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Sex Addiction: Holistic Treatment Goals and Protocols For Body, Brain, and Relationship (Part 1)
Sex Addiction: Holistic Treatment Goals and Protocols For Body, Brain, and Relationship (Part 1)
The Neuropsychotherapist
Sex Addiction:
Holistic Treatment Goals and Protocols
for Body, Brain, and Relationship
(Part 1)
Alexandra Katehakis
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The Neuropsychotherapist
the most logical capacities, and the recognition that unconscious processes form the core of the self throughout life (Schore, 1994; 2003a; 2003b). These thinkers
work made researchers and practitioners appreciate
how both early relational trauma and later untreated
trauma lay the neural groundwork for an addictive
system. Most important, in the last decade, affective
neuroscience has shown that adults with insecure attachment styles can earn a secure attachment through
relational therapy centred on interpersonal attunement,
and finally achieve neural integration of affective states
(Siegel, 2009; 2007). The human longing for social affiliation motivates people to seek warm, stable and intimate interpersonal relationships, form friendships, and
affiliate with specific groups (Hecht, 2014, p. 1) in lieu
of addictive behaviors.
So aiming past merely managing addictive behavior
to creating neural and psychological integration and,
thus, real recovery, SA (or any addiction) treatment requires a unified constellation of psycho-biological and
affective goals and protocols to extinguish addictive behaviors and repair the underlying trauma fuelling them.
The psychobiological approach to sex addiction treatment (PASAT) blends a CBT approach that includes a 12step addiction recovery program with one using affect
Boundaries
SAs struggle with intrapsychic, interpersonal, and,
sometimes, physical boundaries. For example, a female
love addict abused by a male in childhood may later let a
male authority figure touch her inappropriately because
she does not feel entitled to say no. An interpersonal
boundary disturbance may be layered over the intrapsychic, manifested in her stalking an uninterested love object without registering the emotional and physical risks
to herself or the other.
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Unrealistically optimistic in their evaluation of circumstances, sex addicts really believe they will never get
caught cheating. This highly selective attention is typically associated with the left hemisphere (McGilchrist,
2009), as are antisocial traits like manipulation and
exploitation with disregard for the welfare of others
(Hecht, 2014, p. 2). And the tendency to use reason to
dominate interpersonal interactions lets the addict focus on his or her concocted, self-serving reality in support of his or her denial. It also allows SAs to stay online
for hours cruising or looking at pornography, as well as
to create elaborate rituals for carefully organizing, executing and hiding all traces of the sexual experience.
The left brain is more at home dealing with distorted,
nonrealistic, fantasticultimately artificialimages
(Laeng, Shah, & Kosslyn, 1999; Zaidel & Kasher, 1989,
in McGilchrist, 2009, p. 56). This may be because they
invite analysis by parts, rather than as a whole (McGilchrist, 2009, p. 56). Such minute management confirms
addicts belief that they are brilliantly handling the contradictory parts of their life. The left brain focuses solely
on its generated schema and suppresses as irrelevant
Vol 4 Issue 9 September 2016
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things that are known, fixed, static, isolated, decontextualized, explicit, disembodied, general in nature, but
ultimately, lifeless (McGilchrist, 2009, p. 174). These
traits are the speciality, and the liability, of the highfunctioning sex addict.
However, when the therapists left brain is at work,
she or he is using denotative language to verbalize rather than to discount reflections and somatic or affective
experiences. Delivery of those interpretations so that
the patients right brain may receive them somatically
may experience the interpretation (Quillman, 2011)requires the therapists interoceptive, or bottom-up, process. In it the patient somatically grasps not so much the
therapists words but the impulses arising in the therapists body during the exchange. For regardless of the
patients literal communication, the therapist picks up
emotional meaning in a bottom-up fashion from his or
her own inner world (Schore, 2011, p. 77). Fortunately, because the left brain identifies by labels and not by
context, talking about attachment trauma, family-oforigin dysfunction, or implicit processes can be easily
assimilated by an addict in early treatment. So arriving
at a diagnosis of SA is a function of the left brain that can
greatly relieve some patients. Likewise, basic education
about neurobiologyhow a childs bodily based experi-
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the right amygdala has been called the seat of the unconscious, which guides and drives the individual. This
brain stores the internal working model of attachment
and generates love, connectedness, intuition, metaphor, and images. It has its own primarily nonverbal language of eye contact, facial expression, gesture, touch,
and prosody. Possibly the seat of spirituality, when fully
operational the right leans toward understanding the
world experientially and toward caring for something
beyond itself, while the left is disposed toward control
and its own concerns, both hallmarks of sex addiction:
The right hemisphere is conscious of the Other, whatever it may be, the left hemispheres consciousness is
of itself (McGilchrist, 2009, p. 175). And Lyons-Ruth
(1998) explains that, rather than literal communication,
implicit relational knowingthe right-powered intersubjective, affective, and interactive processes between
patient and therapistis the bedrock upon which therapeutic change takes place.
A holistic treatment makes these two operating systems capacities (left-brain powers over cognitive-be-
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just the symbolic one of classic psychoanalytic or psychodynamic therapy. To work, the therapist and the patient both participate in the intense, difficult situations
that force change. Travelled together, these life-altering
experiences can prove salvific, as they demand learning, flexibility, adaptability, and emotional intensity not
heretofore experienced by the addict.
PASAT, then, merges treatment and psychotherapeutic approaches. It lets CBT dominate in the initial
phases, while also attuning to and regulating the patient, and reserves deeper affective investigations until
after the addiction abates. Once the destructive sexual
behaviors have been arrested, the healing process shifts
from treatment to psychotherapy: Bodily based and affective state changes move into the forefront to heal
trauma, while task work and exploration of faulty beliefs
and problematic behaviors receives ongoing monitoring
in group therapy, a 12-step program, and the therapists
regular tracking of the patients sexual sobriety to ensure his or her safety.
CBT
In the early stages of treatment, cognitive interventions challenge the addicts distorted thinkingthe
twisted thicket of attitudes and beliefs that protect behaviors and obscure the true self, the world, and others.
For SAs tend to externalize not just the fix, but the blame
for all their problems (onto parents, boss, or spouse),
creating a cozy harbor for resentments, major or minute, that globalize into a breathtakingly epic mythology
of victimhood by which they justify acting out sexually
as simple parity. That is, SAs have difficulty not just with
lofty insight but with basic mentalization. Compromised
in addicts, this left-brain--dominant, cortically based,
voluntary, conscious, slow affect regulation system
(Hill, 2015, p. 98), which develops later than the primary
system, lets one read ones own mental state while simultaneously reading that of another (Fonagy, Gergely, Jurist & Target, 2002)say, ones betrayed partner.
Bona fide narcissists cannot access internal representations of healthy relationships in order to self-regulate or
to develop good bonds with other people (Keely, Stout,
Zywiak, & Schneider, 2006), and affective neuroscience
can now explain why even those with narcissistic traits
like SAsstruggle to read reactions and to feel empathy
for their deceived spouse.
So at first, the cognitive type of empathy must be
taught like a school subject, until relational therapy elicits the higher reflective capacities of the right OFC, which
naturally foster heartfelt, affective empathy. The 12-step
adage, Fake it til you make it, is a cognitive directive
that puts addicts on the right path. Thus, cognitive interventions initially import an intellectual link since CBT
works with faulty beliefsthe domain of the left brain
rather than with the crippled regulatory processes that
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created them. Ultimately, though, the therapists regu- regulation (Hecht, 2014, p.11).
latory capacities become the connection between the
It stands to reason, then, that attachment styles can
brain and body/mind, so that the body/mind can begin to be altered through the process of relying on others to
change some parts of the brain.
view oneself accurately and to get ones needs met relationally. A 2009 study found that attachment styles
of AA members changed over time: They learned that
Why 12-Step Programs Impact
there was a significant increase in ratings of secure atAttachment and Sexual Sobriety
tachment and significant decreases in ratings of anxSex Addicts Anonymous (SAA), Sex and Love Adious and avoidant attachment (Smith & Tonigan, 2009,
dicts Anonymous (SLAA), Sexaholics Anonymous (SA),
p. 170), suggesting that meetings created a secure
and Sexual Compulsives Anonymous (SCA)called S
base built on safety, comfort, connection, and mutugroupscomprise slightly varying 12-step programs
ality. Those whose secure attachment increased found
for sexual recovery based on AA principles (Emrick &
it easy to get close to others and found great comfort
Tonigan, 2004; Gossop, Harris, & Best., 2003; Kelly,
in doing so; the avoidant reported a growing ability to
Stout, Zywiak, & Schneider, 2006; Moos & Moos, 2006;
trust others and less fear of getting close; persons with
Tonigan, 2001; see the Appendix for Principles and Teran anxious attachment began to feel less worry about
minology of S Programs). They all function through
both others being loving toward them or others wantthe intrinsic human need for affiliation, primarily latering to leave them (Smith & Tonigan, 2009). All in all, atalized to the right hemisphere (Hecht, 2014). Interesttachment, and therefore regulatory functioning (and
ingly, only one of AAs 12 steps mentions alcohol; the
presumably sobriety), became more stable over time.
other 11 focus on relationship with a higher power and
Similarly, in very short order, the 12-step program
ones sponsor, and on virtues like the humility needed
chips away at the SAs core beliefs: I am basically a
to take action to improve ones character. Indeed, 12bad, unworthy person; No one would love me as I am;
step programs may be understood as collective interacMy needs will never get met if I have to rely on others;
tive regulators because engagement in social relationSex is my most important need. Walking into a meeting
ships and pro-social activities are essentially adaptive
and hearing the stories of others who have done similar
behaviors, evolutionarily designed to support emotion
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(and sometimes more) shameful actions rapidly diminishes shame, especially when those others seem wellmeaning. So much for core belief one. After the meeting, members invite the newcomer to coffee, comment
on the impact of his or her sharing, or simply say, Welcomethat starts to melt the second core belief. Addicts in recovery offer their phone numbers and remind
the newcomer to call anytime just to check in or when he
or she is tempted to act out; when the newcomer does
so and another person actually listens, core belief three
begins to fray. Finally, the dawning recognition that the
addict needs such relationship, not sex, to feel validated
starts to dissolve core belief four.
Yet in addition to attending 12-step meetings, meaningful engagementconnection with a trusted sponsor; gathering in fellowship with members before or
after a meeting, often for a meal; making outreach calls;
and genuinely working the steps are essential, if unconscious, agents in changing ones attachment style:
The prescribed AA behaviors activate shifts in attachment style, and...these shifts are not cognitively or
consciously directed (Smith & Tonigan, 2009, pp. 171
172). These results further support the recognition that
coregulatory processes central to optimal function and
well-being may be practiced and learned throughout
life. So even the treatment CBT phase for SA prepares
the soil for the psychotherapeutic relationship that can
finally bring healthy human connectivity.
Before he left for a 12-step meeting that evening,
Robert faced his bathroom counter and lined up all of
the pharmaceuticals he had amassed over years, unconsciously saved for just such a day. Percocet, Valium, Vi-
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in familial relationships: Romantic partnerships and relationships with parents, children, and siblings were said
to have improved remarkably, and while some marriages proved irreparable, overall sexual and life satisfaction
were judged as high (Carnes, 2000; 1998).
The study discerned six stages of recovery. The first,
Developing Stage (up to 2 years), sees addicts reduce
or replace some damaging behaviors. Minimization, a
premier defense, may still operate even in the face of
a growing recognition of the problem. Interestingly, at
this phase, many therapists also seem to fail to confront
or appreciate the gravity of SA.
The second, Crisis/Decision Stage, may last for a
single day or up to 3 months, galvanized by a personal
catastrophe (being caught by a spouse, or arrested, or
fired; contracting an STI or being terminated by a therapist for noncompliance) or by a spontaneous recognition
of their lifes unmanageability. After the addict genuinely decides to change, the third, Shock Stage may continue from 6 to 8 months. Rather like mourning, shock
engenders reactions of denial, anger, depression, bargaining, and loneliness. In addition, many suffer intense
withdrawal symptoms of disorientation, numbness, and
despair. In fact, obeying limits set by therapists, family
members, or a sponsor can elicit these feelings until the
addict at last begins to experience a supportive sense
of community. The 12-step adages, One day at a time
and Easy does it, speak directly to this phase of recovery just before the addict appreciates actual relief.
Yet around 6 months into recovery, the Grief Stage
appears. Once the impact of the initial discovery, decision to change, and shock begins to wane, the underlying emotional pain of this fourth stage sears. The person
in recovery suddenly recognizes a new loss: He or she
had already acknowledged forfeiting a primary relationship, connections with family members, job, time,
money, or self-esteem. But this second one is the loss
of the addiction itself. For many, that behavior provided
the only stable, reliable succor. Saying goodbye to it can
feel like parting from an old, ever-understanding friend
and can evoke tremendous sorrow. In addition, forsaking the autoregulating actions exposes the deeper pain
of early relational trauma. Without this comforting behavioral bandage, horrendous childhood memories the
addiction served to cover lie raw. That agony helps explain the high relapse rates this stage of recovery invites
(Carnes, 2000; 1998).
For those who persist, the fifth, or Repair Stage occurs between 18 and 36 months. Respondents reported measurable improvement in satisfaction as they
brought structural and functional changes into their
lives. They stated that healthier beliefs about themselves, sex, and family had restored their values. That is,
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