A biopsychosocial view of sex addiction – Part 2
“The psychology of sex addiction
There are numerous psychological factors that feed into addiction processes and into the development and continuation of sexual addiction. An understanding and exploration of the emotional and cognitive influences are important for ensuring that treatment moves beyond biological symptom relief and change, to the deeper psychological processes that can both cause and drive the unwanted behaviours
A psychodynamic point of view
From a psychodynamic viewpoint, sexual addiction can be seen to be rooted in issues of attachment, trauma and/or object relations. Secure attachment is widely understood by psychodynamic theorists to be an important precursor for healthy adult relationships and healthy sexual expression. People with avoidant attachment styles are more likely to seek relationships and sexual encounters where there is little or no emotion or affection, such as sex workers and pornography, whereas those with disorganised attachment styles may find themselves drawn into an ever increasing number of sexual relationships or liaisons in order to receive validation and affection.
People with ambivalent attachment styles may choose additional sexual relationships outside of their primary relationship as a way of warding off fears of rejection or suffocation (Samenow, 2010). A further hypothesis is that once an attachment has been made to an addiction as a source of comfort, it is harder for an addict to create a secure attachment within a relationship and, hence, the cycle of insecure attachments within relationships continues and the attachment to the addiction becomes stronger. Not everyone who has experienced trauma will go on to develop an addiction but evidence suggests that sexual trauma, in particular, is over-represented amongst the sex addiction population (Schwartz, Mark, & Galperin, 1995).
From a psychodynamic perspective, therapy is likely to focus on developing secure attachment and self-integration whilst working through any trauma issues, perhaps with additional resources such as sensori-motor work or EMDR.
A systemic point of view
A systemic view of sex addiction might look at the role the problem plays in relation to other people within the systems which the individual is part of. Family of origin work might identify learnt patterns of addictive behaviour, a history of secrets in the family and/or poorly adapted coping skills. In my clinical experience, I have seen many clients who have received significant negative messages about sex being shameful and have consequently found it difficult to healthily embrace sexual needs and feelings .
Conversely, I have seen many clients who have experienced very liberal attitudes to sex and sexual boundaries where pornography and the use of sex workers was seen as the norm.
A cognitive-behavioural point of view It is widely accepted within cognitive behavioural therapy that all addictions, both chemical and process, are used as a form of affect regulation. There is, of course, nothing wrong with using sex, or, depending on your viewpoint, alcohol, to alleviate difficult emotions and to create a sense of wellbeing, but if alcohol or sex become a primary coping mechanism on which a person depends, in spite of negative consequences, then it might be considered an addiction. Cognitive practitioners would likely focus on the thoughts, feelings and behaviours triggered by sex addiction. Exploring impulse control, triggers, urges and negative thinking patterns can all be a way of initiating behaviour change towards coping mechanisms that the client feels more confident and comfortable with and the use of motivational interviewing techniques may help to cement change (Fuller & Taylor, 2010).
A relative newcomer to cognitive therapy, developed by Young, Klosko and Weishaar (2003) is schema therapy. Schemas are a stable, enduring, negative pattern of beliefs and feelings about oneself that develop during childhood or adolescence and are elaborated, usually without awareness, throughout an individual’s life. By bringing schemas into conscious awareness a client can be helped to re-write the script and thereby make more conscious choices about how they wish to feel, think and behave in their world.
Both shame and guilt are emotions that can only exist within the context of others since both are judgements made about the self as viewed in relation to the overt or covert expectations of family, religious affiliation and/or society. Shame and guilt have a long tradition as both causes and consequences in people experiencing addictions but recent research has shown that whereas shame is likely to increase addictive behaviour, guilt can be a significant motivator to overcome it (Gilliland, South, Carpenter, & Hardy, 2011). Shame can be described as a painfully negative emotion where the self is deemed bad and unworthy, whereas guilt is a negative judgement about a behaviour. Hence a guilt script says ‘‘I have done something bad’’ whereas a shame script says ‘‘I am bad’’. Unresolved shame experienced in childhood can result in exaggerated feelings of shame in adulthood, which may be medicated against through an addiction. However the addiction often becomes a source of shame in itself and hence perpetuates an addictive cycle.
The distinction between shame and guilt is particularly important for understanding sex addiction within a societal context. Although our world may appear to be more open about sex, there is no doubt in my mind that sexism, homophobia, sexual repression and religious fundamentalism still exist, as well as societally assumed norms of monogamy. These factors can fuel a sense of shame of those who step outside of these norms, taking the power away from the individual to decide if guilt, or indeed acceptance, is a more appropriate response.
Contrary to the belief of some clinicians, the shame experienced by sex addicts is frequently not from any ethical or anti-sex perspective. On the contrary, most of the clients I work with have no moral objection to watching pornography or visiting sex workers, their shame comes from prioritising these activities over and above their commitments to partners, children, friends, work, finances, health and career and personal development.
Shame can damage an addict’s sense of self to the point where they no longer see themselves as worthy of the love of a partner, or the respect of children, or the unconditional regard of friends, or the promotion from a boss. They may experience a sense of guilt at the number of times they have lied or let down others due to prioritising a secret sex life, but the shame can wound to the point where change feels impossible. To overcome any addiction, the client can be helped by empathically evaluating their behaviour and reducing shame. With shame removed they may then decide that their behaviour is no longer a problem or by reframing to guilt they may be more empowered to change (Gilliland et al., 2011).
Developing a bio-psychosocial model demonstrates the importance of not simply focussing on reducing behavioural symptoms through relapse prevention strategies and arousal re-conditioning, but also ameliorating the underlying psychological issues and exploring the societal context within which a client has developed their meaning of the problem. Achieving this requires multiple skills, which I believe are beyond traditional addiction treatment strategies and basic training in psychosexual therapy. Clients are understandably confused when professionals who not only cannot agree on whether or not their problem exists, or what it’s called, then go on to dispute the mixed merits of rehab treatment, 12-step fellowships, cognitive behavioural therapy, existential therapy, Jungian analytical, psychosexual therapy, psycho-educational work, couple counselling, individual work, group work and so ad infinitum. In my view, the biggest barrier to understanding sex addiction is professional defensiveness and misdiagnosis. We all have much to learn about this subject and even more that we can learn from each other’s experience.
In the meantime, clients continue to come to our door. I feel passionately about this client group and it frustrates me that so many are hearing the message that their problem does not really exist or that they simply need to develop more self-control or come to terms with their behaviour. I have heard countless stories of how sex addiction has devastated lives: how men have lost their partners, families, friends, jobs, homes and, perhaps most importantly, their self-respect and integrity. And the stories of women who are shocked and confused to discover that their loving partner, who they assumed had low desire since they rarely wanted to sleep with them, has been spending six hours a day, every day watching pornography and having cybersex…”
Misunderstanding and ignorance …”creates an unwanted and additional problem that the shame caused by widespread misunderstanding further damages self-esteem and fuels the addictive cycle.”
1. 1. Hall, P. (2011). A biopsychosocial view of sex addiction. Sexual and Relationship Therapy, 26(3), 217-228.