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 fourth pay 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.
The second premise of this presentation is that sexual problem often overlaps 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 to 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 a 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 in 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 effect 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 effective 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.
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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.
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 between the child and the environment. The 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 the 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.
A 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 and without threat to the primary bond.
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Photo by Scott Webb
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 hypersexual 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 increasing 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 modulate 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 a 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 have developed a technique to remap attachment representations using the "Ideal Parent." See Table f. 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.
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 effective 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.
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 the group.
Once the individual has established control over out-of-contraband behavior, it is imperative that they begin to turn to people for comfort. Often they need to support the social and dating anxiety and coaching, regarding boundaries and how to receive affection. Table Il 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 are 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 result 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 be too good will surely be followed by something bad. With this in mind, the sexually compulsive individual commonly perceives the world through these lenses:
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:
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 behavi0L while creating a life capable o} e>iencing both joy and pain.
After developing a (W Table Ill lists a summary of the components for facilitating sec cohesive written narrative that is also presented in a 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 R 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 I' 2K facilitating earned secure attachment with self and others.