sober Coaching

Once the individual has established control over out-of-control urges and behavior, it is imperative that they begin to turn to people for comfort. Often they need support with social and dating anxiety and coaching, regarding boundaries and how to receive affection. Table III shows the areas we initially assess. The blueprint of how we live as adults is written by how we were loved as children. If we didn’t have maternal nurturing, we may not have the structural capacity to give it. If love consisted of caring for others, we might search out partners requiring caretaking.

We have noticed wide differences in our assessment of skill deficits, idiosyncratic to the individual. Typically, clients don’t know what they don’t know. Their thinking and behavior suggest structural deficits in self-regulation, relating, pre-symbiotic affect communication, representing and differentiating experience, and representing internal experiences of self-observation. Using life coaching to practice new behaviors can help to assess such deficits, practice new behaviors and not avoid anxiety-producing solutions. Since clients don’t know what they don’t know, watching their behavior in social situations can uncover some circumstances that provoke childlike responses to adult situations, and other circumstances in which excessive dependency is followed by walling off people. Mindful self-observation and modeling by the life coach is ameliorative.


Denial, rationalization, and minimization are the core criteria for addictive behavior. Individuals deny, minimizing and distorting their life narrative, maintaining loyalty to their family system and idealizing people who repeatedly injure them. Add to this their amnesia of traumatic events and inability to accurately remember the first five years of their lives, and developmentally based psychotherapy would seem impossible. Trauma-based psychotherapies are premised on the idea that all memory is potentially inaccurate, since the experiences are selectively filtered through a child’s central nervous system, not yet fully differentiated, and then selectively remembered in addition to that. We have nonetheless found that facilitating a coherent, cohesive narrative of one’s perceived development is critical for developing a coherent sense of self. Interviewing family members and friends can be extremely helpful.

As Kohut ( 1971) has emphasized, each interaction with others provides a potential mirror for self-development. Being aware of cognitive processing of external feedback is critical. Fonagy (2002) has written extensively on meta-communication — “thinking about thinking.” Distinct skills contribute to meta-cognitional capacity, such as the ability to reflect on and make meaning of one’s mental states (I’m irritable because I didn’t sleep well last night) or elaborate a theory of the other’s mind (Mommy is irritable because she has been fighting with Daddy), and decentralize, thereby making sense of others and contextualizing accurately. Shame, self-hatred, and the inability to empathize with self or others results in the erroneous coding of feedback. The individual can have inflexible self-focused attention, perseverative thinking styles in the form of rumination related to the past or future, or attentional styles of threat-monitoring and coping patterns based on erroneous beliefs (Wells, 2005). The individual believes he or she must worry in response to negative thoughts in order to be prepared. By paying attention to every perceived danger, harm can be avoided. Positive thoughts might tempt fate and being too good will surely be followed by something bad.

With this in mind, the sexually compulsive individual commonly perceives the world through these lenses:

• I am an imposter
• If people knew that I lack integrity, they would not respect me
• Therefore, I must not allow myself to get close enough for others to see me
• I am defective
• I am not like other people
• I must present an image to others that they like
• I must not disappoint other people

• I am a pervert
• I will be despised for my affliction
• I was born broken
• It is unfair and since life is unfair to me, I am not responsible for hurting others

• My behavior is not my choice
• I cannot stop it
• No one can understand

• I am not like others
• I must keep it a secret
• I can pretend to change but the only relief is death
• I cannot reveal the truth

With such filters, every interaction with others can result in anxiety relieved only by acting out. Monitoring cognitive distortions and altering conversations with self is thus critical to recovery and establishing a core sense of self. This requires a daily commitment to uncovering and challenging each self-statement.

Brown and Elliot (2016) review extensive literature related to metacognition. The core
features are:

    • (1) mental state of self, i.e. “ I am defective,”
      (2) mental state of others, i.e. “Nobody could care for someone such as me,”
      (3) developmental aspects of mental states, i.e. “Because girls rejected me in high school, no one will ever desire me,”
      (4) decentralization, i.e. “I am the only person with this affliction,”
      (5) mastery, i.e. “there is nothing I can do to have a desirable partner,” and
        (6) relation with therapist, i.e. “if they knew the truth they would despise me.”
  • These errors in thinking resemble Samenow’s (2000) description of the “criminal personality.” Ultimately, psychotherapy targeted toward the disorganized attachment style and focused on assessing and then altering such thinking is critical to moving toward “earned secure attachment.” We use a specialized group for metacognitive reprocessing with weekly “homework” assignments to change patterns of thinking. We find large variance within group members in our assessments of meta-cognitional deficits; therefore, individualized assignments are critical.


    Sexual compulsion is more about intimacy, attachment, and connection with self and others, and less about sex. Desire and arousal emerge developmentally from optimal caring, compassion, and competent parenting attuned to the unique temperament of the child. The attachment system can become deactivated when a person feels engulfed and activated when a person perceives abandonment. Therefore, recovery is a process that encourages repair of the attachment system. For individuals with sexual compulsion, however, hypersexuality is used to both activate and deactivate attachment, mirroring their early history of disorganized attachment. It is imperative to work with cognition, affect, and behavior to facilitate internal integration and seed an interrelated, cohesive sense of self before facilitating closeness with others that might activate trauma bonds and unconscious or conscious fear.

    Additionally, the ability to experience and articulate emotions as a signal for constructive actions is a requisite for secure attachment. Assessing one’s past with “fresh” adult wisdom and gaining perspective in relation to intergenerational and cultural influences is critical. Making meaning and working through losses and grief can allow for greater ability to be present and to experience life in the moment. Mapping recovery as creating the capacity for secure attachment allows clients to delineate the steps necessary to abstain from compulsive behavior while creating a life capable of experiencing both joy and pain.

  • Table III lists a summary of the components for facilitating secure attachment. After developing a cohesive written narrative that is also presented in group, we examine family loyalties, idealizations, and extremes of contemptuousness versus “placing on a pedestal,” as well as “involving” taking care of others. We assess the childlike capacity to play and feel joy, and degrees of self-hatred, perfectionism, and punitiveness. Issues of loss and grieving are related to the capacity to feel affection. Finally, the attunement of the client with the therapist, values toward connection, and the ability to look at oneself flexibly are all part of metacognitive capacities. These components, taken together, form the core of facilitating earned secure attachment with self and others.

    Table I

    Ideal Parent

    Physical Presence
    Attunement (behavior, internal state development)
    Soothing and Reassurance
    Express Delight
    Encouragement for Exploration
    Outer Exploration



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    Gillath, O. & Schachner, D.A., (2006). How Do Sexuality and Attachment Interrelate? M. Mikulincer and G. Goodman (Eds.), Dynamics of Romantic Love (pp 337-355). New York: Guilford.
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The Masters and Johnson Model

Posted by on Aug 5, 2017 in Articles, Attachment, Childhood Trauma, Dual Diagnosis Co-occurring Disorder, Healing Intimacy Disorders, Intimacy Disorders, Love, Trauma | 0 comments

Update on the Masters and Johnson Model for Treatment of Sexual Desire Phase Disorders


Factors Contributing to Low Desire and Arousal

Masters and Johnson wrote very little about their approach to desire phase disorders. In 1986, Dr. Masters and I co-authored a paper reviewing the Institute’s conceptual approach to inhibited sexual desire. Dr. Masters wrote:

“As we mature, sexual response is a natural manifestation of attraction to a person perceived as appealing. This attraction evolves into a casual or committed relationship. Once a pair-bond is established, sexual desire is a natural way of expressing the sense of intimacy that develops within a committed relationship. Therefore, anything that enhances or inhibits relational intimacy may positively or negatively influence the individual’s levels of sexual desire. Sex is innately pleasurable – unless something mitigates that pleasure. Couples who evidence little intimacy in the living room usually will feel distant from each other in the bedroom. Therefore, persons who are bored, pressured, fatigued, angry, guilty, fearful, anxious, or suffocated in a relationship are ‘entitled’ to low levels of sexual desire.”

Thus, the Institute’s approach to treating inhibited sexual desire was similar to their treatment of sexual dysfunction. The “relationship” was the primary focus of treatment rather than the symptomology. As the couple placed themselves in social isolation and followed daily suggestions to increase closeness, connections, communication and intimacy, the roadblocks that interfered with sexual desire would become obvious. Directive forms of psychotherapy were used to “neutralize” these roadblocks, and the couple’s newfound levels of intimacy eventually elevated their sexual desire. Masters and Johnson therefore concluded that there was no such thing as an uninvolved partner and maintained their treatment focus on the relationship.

This focus on the relationship has shortcomings, however, since many roadblocks can exist to blunt sexual desire, both in the individual and the relationship. Hypogonadism, certain medications, and other physical conditions can cause a man to have generally low initiatory behavior and low arousal. But present this man with a new partner, or disinhibit him with small amounts of alcohol, and he may become very desirous or aroused. Thus, dispositional and situational factors can affect desire. Similarly, if the same man has been enmeshed with his mother, sexually abused, or developed body dysmorphia or any other injury to sexual unfolding, he may evidence disturbance of desire. The treatment of inhibited sexual desire must vary relative to its contributing factors, using different interventions to achieve successful treatment.

In addition, since individuals often choose partners who have similar or compounding issues, two people together can create a more complicated problem, often because when one person says no to sex, the other may feel unloved or rejected. The couple then manifests marital distress and conflict in other areas of their relationship. This starts a domino effect, a series of deleterious influences on levels of sexual desire in the relationship. Both partners may label the person most affected as hyposexual. The other partner feels undesirable and frequently reacts by increasing his or her demand for sexual interaction. This elevated level of sexual demand increases performance anxiety in the inhibited partner and may lead to sexual dysfunction, which further lowers desire.

More dominos fall if the individual with low desire attributes the problems to “falling out of love.” Feelings of low self-esteem, insecurity, guilt, and other negative emotions, such as depression, follow. Add a serotonin reuptake inhibitor to treat the depression and you put the “icing on the cake” for serious sexual and relationship damage.

The most frequent relational issue contributing to low sexual desire is ignorance. We consider the lack of knowledge about sex and physical intimacy a public health crisis; few people know adequate techniques for mutually pleasurable lovemaking. Instead we often see a compulsively driven, mechanical interchange focused on orgasm, ejaculation and tension release. The intimacy, connection, tenderness, and exchange of affection is limited. The widespread availability of pornography, with images of sex acts that reward size, staying power, and jackhammer-like technique, have added to the crisis, since many people “learn” about sexuality through these images. Younger generations are showing a tendency to be even more mechanical, less affectional, and less responsive to touch.

Another common couple issue influencing sexual desire is explicit and implicit contracts. For example, a traditional couple might make an implicit contract that the man will be the provider, the woman the homemaker. If either fails to hold up their end of the bargain, sexual desire can be affected. Many of these contracts are doomed from the start, since the assignment of such roles creates inherent contradictions. A partner might expect the spouse to be a successful surgeon, yet also want an engaged and equal partner to assist in raising the children. When the spouse cannot do both, the partner becomes frustrated and loses sexual desire. In other couples, if the woman earns more money than the man, the man may feel threatened and insecure and lose sexual interest.

A common factor therefore with low sexual desire is the inability to express emotions to the partner, such as hurt, frustration, or anger to solve conflict. Conflict, if handled optimally, can bring a couple closer, but rarely do the partners have the tools or training to deal with disagreements. A partner unable to feel, label, or express emotions may instead rely on sex to feel loved, placing extraordinary pressure on the other partner. For this reason, marital and relational therapies are almost always integrated into the sex therapy.

Another major factor contributing to low desire is the reduction or absence of courting behavior once married. A couple fails to give a high priority to having fun, playing or being romantic once they are ensconced in their marriage. Instead they fill their time with work obligations and childrearing. They forget or never discover how to be spontaneous and enjoy non-goal interactions. Their sexual expression mirrors their serious hard-working lifestyles and becomes mechanical or boring. Perfectionism leads to goal orientation; the harder one works at sex, the less spontaneous, playful and enjoyable it can become.

Although immediate factors contribute to maintaining low desire, as Helen Kaplan (1974)  noted, “deeper” issues are frequently at the core of desire and arousal problems.   Masters and Johnson focused on the “relationship,” that is, the difficulties that both the individual and the couple have in becoming bonded. Bonding disorders originate in the developing attachment systems and the cohesiveness of self-development, discussed later.

Intimacy and Intimacy Disorder

A couple often establishes a reactive distance related to dependency-independency, closeness-distance, freedom versus control, privacy versus self-disclosure, which once established, the partner often adapts to: low sexual desire is usually a sign that this distance is too little or too much and needs realignment. Often the attachment styles of each individual complement each other.

The Development of the Affectional Systems

It is valuable to view sexual desire through the lens of attachment theory because, as Dr. Masters noted, desire is often an aspect of pair bonding, courtship, attraction, love, affection, and intimacy. Sexual desire and arousal are the endpoints of a series of developmental events that begin with genetics and temperament, move through the child’s early attachment environment with caretakers, and can be disrupted by subsequent experiences that are so overwhelming the child is unable to assimilate them. This disruption can result in affect dysregulation and impaired gender-related socialization and self-development, all activated by pubertal hormones.

A person’s attachment style is established in the first two years of life and remains stable from 18 months to 20 years with about 72% consistency (Soloman and Main, 1997). The mother’s attunement to her child facilitates the experience-dependent maturation of the child’s neurological structure, which directly influences the child’s biochemical growth process, as well as dendritic and axonal developments in the first two years of life. When feedback from caretakers is absent, punishing, frustrating, invalidating or rejecting, the consequences can be written into the structure of the developing personality. Children may be emotionally constricted (Main and Soloman, 1995), turn into themselves and disconnect from others (avoidant), or emotionally dysregulated. An emotionally dysregulated child will either fail to use others for comfort or become anxious, fearful and so dependent on others for comfort that he or she refuses to separate and explore the environment.

As children age, they seek familiar, consistent environmental interaction, even if it may be damaging to the self. So they will recreate and reenact familiar early rejection and frustrations (Stroufe, 1988). Injured early attachment bonds, like those described, are highly predictive of later relational distress and create the framework for how an adult couple will interact sexually. Table II lists attachment classifications: Individuals rated anxious/ambivalent are both starving for affection and fearful of close relationships; avoidant individuals report never having been in love or having had strong experiences of love.

Individual differences on the anxiety and avoidance dimensions accurately predict differences in the way people experience romantic and sexual relationships.   People who rank low on anxiety and avoidance (i.e., securely attached) tend to have long, stable, and satisfying relationships characterized by high investment, trust, and friendship (Collins & Read, 1990; Simpson 1990.  In the sexual realm, they are open to sexual exploration and enjoy a variety of sexual activities, including mutual initiation of sexual activity and enjoyment of physical contact, usually in the context of a long-term relationship (Hazan, Zeifman, & Middleton, 1994).   Secure adolescents engage in regular dating and establish romantic relationships. They are more likely than insecure adolescents to be involved in long-term relationships, and they report having more frequent sexual intercourse than avoidant adolescents (Tracy et al., 2003).

Avoidant adolescents, as one might predict, tend to avoid sexual relationships altogether.  Tracy et al. (2003) found that avoidant adolescents were less likely than their anxious or secure peers to have had a date, sexual intercourse, or any sort of sexual experience. Avoidant virgins scored high on measures of erotophobia.  Avoidant people are less likely than their counterparts to fall in love (Hatfield et al., 1989), and their love style is characterized by game playing (Shaver & Hazen, 1988). Tracy writes “attachment avoidance interferes with intimate, relaxed sexuality because sex inherently calls for physical closeness and psychological intimacy, a major source of discomfort for avoidant individuals” (2003, p. 141).

The type of insecure attachment style also helps to determine a person’s behavior in romantic and sexual relationships. Persons who rate high on the anxiety dimension and low on the avoidance dimension tend to become obsessed with their romantic partners (Hazen & Shaver, 1987) and experience low relationship satisfaction and a high breakup rate (Carnelley, Pietromonaco, & Jaffe, 1996; Collins, 1996 & Read, 1990).  They are more likely than secure or avoidant people to experience passionate love (Hatfield, Brinton & Cornelius, 1989) and exhibit an obsessive, dependent style of love (Collins & Read, 1990; Feeney & Noller, 1990; Shaver & Hazen, 1988).  On average, they display a stronger preference for the affectionate and intimate aspects of sexuality (hugging and cuddling) than for the genital aspects (vaginal, anal or oral intercourse; Hazen et al., 1994).  Attachment anxiety is also associated with concern about one’s own sexual attractiveness and acceptability, an extension of anxious individuals’ general concern with rejection and abandonment (Hazen et al., 1994; Tracy et al., 2003).

The cost of living with an avoidant style of attachment is numbing: the absence of emotions, including compassion, plus an inability to experience the full breath of love, and the sheer beauty of the world. Avoidant persons feel a spiritual disconnection with the planet and its people. To avoid the pain of loss and grief, they must limit the capacity for pleasure and play — both essential for satisfying sex.

Development of Self

One of the remarkable findings of Sroufe and his colleagues (2009) is that children who developed a pattern of disorganized attachment, with co-existing avoidant and preoccupied strategies at 18 months, were dissociative in long-term follow-up, suggesting segregated internal models of self and the attachment figure. The individual clinically presents with a statement such as, “ I don’t know who I am,” I feel like an imposter,” or “I feel like I’m bad and pretend to be good.”

At the core of one’s capacity to bond are self-empathy and the capacity for self-care. In the absence of alternative validating caretakers, the individual does not internalize a caring relationship with self. A rejected or abandoned child tends to develop negative core schema or beliefs about self and in some cases about their gender or body.

Accompanying modes of processing and organizing information unfold such that these beliefs become self-perpetuating. These modes ultimately organize an individual’s range or type of interactions, which constrains possibilities of new learning with respect to intimacy.

The self comes to exist primarily in the context of others, within an aggregate of experiences of “self-in relationships.” Invariant aspects of self and others are abstracted into what Bowlby called “internal working models.” New experiences are then absorbed into earlier representations, creating and maintaining and repeating core schema. The internal working models of individuals with disorders of intimacy may be filled with self-hatred, so the person compensates by being powerful, controlling, dominating or alternatively feeling inadequate and weak.

The effect on sexual desire is that sex is used as a performance to feel adequate, desirable, and attractive and to “keep the partner satisfied” rather than for mutual satisfaction. They experience “otherization,” being overly focused on others at the expense of self. Sex as a performance creates enormous pressure to perform well, which can eventually degrade performance and desire. The result is the same type of numbing noted in the earlier descriptions of avoidant adolescents.

During the second or third year of life, tolerance for separation and the capacity for self- soothing is organized. Having a “secure base,” allows for exploration and the capacity to master and solve problems, thereby feeling effective, competent and powerful. The secure child begins to internalize the belief in “being valued and loved,” and does not need constant reassurance.

Individuals with attachment injury do not form this secure base and need the constant mirroring of others to maintain their sense of self. They can become suggestible and susceptible to influence. They become human “doings,” perfectionists always trying to not disappoint others, feeling only as good as their last accomplishment. They tend to have difficulty with creative problem-solving, constant worry and feeling powerless. Often they suppress affect, becoming mechanical and instrumental. In their attempt to gain affection, they need to conquer the partner who is rejecting them. Once they conquer, their sexual arousal diminishes and their sexual goal is for physical release rather than true affection. Intimacy terrifies them due to to fears that the closeness makes them vulnerable to abandonment. To protect themselves, they create distance by losing interest in the partner, and using pornography, affairs, or other distractions to stay busy and tired.

The attachment system evolved as a biological alarm. It ensures the survival of the species by detecting potential harm and signaling terror to stimulate action. If the caretaker moves away, disrupting the secure base, and the individual has an internalized working model to create a secure base, the attachment system will be activated and the natural result will be terror. The child will seek the caretaker or cry for attention.

For the preoccupied individual who lacks a secure base, people wanting to have sex with him or her is reassurance of desirability and reduces fears of abandonment. In avoidant attachment, getting close activates fears of danger or annihilation, since the people a child once depended on were dangerous or neglectful. In disorganized attachment, both systems alternate, thus needing sex and needing distance simultaneously. Many symptoms of relational distress as well as psychiatric symptoms can be better understood when seen through the lens of attachment activation. Helping the individual form internal and external safety zones can neutralize fears related to closeness and distance and reverse sexual desire issues.

Most critical for developing a secure base are self-core schemas of safety, trust, esteem, power, control, and intimacy. The development of these core schemas is altered when early events engrave negative beliefs into the developing brain — i.e. “I feel fat. I am stupid. I am bad.” — although the thoughts are irrational and without evidence. Such self-hatred requires the person to perceive others consistent with these beliefs, thereby setting up biased filters. So if the partner is perceived as smart, beautiful and thin, the signal of fear is activated, increasing a preoccupied person’s desire for reassurance, or an avoidant person’s loss of interest.

Love Maps

Another critical component of the developing affectional systems is what John Money (1981) defines as a “Love Map: a personalized developmental representation or template in the mind that depicts the idealized lover and the idealized program of sexual erotic activity with the lover as projected in imagery and idealization or actually engaged in with the lover.”

Money believed that actual biographical events related to attachment and trauma influenced the development of love maps, and that they can be “vandalized.” Too much punishment associated with the unfolding of genital sexuality or premature sexualization in the family can interfere with sexual arousal development. (See also the book Sexualized Children by Eliana Gil and Toni Cavanagh Johnson.)

The developing love map includes partner characteristics that sexually arouse the body to respond to touch, and the sense of self as attractive, which indirectly influences the perception of another as desirable. The love map is hard-wired to respond to a variety of emotions such as illicitness, conquest, fear, intimacy, romantic love, and challenge. Early themes such as taking care of others or caretakers being out of control, hostile or abusive become templates for “falling in love.” The way one is loved as an infant can become a “blueprint” for adult affectional style. Puberty then activates the love map that was established throughout childhood.

The fantasy or imagery a person uses to arouse him or herself in masturbation can then organize the choice of partner, affectional interchange, and sexual desire and arousal. If the adolescent uses pornography, these images then serve to over-learn certain arousal patterns; some individuals use it as a form of disengagement. For these individuals, more and more stimulation seems to become necessary to reach orgasm. Tolerance to stimulation increases, probably because of a kindling effect on the central nervous system. Sexual arousal becomes channeled toward the computer screen rather than through the natural channels of touch, closeness, and affection.

If a man develops avoidant attachment, for example, he might become fixated on the woman’s breasts and become aroused by the image of the breasts rather than the woman, a strategy that allows him to maintain a distance from the person. Another man might require the image of his “secretary” or a scene from pornography to maintain distance and not become too intimate. Eventually, the imagery alone satiates, undermining any sexual interaction with the partner. For preoccupied individuals, sexual activity can become a means of reassurance that their partner desires them, and sex then becomes obsessive, mechanical, and obligatory, often reversing the partner’s desire for sex.

Treatment Implications

Mate selection, as driven by attachment theory, would often find the avoidant person pairing with a partner with preoccupied attachment. This coupling establishes a merger-seeker relationship in which the sex drive is high for the merger and low for the seeker. The couple presents with the seeker labeled as having low sexual desire, with subsequent damaging domino effects to the relationship, when the actual problem is their complimentary attachment patterns. If either had chosen a partner with secure attachment, he or she might have avoided sexual difficulties. The focus of therapeutic intervention in these cases would be on individual and couple issues as well as what Helen Kaplan (19__ )  called “deeper issues.”

Our work on deeper issues has focused on shorter-term interventions to move individuals towards what Mary Main defined as “Earned Secure Attachment,” which refers to repairing insecure attachment (Schwartz 2017). Table 2 lists the components of our work to develop Earned Secure Attachment, derived from Main’s Adult Attachment Interview Assessment. The treatment consists of helping the individual revisit their memory of sequential developmental experiences and (as summarized by Brown & Elliot, 2016) “become more aware of his or her immediate mental state, learning to accurately mark, label, and understand affective states and cognitive status, such as maladaptive beliefs and schemas, becoming sensitized to the limitations of knowledge and beliefs, learning to identify states of mind, and becoming able to mentalize about others’ state of mind and about the transference in their therapy.”

The ultimate aim is a reappraisal of their life experiences and reconsideration of their fixed beliefs and conclusions about self, others, and their capacities to master and resolve problems. Core schema related to trust, safety, power, control, and intimacy are reconsidered and become more rationally based in their adult world as opposed to frozen, fixed beliefs based on past traumas or adverse developmental events. At the core of one’s capacity to bond are self-empathy, the capacity to be alone, and self-care.

In the absence of validating caretakers, the developmentally disturbed individual does not internalize a caring relationship with self. A child who is rejected or abandoned may develop negative core schemas or beliefs about self, which organize ways of relating to others. Sroufe (2016) reports that a history of maltreatment as a child, in a longitudinal follow-up of 170 children from birth of adulthood, “almost never has a positive outcome.” The individual attempts to create safety and consistency in maladaptive ways, such as finding others who need taking care of, to create an illusion of safety and control. Sroufe also found that the long-term result of early disorganized attachment patterns left individuals vulnerable to fragmentation of the self — dissociation. Such fragmentation leads to the proverbial “addictive personality,” or internally felt emptiness in which the individual never quite feels connected or safe.

Thus, the critical feature of recovery is learning to use other people as a reliable source of comfort and safety. To do this, we integrate trauma-resolution therapies and grief work into the process, with a focus on challenging family loyalties, fixed beliefs, or shame-based family rules. As the client experiences greater self-compassion and resolves past “unfinished business,” they are less likely to project their internal conflicts onto their partner and use sex to feel safe and connected. Repairing vandalized love maps requires revisiting the critical experience and reactivating the affect in the safety and containment of the therapist’s office, allowing for reconstruction of core schema. Our experience is that fantasy and sexual arousal patterns shift as the client uses others for secure attachment, and becomes channeled toward touch, closeness, and affection.


Repairing sexual desire is complex and requires a focus on deeper capacities for intimacy and connection to self and others, as well as choice of partner and subsequent relational dynamics. All of this is further influenced by biochemistry, drug use, factors shaping the CNS structure during critical periods of sexual unfolding, and the mind’s development of love maps. Therapeutic intervention is now more targeted and effective, as the conceptual model has shifted from sex to love. The ultimate goal of successful therapy and healthy sexual functioning is to strengthen the individual’s capacity to be fully present and available in a safe and trusting relationship.


Sexual Anorexia by Dr. Mark Schwartz

Posted by on May 4, 2016 in Articles, Eating Disorders | 0 comments

Sexual Anorexia by Dr. Mark Schwartz

Anorexia is a complicated illness.

Each client tends to be more different than similar, and the development trajectory for each client is complex. Most anorexics will move into bulimia, while many bulimics who get under control will attempt to restrict; therefore, one common feature of the illness is that over-control eventually leads to out of control, and getting under control results in over-control.

The Potential for Combination of Disorders

The vast majority of anorexics and bulimics likewise, manifest sexual over control and out of control difficulties. In their disease, they are unaware of cues for appetite or satiations. In a similar manner, the cues for sexual appetite are confused. Once they are eating and re-fed, often they will experience sexual arousal, but the ability to use those cues to make sexual decisions is blurred. These primary interactions with others are geared to avoid disappointment, as well as to please. It is as if they do not have a core sense of self to know or determine what they deserve, so they make decisions regarding their wants in relation to not displeasing others. Unfortunately, sex, for the sake of the other can be disastrous, since it typically feels like an assault to the body when there is little desire combined with intense fear. The result of these juxtaposition and disconnections is a pattern of sexual behavior that is out of control, many patterns in a short span of time, while simultaneously experiencing low desire as even sexual aversion. When they do find a partner who is desirable, after their body is too traumatized, by prior objectification and bypassing to respond.

12 Critical Factors to Consider When Selecting an Eating Disorder Clinic

Posted by on May 3, 2016 in Articles | 0 comments

12 Critical Factors to Consider When Selecting an Eating Disorder Clinic

Critical factors to consider for an eating disorder clinic

1. Does the program offer three individual sessions per week with a primary therapist?

2. Does the primary therapist do eating disorder work, trauma, and family of origin work, family work?

3. Does the program offer expressive therapy twice per week?


Eating Disorder Treatment — the Disconnect Between Body and Mind

Posted by on Apr 30, 2016 in Articles, Eating Disorder Treatment, Eating Disorders | 0 comments

Eating Disorder Treatment — the Disconnect Between Body and Mind

When human psychological factors cause an illness, it is called psychosomatic – of the mind and of the body. Of all disorders, an eating disorder is the epitome of a toxic relationship between psyche and soma, yet the body is our interface for navigating the world. Medical writer Jonathan Miller states:

The body is the medium of experience and the instrument of action. Through its actions we shape and organize our experiences and perceptions of the outside world from the sensations that arrive within the body itself. [The body is] possessed by the person who has it, it also possesses and constitutes him (1978, p.14).

In ​”The Body Betrayed,” by Kathryn J. Zerbe (1993), explores how the psyche and soma become at war with each other, no longer unified in the process of sustaining life or effectively reaching out into the world together, and how the body becomes hated. “Anorexic and bulimic individuals do not experience their minds, hearts, and bodies in unison,” (p.22). She recalls the 1959 study by Rene Spitz wherein he observed the behavior of infants whose mothers gave birth while incarcerated. The baby’s basic needs of eating, cleaning, and changing were met at a prison nursery but they were not cuddled and caressed. Spitz noted that the babies seemed to have given up hope and many died because their immune systems had shut down. (more…)

Eating Disorder and Sexual Compulsivity

Posted by on Apr 29, 2016 in Academic Papers | 0 comments

Eating Disorder and Sexual Compulsivity

Eating Disorder and Sexual Compulsivity: Commonalities in Syndromes

by Mark F. Schwartz D.S

2015 © All Rights Reserved. Dr. Mark Schwartz

Harmony Place Monterey
398 Foam St. Suite 200
Monterey, CA 93940

I. Introduction

The purpose of this paper is to discuss similar pathognomonic features of eating disorders and sexually compulsive/sexually anorexic behaviors, and reasons for this frequent comorbidity. Recognizing the similarities between these two disorders can facilitate the understanding, development, and treatment of both. The common features the disorders share include polarizations in the following areas:

    • Each is characterized by over-controlling, contributing to out-of-control behavior of a natural function.
    • Each serves as a manifestation of impulsivity and compulsivity related to post-traumatic stress and affect regulation, as well as a means to cope with anxiety.
    • Each unfolds in the absence of a true self and instead, is marked by a lack of self-cohesion resulting in disassociated and polarized parts of the personality.
    • Each evolves as the result of disorganized attachment and resultant inability to utilize self or others as a resource for self-soothing, comfort, or affect regulation.
    • Each allows for the reenactment of childhood core schemas related to shame and powerlessness.
    • Each provides an illusion of control while engaging in behaviors when, paradoxically, the individual is out of control.


Attachment – What’s Love Got To Do With It?

Posted by on Apr 20, 2016 in Articles, Attachment, Blog | 5 comments

Attachment – What’s Love Got To Do With It?

What is Attachment?

For children, a “felt sense” of security becomes internalized and helps them approach the world as a relatively safe place, be able to reach out to others in times of crisis, work difficulties through to resolution (instead of being immobilized by them), and gives them the courage to take appropriate risks in order to grow emotionally.

Attachment – what a strange word! It sounds like an add-on to a vaccuum cleaner, but the basis of “attachment theory” is something quite different. It helps us understand what is fundamental to the emotional life of human beings.

We come from within our mothers, born out of the union of two individuals. For survival we are – we must be – attached to our mother’s (or some caretaker’s) body for protection. That is how we stay safe from predators when we are small and defenseless.


Opiate Addiction Treatment Center – Choose the Best

Posted by on Mar 20, 2016 in Addiction, Articles, Opiate Addiction, Opiate Addiction Treatment, Opiate Treatment | 0 comments

Opiate Addiction Treatment Center – Choose the Best

Prescription drug addiction, especially painkiller addiction is a tragic and growing problem.

If you or your loved one is struggling with an addiction to opiates, you want to make sure you choose the best treatment center for your or your loved one’s specific needs and goals. Let us help you choose what’s best.

Inpatient vs. Outpatient

The choice between an inpatient or outpatient opiate treatment center will depend on several factors including, but not limited to: the severity of your addiction as well as the support system you have around you.

While outpatient treatment offers you the convenience of scheduling your treatment around work or school, many patients who are addicted to opiates (and how easy it can be to access them) find that they are unsuccessful in these types of programs since there’s a lack of stability and continuous care. (more…)

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