CBT for Compulsive Sexual Behaviour

A guide for professionals

Thaddeus Birchard

• Publisher: Routledge
• Year: 2015
• ISBN:
  9781317532101
• Edition: 1
• Topic: Psychology
• Subtopic: Psychotherapy Counselling
• Index: Psychology

Increasing numbers of therapists are coming into contact with the problem of compulsive sexual behaviour disorders. However, it is still a relatively new field and there is little in the current literature available that enables the therapist to work with and treat this problem. CBT for Compulsive Sexual Behaviour: A guide for professionals addresses this by providing a guide to cognitive-behavioural theory and practice which includes the assessment, diagnosis and treatment of addictive sexually compulsive disorders.

Beginning with a description of addictive sexuality and an overview of cognitive behavioural therapy in which CBT is presented as the most useful response, Thaddeus Birchard provides clear therapeutic information about the implementation of CBT treatment intervention. The chapters included cover the neuroscience that underpins the addictive process; a 'how to' chapter on the use of groups; paraphilias; trauma and attachment; comorbid disorders and cross-addictions and analysis on the function of internet pornography, all written from a cognitive behavioural stance.

Using case vignettes throughout, Thaddeus Birchard draws on his own experience as a psychosexual therapist, along with the latest research in the field, to enable the therapist to treat a range of compulsive sexual problems in a way that can be applied in individual practice or in a group setting as well as how to prevent relapse. This book will be essential reading for psychosexual therapists, cognitive behaviour therapists and other professional working with sexual compulsive disorders.

Chapter 1
Sexual addiction

Introduction

The term ‘addiction’ comes from the Latin addicare, which means ‘to be bound over by judicial decree’. It suggests a loss of will. It describes a state or condition that seems beyond individual control. There are overtones of slavery to a substance or a behaviour that is outside volition or personal determination. This chapter will describe and define sexual addiction. It will outline the historical antecedents and explore nomenclature. The aetiology of sexual addiction will be considered and the concept will be located in a variety of contexts. The chapter will examine the drivers for sexually compulsive behaviour and briefly explore addiction as a means of affect regulation, as well as considering comorbid conditions. The objections to the concept of sexual addiction will be considered. The chapter will end with two illustrative case studies of sexually addicted men. I will use the following terms interchangeably: sexual addiction, sexual compulsivity, hypersexuality and ‘out of control’ sexual behaviour. By this use, I attribute no particular preference for one term over another and no term implies any particular aetiology.

Definitions

Sexual addiction is the label given to a pattern of sexual behaviour that is compulsive and preoccupies, that is difficult to stop and stay stopped, and that brings with it harmful consequences. The behaviour is continued in spite of these harmful consequences. It is largely used to anaesthetise intolerable affect states. It emerges from the life story of the addicted individual.

Goodman gives the following definition of sexual addiction: ‘A condition exists in which the subject engages in some form of sexual behaviour in a pattern that is characterised by two key features: recurrent failure to control the behaviour and the continuation of the behaviour despite significant harmful consequences’ (Goodman 1998: 9).

Kingston and Firestone (2008) cite Goodman as writing that the function of excessive sexual behaviour is to produce pleasure and provide escape from pain. Carnes and Wilson (2002) propose that a process would be considered an addiction when the behaviours fulfil the following three criteria: 1) loss of control 2) continuation in spite of harmful consequences, and 3) obsession/preoccupation. Carnes expands this definition by drawing up what he calls the ‘Ten signs of sexual addiction’:

1. A pattern of out-of-control behaviour.
2. Severe consequences due to sexual behaviour.
3. Inability to stop despite adverse consequences.
4. Persistent pursuit of self-destructive or high risk behaviour.
5. Ongoing desire or effort to limit sexual behaviour.
6. Sexual obsession and fantasy as a primary coping strategy.
7. Increasing amounts of sexual experience because the current level of activity is no longer sufficient.
8. Severe mood changes around sexual activity.
9. Inordinate amounts of time spent in obtaining sex, being sexual or recovering from sexual experience.
10. Neglect of important social, occupational or recreational activities because of sexual behaviour.

(1991: 11–12)

According to Carnes, sexual preoccupation becomes an ‘analgesic fix for the sex addict’ (1991: 21). He asserts that ‘sex addicts use their sexuality as a medication for sleep, anxiety, pain and family and life problems’ (1991: 23). This self-medication view of sexual addiction has also been proposed in other forms by many researchers from different perspectives (Bader 2008; Fenichel 1946, reprinted 1996; Kahr 2007; Weisse and Mirin, 1997).

I define sexual addiction as a pattern of sexual behaviour that is made up of four components:

1. It is experienced as out of control and preoccupying.
2. People try to stop but they cannot remain stopped.
3. The sexual behaviour brings with it harmful consequences.
4. It is primarily used to anaesthetise some negative feeling state.

There is increasing information that some people wander into sexual addiction by experimentation. They opportunistically look at sexual sites and, by the strong reinforcement provided by arousal and orgasm, find that they become addicted (Hall 2013). However, in my clinical experience, I am not persuaded that this is just a matter of opportunity, but rather a case of opportunity meeting a pre-existing need.

Descriptive examples

It may be useful to illustrate the concept of sexual addiction with a range of descriptive examples of the behaviours of clients with whom I have worked on an individual basis and in a group setting. Additional material, in the form of two case studies, is provided at the end of this chapter to further illustrate the concept of sexual addiction. In each case, both the patient and I have come to the conclusion that the behaviour fits the description of sexual addiction. The cases cited are composite examples and do not represent any one patient. In my individual work, I have witnessed the following:

• A young heterosexual male with a female partner and three children exhibited ‘addictive’ behaviours involving exhibitionist homoerotic masturbation in showers and changing rooms and other public places.
• A middle-aged married heterosexual male had little control over his use of internet pornography. He would go online for half an hour and then compulsively masturbate for much of the night while on the internet. Sometimes this would go on for several days.
• A young gay man took pictures on his phone, at the gym, of men in the shower without their permission.
• An extremely able young male medical doctor had ritualised telephone sex while talking through a fantasy of innocence and seduction. He told me that he wanted a normal married life and a family.

Each of these patients reported some, or all, of the following harmful consequences: powerlessness, self-contempt, personal danger, health risks, loss of creative time and career opportunities, financial loss and impaired capacity for intimate relations with a domestic partner.

Within my group treatment programme, participants have revealed the following behaviours: one man having anonymous sex with men in public places, one masturbating to pornography of women being beaten, another masturbating over a mixed repertory of images of bondage and domination, two men using sex workers in spite of being committed to fidelity in long-term relationships, and two others compulsively masturbating over heterosexual pornography. In all but one case, these men have problems with emotional intimacy and being sexual with significant others. It is important to emphasise that this is not about heterosexual, homosexual or solitary behaviours. The issue of concern here is not the type of behaviour, or the amount of time it consumes, but rather the experience, function and consequences of that behaviour in the life of the individual.

A historical perspective on sexual addiction

The notion of addiction starts deep in the Judeo-Christian tradition, with the movement of the Hebrew people out of slavery into the Promised Land. Addiction has overtones of slavery. This theme is taken up in the Christian tradition. In a chapter referring to slavery, Paul writes: ‘For what I do is not the good I want to do; no, the evil I do not want to do, this I keep on doing’ (Romans 7:19). This is the language of addiction.

Later in the third century, Augustine writes as follows:

The enemy had my power of willing in his clutches, and from it had forged a chain to bind me. The truth is that disordered lust springs from a perverted will; when lust is pandered to, a habit is formed; and when the pattern is not checked, it hardens into a compulsion. These were the interlinking rings forming what I have described as a chain, and my harsh servitude used it to keep me under duress.

(Translated by Boulding 1997: 192)

Once again, we see the language of slavery and compulsion. It is not an accident that one of the first self-help group for sex addicts, Sex and Love Addicts Anonymous, calls itself the ‘Augustine Fellowship’.

It is evident that the concept of addiction provides us with a way of thinking about and describing age-old patterns of behaviour that we have always known about but have not always framed as addictive or compulsive (Butts 1992). In 1812, Benjamin Rush, the Father of American Psychiatry, published (with Samuel Merritt) Medical Inquiries and Observations Upon the Diseases of the Mind. This book includes a chapter entitled ‘Of the morbid state of the sexual appetite’. In this chapter, Rush and Merritt give three examples of the sexual appetite that today we might call ‘sexual addiction’. The interesting thing about this publication is that some of the remedies they suggest are much the same as modern interventions: the avoidance of alcohol (which disinhibits) and pornography, the avoidance of idleness, exercise, the use of music to intercept fantasy, and an involvement with meaningful and fulfilling pursuits.

In 1886, Krafft-Ebing, an Austro-German psychiatrist, published the Psychopathia Sexualis, a collection of 238 case histories of a variety of sexual patterns. He introduced the term ‘sadism’, from the writings of the Marquis de Sade and ‘masochism’ after the book, Venus in Furs, by Leopold von Sacher-Masoch. Krafft-Ebing writes:

Sexual appetite is abnormally increased to such an extent that it permeates all his thoughts and feelings, allowing of no other aims in life, tumultuous and in a rut-like fashion demanding gratification without granting the possibility of moral or righteous counter-presentations, and resolving itself into an impulsive insatiable succession of sexual enjoyment . . . this pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honour, his freedom and even his life.

(Krafft-Ebing 1886: 70)

I often give talks on sexual addiction under the title ‘This dreadful scourge’. This seems to accurately capture the experience of many.

In 1946, Otto Fenichel published The Psychoanalytic Theory of Neurosis. In this book there is a chapter entitled ‘Addiction without drugs’. He writes that ‘the mechanisms and symptoms of addiction may also occur without the employment of any drugs, and thus without the complications brought about by the chemical effects of drugs’ (Fenichel 1946, reprinted 1996: 381). He also writes of love addicts and the hypersexual, and notes the connection with paraphilias. He connects hypersexuality to a number of comorbid conditions including anxiety and depression (Fenichel 1946, reprinted 1996: 384).

The concept of ‘sexual addiction’ became popularised in 1983 when Patrick Carnes first published Out of the Shadows. Shortly afterwards, Quadland (1985) and Coleman (1988) characterised the same syndrome as ‘sexual compulsivity’. Various researchers label it differently, with each label suggesting a particular aetiology. Barth and Kinder (1987) described it as ‘sexual impulsivity’, and it has also been labelled ‘hypersexuality’ (Brotherton 1974). Bancroft and Vukadinovic (2004) used the term ‘out of control’ sexual behaviour.

For our purposes, suffice it to say that, regardless of the term used to describe this behaviour, the clinical literature on the topic has been overwhelmingly consistent in the set of symptoms ascribed to the phenomenon (Gold and Heffner 1998). Zapf et al. (2008) list the features of sexual addiction as recurrent failure to resist, increased tension prior to the behaviour, pleasure and loss of control, attempts to curb, not fulfilling obligations, and acting out in spite of harmful consequences. In clinical observation, we see patients spending a great deal of time pursuing sexual behaviour or resisting urges to pursue sexual behaviour. We see a repetitious return to the behaviours with little regard for the consequences. A period of relief is normally followed by guilt, shame and remorse. We can conclude that the syndrome remains the same no matter what we call it (Gold and Heffner 1998).

The concept of addiction

The standard medical dictionary defines addiction as ‘the state of being given up to some habit, especially strong dependence on a drug’ (Jacobs 1997: 170). This definition specifically includes habit, as well as substance. Griffin-Shelley (1993) writes that we are now better able to see similarities between addictions to behaviours and addictions to substances. He mentions addictions to sex and love, as well as to food and religion. This is also captured in the definition of an addiction offered by the American Society of Addiction Medicine in 2011 – namely, ‘a chronic brain disease that affects the reward, motivation and memory systems and combines both substance and behavioural addiction under a common umbrella’ (Hilton 2013: 2). There is increasing evidence that sexual compulsivity is an addiction. That evidence is multifaceted and based on a growing understanding of the role of neural receptors in addiction processes (Hilton 2013). This will be explored further in Chapter 3.

I am persuaded of the reality of behavioural addictions, including making money, exercise, romantic infatuation, pathological gambling, perhaps food, sometimes ecstatic religion and sex. Many researchers agree that numerous people engage in excessive sexual activity that creates problems and interferes with social and occupational functioning (Lloyd et al. 2007).

The principal objection to the term ‘addiction’ is that it provides an excuse for the behaviour and suggests denial of responsibility. This view continues to circulate although it has little foundation. It is not discussed in either our treatment programmes or in the Twelve Step recovery fellowships. Further information about recovery fellowships can be found in Chapter 8. However, professionals must address their distinctive constituencies and the choice of nomenclature is dictated as much by political and social agendas as by clinical consideration.

In the literature, it is common to find the terms ‘addictive’ and ‘compulsive’ linked together to describe this behaviour. For example, American specialists working in this field founded a journal entitled Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention. In the United Kingdom, the Association for the Treatment of Sexual Addiction and Compulsivity was founded. The word ‘compulsion’ is normally associated with the relief of painful affect and the word ‘addiction’ with the production of pleasure. As these behaviours serve both functions, they are rightly combined.

The medical context

If we consider sexual addiction from a medical perspective, there are two key frameworks to take into account – namely, the International Classification of Diseases (ICD-10) and the American Psychiatric Association’s Diagnostic and Statistical Manual of Mental Disorders (DSM-V). In the following section, I focus primarily on DSM-V for two reasons: first, most of the work on sexual addiction is American and, second, the DSM is widely used in the United Kingdom as a guide to diagnosis. While there is general debate about the usefulness of the DSM (Kutchins and Kirk 1997), it is important and influential in the medical profession and the professions allied to medicine. Understanding sexual addiction in relationship to the DSM is therefore important so that practitioners can effectively communicate across the disciplines.

The International Classification of Diseases (ICD-10) was endorsed by the 43rd World Health Assembly in 1990 and came into use in the World Health Organization (WHO) member countries in 1994. A current revision is under way and will be published in 2017. ICD-10 has two classifications relevant to sexual addiction: ‘F98.8 Behavioural and emotional disorders occurring in childhood and adolescence’, which designates ‘excessive masturbation’, and ‘F52.7 Excessive sexual drive’, which includes nymphomania and satyriasis. This does, in fact, give us a clear identification of sexual addiction/hypersexuality as a medical disorder.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) has been published by the American Psychiatric Association since 1952. The fifth edition, DSM-V, was published in 2013. Major efforts were made to have sex addiction, under the heading of ‘Hypersexual disorder’, included in DSM-V. However, these were unsuccessful, the justification being that ‘at this time there is insufficient peer-reviewed evidence to establish diagnostic criteria and course descriptions needed to identify these...

Table of contents

• Cover
• Title
• Copyright
• Dedication
• Contents
• List of figures and tables
• Foreword
• Preface
• Acknowledgements
• 1 Sexual addiction
• 2 Cognitive behavioural therapy and sexual addiction
• 3 The neuroscience of sexual addiction
• 4 The therapeutic alliance
• 5 The primary interventions
• 6 The principal interventions
• 7 The ancillary interventions
• 8 Group work
• 9 Paraphilias
• 10 Internet pornography addiction
• 11 Trauma and attachment
• 12 Cross addictions and comorbid disorders
• 13 Conclusion
• Case studies
• Appendices
• Bibliography
• Index