Understanding and Treating Sex and Pornography Addiction

A comprehensive guide for people who struggle with sex addiction and those who want to help them

Paula Hall

• Publisher: Routledge
• Year: 2018
• ISBN:
  9781351112611
• Edition: 2
• Topic: Psychologie
• Subtopic: Conseil en psychothérapie

Understanding and Treating Sex and Pornography Addiction demonstrates why people's lives are being destroyed by compulsive sexual behaviour and what we can do to help them. The book examines the latest research into these conditions and outlines the new integrative C.H.O.I.C.E. Recovery Model, a practical, sex-positive model which incorporates CBT, ACT and psychodynamic theories to help people enjoy lifetime recovery.

This new edition has been updated throughout, with new material covering pornography addiction, ChemSex, internet offending and female sex and love addiction. Written in a clear and informative manner, this book contains support and advice for both the clinician and for those who suffer from sex addiction, and provides tools for securing confident and rewarding recovery.

Understanding and Treating Sex and Pornography Addiction is essential reading for anyone looking to make an enduring recovery from these conditions, as well as for clinicians new to the field and those wanting to update their skills and knowledge.

Part I

Understanding sex and porn addiction

Part I has been written primarily for professionals and for those who want an academic overview of what sex and porn addiction is – and what it is not. In Chapter 1 you will find definitions of addiction, including the psychological function addictions play and the latest in neuroscience. Chapter 2 is a practical chapter that explains the different categories of addiction and provides comprehensive assessment tools. In Chapter 3 we look at how addiction gets set up from a biological, emotional, relational, social and cultural perspective. There is also an exploration of common childhood and adolescent themes. We then move on to consider how sex and porn addiction is maintained and reinforced through the six-phase cycle of addiction. We conclude Part I with an overview of the devastation that sex and porn addiction so often has on partners and relationships and the direct impact this can have on addiction recovery.

1 Defining sex and porn addiction

The controversy around sex addiction has not subsided since I wrote the first edition of this book and, like its most recent companion, porn addiction, it continues to be one of the most controversial problems to have entered the public arena in the past 50 years and media interest has not waned. While a growing number of public figures and celebrities battle their condition in the face of public scorn and criticism, others claim it’s nothing more than a made-up condition invented to excuse high-flying men who can’t control their sex drives. And others sceptically say it’s a problem created by sex-hating prudes who moralise sexual diversity and freedom.

Unlike other questionable conditions, the argument over the existence of sex and porn addiction often becomes a moral one, rather than an issue of health. This is undoubtedly because the focus of public and clinical attention is on the word ‘sex’ or ‘porn’ rather than on the word ‘addiction,’ which is the nub of where the problem truly lies. If one considers other addictions that have been thrown into the social ether, such as TV, gambling, shopping, the Internet and even chocolate, they may be vilified but sufferers receive the help they need nonetheless. But when ‘sex’ is added to the title it becomes a matter of contention, and the first challenge facing many sufferers and the therapists who want to help them is to decide if they really are ‘addicted’ to sex or porn, or if they simply need to get a grip. Unfortunately, this moral debate over what the condition means and whether it truly exists results in many thousands of sufferers struggling to find help and many clinicians wasting hours of therapeutic time on definition and diagnosis rather than helping the client overcome their problem and move on with their life.

One argument that is proffered against sex and porn addiction’s existence is that it seems to have appeared on the social scene so recently, but sex has obviously been available since the dawn of time and erotic images have been found dating from as early as 2000 BC. ‘If sex and porn was “addictive” how come it’s only happened so recently?’ ask some. The answer to this is simple: the Internet, and more recently, the smart phone. The World Wide Web and phone technology have made sexual services, anonymous hook-ups and porn available and accessible to all, and accessible within relative anonymity, hence bypassing the usual social inhibitors.

As millions of sufferers would testify, sex addiction and porn addiction definitely do exist, but like many conditions, they are complex and not easily defined. There are some ‘classic’ cases that easily fit, yet to be validated, diagnostic criteria but others that do not. Like all addictions, problems may be mild or severe, they may have existed for many years with no apparent cause or they may have been triggered by a particular event and be a relatively recent problem. Or it may be a problem that crops up in someone’s life only occasionally. Sex addiction has many guises and encompasses a wide range of sexual behaviours. Most recently, there has been a movement to classify porn addiction separately from sex addiction by both sufferers and the clinical community, but there are many common denominators as we will see in the following chapter. But before we move on, this chapter will explore a variety of definitions and seek to understand why sex and porn addiction causes such emotional, physical and social devastation in people’s lives.

What is sex addiction?

The simplest and broadest definition of sex addiction would be that it’s a term that describes any pattern of out-of-control sexual behaviour that causes problems in someone’s life. Furthermore, it is a pattern of behaviour that cannot be stopped, or does not reliably stay stopped. The type of behaviour does not define addiction, but the dependency on it. Some of the therapeutic community have been critical of writers who list the different sexual practices that may have become compulsive, saying that this pathologises what, for some, are normal and healthy behaviours. This list has often been mistakenly interpreted as a list of signs of addiction, rather than merely a list of behaviours, and has hence been unhelpful. If we were talking about alcohol addiction, we wouldn’t list all the beverages that are addictive, it is getting drunk that can be addictive, not gin or whiskey. Similarly, sexual arousal can be addictive, whether that’s through watching pornography, having physical sexual encounters, or fantasising about them. It’s not the behaviour itself that is the problem but the relationship to the behaviour. When we become dependent on something and can’t stop doing it, in spite of the problems it’s causing in our lives, we generally use the term addiction. Whether that’s an accurate label or not will be explored soon.

One of the most common misconceptions about sex and porn addiction is that it’s linked to sexual desire. In my clinical experience, backed up by a growing body of research, neither sex nor porn addiction is the same as a high sex drive (Stulholfer et al., 2016). Many of the addicts I’ve worked with do not get sexual pleasure from what they’re doing and it does not satiate their drive. In fact some would go so far as to say they consider themselves to have a very low sex drive or indeed that their addiction has robbed them of their libido.

Whilst their compulsive behaviours are sexual in some respect, the primary motivation is not satiation of sex drive. Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy biological craving in the brain. If you consider a typical porn addict who might spend up to seven or eight hours online at a time, postponing ejaculation for as long as possible, how can we think that their goal is drive satiation? The real motive for such behaviour is escaping from reality and enjoying the aroused brain state, even more than genital stimulation.

In many ways, sex addiction has more in common with eating disorders than it does with other addictions (Goodman, 1993). In one study by Patrick Carnes (1991) 38 percent of his sample had an eating disorder, and in the UK 79 percent of those with another addiction cited eating disorders (Hall, 2013). In the same way that bulimia, anorexia and compulsive over-eating are about an unhealthy relationship with food, sex addiction is an unhealthy relationship with sex. In healthy individuals, both sex and food satisfy a natural, innate and primitive drive, but when the relationship becomes distorted, sex addiction has no more to do with sex drive than eating disorders do with hunger.

However, there are definitely some who suffer with sex or porn addiction who think that they do have a high sex drive and describe their initial motivation for acting out as being a way of meeting their sexual needs. But further investigation and exploration of their feelings often exposes this as mistaken. In the same way as someone with an eating disorder might misinterpret feelings of hunger or fullness, so someone with sex addiction can misinterpret their sexual desire. When sex, porn or food are used compulsively, to the point where it’s causing significant problems in someone’s life, the function is not to satiate a natural desire but to meet a deeper need. In addiction, the attempt to satiate the deeper need may also be accompanied by cravings and therefore the two can become confused. For example, if someone masturbates every time they feel lonely or bored or angry or sad, after a while they will associate each of those emotions with cravings. Like Pavlov’s dogs who salivated every time they heard a bell whether there was food or not, the addict may seek sexual gratification every time they feel a negative emotion whether or not they feel genuine desire.

But is it really an addiction?

Historically the term ‘addiction’ was only used for chemical addictions – substances such as alcohol, tobacco, heroin and other drugs that cross the blood–brain barrier and alter the brain chemistry.

The notion of an activity being an addiction is a relatively new one but one that is becoming increasingly recognised (Dickson, Derevensky and Gupta, 2002; Chamberlain et al., 2016, Kraus et al., 2016, Kardefelt-Winther et al., 2017). These are often referred to as ‘behavioural’ addictions as opposed to ‘chemical’ addictions. But the term ‘addiction’ is still an issue for some and consequently you may find people referring instead to video game overuse, pathological gambling, problematic porn use, compulsive debting, problem over-eating and so on. To be honest, the bottom line is that both sufferers and clinicians will use their own favoured term and it doesn’t matter what that is as long as help can be offered. But it is precisely the provision of help and its socio-political implications that perpetuate the argument over its name.

How we classify a condition as a society is not just about health, it is also about money and politics. The Diagnostic and Statistical Manual of the American Psychiatric Association, or DSM for short, is a widely used and accepted reference tool for recognised mental health conditions. When something is in DSM, it formally exists. And if it formally exists, the public can rightly demand treatment for it. In the world of addictions, there might also be an argument that if a substance or a behaviour has been formally accepted as being ‘addictive’ then prevention strategies need to be put in place; perhaps there also needs to be controlled access and/or distribution, and compensation may need to be available for innocent sufferers. So if pornography addiction were to officially appear in DSM, just consider how much that could cost the government in treatment provision and policing the industry. Personally, I think as a society we should be taking much more responsibility for the porn industry as we increasingly are with gambling since ‘pathological gambling’ entered DSM, but the financial ramifications are enormous. Neither sex addiction, nor porn addiction are currently in DSM, though the latest edition, DSM-5 does include substance related and addictive disorders and lists gambling disorder. But another major player in the diagnostics field, used more widely internationally than the DSM, the ICD (International Classification of Diseases), is considering including Compulsive Sexual Behaviour Disorder in its next edition, ICD-11 – scheduled to be published in 2018, (Krueger, 2016).

There are other controversies around DSM and ICD. If a condition is listed then it means it is a problem that needs to be treated or managed, and further researched, rather than a difference to be accepted. And the sufferer may then be saddled with a label that could potentially cause shame and discrimination. It’s interesting to note that Asperger’s Syndrome was only accepted by DSM in 1994 and homosexuality was not removed until 1973. So up until relatively recently, anyone who was gay was considered to have a mental health problem and there was no support or funding available to help children with Asperger’s. Being labelled with a condition or a problem can be both a blessing and a curse. For some it allows them to understand that what they’re struggling with is something that’s caused problems for many others. The stigma may be removed and energy can be focused on overcoming the problem rather than feeling to blame. But the flipside of this is that for some people, the label becomes a heavy burden under which they feel they have no power or escape. Therefore, the most important thing is to discern what the client wishes to call their problem and what that definition means to them.

Another reason why many health professionals struggle with the label ‘addiction’ is an assumption that the name implies only one possible treatment approach. Some therapists say they do not subscribe to ‘the addiction model’ when working with human sexuality, but as we will explore further in this chapter, there are many different ‘addiction models,’ so it’s often difficult to discern what is meant by this. Where alternative treatment approaches are preferred, other names may be suggested, for example hypersexual disorder (Kafka, 2010), Sexual compulsivity (Coleman, 2003), OCSB, (Out of Control Sexual Behaviours), (Braun-Harvey and Vigorito, 2015), or PCSB, (Problem Causing Sexual Behaviour), (Schaefer and Ahlers, 2017). I suspect the terminology list will continue to grow and whilst this may be confusing for some, what is heartening to me, as a therapist, who has been writing about this topic for many years, is that it demonstrates that there is now little doubt that the problem exists.

While the medical and therapeutic communities continue to debate the best name for the problem, the terms ‘sex addiction’ and ‘porn addiction’ are becoming increasingly popular on the street and in the media, and many therapists rightly worry that these terms are also being overused, misused and misdiagnosed. According to my survey it seems that the term ‘sex addiction’ is favoured, with 43 percent of sufferers defining it thus, 22 percent preferring ‘love addiction,’ 17 percent ‘sexual compulsivity’ and only 10 percent favouring ‘hypersexuality’ (Hall, 2013). Whatever the problem is called, what really matters is its definition, not its name.

Variations of sex addiction

Porn addiction

Porn addiction is a subset of sex addiction but sometimes has very different roots to other forms of sex addiction – especially for younger people who have grown up with easy access to internet porn. There is a growing body of research demonstrating the powerful effect of high-speed porn on the brain, which we will explore later in this chapter, but this emerging science has left many people recognising that, unlike traditional sex a...