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1 This article was downloaded by: [Maple Moriji] On: 10 February 2012, At: 09:22 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: Registered office: Mortimer House, Mortimer Street, London W1T 3JH, UK Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention Publication details, including instructions for authors and subscription information: Therapeutic interventions recommended for treatment of sexual addiction/ compulsivity Sallie H. Swisher Ph.D. Available online: 08 Nov 2007 To cite this article: Sallie H. Swisher Ph.D. (1995): Therapeutic interventions recommended for treatment of sexual addiction/ compulsivity, Sexual Addiction & Compulsivity: The Journal of Treatment & Prevention, 2:1, To link to this article: PLEASE SCROLL DOWN FOR ARTICLE Full terms and conditions of use: This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. The publisher does not give any warranty express or implied or make any representation that the contents will be complete or accurate or up to date. The accuracy of any instructions, formulae, and drug doses should be independently verified with primary sources. The publisher shall not be liable for any loss, actions, claims, proceedings, demand, or costs or damages whatsoever or howsoever caused arising directly or indirectly in connection with or arising out of the use of this material.

2 THERAPEUTIC INTERVENTIONS RECOMMENDED FOR TREATMENT OF SEXUAL ADDICTION/ COMPULSIVITY Sallie H. Swisher, Ph.D. This study surveyed 248 counselors, members the American Mental Health Counselors Association (AMHCA) or International Association for Addictions and Offender Counselors (IAAOC), divisions of the American Counseling Association, regarding their perceptions of the nature and treatment of sexual addictionlcompulsivity. Findings indicated that counselors perceived sexual addiction as an obsessional illness, characterized by out-of-control sexual behavior. A combination of individual and group therapy was most often suggested. Strategies most often recommended for treatment of sexual addiction included cognitive restructuring, defining behavioral boundaries, empathy, positive self-talk, and recognizing and avoiding high-risk situations. Patrick Carnes Out of the Shadows, the first major work defining sexual addiction, was published in Many counselors who are proponents of the existence of sexual addiction/compulsivity agree that sex addicts go through an addiction cycle and that recovery has definite stages (Carnes, 1992; Earle & Crow, 1990; Schneider & Schneider, 1989; Sprenkle, 1987). Many authors agree that sexual addiction is out-of-control sexual behavior (Adams, 1991; Carnes, 1991, 1992; Earle & Crow, 1989; Kasl, 1989; Address correspondence to Sallie H. Swisher, Ph.D., 7000 Independence Parkway # , Plano, TX Sexual Addiction & Compulsivity, Volume 2, Number 1, Brunner/Mazel, Xnc. 31

3 32 Sexual Addiction 4 Compulsivity Schneider, 1988, 1991; Sprenkel, 1987). However, definitions of sexual addiction/compulsivity vary, and acceptance of sexual addiction as a specific mental disorder continues to be controversial (Barth & Kinder, 1987; Coleman, 1992; Edwards, 1974; Levine & Troiden, 1988; Quadland, 1985). Diagnosis and treatment of sexual addiction/compulsivity is hampered by this lack of consensus among mental health professionals regarding what constitutes sexual addiction. Using DSM-111-R (APA, 1987) nomenclature the majority of counselors responding to this survey stated they would diagnose sexual addiction as an obsessive-compulsive disorder (29%), sexual disorder (26%) or impulse control disorder (21%). Under the proposed DSM-IV (APA, 1994) nomenclature, 35 YO indicated out-of-control sexual behavior should be diagnosed as a separate sexual disorder, 24% as obsessive-compulsive disorder, and 13% as an impulse control disorder. Schwartz (1992) proposed that sexual compulsivity be treated as post-traumatic stress disorder. Four percent of respondents diagnosed sexual addiction as post-traumatic stress disorder under DSM-111-R and/or DSM-N criteria. Many sex addicts have a long history of therapy that failed because their therapists did not address the real problem of sexual addiction. Frequently people will receive the diagnosis of depression or alcoholism, when the primary challenge in their lives is sexual addiction/compulsivity.... Since few people want to talk about sexual addiction, or for that matter any sexual problem, it is unlikely to be pushed by the patientlclient, and thus it is essential that the therapist raise the issues (Earle, February 1993, personal communication). Additionally, therapists who minimize sexually compulsive behavior may unwittingly become professional enablers (Earle & Crow, 1989). This prevalence of misdiagnosis and reluctance of clients and therapists to raise issues related to sexuality are supported by data in this study. Lundy ( 1994) identified 13 out-of-control, obsessive-compulsive behaviors that mental health professionals have attributed to sex addicts. He called for research to investigate effective treatment modalities and to address the question Can criteria be established to predict sexual addiction? Lundy also asked for research to determine whether there are significant differences among mental health professionals based on individual theoretical orientation. Findings from this study address Lundy s call for empirical information regarding effective treatment modalities and differences among mental health professionals based on individual theoretical orientation. METHOD The purpose of this project was to compile practical information that would be useful to counselors in the diagnosis and treatment of sexual addic-

4 Treating Sexual Addiction 33 tion/compulsivity. A survey was piloted in 1993 at the National Council on Sexual Addiction/Compulsivity Conference in Scottsdale, Arizona, and the Trauma Resolution Conference in Tuscon, Arizona. Based on input from the pilot samples, a revised survey was sent to 250 mental health counselors and 250 addiction counselors, randomly selected from the membership of the American Mental Health Counselors Association (AMHCA) and the International Association for Addictions and Offender Counselors (IAAOC), divisions of the American Counseling Association. This population was selected because its members are actively involved in providing counseling to people whose numbers are most likely to include sex addicts/compulsives. Of those selected, 118 mental health counselors and 130 addiction counselors completed and returned the survey. A five-point Likkert scale from 1 (strongly agree) to 5 (strongly disagree) was used to rate respondents perceptions of the nature and treatment of sexual addiction. Survey respondents ranged in age from 21 to 61 or more years of age. Eighty-one (33%) were male and 167 (67%) were female, which corresponds to the percentage of male and female members in the divisions represented. The majority were Caucasians 233 (94%). Minority representation included 3 (1%) African Americans, 1 (.4%) Hispanic, 1 (.4%) Native American, and 1 (.4%) Asian. Nine respondents (3%) chose not to indicate ethnicity. Counselors represented all geographical regions of the United States; 109 (44%) from the northeast, 52 (21%) southeast, 40 (16%) northwest, and 47 (19%) from the southwest. Ethnic and geographic distribution of division members was not available from the American Counseling Association. The majority of respondents held masters degrees (79%) or doctorates (15%) and had 6-19 years of counseling experience. One hundred sixty-five (67%) were certified, 125 (51%) licensed, and 91 (37%) were both certified and licensed. Where interval data were involved, step-wise regression analysis was used. Cross-tabulations with appropriate tests of statistical significance were used when dependent variables consisted of nominal or ordinal data. An alpha level of (p<.ol) was selected to reduce the likelihood of type I errors (Kachigan, 1986). A follow-up structured interview was conducted with 20 counselors selected from survey respondents who frequently encountered sex addicts/ compulsives in their practice and indicated their willingness to participate in such an interview. The interview served the purposes of exploring specific factors and circumstances counselors deemed important to the client/counselor relationship in recovery from sexual addiction, and provided an opportunity to probe unexpected information that was disclosed by the survey.

5 34 Sexual Addiction 4 Cornpulsivity RESULTS Diagnosis Findings indicated that while all survey respondents did not agree on the use of the term sexual addiction, and did not agree that all sex offenders are sex addicts, the majority of counselors responding agreed: 1) Sexual addiction is best described as an obsessional illness, with a definite set of symptoms, characterized by out-of-control sexual behavior. 2) Sex addicts who present for therapy are most often heterosexual males who are likely to have multiple addictions, though sex addicts may also be females, homosexuals, or bisexuals. 3) Sex addicts are likely to have been physically, sexually, and/or emotionally abused as children. Emotional abuse included covert incest. Covert incest defined by Adams (1991) occurs when a child becomes the object of a parent s affection, love, passion and preoccupation (p. 9). 4) Sex addicts are also likely to have come from families where at least one family member was a substance abuser or was sexually abused. A correlation between childhood abuse and adult addiction appears clear and supports Carnes and colleagues (1993) findings of such a correlation with identified. sex addicts. One hundred sixty-three (66%) respondents agreed that sexual addiction was most often misdiagnosed as relationship issues. Twenty-four (10%) gave substance abuse as the most frequent misdiagnosis, another 16 (7%) cited depression, 15 (6%) chose midlife crisis, and 28 (11%) did not indicate that they thought sexual addiction was being misdiagnosed. Respondents indicated that sexual addictiodcompulsivity should be explored as a possible diagnosis when clients report a history of: 1) family dysfunction, 2) physical abuse (including invasive medical procedures), 3) sexual abuse (covert as well as overt), 4) emotional abuse (including fear of abandonment resulting from long hospital stays, and emotionally absent parents), 5) addiction by family members, 6) inability to build or maintain intimate relationships, 7) compulsive or addictive behaviors, 8) self-destructive behaviors relating to sex, 9) panic attacks, 10) depression, 11) posttraumatic stress, 12) sexual dysfunction, 13) regular use of pornography, or 14) excessive religiosity in family-of-origin or client. Since 218 (88%) of survey respondents indicated that in their opinion, sexual addictionicompulsivity is being misdiagnosed, interviewees were asked to provide reasons for the misdiagnosis. Interviewees responses indicated that sexual addiction was not only being misdiagnosed but was also going undiagnosed. Fifty percent of counselors interviewed thought that sexual addiction was more often undiagnosed than misdiagnosed; 25 % thought it was most often misdiagnosed, and 25% thought both were major problems. Forty-five percent indicated this was due to counselors unwillingness

6 Treating Sexual Addiction 35 to deal with sexual issues because of unresolved difficulties in their own history (e.g., abuse or addiction). Thirty-five percent cited lack of consensus among counselors that sexual addiction was a disorder. This lack of consensus was attributed primarily to inadequate preparation of counselors in counselor training programs. It was recommended that this could be greatly rectified by requiring course work on addictions in general and sexual addiction in particular in all counselor education programs, regardless of specialty area. Fifteen percent cited clients reluctance to disclose the presence of out-of-control sexual behavior or other sexual information as a reason for sexual addiction going undiagnosed. Only 5% cited the presence of other pathology (e.g., depression or substance abuse) as a factor in misdiagnosis of sexual addiction as the primary cause of clients dysfunction. Therapies Cross-tabulations disclosed that a combination of individual and group therapy was most often suggested. Two hundred thirty-three (94%) would use individual therapy; 231 (93%), professional group counseling; 162 (65%), couple/marital counseling; 157 (63%), family counseling; and 176 (71 % ), involvement in twelve-step groups specifically focused on facilitating recovery from sexual addiction/compulsivity. Only 45 (1 8%) would use aversive therapy and 17 (7%) would consider using electric shock therapy in treatment of sexual addiction. Counselor s age, years of experience, and geographic region did not significantly influence therapy choice. However, recommendations for professional group counseling for sexual addiction was influenced by counselors educational level (p<.ool ). Counselors with a bachelor s degree were significantly less likely to recommend professional group therapy than those with a master s degree or higher. Fourteen percent of survey respondents did not endorse twelve-step groups. Interviewees who preferred professional group counseling over twelve-step groups indicated they felt more was accomplished in professional counseling groups led by trained counselors who could control group membership and provide goals and structure not possible in twelve-step groups. Counselors decisions to recommend family therapy were influenced by counselors theoretical orientation (pe.01). Not unexpectedly, counselors who reported their theoretical orientation was family counseling recommended family therapy significantly more often than those counselors with other theoretical orientations. Of the 63 YO who agreed that family therapy should be a part of the treatment for sexual addiction/compulsivity, the majority state.d they would use family systems therapy.

7 36 Sexual Addiction Compulsivity TABLE 1 Treatment Options that Varied with Counselor s Highest Educational Level by Percent (N=246) Variable Bachelors Masters Doctorate Other n=9 n= 197 n=36 n=6 Contracting* Letter Writing * Role Playing* * Self-Help Groups* * *p=<.ol; **p=<.ool Note: Other responses by counselors with associate degrees or other types of degrees. Data collected from the interviews indicated that there is a wide interpretation of what constitutes family systems therapy. Some respondents defined family systems therapy as brief, intensive therapy directed at bringing about major change in family dynamics in a short period of time. Other counselors defined it as classic Bowen or as a combination of the brief and classic family systems therapy. Treatments The treatments most often recommended by counselors of all ages were: defining behavioral boundaries, and recognizing and avoiding high-risk situations. Cross-tabulation of the 30 treatment options in the survey with counselors demographic data disclosed that selection of treatmendstrategies was influenced by highest level of education (Table 1) and/or counselor s age (Table 2) (p<.ol). The four treatments that varied statistically by counselor s highest education level were contracting, letter writing, role playing, and self-help groups. The 10 treatments that varied significantly with counselors age were assertiveness training, cognitive restructuring, contracting, meditation, mental imagery, modeling, positive self-talk, relapse rehearsal, role playing, and self-help groups. There was a statistically significant difference (p<.01) between counselors approaches to the treatment of sex addicts and the frequency with which counselors encountered people with sexual addiction in their practice. Responses by counselors who frequently encountered sex addicts were compared with those of counselors who indicated they seldom or never encountered sex addicts in their practices. Treatments most often recommended by counselors who frequently encountered sex addicts in their practices included anger management, cognitive restructuring, confrontation, contracting, defining sexual sobriety, defining behavioral boundaries, empathy, and grief counseling.

8 Treating Sexual Addiction 37 TABLE 2 Treatment Options that Varied with Counselor s Age by Percent (N=248) Treatment Assertiveness Training* * Cognitive Restructuring* * Contracting* * Meditation and Yoga* Mental Imagery Modeling* Positive Self-Talk* Relapse Rehearsal* * Role Playing* Self-Help Groups* Age n= n= n= n= n=ll Additionally, 64% of counselors responding they often encountered sex addicts in their practices reported they would treat the most severe addiction first or all addictions simultaneously when dealing with clients who presented with multiple addictions. In contrast, 75 % of counselors responding they did not encounter sex addicts frequently in their practices reported they would be inclined to treat the problem that the client wanted addressed. Since 191 (77%) survey respondents indicated that multiple addictions were likely to be present in a person with sexual addiction, counselors approaches to treatment of sex addicts with multiple addictions were compared with counselors demographic data. There was no statistically significant difference in treatment of sex addicts with multiple addictions and counselors demographics at the p<.ol level. However, at the practical level of p=.05, counselors theoretical orientation clustered around certain approaches to treatment. Forty percent or more of cognitive behaviorists, gestalt therapists, and reality therapists preferred to deal with the most severe addiction first. Forty-one percent of humanist/ person-centered therapists preferred to address the problem that.the client wanted addressed first. A short period of inpatient treatment for all sex addicts was suggested by 50% of interviewees on the premise that such an intervention could provide an immediate safe atmosphere in which to rapidly build trust and make substantial progress in overcoming sexual addiction, thus compressing initial recovery time. This may be an important option under managed care. Inpatient programs also provided opportunities for family participation in

9 38 Sexual Addiction 4 Cornpulsivity the sex addict s recovery to facilitate changes in family dynamics, which are essential to long-term recovery. Studies addressing the usefulness of medications in treatment of sexual addiction have been limited both in number and in size of sample. Stein et al. (1992) noted that nonparaphilic sexual obsessions and compulsions may respond more robustly to serotonin reuptake blockers, such as Prozac, than paraphilias. Kafka ( 1991) reported success in treatment of nonparaphilic sexual addiction with antidepressants. Referral for medication was considered appropriate by counselors interviewed if the client appeared to be too depressed to benefit from therapy alone, was unable to control obsessivecompulsive behavior, was having panic attacks, and/or had a history of need for certain medications to control conditions such as schizophrenia or bipolar disorder. DISCUSSION Diagnosis of the presence of sexual addiction is currently dependent on informal techniques, which vary among counselors, or client self-report, unless corroborating data are available from court records or other respondents. A major goal of future research should be development of a normed instrument that would build on the Sexual Addiction Screening Test (Carnes, 1989) and incorporate predisposing factors in order to facilitate identification of sex addicts across gender and special populations. While criteria were not established to predict sexual addiction, factors were defined that counselors felt predispose people to develop sexual addition. Whether or not these factors predispose or only exacerbate the client s problem must be answered through future research. This survey identified treatment modalities that counselors deemed effective in the treatment of sexual addiction/compulsivity, and can be used as a foundation for future inquiry. Future research should compare treatment modalities counselors selected with those diagnosed sex addicts define as being effective in facilitating their recovery, such as those noted in Milam s study (1990). Collection of empirical data documenting effectiveness of various treatment options with each behavioral type of sex addict would also be useful to counselors in the field. REFERENCES Adams, K. (1991). Siiently seduced: When parents make their children partners. Deerfield Beach, FL: Health Communications.

10 Treating Sexual Addiction 39 American Psychiatric Association. ( 1987). Diagnostic and statistical manual of mental disorders (3rd ed. rev.). Washington, DC: Author. American Psychiatric Association. ( 1994). Diagnostic and statistical manual of mental disorders (4th ed.). Washington, DC: Author. Barth, R., & Kinder, B. (1987). The mislabeling of sexual impulsivity. Journal of Sex 6 Marital Therapy, 13, Carnes, P. (1989). Contrary to love: Helping the sexual addict. Minneapolis: Compcare. Carnes, P. (1991). Don t call it love: Recovery from sexual addiction (2nd ed.). New York: Bantam Books. Carnes, P. (1992). Out of the shadows: Understanding sexual addiction (2nd ed.) Minneapolis: Compcare. Carnes, P., Skilling, N., Nonemaker, D., & Delmonico, D. (1993, June). Study of the relationship between childhood abuse and adulthood addictive behavior in a sample of identified sexual addicts. Paper presented at the National Council for Sexual Addictions Conference, Scottsdale, AZ. Coleman, E. (1992). Is your patient suffering from compulsive sexual behavior? Psychiatric Annals, 22, Earle, R., & Crow, G. (1989). Lonely all the time. New York: Pocket Books. Earle, R., & Crow, G. (1990). Sexual addiction: Understanding and treating the phenomenon. Contemporary Family Therapy, 12, Edwards, C. (1974). Drug dependence. New York: Jason Aronson. Kachigan, S. K. (1986). Statistical analysis. New York: Radius Press. Kafka, M. P. (1991). Successful antidepressant treatment of nonparaphilic sexual addictions and paraphilias in men. Journal of Clinical Psychiatry, 52, Kasl, C. (1989). Women, sex, and addiction. New York: Tichnor & Fields. 6 Levine, M., & Troiden, R. (1988). The myth of sexual compulsivity. Journal of Sex Research, 37, Lundy, J. P. (1994). Behavior patterns that comprise sexual addiction as identified by mental health professionals. Sexual Addiction and Compulsivity, 1, Milam, B. J. (1990). Sexual addiction: Boundaries, didactic education, twelve-step programs, psychotherapy issues, and effective treatment strategies and recovery. Doctoral dissertation, United States International University, San Diego, CA. Quadland, M. (1985). Compulsive sexual behavior: Definition of a problem and an approach to treatment. Journal of Sex & Marital Therapy, 11, Schneider, J. (1988). Back from betrayal: Recovering from his affairs. Center City, MN: Hazelden Educational Materials. Schneider, J. (1991). How to recognize the signs of sexual addiction. Postgraduate Medicine, 90, Schneider, J., & Schneider, B. (1989). Rebuilding trust for couples committed to recovery. Minneapolis: Hazelden Educational Materials. Schwartz, M. (1992). Sexual compulsivity as post-traumatic stress disorder: Treatment perspectives. Psychiatric Annals, 22, Sprenkle, D. (1987). Treating a sex addict through marital sex therapy. Family Relations, 36, Stein, D., Hollander, E., Anthony, D., Schneier, F., Fallon, B., Liebowitz, M., & Klein, D. (1992). Serotonergic medications for sexual obsessions, sexual addictions and paraphilias. Journal of Clinical Psychiatry, 53,