The Treatment of Sex Addiction - An Analytic Approach

It is well known among people in the 12-step sex programs that of all the addictions, sex is the most difficult to master. Far from the notion that sex addiction is the "fun" one, the suffering of dealing with this affliction is enormous. The compulsion is so compelling that it is common for members of the sex recovering groups to be unable to maintain any continuous time of sexual sobriety, giving way to despair and hopelessness. Before treatment, sexual enactment is the addict's only source of safety, pleasure, soothing and acceptance. It vitalizes and connects. It relieves loneliness, emptiness and depression. Sex addition has been called the athlete's foot of the mind: it is an itch always waiting to be scratched. The scratching, however, causes wounds and never alleviates the itch.

Furthermore, the percentage of people who go to therapy or a 12-step program is quite small. The majority of sexual compulsives live in isolation filled with feelings of shame. Almost 100% of the people who come to me for an initial consultation, whether it be for compulsive use of prostitutes, phone sex, a fetish, cross dressing, or masochistic encounters with dominatrixes, relay that beneath the shame they feel in telling me their story, they also experience a sense of freedom that comes from finally being able to share with another human being the hidden, shameful, sexually compulsive acts that imprison them.

This is a condition that gradually bleeds away everything the person holds dear. The life of a sex addict gradually becomes very small. The freedom of self is impaired. Energies are consumed. The rapacious need for a particular kind of sexual experience drives the addict to spend untold hours in the world of his addiction. Inexorably, the compulsion begins to exact higher and higher costs. Whether it be on the internet indulging in sexual fantasies with fantasy people, being on the phone to the sex hot-lines, or frantically searching the net and the S&M clubs for someone who will act out a particular, ritualized fetish fantasy, or cruising the bars searching for the "one" who will have sex in a public toilet, or going to dungeons to be whipped, flogged and humiliated, sex addiction is a devastating illness that takes an enormous toll. Friends slip away. Hobbies and activities once enjoyed are dropped. Financial security crumbles as sums as high as $40,000 or $50,000 a year are spent on sex. Then there is perpetual fear of exposure. Relationships with partners are ruined, as the appeal of intimate sex with a partner pales in comparison to the intense "high" of indulging in the dark and devious world of sexual compulsion.

What is a sex addict? Sex addiction, of course, has nothing to do with sex. Any sexual act or apparent "perversion" has no meaning outside of its psychological, unconscious context. A simple definition of sex addiction is not dissimilar to definitions of other addictions. But a simple definition of this complex and intractable condition doesn't suffice. What sets sex addiction apart from other addictions and makes it so persistent is that the subject of sex touches on our innermost unconscious wishes and fears, our sense of self, our very identity.

Current treatment might include participation in a 12-step program, going to an outpatient clinic, working with the Patrick Carnes material, aversion therapy, or the use of medications to stave off hypersexuality. Most therapy is cognitive-behavioral, designed to help the patient to control or repress the instinct for a period of time, usually out of a desire to comply with the group norms of their 12-step meeting or a need to please the therapist. While I recognize the efficacy the 12-step programs to provide structure and support, in my opinion, the reason that relapse is so prevalent is that these treatment modalities do not effect long-term structural personality change that eliminates the compulsion at its roots. Current treatment does not aim to transform psychic energies so that the reality sector of the mind dominates the personality so that the impulse to act out can be understood and controlled.

While the definition of sex addiction is the same as that of other addictions (recurrent failure to control the behavior and continuation of the behavior despite increasingly harmful consequences), sexual compulsion is set apart from other addictions in that sex involves our innermost unconscious wishes, fears and conflicts. Sex addiction is a symbolic enactment of deeply entrenched unconscious dysfunctional relational patterns with self and others. It involves a person's derailed developmental process that occurred as a result of inadequate parenting. Hence, permanent growth and change are most likely to occur in the arena of contemporary psychoanalysis, which seeks understanding and repair of these unconscious dysfunctional relational patterns along with the development of a more unified and structured sense of self. This new personality restructuring can better self-regulate feeling states without the use of a destructive defense like sexualization and can find meaning, enjoyment, intimacy, meaningful goal setting and achievement from attainable and appropriate sources in life.

The remainder of this paper will give a brief overview of the historical psychoanalytic views about sexual deviance, and will then articulate the current analytic understanding about the dynamics and treatment of sexual compulsions.

Any discussion of historical psychoanalysis must, ipso facto, begin with Sigmund Freud. Freud formulated that sexual deviance occurs due to an incomplete resolution of the Oedipus complex, with its concomitant castration anxiety. Unconscious castration anxiety occurs in the person's present-day consciousness in the form of fear of confrontation, retaliation, or rebuke, a sense of inadequacy, and perhaps doubts about gender identity. Sex addiction, according to Freud, is a defensive way to cope with a tenuous sense of masculinity combined with unrelenting anxiety about sex, women, intimacy, aggression, and competition. Analysts that followed Freud held varying views. Sexual compulsions derive from an insatiable need for approval, prestige, power, bolstering of self-esteem, love and security which are experienced as being necessary for survival. The addict experiences the absence of sexual acting out as a threat to his very existence.

Characteristic of any addict is a long history of a disturbed mother-child relationship. An unempathic, narcissistic, depressed or alcoholic mother has low tolerance for the child's stress and frustrations. Nor is she able to supply the empathy, attention, nurturing and support that foster healthy development. The result in later life is separation anxiety, fear of abandonment and a sense of imminent self-fragmentation. This anxiety sends the sex addict running to his eroticized, fantasy cocoon where he experiences safety, security, a diminution of anxiety as well as the quelling of an unconscious wish to establish and maintain the missing, yet essential tie to mother. Typical of this person is the hope that he can find an idealized "other" who can embody, actualize and make concrete the longed for endlessly nurturing parent. This approach is doomed to failure. Inevitably, the other person's needs start to impinge on the fantasy. The result is frustration, loneliness and disappointment.

On the other hand, a mother can be overly intrusive and attentive. She may be unconsciously seductive, perhaps using the child as a replacement for an emotionally unavailable spouse. The child perceives the mother's inability to set appropriate boundaries as seductive and as a massive disillusionment. Later in life, the addict is hypersexual and has trouble setting boundaries. Real intimacy is experienced as an engulfing burden. The disillusionment of not experiencing appropriate parental boundaries is acted out later in life by the addict's unconscious belief that the rules don't apply to him with regards to sex, although he may be regulated and compliant in other parts of his life.

A major theme for all addictions is that they have experienced profound and chronic need deprivation throughout childhood. Addicts in general sustain emotional injury within the realm of the mother-infant interaction as well as with other relationships. Intense interpersonal anxiety is the result of this early-life emotional need deprivation. In later life, the person experiences anxiety in all intimate relationships. Because the sex addict has anxiety about being unable to get what he needs from real people and because his desperate search for the fulfillment of unmet childhood needs inevitably end in disillusionment, he inevitably returns to his reliance on sexual fantasies and enactments to alleviate anxiety about connection and intimacy and as a way to achieve a sense of self-affirmation.

Sex, for the addict, begins to be his primary value and a confirmation of his sense of self. Feelings of inferiority, inadequacy, and worthlessness magically disappear while sexually preoccupied , through acting out or through spending untold hours on the internet. However, the use of sex to meet self-centered needs for approval or validation precludes using it to meet the intimacy needs of a cherished other. Characteristic of this kind of narcissism is the viewing of other human beings not as whole people who have their own feelings, wants and needs, but rather as deliverers of desperately needed satisfaction that shores up a fragile sense of self. This sets up a cycle wherein his narcissism prevents him from deriving satisfaction from mutual, reciprocal relationships in real-life. Sexualizing, once again, is returned to as a magical elixir wherein his needs are magically met without having to negotiate the very real vicissitudes of intimate relationships.

A client of mine, a 48-year-old attractive single man, is in the process of the breaking up of yet another relationship. After spending years of living a noxious childhood household, he went into his own world of fantasizing and masturbation as a way to soothe and protect himself.

"When I was a kid, I was obsessed with beautiful women in the magazines. When I was able to date, I went through one woman after another. In adulthood, I knew there was sadness and anger I didn't want to face. To evade them, I had a steady stream of women who worshipped me, soothed me, paid attention to my needs. I went to peep shows and I visited prostitutes. Many a night I would spend hours in my car circling the block looking for just the right street-walker to give me oral sex in my car. One night I had sex with a transvestite. I cried all the way home."

He met a girl whom he designated as "perfect - my redemption, my salvation." He became engaged but soon lost interest in the sex, which he described as "boring". While still engaged, he started picking up hookers for oral sex in the car and began compulsively using phone sex.

His current relationship is breaking up because he picked a woman for her youth and beauty (which reflected well on his narcissistic self). The rest of the story is predictable. They moved in together and the beautiful, young, sexy female started become real and having needs of her own. He admits he never felt warmth or love for her; she was merely a supplier of his narcissistic needs. As the relationship deteriorates, he fights the impulses to return to sex with strangers who don't make demand on him.

Another client of mine, a 38-year-old married man, has a compulsion to visit prostitutes. Three years into the treatment, he was finally able to talk about his anger towards his mother for depriving him emotionally through neglect and for never touching or caressing him. He can now make a connection between visits to the prostitutes and his hostility against mother for depriving him of sensual pleasure. He got lost in the mire of his parents' constant feuding.

"When I was very young I would put a blanket on my genitals as a kind of soothing which I wasn't getting from my parents. The rest of my life was a struggle to find other ways to soothe myself. When I discovered prostitutes, I thought I was in heaven. I can get sex now and be in total control. I can have it immediately, any way I want it, whenever I want it. I don't have to concern myself with the girl, as long as I pay her. I don't have to concern myself with vulnerability and rejection. This is my controlled pleasure world. This is the ultimate antithesis of the deprivation of my childhood."

The use of sexualization as a defense is a common theme that runs through the psychoanalytic literature. A defense is a mechanism the young child devises to psychologically survive a noxious family environment. While this way of protecting himself works well for a period of time, the continuous use of it as an adult is destructive to the person's ongoing functioning and sense of well being.

By losing himself in sexual fantasies and constantly seeing others as potential sex partners, or by erotic internet enactments, the sex addict is able to significantly reduce and control a wide variety of threatening and uncomfortable emotional states. Most addicts control or bind potentially overwhelming anxiety via the addiction process. Diminution of depression, anxiety and rage are some of the pay-offs that operate to facilitate and maintain life in the erotic cocoon.

I quote another patient which illustrates a case of narcissistic personality together with the use of sexualization as a defense. He is a 52-year old attractive, successful single man.

"I went on a date the other night. She wanted sex. I didn't. It's predictable. I don't think I can even maintain an erection anymore. While a spend untold hours compulsively websurfing to live in my erotic fantasies, when it becomes real, when you find someone who seems to be the embodiment of your sexual pre-occupation, interest soon wanes as her wants and needs come into the picture. Sometimes, I don't even bother with the pursuit of real women, because I know the inevitable result is disillusionment. I'm simply not prepared to meet somebody else's needs.

Oddly enough, my life is still dominated by sex. It becomes the lens through which I view everything. I go to a family gathering and get lost in sexual fantasies about my teenage nieces. I live in constant fear of being found out to be a "pervert". I see a woman on the train dressed in a way that triggers me, and I'm ruined for the day. Regular sex just doesn't do it for me anymore. It's got to be bizarre or forbidden or "out of the box". I arrive at work in an erotic haze. Women around me are all objects of sexual fantasy. I'm distracted; not focused. If something requires my attention, when real life intrudes and yanks me out of my sexual preoccupation, I get angry. Real life is so boring. Ordinary sex with a girlfriend holds no interest for me."

This patient uses sexualization as a defense. He uses his sexual pre-occupation as a way to ward off chronic feelings of loneliness, inadequacy and emptiness born of a childhood trying to get nurturing from a withdrawn, depressed mother. When stress or anxiety begins to overwhelm the regulation of his emotions, he is beset by intense urges to indulge in his fantasies and enactments. Sexualization thus becomes his standard way of managing feelings that he perceives to be intolerable as well as a way of stabilizing a crumbling sense of self-worth.

It is my belief that sex addiction requires a contemporary psychoanalytic approach. Psychoanalysis changed drastically in the 1970's with the work of a prominent psychoanalyst who jettisoned the Freudian approach and established a kind of treatment that is particularly useful in treating sex addiction. Contemporary analysts no longer conduct treatment three-times a week on the couch. They do not unearth hidden meanings, or remain silent, or put themselves on a "thrown" as being the "One Who Knows". The process is a shared one and the relationship between patient and therapist is co-created and mutual.

Some contemporary psychoanalysts use the concept of a vertical split in treating the addict. The split exists from inadequate parenting which results in structural deficits in the personality. Patients often report that they feel fraudulent, living two separate lives with two different sets of values and goals. They feel they're acting out a version of "The Strange Case of Dr. Jekell and Mr. Hyde."

One sector of the personality, the one anchored in reality, is the responsible husband and father. This part of the person is conscious, adaptive, anchored in reality, structured, and often successful in business. This is also the sector that experiences guilt and shame about his sexual behaviors and ultimately drives him to seek therapy to ameliorate his misery.

The "Mr. Hyde" side of the vertical split has a completely different set of values and seems to be impervious to his own moral injunctions. "Mr. Hyde" represents the unconscious, split-off part of the personality. It is impulse-ridden, lives in erotic fantasy, and is sexualized, unstructured and unregulated. This side of the vertical split seems to be incapable of thinking impulses through, and thus is oblivious to the consequences of his behavior. This is the part of the self that is hidden, dark, driven and enslaved.

A comprehensive discussion of the actual process of therapy is beyond the scope of this paper. Suffice to say, the therapist uses him/herself as an instrument in integrating the split which results in personality structure building. Treatment bridges the gap of the split. Its aim is the establishment of a relationship with the therapist that regulates emotional states, is used as a "laboratory" to bring to consciousness maladaptive relationship patterns, provides empathy and understanding and reconstructs the childhood origin of the addiction. The goal is an integrated self that is able to merely experience a sexual fantasy without being preoccupied with it and without acting out a damaging sexual scenario.

The patient achieves some ability to self-regulate moods, and to seek out adequate and sustaining available supportive relationships both in and out of treatment. He is then free to put sexuality in its proper place and free up energies to gain satisfaction from real relationships, pursue creative or intellectual goals, obtain pleasure from hobbies and activities, and have a heightened sense of self-esteem, thus enabling him to end his isolation. He is then free to love, to have deeply satisfying, self-affirming sex, work to his potential, and experience being a valued member of the human community. Sex