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Sexual Addiction & Compulsivity: The
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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, 31-39
To link to this article: http://dx.doi.org/10.1080/10720169508400064
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THERAPEUTIC INTERVENTIONS
RECOMMENDED FOR TREATMENT
OF SEXUAL ADDICTION/
COMPULSIVITY
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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 1983. 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 #160-155,
Plano, TX 75025.
Sexual Addiction & Compulsivity, Volume 2, Number 1,1995 0 Brunner/Mazel, Xnc.
31
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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-
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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.
34
Sexual Addiction 4 Cornpulsivity
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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
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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 (18%) 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.
36
Sexual Addiction
Compulsivity
TABLE 1
Treatment Options that Varied with Counselor’s
Highest Educational Level by Percent (N=246)
Variable
Contracting*
Letter Writing*
Role Playing**
Self-Help Groups**
Bachelors
n=9
Masters
n= 197
Doctorate
n=36
Other
n=6
44
33
67
67
86
81
85
87
86
81
81
83
100
100
83
100
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*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.
37
Treating Sexual Addiction
TABLE 2
Treatment Options that Varied with Counselor’s Age by Percent (N=248)
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Treatment
Assertiveness Training**
Cognitive Restructuring**
Contracting**
Meditation and Yoga*
Mental Imagery”
Modeling*
Positive Self-Talk*
Relapse Rehearsal**
Role Playing*
Self-Help Groups*
21-30
n=19
3140
n=46
Age
41-50
n=114
51-60
n=58
61+
n=ll
95
95
84
53
90
84
100
90
80
68
80
98
93
52
78
87
96
87
89
91
86
94
89
68
86
80
92
93
83
89
79
86
76
67
79
74
86
90
88
86
27
55
55
73
64
46
73
46
55
73
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
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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.
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Treating Sexual Addiction
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