Watson, R., 2010. How Can Cognitive Analytic Therapy Contribute To The Understanding And Treatment Of â€œSex Addictionâ€. Reformulation, Winter, pp.13-16.
I have worked as a clinical psychologist in NHS Sexual Health settings for many years, and I have seen many clients who were troubled by their sexual behaviour, and/or were at risk of physical or emotional harm because of it. Many of the clients I worked with expressed a harsh and critical attitude to their problematic sexual behaviour, often using words like “sick”, “perverted”, or “cheat”. It was also common to work with clients where the referrer described the problem as a “sex addiction”, and the clients also believed they had a “sex addiction or compulsion”. They would, when asked what they want out of therapy, say that they were hoping to be cured and often enquired if there was a pill I could give them to make them stop. Further discussion identified the harmful impact their sexual behaviour was having on their lives, and motivation appeared strong to make changes. Why then, did the experience of therapy often take a very different course, when interventions combining cognitive-behavioural therapy and motivational interviewing approaches (that have a good evidence base in other contexts) had if anything, only a short-lived effect? In answering this question in this article, I will draw on my clinical experiences of applying the theory and practice of CAT in this area of work. I will describe how doing so led me to propose that the traditional concept of sex addiction is limited in its usefulness, and propose that the theory and practice of Cognitive Analytic Therapy (CAT) may provide a far richer understanding of problematic sexual behaviour. This is because in my view it explores the ways people relate to themselves and others, and this has fundamental importance for sexual functioning. I argue that “Sex addiction” can be associated with problematic reciprocal role and self-management procedures often associated with histories of emotional deprivation or abuse. For this reason CAT is clinically useful because it aims to recognise and revise the underlying relational processes that may underpin behaviour that could be classed as “sex addiction”. I will also reflect upon the ethical dilemmas I encountered in this area of work.
There is a variety of opinion about the concept of sex addiction. Carnes (1991) views sexual addiction as a pathological relationship with a mood altering experience. Levine and Troidan (1988) argue that the concept of sex addiction invents a disease based on people’s choices and actions and is an attempt to repathologise forms of erotic behaviour that became acceptable in the 1960s and 1970s. Earle, Earle and Osborn (1991) regard sex addiction as originating from unresolved childhood issues, while Goodman (1992) suggests that a strong element in such behaviour is a neurological predisposition to addiction – the idea of the “addictive personality”. The most popular model used to understand out of control sexual behaviour is the addictions model. Traditionally ‘addiction’ is defined as a state of dependency on a chemical substance (e.g. alcohol, cocaine, cannabis, nicotine) which involves a strong physiological and psychological need and a compulsive inability to resist taking the substance, despite the individual anticipating probable negative consequences. If sexual behaviour is considered similarly, then it would have to cause significant harm or impairment in social, occupational, and family/relationship contexts; both the loss of control and harm are important criterion featured in DSM-IV (American Psychiatric Association, 1994). Phenomena observed in substance addictions such as a need for markedly increased amount or intensity of the behaviour to achieve the continuation of the desired effect, and the same (or a closely related) behavior being engaged in to relieve or avoid withdrawal symptoms, would have to be present to warrant a diagnsois of Sex Addiction.
With the arrival of the internet many clients report difficulties with the excessive use of internet pornography either alone or in conjuction with physical sexual contact. The use of internet pornography may escalate to the point where it causes significant problems to the individual’s ability to function in daily life and produces adverse negative consequences in the areas of relationships, work or emotional well-being. An individual suffering from pornography addiction might typically spend hours using internet pornography each day, with the result that they may not be able to meet their job demands or engage in relationships with others. There is debate about whether the term addiction is appropriate in this context as with sex addiction overall, but it is recognised that for some people their use of internet pornography can become highly problematic and in some cases lead to contact with law enforcement agencies.
I certainly accept that some people can lose control over their sexual behaviour in a way that causes harm to themselves and those around them. In my view however the formulation of this as an “addiction”, akin to substance addiction is misleading because it overlooks the central roles of psychological and social determinants of sexual behaviour. Just because someone says they cannot understand why they do something, and cannot stop, does not constitute an addiction in my view. For these reasons, CAT can contribute to different and more accurate understandings. I will illustrate how problematic sexual behaviour can be linked to the key features of CAT; that is, damaging reciprocal role procedures and their associated traps and dilemmas, difficult self-states, and the alleviation of core pain.
Positioning the individual as passive and “diseased”, the concept of sex addiction fails to acknowledge the functional and dynamic components to sex addiction. It is very likely that a client will not stop using sex (or drugs or food for that matter) harmfully if they are unaware of the underlying reciprocal role procedures driving such behaviours as well as the difficult and sometimes unmanageable feelings sex may be attempting to alleviate. My argument is therefore that reformulation is essential to helping clients to understand and observe these patterns and ultimately revise them. For example, I worked with a gay male client in his twenties where we indentified that he would either anxiously strive or defiantly rebel in response to a demanding and critical inner voice. The childhood origin of this reciprocal role was identified to an anxious mother who wanted him to be a good advert for the family and a critical father who openly had affairs. We described two relevant self states – that of “saint” and “devil” associated with the two poles of strive or rebel. In the “devil” state the client felt provocative, sarcastic, sexual and outrageous. In the “saint” state he felt hardworking, virtuous, and in control. In “devil” mode he would spend many hours in saunas having sex, and would often put himself at risk of HIV and other sexually transmitted infection through unsafe sex.
Early work helped him to recognise the procedures that would lead to switching from one state to another, which was usually the product of built-up frustration and anxiety associated with striving. We were then able to begin the process of recognition and revision and address the underlying emptiness that lay behind his sexual difficulties. Formulating the problem as an addiction would not have allowed these understandings to be brought to his situation and would have probably meant that the underlying feelings remained disavowed.
I have found that one of the strengths of CAT in this work is that it can quickly mobilise client’s abilities for self-reflection. This allows a new awareness to be brought to the problem, particularly if it is disconnected and cut off from other aspects of self. In my view this is more likely if there is a poor level of personality integration, and more extreme switches between difficult self-states. My work with a client in a longer-term CAT therapy highlights these points, and also draws attention to the challenges that present therapeutically when working with problematic sexual behaviour where the early sessions of CAT are devoted to information gathering for the purposes of reformulation. My client was a gay male who at the start of therapy had just finished taking post-exposure prophylactic (PEP) drug therapy for HIV infection. Individuals can begin taking PEP within 72 hours following possible exposure to HIV infection and need to take it for one month. There is moderate efficacy for PEP but no guarantee that it will prevent HIV infection. He gave a history of intermittent high-risk sexual behaviour over many years, felt he had little control over this, and would understandably become highly distressed and anxious following exposure because of concerns about HIV and other sexually transmitted infections. As his therapist I immediately felt a sense of grave urgency to address the risk aspect of his behaviour. I imagine in part this reflected a reciprocating counter-transference to his helplessness and perhaps his desire to be rescued, but also the reality of the need to minimise his risk of acquiring a life-threatening infection. There was a tension within me between this priority and the time usually devoted to written reformulation in the early stages of a longer-term CAT. Diagrammatic reformulation was therefore given priority over written because of the need to engage the client in active monitoring of triggers and meanings associated with unsafe sex. I asked him after the first session as a homework task to write down the attractions and costs of this behaviour. The result was that the client was struck by how much he was cut-off from the harmful aspects of unsafe sex. This might seem surprising given the obvious risks, but he became aware how unsafe sex had become eroticised. He also recognised it had become romanticised, connecting it to a previous long-term relationship in his twenties that he was idealising in the here and now, and to some extent still mourning its loss. One of the strengths of using CAT in this case was that it provided a language and tools for the client to understand that in an attempt to overcome underlying feelings of emptiness through sex, he ended up abandoning himself in the process in unsafe sex, and ended up back where he started, feeling empty.
In my experience heterosexual men attending for problematic sexual behaviour usually paid for sex. This has often been regarded as a sign of male sexual inadequacy. Brooks-Gordon and Gelsthorpe (2003) discuss the dominant discourses surrounding prostitution and a key assumption is that the “the normal male should have no need to visit prostitutes” (cited in Brooks-Gordon & Gelsthorpe, p.442). Such assumptions are likely to be as stereotypical as the “dirty old man in a raincoat” caricature, and lead to positioning men who buy sex as inferior in some way. Mancini (1963) in Prostitutes and Their Parasites described men who paid for sex as “So physically unattractive, that only a prostitute would consent to having anything to do with them” (Cited in Brooks-Gordon & Gelsthorpe, p.442). By contrast Pitts et al. (2004) interviewed 1225 adults in Melbourne, Australia, and found nothing unusual or deviant in the reasons men gave for buying sex. They cited meeting sexual needs as the principal reason specifying ease, engagement and arousal as important considerations.
Several male heterosexual clients who paid for sex and felt it was out of control told me that this encounter was the only space where they felt free from the demands of others, be that children, partners, or employers. One client said, “It is the only place I know I don’t have to look after everyone.” This suggests to me that these men may find themselves in a dilemma where they either try to be perfect and become overwhelmed by their own and other’s expectations, or feel lonely and deprived and break the rules. In this sense buying sex is a coping mechanism whereby they can feel more in control again, and obtain an experience of being “looked after”. In this context one of the questions I have found useful to ask men is; “Can you tell me in what ways you treat yourself or have opportunities to enjoy yourself?” Often clients reply that they don’t and cite pressures of work or family life as reasons. In these instances I have found it important to understand the underlying needs that they are attempting to meet.
In some instances where I have worked with men who buy sex, and who are also in a regular relationship, there have been reciprocal role procedures that lead to feelings of anger and resentment about their relationship. They don’t seem to have a language to understand the emotional turmoil they experience when their needs are not met or disappointed. I worked with a client who was referred for addiction to buying sex. He had been buying sex throughout his five-year marriage and was distressed by his inability to stop. His childhood was characterised by rejection and harsh criticism from parental figures. These experiences were described as the reciprocal role of critical and rejecting in relation to criticised and rejected. Understandably this dominant reciprocal role made it difficult for him to feel secure in relationships. In his marriage he attempted to reduce his fear of rejection by trying to be a perfect husband and invested a lot of himself in this. The “routine” rows and disagreements of the relationship would have a devastating impact leaving him feeling criticised and fearful as well as angry and resentful that his efforts were not recognised. This would lead to buying sex, a kind of secret revenge that turned out to be a hollow victory because he would then become overwhelmed by guilt and fear rejection even more because of the possibility of discovery. This would lead him back to where he started, attempting to be the perfect husband. Without these opportunities for recognition and hence revision my view would be that this client would find it very difficult to stop buying sex, and hence carry the “flavour of addiction”.
My experience of working with problematic sexual behaviour has led me to consider that in some cases it can be a behavioural marker for narcissistic personality disorder. DSM-IV criteria for this disorder include a grandiose sense of self-importance, preoccupation with power and success, and interpersonal exploitation. This not surprisingly leads many clinicians to struggle when working with these clients. The DSM-IV criteria in my view overlook the underlying deprivation and emptiness at the core of this condition, and that grandiosity is overcompensation for feelings of emotional deprivation and defectiveness. The childhood origins of NPD according to Ryle and Kerr (2002) are loneliness and isolation. Often the child was required to be pretty or clever in order to meet the parent’s own needs, while being deprived of unconditional love and care. Natural vulnerability or failure was punished or ridiculed and shaming. These childhood experiences commonly observed in NPD are understood in CAT to result in a split between two polarised reciprocal roles: admiring to admired, and contemptuous to contemptible and are represented diagrammatically as the “split egg”. There is the top half where, sustained by the admiration of others, the client naturally wishes to stay because this will protect him from the bottom half characterised by powerlessness and shame. Sex in this context can be a mechanism to either avoid being in the bottom half (contemptuous in relation to contemptible) or as a way of re-establishing contact with the top-half (admiring in relation to admired). The top half of the egg is an idealised world; falling off the perch is inevitable and requires replenishment and sex can be recruited for this purpose. I worked with one client who was concerned only with success and avoiding failure; setbacks and mistakes in his high powered job always took him to the bottom half of the egg, and impulsive sex was the way he tried to reach the top half.
An important part of CAT is the identification and naming of “core pain”, and this is the idea that there are disowned and hard to access feelings associated with a past core experience, for example, abuse or deprivation. I have been struck by my experience that underneath problematic sexual behaviour, there are often profound feelings of emptiness, sadness or failure. Interestingly, authors including Bancroft (2006) and Wolfe (2000) have discussed the relationship between sex addiction and mood regulation. They recognise that this relationship is not straightforward, for example, Bancroft (2006) reported that in a sample of gay men, a significant minority reported that anxiety and depression led to an increase in sexual behaviour. My view would be that mood is a key component of reciprocal roles and the way this links with problematic sexual behaviour would need to be understood using the CAT reformulation tools. If anxiety or depression in some of Bancroft’s sample was associated for example, with being in the bottom half of the egg, then it may well lead to increased sexual behaviour to secure the necessary amount of admiration to regain position in the top half.
It is worth mentioning that history abounds with examples of certain sexual practices being regarded as legitimate reasons for persecution, abuse or mistreatment because of the power of prevailing social norms, and this can result in abusing in relation to abused dynamics between professionals and clients. In the 19th century masturbation was seen as cause of many physical ailments and insanity – hence the masturbatory insanity hypothesis. Stengers and Van Neck (2001) refer to a British Psychiatrist, who writing in 1861 said: “When insanity is suspected in young men under 25 yrs, there is every reason to fear that these symptoms are due to habits of a most pernicious nature” (cited in Stengers & Van Neck, p. 109). This masturbatory insanity paradigm was used to justify abusive practices such as circumcision in girls and painful metal chastity belts in boys. As a gay man I am aware of the prejudices that can exist towards gay men’s sexual behaviour, particularly in the context of the HIV epidemic. These considerations are important because conceptualisations of sex addiction clearly will interface with cultural values and personal preferences and they seem to complicate the issues around what constitutes “sex addiction”. In my view they also partly account for the considerable disagreement described previously amongst professionals as to what constitutes sex addiction and how best to treat it. Cultural values also seem to have some bearing on differences in the way groups obtain sex in cases of “sex addiction” presenting to clinic. For example, in my own clinical experience heterosexual men presenting with problems of sex addiction usually buy sex from prostitutes while gay men often use saunas or internet sites to acquire sexual partners.
Moreover, as Ryle and Kerr (2002) discuss it is impossible for therapists to dissociate themselves from their own social and cultural anchoring. I have found that in working with problems associated with sex and sexuality you cannot disconnect from your own values and attitudes towards sexuality. Sometimes this can be an uncomfortable process. I am very aware that my values towards sexuality have been shaped by own experiences of being brought up in a family that was liberal and open about sex and sexuality and where my own gay sexuality was accepted. I am also aware that the field of psychotherapy is a diverse one, and I have encountered views in some quarters that suggest sexual behaviour that does not fit a model of heterosexual monogamy is regarded as pathological. This no doubt reflects wider discourse in society. These can be experienced as oppressing and sadly in my experience can mean that sexual minorities react to these dialogues by replacing them with opposite, but equally restricting values, for example, that monogamy is outdated and having multiple sexual partners is mandatory. The reason I raise these points is that often there are no concrete answers to what constitutes healthy sexuality and harm. For example what is the acceptable number of sexual partners per year or frequency of sexual activity per week? When would such numbers or frequencies constitute an addiction? The role of the therapist in my view is to prevent harm but also to help identify the internalisation of restricting values, and provide a space where sexual expression that is affirming and beneficial to emotional well-being can be nurtured. This position, which I adopt in this work, is of course not neutral.
As a psychologist I suspect that to some clients I may symbolise social control or morality. I remarked previously on the harsh language some clients use to describe their behaviour. What you say depends on who you are talking to. I would have a very different conversation about sex with my grandmother compared to my friend. I do wonder if some of the language clients use is an attempt to deflect expected criticism or judgement by me. Adopting a harshly critical attitude to aspects of their sexual desire can make it challenging to help clients explore their legitimate sexual needs. Given the popularity of the sex addictions paradigm, it is not surprising that the Alcoholics Anonymous Twelve Step Recovery Programme has been used to treat “Sex Addicts”. One of the problems with this approach in my view is that clients are expected to surrender to a “higher power greater than me” thus creating the danger of entering into an idealising fantasy, instead of building on their own capacities for change. There is also a requirement for sexual abstinence. My concern would be that some clients would attempt to lead a life that is unsustainable, resulting in sudden acts of rebellion or escape via sex.
Similarly to the spiritual and religious overtones of the Twelve Step approach, I have sometimes felt the transference with clients to be as if I had become a modern equivalent to the confessional. I have also felt that with some clients there has been a kind of pseudo therapeutic alliance when it seems that attending therapy provides some sense they are addressing the problem, while underneath they are terrified of being left without this coping mechanism. A colleague of mine once described this as the “judging parent-rebellion transference.” On other occasions I have felt as if the client is waiting for me to rescue him from his “addiction”; the question “Can you give me a pill that will make me stop?” conveys a hope that I could wave a therapeutic wand. More disturbingly for me I have felt that some clients have attempted to draw me into their world by excessively graphic sexual detail and titillation, but perhaps surprisingly this has been rare.
I hope that I have highlighted how for me behind problems of sex addiction there are often histories of emotional deprivation and unmet need and these are manifest in harmful reciprocal role procedures incorporating sex as an attempt to manage difficult states of mind. Approaches to treating the problem need to consider these in some way. It is also important in this area of work to consider how your own values and dominant dialogues in society may both help and hinder the development of healthy sexuality, and lead to the therapist adopting an overly pathologising stance or minimising the problem. I would also not want to give the impression that CAT has all the answers to working with problems of sex addiction. Far from it, like any model of therapy it has its strengths and limitations. I do feel that is contributes to more humane and sane understandings of problematic sexual behaviour. Finally I do carry some anxiety that the visibility and importance of this sexual health work may be lost in today’s NHS. I feel that this would be a loss as for many people it is the only space they have to think about this part of themselves.
My interest in applying CAT to the area of Sexual Addiction developed whilst working as a Clinical Psychologist in NHS Sexual Health/Genito-Urinary Medicine Clinics in Central London, and whilst undertaking my CAT practitioner training. I have a commitment to, and interest in, working with wider issues related to sexuality, and promoting sexual and emotional well-being. I currently work as a Clinical Psychologist and CAT Therapist in private practice, in a partnership with two colleagues. I would welcome comments and discussion about this article; I can be contacted at firstname.lastname@example.org
I would like to thank Annie Nehmad for reviewing the article, and Hilary Beard for encouraging me to apply CAT to the area of sex and sexuality during my training. I would like to draw readers’ attention to a forthcoming publication: Watson, R. & Vidal, M. “Do you see other men who do this?” Reflections upon working with men who visit commercial sex workers in a NHS Sexual Health Clinic’. Journal of Sexual and Relationship Therapy (to be published February 2011).
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