Daniel A. Glaser MSW, LCSW
The New Orleans Institute
River Oaks Hospital
SASH, 2013
Excessive use of mood altering behaviors are a
sex addict’s path of escape from life stress
and overwhelming emotions of loneliness,
anger, fear and shame.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
Seeking altered consciousness here and now to
evade distressing feelings.
Something outside me can fix what is wrong or
missing inside me.
egs. Pornography will replace lack of
excitement.
Food indulgence will compensate for
loneliness.
Gambling success will override lack of
promotion.
[Prin, John (2006). Secret Keeping: Overcoming Hidden Habits & Addictions]
Self Harm
Intentions
External Factors
(circumstances)
 Social isolation, poor family
support, sudden losses,
abusive relationships.
Internal Factors
(psychological state)
 Depression, perfectionism,
tendency to suppress
emotions.
[Palmer, ed. (2008) Suicide: Strategies and Interventions for Reduction and Prevention.]
Direct and Indirect
Self Harm
Exploitative experiences may create a sense of
powerlessness and helplessness. Lack of control
may lead to control seeking behaviors (e.g.
eating disorders, self destruction, or exploitation
of others.)
[Ryan et .al. (1999). Web of Meaning.]
Basic Motives of the Self
Terror Management Theory – (organismic preservation)
• Emphasizes the defensive aspects of self and the
fundamental motive of anxiety control
• Defends against dangers
Self Determination Theory – (organismic expansion)
• Emphasizes the expansive aspects of self and the
processes of intrinsic motivation and growth
• Skills development
[Leary & Tangney [eds.] Handbook of Self & Identity, 2003]
Self Regulation
 Ability to be aware of, control and monitor
emotional reactions, impulses, and behaviors.
 Ability to repair emotional distress, usually through
taking control and renegotiating the environment.
[Katehakis (2010). Erotic Intelligence]
Coping With the World
1. Unhealthy passive coping skills = escape, avoidance,
chronic sexual fantasies, isolation and withdrawal
from others. This unhealthy non-relational set of
skills is referred to as auto-regulation.
2. Unhealthy active coping skills = gamut from
substance abuse to engaging in process addiction
(i.e. sexual addiction). The relationship is with the
substance or the experience (i.e. excessive
masturbation, pornography, strip clubs, sexual
massage parlors, frequenting sex clubs, hiring
prostitutes, cruising restrooms, voyeurism,
exhibitionism, etc.)
[Katehakis (2010). Erotic Intelligence]
Coping With the World
3. Healthy passive coping skills = solitary
activities such as journaling, reading,
meditating and contemplation.
This healthy set of auto-regulatory skills is a
form of self regulation which can be done
alone or include other people (physical
activities = skiing, swimming, hiking;
creative expression = composing music,
writing, art).
[Katehakis (2010). Erotic Intelligence]
Coping With the World
4. Active coping skills = engaging or acting upon the
environment, such as seeking support or solace from
others and getting help to generate possible
solutions.
 Active coping (a form of self regulation) seeks
control of the situation using productive methods
to build resilience. (12-step meetings, asking for
hug, reaching out, forming friendships).
 Interactive regulation is getting comfort and
support from relationships or other people.
[Katehakis (2010). Erotic Intelligence]
Behavioral Addictions
Pathological gambling
Pathological skin picking
Kleptomania
Compulsive buying
Trichotillomania
Compulsive Internet use
Pyromania
Compulsive sexual behavior
Intermittent explosive
disorder
Self injurious behavior
Binge eating
Hoarding
[Grant (2008). Impulse Control Disorders.]
Compulsions
Compulsive Behavior
1. Comes from an identifiable source,
2. Operates in a predictable pattern, and
3. Can be alleviated through a process of
awareness, clarification and recovery.
“Compulsions serve as clues to the deeper stories of
our lives, an individual’s history of emotional
woundedness.”
[Larkin & Whiting (1991)]
Behavioral Addictions
Core qualities of many impulse control
disorders:
1. Repetitive or compulsive engagement in a
behavior despite adverse consequences.
2. Diminished control over the problematic
behavior.
3. An appetitive urge or craving state prior
to engagement in the problematic
behavior.
4. A hedonic quality during the
performance of the problematic behavior.
[Grant (2008). Impulse Control Disorders.]
• Considered a severe intimacy disorder because
one’s “significant other” is a mood altering
behavior rather than a substance or a real
person.
• Often progresses to
the point of risking
everything for the
euphoria and escapism
of a sex “Fix.”
• Some have ready excuses to minimize,
rationalize or deny their addiction
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
• Many feel deep shame about
acting outside their rules.
• Many fear the risk and
consequences but are unable
to quit.
• With addiction there is a broken promise; a
promise to oneself or to another person.
• Misguided efforts to self soothe the
discomfort of extreme emotions.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
“The pain in the past hijacks the present,
activating reactive behavior to current events!’
“The difference between the past and
present related to trouble controlling
sexual desire is that today there are
many more sources for sexual
gratification and many more ways to
establish secrecy than in the past.”
[Sbraga & O’Donohue (2005). The Sex Addiction Workbook.]
Numbing
Fantasy
Deprivation
Arousal
Seeks a calming, soothing,
relaxing, or sedative
experience.
Escape to alter perception of
reality.
Control is the goal and self
deprivation is the surest way
to defend against terror. This is
the purge portion of a binge /
purge cycle.
All about pleasure and intensity.
[Gerogianna, Underhill, & Kelland (2010). Hyperstimulation: Teens, Pornography, and
Online Addictions.]
• Addicts as children did not learn positive
adaptive behaviors for emotional selfregulation.
• Children who experience trauma learn
maladaptive responses: they dissociate, numb,
and develop negative core beliefs.
• Stress Response Syndrome: brains are hijacked
by memories of trauma, emotional responses
are spontaneous and their self medicating
actions are impulsive and lack adequate
forethought.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
• Chronic state of hyperarousal in which
exaggerated emotions compel one to seek an
escape.
• Escape comes from compulsively arousing
and soothing with sex.
• Habitual sexual “doping” forges an arousal
template in the addict’s brain which
establishes a consistent and reliable pattern
of mind-altering escape (psychological,
biological and chemical).
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
Neuropathways are strings of chemical
transmitters that, when stimulated by sexual
thoughts or behaviors, provide intense relief
by producing sensory and emotional
experiences of fantasy, arousal, numbing
and/or deprivation
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
Neuropathways of Addiction
 Programmed sexual response to intense emotion.
 Without conscious effort, the addict “mainlines” the
sexual drug directly to the pleasure centers of the
brain.
 A tolerance develops as sex is used repeatedly with
neuropathways activated.
 Larger doses of the sexual drug will be needed to
promote the same emotional effect which requires
increasing the risk, intensity or frequency of sexual
behaviors.
 Most addicts combine, alternate, and cycle in and out
of their use of neuropathways.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
• The roots of addiction
are usually found in
childhood trauma.
• Sex is an extremely
powerful force in-and-of
itself.
• The ultimate addiction because it taps into a
biological life force.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
• The availability of pornography on the internet.
• iPorn is plentiful, cheap, and private.
• Adding fear and aggression supercharges the
experience.
• Graphic images lead viewers deeper into a world
of chemically charged fantasy and further away
from real relationships.
• iPorn is a gateway to more
intense and risky sexual
behavior, both on and off line.
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
• So prevalent, its use is often
seen as unremarkable and
even routine.
• Excessive use of porn may
become a portal to a more
extreme fantasy or
experience.
• Increased tolerance and
cravings can drive one into
risky real life encounters
[Lofgreen (2012). The Storm of Sex Addiction: Rescue & Recovery.]
Pornography’s hidden power is not limited to
its elusive nature, availability and compelling
styles and formats, but it is also based on its
ability to produce extremely pleasurable
experiences.
[Maltz & Maltz (2008). The Porn Trap: The Essential Guide to Overcoming
Problems Caused By Pornography.]
1.
2.
3.
4.
Learning About Sex
Belonging to a Group
Sexual Permission and Pleasure
Coping With Emotional Stress
[Maltz & Maltz (2008). The Porn Trap.]
The Porn Relationship
• Porn is always there, seducing
and enticing us to start or
continue a relationship.
• Porn is about having a good time,
escaping worries and pressures
and getting a chance to do things
one couldn’t do in real life.
• Porn is about developing an
emotional and sexual relationship
that can lead to a whole host of
problems.
[Maltz & Maltz (2008). The Porn Trap.]
• Porn can slip into the role of
“Significant Other.”
• Studies show that about half of the
men and one-tenth of the women
exposed to pornography in
childhood go on to use it regularly
as adults.
• Use encourages more use because
we learn to associate pleasure
with each interaction.
[Maltz & Maltz (2008). The Porn Trap.]
Commitment to the 4
“C’s” of Treatment
1.CHALLENGE old thoughts
2.COPE with strong feelings
3.CHANGE your environment
4.CREATE a balanced life
Cognitive Process in
Targeting Dysfunctional
Thoughts
(1) Identify the Situation
(2) Identify the Feelings
(3) Identify the Underlying
Thoughts
(4) Evaluate the Thought
(5) Take Action
[Mueser, Rosenberg, & Rosenberg (2009). Treatment of PTSD in Special Populations.]
Format for Challenging
Self Limiting Beliefs
Where did the belief originate?
How does the belief impact/affect life
now?
What situations provoke this belief?
What are negative consequences to the
belief?
What are the positive consequence of
continuing this belief? (What am I
getting? What am I avoiding?)
[Dr. Jordan & Margaret Paul, From Conflict to Caring, 1989]
1. Mindfulness – address maladaptive thought processes and
teaches skills for improved self monitoring and regulation.
2. Emotional Regulation – addresses mood lability and
affective dysregulation and teaches skills for effectively
identifying and managing emotions.
3. Distress Tolerance – addresses maladaptive coping
behaviors and teaches skills for managing impulsive/
harmful behaviors in the face of inevitable life stressors.
4. Interpersonal Effectiveness – addresses interactions with
others and teaches skills for more effectively meeting
needs/goals without violating the rights/needs of others.
[Marlatt & Donovan (2006). Relapse Prevention]
• Consciousness Raising: Learns
more about self and causes,
consequences and coping.
• Self Liberation: Becomes aware of
alternatives and makes more active
choices in life.
• Social Liberation: The
environment allows more choices.
• Counterconditioning: Changes
responses to stimuli, substituting
healthy behavior.
[Wenzel, Luise, Bech, & Freedman Wheeler (2012). Group Cognitive Therapy for
Addictions.]
• Stimulus Control: Manages
triggers that prompt problem
behaviors.
• Self Regulation: Assesses
feelings and thoughts about self
with and without the problem
behavior.
• Environmental regulation:
Considers the social and physical
impact of the problem behavior.
[Wenzel, Luise, Bech, & Freedman Wheeler (2012). Group Cognitive Therapy for
Addictions.]
• Contingency Management:
Changing the contingencies in the
environment (rewards /
punishers).
• Helping Relationships: Uses
relationships in life to garner
support for changes.
• Dramatic Relief: Experiences
and expresses affect about
problems and proposed solutions.
[Wenzel, Luise, Bech, & Freedman Wheeler (2012). Group Cognitive Therapy for
Addictions.]
Psychological Family
 Intrinsic in the human psyche.
 Compensates for loss.
 Collection of remembered ties.
 Active and affective bond that helps people live with loss and
trauma in the present.
 Private perception of home and family for coping.
 May coincide or conflict with official records.
 Who is viewed as being in the family is of therapeutic importance.
 Staying connected in the mind’s eye.
 Relational reality is comprised of more than can be objectively
quantified or physically measured.
[Boss (2006). Loss, Trauma and Resilience: Therapeutic Work With Ambiguous Loss.]
1. Recovery for the whole person =
physiological and spiritual healing.
2. Law of Increase / Decrease = “What you
feed grows, what you starve dies.”
[Leahy (2008). Porn Nation: Conquering Americas #1 Addiction.]
1. Tell someone else about your porn
problems.
2. Get involved in a treatment program.
3. Create a porn-free environment.
4. Establish 24-hour support and
accountability.
5. Take care of physical and emotional health.
6. Start sexual healing.
[Maltz & Maltz (2008). The Porn Trap.]
4 “P’s” of Anger
1. Your anger has a PAST – when you learned hurtful
ways of dealing with angry feelings.
2. Your anger has a PURPOSE – what you use anger
for.
3. Your anger has a PATTERN – what you think, feel,
and do over and over in response to the same
kinds of situations.
4. Your anger has a PAYOFF – what you get by being
angry and acting it out.
[Men & Anger [1995] Cullen & Freeman-Longo]
Techniques
 List reasons to identify feelings.
 List ways to have expressed feelings.
 Keep feeling journal (log).
 Do feeling lifeline.
 Identify blocks to feelings.
 Identify stuffed feelings.
 List positive and negative effects of feelings.
 Situation Perception Training (triggers, thoughts, feelings, action).
 Distinguish between healing reaction and feeling response.
[Adapted from Men & Anger [1995] Cullen & Freeman-Longo]
Facing Fear
Breathing – (“combat Lamaze”) train the fear
response. Breathing is so powerful because the
breath is one of the few actions that reside in both
our somatic nervous system (which we can
consciously control) and our autonomic system
(which includes heartbeat and other actions we
cannot easily access). So the breath is a bridge
between the two. By consciously slowing down
the breath, the primal fear response can deescalate.
[Ripley (2008). The Unthinkable]
Facing Fear
Studies have shown that brain tissue in the parts of
prefrontal cortex that are engaged in meditation – the
parts that handle emotion regulation, attention and
working memory, all of which help control stress –
thickened during meditation.
Laughter, like breathing, reduces our emotional arousal
levels. It has the benefit of making us feel more in
control of the situation.
The single strongest weapon is a mental plan of what you
will do in a certain crisis, and an absolute commitment to
follow through.
Self-confidence can save your life.
[Ripley (2008). The Unthinkable]
Trauma Related
Guilt
Guilt = an unpleasant feeling accompanied by a belief(s)
that one should have thought, felt or acted differently.
Self Monitoring Homework
Track:
1. Statements that include “should have,”
“could have,” “if only” or “why.”
2. Self put-down statements.
3. “I feel…” statements that end with
words that are not emotions.
[Kubany in Cognitive Behavioral Therapies for Trauma [1008] ed. Follette, Ruzek, Abueg]
Facing Fear
Resilience – People who have
resilience tend to have three
underlying advantages:
1. A belief that they can influence
life events;
2. A tendency to find meaningful
purpose in life’s turmoil; and
3. A conviction that they can learn
from both positive and negative
experiences.
[Ripley (2008). The Unthinkable]
Emotion Regulation
Skills
 Recognizing
your emotions
 Overcoming barriers to healthy emotions
 Reducing physical vulnerability
 Reducing cognitive vulnerability
 Increasing positive emotions
 Being mindful of emotions without
judgment
 Emotion exposure
 Doing the opposite of emotional urges
 Problem solving
[McKay, Wood & Brantley (2007) The Dialectical Behavior Therapy Skills Workbook]
Healing Interventions
Focusing Techniques:
Sit quietly and focus
on body sensations.
Notice prominent
sensations or feelings.
Hone kinesthetic
awareness.
Focus on all five
senses.
[Crowder (1995). Opening the Door.]
Healing Interventions
Increasing Affective Expression:
Gestalt Empty Chair
Psychodrama
Letter Writing
Art Work (collage)
Anger List
Role Play
Breathing Techniques
Bioenergetic Release
Debrief Affective Experiences
[Crowder (1995). Opening the Door.]
Healing Interventions
Visualization:
Identify “anchors” for adult self.
Inner Self Visualization
Container Visualization
Safe Place
Resource Visualization
[Crowder (1995). Opening the Door.]
Boundaries
Boundaries can be too open or too closed.
1. “Too Open” boundaries:
-Can’t say no.
-Share too much personal
information.
-Take responsibility for other’s
feelings.
-Allow yourself to be abused.
-Reveal personal thoughts,
feelings, or experiences.
-Believe you deserve bad
treatment.
-Can’t see flaws in others.
[McGee & Buddenberg (2003).
Unmasking Sexual Con Games.]
-Will do anything to avoid
conflict.
-Engage in public displays of
affection.
-Wear revealing or seductive
clothing.
-Stand or sit too close to others.
-Make sexual comments, jokes,
or voices in public.
-Trust strangers.
-Believe everything you hear.
-Have sexual encounters with
strangers or acquaintances.
Boundaries
Boundaries can be too open or too closed.
2. “Too Closed” boundaries:
-Always say “No” to request that
might require you to get too close.
-Share little or nothing about yourself.
- Unable to identify your own wants,
needs, and feelings.
-Don’t have any friends.
-Never ask for help, even when
needed.
-Don’t allow others to help.
-Refuse to let trustworthy people
touch you appropriately (pat on the
back, handshake).
[McGee & Buddenberg (2003).
Unmasking Sexual Con Games.]
Relapse Warning Checklist
Impatience: feeling things aren’t happening fast enough.
Argumentativeness: always needing to be right.
Depression: experiencing despair, hopelessness,
overwhelmed.
Self
Pity: refusing to accept “what is.”
Arrogance: believing you have it all fixed or solved.
Complacency: forgetting recovery, not repeating affirmations.
Exhaustion: overly tired or poor health.
Dishonesty: telling unnecessary little lies.
Unrealistic Expectations: setting goals that are too high.
Forgetting Gratitude: preoccupied with problems, forgetting gains.
Difficulty Managing Emotions: over or under-reacting.
Difficulty Managing Stress: not recognizing or reducing stressors,
lack of replenishment.
[Sbraga & O’Donohue (2005). The Sex Addiction Workbook]
1. Understand the origin of shame and its function.
2. Differentiate between shame and guilt.
3. Identify the defenses utilized to deny painful feelings
created by the shame.
4. Utilize specific shame reduction
strategies at critical points in the
treatment process.
5. Change negative core beliefs that
reinforce shame.
[Adams & Robinson in Carnes & Adams (eds) 2002. Clinical Management of Sex Addiction]
•
•
•
•
•
•
Managing Urges
Repairing Existing Close Relationships
Developing Healthy New Relationships
Managing Unpleasant Emotions
Problem Solving
Leading a Healthy Lifestyle
[Wenzel, Luise, Bech, & Freedman Wheeler (2012). Group Cognitive Therapy for
Addictions.]
Gender Identity
Object Choice
Intention
Sexual Desire
Arousal
Orgasms
Satisfaction
Gender Identity
Object Choice
Intention
Sexual Desire
Arousal
Orgasms
Satisfaction
[Althof in Leiblum/Rosen (eds.) (2000). Principles & Practice of Sex Therapy]
Nurturing is the most fundamental
and important pattern of relating. It
translates into a commitment to both
taking care of and receiving care
from our partner.
Nurturing is one of the most important ways
love is expressed and connection is experienced.
Without nurturance, there will be marital
malnourishment.
[Sharpe (2000). The Ways We Love: A Developmental Approach to Treating Couples]
1. Be impeccable with words.
2. Don’t take anything personally.
3. Don’t make assumptions.
4. Always do your best.
[Ruiz (1997). The Four Agreements]
1. Does the thought or image make me feel better?
2. Does the thought or image help me behave the way I
want?
3. Does the thought or image help me think productively
about the situation?
4. Does the thought or image reinforce positive images
about myself?
5. Does the thought or image improve my relationship?
Challenge: Offer positive images or fantasy
coupled with positive reinforcing statements.
[Zilbergeld (1992). The New Male Sexuality.]
1. Stop what you are doing and admit you are in a
danger zone.
2. Get away from porn thoughts and materials.
3. Calm yourself physiologically and emotionally.
4. Reach out for supportive help as quickly as
possible.
5. Reaffirm your commitment to recovery.
Alert
Avert
Affirm = Triple A of Mental
Health
[Maltz & Maltz (2008). The Porn Trap.]
1. Identify cycle of behavioral addiction
situation/event (trigger) – present tense
feelings (emotions) – present tense
fantasy/obsession – past tense
planning (“I will”) – future tense
act on plan (relapse behavior) – present tense
2. Prepare list of adaptive coping responses (ACR’s).
3. Read cycle and at key points interject refrain “As I
reflect, healthy choices I can make are…”
4. Identify at least three healthy choices (ACR’s) after
each refrain.
5. Refrain used
1 x after situation/event
1 x after feelings
3 x on the fantasy
3 x in the planning
1 x after act on plan.
6. Tape the imaginal desensitization when completed and
approved.
1.
2.
3.
4.
5.
Engage in Courtship
Talk with Partner About Sex
Expand Sensory Awareness
See Partner with New Eyes
Increase your Touch
Vocabulary
6. Explore Sexual Pleasure
7. Involve Your Heart in Sex
[Maltz & Maltz (2008). The Porn Trap.]
Gifts of Recovery
Diminishing Fear
Reducing Shame
Transforming Anger
Healing Grief
Reclaiming Damaged Dreams
[McDaniel (2008). Ready to Heal]