My 25 Years in SASH: A Clinicians Perspective

1. My 25 Years in SASH:A Clinicians Perspective Kenneth M. Adams, Ph.D., CSAT

2. Different Labels- Same Construct? • Sexual Addiction • Sexual Compulsion • Hypersexual • Problematic Sexual Behavior

3. What’s In A label? • Accurate label directs differential diagnosis • Differential diagnosis guides treatment • Proper differential diagnosis leads to treatment success • In contrast, inaccurate label and differential diagnosis leads to treatment failure

4. Sexually Addictive Disorders • Minimizing • Rationalizing • Intellectualizing • Denial • Sincere delusion • Gas lighting

5. The Clinicians Dilemma • Who is right? • What works? • Not wanting to be dismissed • Research that makes intuitive and clinical sense

6. Similarities to the 1930’s ? • AA founded in 1935 • Drinking was a “choice”, moral issue • Frustrated by the lack of help and awareness on the part of the medical community, AA was founded • Currently, APA recommends sustained treatment in conjunction with AA for chronic alcoholics unresponsive to brief treatment • Over 2 million members worldwide

7. Collective Wisdom Regarding Alcoholism Treatment • “To me, the answer lies in the long-term change. The process that is rooted in the twelve steps is about the only thing over seven decades of relative success. Many other forms of “cure” have passed through the halls of treatment. Most are posters on the halls of history. Like many things, they work well for some individuals. However, they flop miserably for the masses. The overwhelming data is in the lives we see changed (italics added).- Jes Montgomery, M.D., SASH, IITAP post 6/10/12

8. Controlled Drinking Advocates • Some still believe problem drinking is a choice • “The bottom line is this: drinking is a choice” (J. Schaler, 2012, web site post) • March 2000, AureyKishline, founder of “Moderation Management” self-help alternative to AA, killed a father and his 12 –year-old daughter, Richard Davis and LaSchell, in a head on collision driving the wrong way drunk in WA • What is the Davis’ family view of “controlled “ drinking?

9. The “S” Programs • Programs host 5-10 Million Americans per year • SAA has 1,200 meetings globally (J. Cloud, TIME) • Different perspectives but share a common experience of out of control sexual behavior and a frustration with therapy as an process that has not historically helped

10. The Problem • “Addictive sexual behavior, acting-out behavior we sometimes call it, leads to feelings of shame and depression: it has the effect of masking, covering up, or numbing feelings; and it leads to isolation and a complete loss of control. Healthy sexual behavior, on the other hand, is characterized by mutual respect, a sense of clarity about feelings and communication, joyfulness, and genuine intimacy; it tends to make people feel emotionally and physically safe.” Hope and Recovery, 1987 SAA 12-step

11. ASAM Public Policy Statement - 2011 • Addiction is a chronic brain disorder, not just a behavior problem • “Addiction is a primary, chronic disease of brain reward , motivation, memory, and related circuitry” • Harvard mental Health Newsletter ( July 2011): • “Neuroimaging technologies and more recent research…have shown that certain pleasurable activities, such as gambling, shopping, and sex, can also co-opt the brain [like drugs and alcohol].” • “Because addiction is learned and stored in the brain as memory, recovery is a slow and hesitant process in which the influence of those memories diminishes”

12. What Works?

13. Sexual Addiction as an Attachment Disorder

14. Developmental/Attachment Model of Sexual Unfolding • Sexuality integral to early attachment and bonding experiences • Developmental insults leave the person able to be sexual but not able to bond – split off into parts of self • Gap between love and lust (Money) • Erotic feelings merge with other feelings ,i.e.. anger, pain, shame (Carnes) and arousal is dependent on control, power, and rituals - sex is used as a drug to medicate feelings • Arousal can be both hypo and hypersexual • Sexual compulsion is the end point of a series of developmental events (Schwartz)

15. Path to Sexual Compulsion • Schwartz & Southern, 1999 - begin with early attachment difficulties • Subsequent overwhelming experiences and feelings child is unable to assimilate • Affect dysregulation, poor social skills, lack of perceived efficacy in negotiating relationships, limited empathy and compassion, and difficulty with accurate attunement regarding cues from others • Impaired self-development and splitting off self into parts • Impaired gender-related behavior • Sexual compulsion/addiction is a compensatory response to attachment disorder – part of self is addicted

16. Compulsive vs Healthy Sex • “In compulsive sex, individuals use their genitals to avoid feelings, while in intimacy, closeness and affection are enhanced • Healthy intimacy facilitates the growth of both individuals, compulsive relationships are marked by loneliness, possessiveness, jealousy, anger , and alienation from each other • Successful recovery is as much about safely bonding as it is about genital sexuality • Courtship must go slow and be free of gamesmanship • If potential partners cannot cope with honest, slow bonding, the partner is not right” –Schwartz

18. Sexual Addiction as a Dissociative Disorder

19. SELF PROTECTIVE DISSOCIATION/ SPLITTING PROCESS PROTECTIVE (CONTROL, ADDICTION, AVOIDANCE, ETC) VULNERABLE (FEELINGS, HURTS, ETC.)

21. Shame Reduction, Affect Regulation, and Sexual Boundary Development: Essential Building Blocks in Sex Addiction Treatment - Adams and Robinson, 2001

22. Shame Reduction • Understand origin and function of shame • Differentiate between shame and guilt • Identify the defenses against shame • Utilize specific shame reduction techniques at critical points in the process • Revisit critical trauma experiences • Change negative core beliefs

23. Defenses Against Shame • Rage • Contempt • Striving for power • Striving for perfection • The transfer of blame • Internal withdrawal (Kaufman)

24. Affect Regulation

25. Affect and Addiction • Inability to modulate arousal • Inability to tolerate distress • Use of sex sexual behavior to: • self-soothe • distract or abbreviate negative emotion • provide protection and nurturance • Provide a sense of self

26. Treatment • Specific to development of ability to learn to identify and regulate affect • Increased ability to access inner states • The ability to experience and tolerate strong affective states • Understanding the nature and impact of developmental losses and their impact on bonding

27. Sexual Boundary Development

28. Sobriety Statement Three Components: • Abstinence List • Behaviors that are part of the addiction • Boundaries List • Things that you refrain from as they would be hazardous to recovery • Sex and Relation Plan • Exploring sexuality in healthy ways Can use 3-Circle Method to compile statement

29. Treatment Considerations • Must include amelioration of attachment disorder • Compassionate witnessing • Processing of painful parts – unburdening (trauma work) • Developing a narrative story (including affective expression) regarding split off parts • Development of meta-cognitional part and the development of a clear self • Minimize family idealization and loyalties • Resolution of significant losses (Schwartz)

30. Treatment Considerations • Must include addiction treatment interventions • 12-step participation • Telling of “addict’s” story • Assessment for other addictions • Completion of all major core tasks • Disclosure and amends • Acceptance of losses created by the addiction • Capacity for closeness and healthy sexual functioning restored

31. Can I masturbate? (no wisecracks) • Does it lead to powerlessness ? • Does it lead to unmanageability? • Does it lead to a disassociated state? • Does it interfere with the capacity to attach and bond? • If the answer is “Yes”, then the answer is “No”