Short-Term Treatment Plan for Sexual Addiction

Robert A. Delahunt

Liberty University

Author Note

    Robert A Delahunt, student at Liberty University School of Behavioral Sciences.
    Correspondence concerning this article should be addressed to Robert A. Delahunt, 366 Okaloosa Ave, Valparaiso, FL 32580.  E-mail: rdelahunt@liberty.edu.
    This article was written for PSYC307 and is provided as a writing example for future prospective universitiesThe format of this article was changed slightly from APA format to work better as a web page.

    Sexual addiction is a behavioral addiction that is difficult to manage.  Sex addiction has symptoms, characteristics, causes, and genetic factors.  Sex addiction produces withdrawals.  In addition, it is suggested sex addiction drains the US economy.
    This article contains a short-term treatment plan for adult males with sex addiction.  This plan will incorporate individual and group therapy using a synthesis of the medical and spiritual models of addiction.  It will incorporate cognitive behavioral therapy (CBT), dialectic behavior therapy (DBT), and twelve step facilitation (TSF).  It can be delivered to both religious and non-religious clients.  This article will also address obstacles and ethical issues likely to be encountered.

Overview

    Sexual addiction has several symptoms.  Laaser (2004) and Weiss (2015) list symptoms such as poor self-image, sense of entitlement, denial, delusions, blackouts, rigidity, blaming, relational difficulties, attention disorders, depression, and anxiety.
    Sexual addiction can consist of a number of behaviors, divided into different levels by Carnes (2002).  These include masturbation, cybersex, prostitution, exhibitionism, voyeurism, indecent liberties, obscene phone calls, bestiality, rape, incest, and child molestation (Laaser, 2004; Carnes, 2001; Weiss, 2015).
    The main characteristic of sexual addiction is the addict “can maintain control or stop problematic behaviors for only brief periods of time” (Carnes, 2002).  Laaser (2004) expands on this to include the characteristics of using sexual behavior to alter their mood and/or escape from reality, tolerance, codependency, sexual ignorance and confusion, and comorbid addictions.  Another characteristic of sexual addiction is the sexual addiction cycle, which consists of (Carnes, 2001; Laaser, 2004) preoccupation, ritualization, sexual compulsivity, and despair; or (Weiss, 2015) triggers, fantasy, ritualization, acting out, numbing, and despair.
    There are many potential causes of sexual addiction.  Carnes (2003) found that sexual material which taps into unresolved trauma within the viewer can result in compulsive sexual behavior.  For example, child abuse “is a factor for many” sex addicts (Carnes, 2002).  Families that are rigid, authoritarian, excessively religious, overly enmeshed and/or extremely sexually negative can also contribute to sexual addiction (Carnes, 2002; Laaser, 2004; Katehakis, 2009).  The death of a family member can also be a factor in sexual addiction (Carnes, 2002; Ferree, 2013).  Finally, “being exposed to sexually explicit information … as a child” can contribute to sexual addiction (Carnes, 2002; Laaser, 2004).
    Carnes (2002) found that some sex addicts “inherit a genetic structure that disposes them to addictions in general.”  However, sexual addiction, like other addictions, can be passed down via attachment dysfunctions.  One classic example involves children whose father was a sex addict.  When their mother divorces their father due to any one of the behaviors of a sex addict, they grow up in a fatherless home, increasing their risk of attachment wounds (Clinton & Sibcy, 2006).  These attachment wounds make them more susceptible to addiction in general, potentially sex addicts (Carnes, 2001; Laaser, 2004).
    Another pathway of heritability exists within sexual trauma.  Wurtle et al. (2014) found adults who experienced sexual abuse as children were more likely to consume child pornography in adulthood.  Per Carnes (2003), this “tapping into the unresolved” phenomenon can lead adults who were sexually molested as children to become future child molesters.
    Withdrawals from sexual addiction are very well documented.  Among these are depression, anxiety, rumination or preoccupation, guilt or shame, intrusive memories or emotions, physical discomfort, loneliness and social withdrawal, mood swings or irritability, anger, insomnia and nightmares (Inaba & Cohen, 2014; Garcia & Thibaut, 2010; Weiss, 2015; International Service Organization, 2004; Carnes, 2002; Laaser, 2004).
    Current literature does not advocate medication for sexual addiction itself (Sealy, 2002).  However, because sexual addiction involves mood alteration (Laaser, 2004), withdrawal can expose underlying comorbid psychiatric disorders.  Sexual addicts with major depression seemed to respond well to antidepressants (Sealy, 2002).  Sealy (2002) found that sexual addicts with obsessive-compulsive disorder responded well to a SSRI antidepressants.  However, Sealy (2002) found non-psychotropic interventions to be the most effective, other than for validated comorbid mental disorders.
    Laaser (2004) estimated that up to 10% of the Christian population of America were sexually addicted.  The current consensus is roughly 6% of Americans are sex addicts (Polish, 2015; Barrilleaux, 2016).
    The true cost of pornography to the US economy is unknown.  However, the author would like to offer a hypothetical estimate.  First, there is a direct cost to businesses via lost labor.  Carnes (2001) found “most pornography is downloaded between 9:00 a.m. and 5:00 p.m.….”  Let us assume only men view pornography at work, for mathematical simplicity.  It is theorized the average male employee watches pornography at work 13 minutes a day (Warner, 2014).  If there are 143 million American men ages 18-54 (US Census Bureau, 2010), if 88% of them are working (Mui, 2016), and if the average hourly wage rate is $26.17 (Bureau of Labor Statistics, 2018), we can suggest the economic cost of pornography is $185 billion.
    Second, pornography costs the US economy via its influence in divorce.  If the economic cost of divorce is $11 billion (Schramm, 2014), and if pornography is implicated in 60% of divorces because 60% of men who watched pornography within the last year became divorced (Doran & Price, 2014), pornography costs the economy roughly $6.6 billion.  Thus, we have approximately $191 billion in economic harm.
    The author has heard the assertion that pornography “adds back” to the economy.  However, this economic “benefit” of the $12 billion pornography industry (NBC News, 2015) is far lower than the harm of $191 billion.  Thus our net economic harm could be $179 billion.  Note that Carnes (Polish, 2015) states the proliferation of free pornographic media makes the economic value or the pornography industry difficult to estimate.
    Sex addiction is an epidemic that implicates all races.  Becerra, Robinson and Balkin (2011) studied the relationships between race and masculinity as risk factors for men and online sexual addiction, and found race to be insignificant.  Thus there is no race that is significantly more or less likely to consume pornography.

Recovery Plan

Logistics

    This recovery plan targets American males.  It will focus on the individual, though it will briefly mention potentially important group interventions.
    This plan will blend the disease and spiritual models of addiction due to our chosen interventions.  Briefly, the disease model focuses on abstinence, acceptance, and prevention, while the spiritual model focuses on lifestyle change, abstinence, and acceptance (Jenkins & Finner-Williams, 2018).  Thus, these models should coexist nicely.
    This recovery plan will involve mainly the sex addict and twelve step groups.  However, this plan will provide integration points for concerned significant others (CSOs) and churches.
    One of the main ways we integrate faith into recovery is through twelve step advocacy.  It is beyond the scope of this article, but the reader is encouraged to read the book The Twelve Steps for Christians.  This book integrates the Christian religion with the twelve steps.  In addition, the therapist can have a Christian client read specific portions of Scripture, as therapy progresses, that confirm or even teach the skills of recovery.  Another way to integrate faith is to advocate church attendance to the Christian client.  Yet another good practice in Christian clients is to explore and teach the seven spiritual disciplines (Laaser, 2004).  Also, the therapist can assign the client reading from Christian books like Boundaries by Cloud & Townsend, as well as the Clinton & Sibcy (2006) and Laaser (2004) texts.
    It is beyond the scope of this article, but this plan will contain curriculum with parallel subjects, so that (for example) religious clients can learn CBT and DBT from a religious perspective, while non-religious clients can learn CBT and DBT from a non-religious perspective.  This is done to accommodate the beliefs of all clients.
    Differences in approach counseling Christians versus non-Christians do not entail much change.  During intake, the therapist will assess the client’s religious beliefs.  How to have this discussion of spiritual beliefs is beyond the scope of this plan.  This plan incorporates twelve step attendance; however, some non-religious clients may find fault with the twelve steps.  Thus, the therapist could recommend the non-Christian client try the twelve steps, but upon objection from the client, potentially recommend some non-spiritual groups.  Twelve step attendance is not required, but is strongly encouraged.

Treatment Plan

    This short-term treatment plan will suggest fifty two sessions over a period of one year. A highly motivated addict can complete this in one year; however, the plan’s actual time frame is determined by client progress.
    Carnes (Polish, 2015) states recovery from sexual addiction is a “3-5 year process.”  However, some obstacles to a 3-5 year plan could include lack of finances, time, motivation, and/or insurance coverage.  Because of these potential problems, this plan may, out of necessity, end up strongly leaning on twelve step attendance.  For clients who continue treatment past a year, this plan is designed to flow into a subsequent long-term plan extended by the knowledge of Carnes (1991, 2001, 2002), Weiss (2015) and Laaser (2004).
    Thankfully, some excellent assessments already exist for sexual addiction.  Heaton-Matheny (2002) lists the Sexual Addiction Screening Test (SAST) and Gay Assessment Screening Test (GAST) as one of the first steps in screening.  Then the self-assessment survey can be administered (Heaton-Matheny, 2002).  Afterwards, standard DSM assessments can be administered for suspected comorbid problems (Heaton-Matheny, 2002).
    Carnes (2002) lists the recovery process in stages.  This plan coincides Carnes’s (2002) shock and grief stages.  This plan begins at the action stage (Miller, Forcehimes & Zweben, 2011).  For sexual addiction, there is no concept similar to drug court; thus most sexually addicted clients have accepted they have a problem or are on the verge of doing so by the time they seek treatment.  Clients who are in contemplation or precontemplation (for example, those attending therapy only out of coercion from a significant other) should be referred to Motivational Interviewing (Miller, et al., 2011) to move them towards the action stage.
    The shock stage (Carnes, 2002) is first in our plan.  Clients will likely experience “disorientation, confusion, and an inability to concentrate” (Carnes, 2002).  During this phase treatments and interventions will focus on limit-setting and coping skills.  Therapeutic interventions will likely include CBT, DBT, and TSF.
    In the second phase, grief (Carnes, 2002), therapy will focus on grief counseling and coping skills.  In addition, some talk therapy may be conducted to assess past hurts and harms.  Acceptance and re-framing are also good skills for this phase.  Finally, CBT, DBT, MI, and TSF will likely continue in this phase.
    There are several treatments that overlap and are useful in related issues in and around sexual addiction.  This is because, as stated, clients are often using sexual addiction to self-medicate other problems (Carnes, 2002; Laaser, 2004).
    Barrilleaux (2016) and Weiss (2015) found CBT effective for sexual addiction.  This is not surprising given the underlying cognitive distortions that support sexual addiction (Laaser, 2004; Carnes, 2002).  Also, the utility of CBT for depression, anxiety, and other problems likely encountered in sex addiction therapy is established (Guadino, 2013).
    Anxiety and depression are commonly seen in sex addicts.  Thus, DBT will also be utilized, as it has proven effective for anxiety, depression (Ritschel, Cheavens, & Nelson, 2012).  Post-traumatic stress disorder, borderline personality disorder (Harned, Jackson, Comtois, & Linehan, 2010), and substance use (Dimeff & Linehan, 2008).
    Group therapy will be conducted.  Laaser (2004) and Weiss (2015) found group therapy very effective in healing unhealthy shame.  Weiss (2015) advocates group therapy because it “helps addicts learn that their problems are not unique.”  Group therapy curriculum will likely be procured from Pine Grove or similar suitable substitute.
    Finally, TSF will be utilized.  Carnes (Polish, 2015), an outspoken supporter of TSF, and recommends TSF.  Weiss (2015) also recommends the twelve steps, and Laaser (2004) lists them among support resources.  This plan will take into account the various nuances between the twelve step groups (which are outside of the scope of this article) and recommend based on prevalence and client preferences.
    As for the intake process, “Trap Doors” by the Pine Grove Behavioral Health & Addiction Services (2018) will be utilized.  “Trap Doors” is an acronym representing (briefly) sought Treatment, Relational damage, sexually Abused, Preoccupied, Depressed, Out of control, Out of sight, sexual Risk, and Shame.

Issues in Treatment

    Many potential issues can arise during the treatment of sexual addiction.  Among these are obstacles, ethical issues, comorbidity screening, and comorbidity.
    One of the major obstacles sex addicts encounter is the lack of health insurance coverage (Gentle Path at the Meadows, 2015).  Lack of coverage means only those sex addicts who can afford help can get help, except for twelve step fellowships.
    Another obstacle is the lack of local twelve step fellowships.  As an example, the author randomly chose Fluvanna TX (79517) and searched within several sex addiction twelve step groups.  The closest meeting found was Sex Addicts Anonymous in Lubbock, an hour’s drive one way.  There are no close sex addiction meetings.  The author suggests the odds of attendance decreases as transportation difficulties increase.  All other twelve step programs had meetings that were even less accessible.
    Yet another obstacle is lack of social support.  Carnes (1991) points out that American culture tends to reinforce, not modulate, sexual addiction.  Laaser (2004) writes that sexually addicted couples should not expect social support due to American social norms.  This is why therapy groups, church attendance, and twelve step groups can be vital: these may be the addict’s and/or couple’s only source of social support.
    In treating sex addicts, different ethical issues may arise.  One potential ethical violation is sexual relations with clients.  A therapist who crosses this line harms their client.  As well, because sex addicts often present with weak or non-existent boundaries (Carnes, 2002), therapists need to remain vigilant.
    State and local laws regarding sexual crimes and disclosure differ from state to state.  These, plus the Hippocratic Oath, can lead to an ethical situations where the therapist’s choices may all involve harm to someone (disclosure to spouse versus harm to the addict, etc.).  In the interest of brevity, the reader is strongly encouraged to read chapter 10 of Carnes (2002) which deals with the complex issue of disclosure of extramarital sexual activities.
    Sex addicts face many different potential comorbidities.  Major depression (Sealy, 2002) is the most common comorbidity; substance use disorders (SUDs) are also common.  Comorbidity screening should be done during intake, but some comorbidities may reveal after therapy has begun.  Many free screening tools exist for SUDs (Miller et al., 2011), but a complete discussion is omitted for brevity.  Regarding order of treatment, Weiss (2015) recommends sex addicts with SUDs achieve sobriety before attending sex addiction therapy, “unless there is a profound safety or relationship component.”  Sealy (2002) recommends treating sex addiction before depression, bipolar and ADHD after sex addiction, HIV and sex addiction together, and sex addiction after intrusive PTSD.
    This recovery plan also addresses other consequences.  Harm to the marriage caused by sex addiction should result in referral to marital counseling (see Laaser, 2004, and Carnes, 2002, on the subject).  Second, sex addicts facing legal consequences should be referred to legal counsel (Laaser, 2004).

Conclusion

    Sex addiction is a behavioral addiction that is difficult to manage.  It has specific symptoms and characteristics.  Its causes vary.  Withdrawal from sexual addiction can be difficult.  There are no medications to treat it, and it is considered a lifelong affliction.  But help is available.  This treatment plan incorporates both spiritual and secular evidence-based treatments over a period of a year.  Sex addiction therapy work is difficult and sometimes emotionally painful for the sex addict, but if taken one day at a time, is sure to lead to a rewarding life of sobriety.

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