Sex Addiction Treatment: Addressing Hypersexual Behavior in a Rehab Setting
Hardly a day goes by without the national media trotting out the problem sexual misbehavior of some politician, sports star, actor, or religious leader. Oftentimes, within a few days or weeks we hear that same person is “entering treatment” for sexual addiction. This begs the question: What is sexual addiction treatment?
Generally speaking, well-rounded sexual addiction treatment mirrors in many ways the structure and techniques that have proven highly effective in drug and alcohol addiction treatment—focusing on breaking through denial, managing the crisis or crises that drove the person to seek help, social learning, cognitive behavioral therapy, group therapy, relapse prevention, etc. Depending on the individual being treated, the work may center on the person’s immediate life circumstances in an attempt to determine (and find healthy ways to control) the various triggers to his or her sexual acting out. Other addicts, while still needing to learn how to contain their sexual behavior, may have a greater need and ability to work though various forms of past trauma and emotional reactivity—challenges that oftentimes have been lifelong concerns. For all individuals, once sexual sobriety has been established, all useful clinical methods are on the table: art therapy, traditional cognitive behavioral therapy and relapse prevention work, social learning models, equine and experiential work, EMDR, somatic therapies, the support of 12-step meetings, etc.
One significant difference between sex addiction recovery and substance abuse recovery is the definition of sobriety. Whereas abstinence from all mood altering chemicals is the goal in nearly all forms of drug and alcohol treatment, sexual sobriety involves an ongoing commitment to behavior change but not long-term sexual abstinence. Much like an eating disorder—where the person with an eating problem still needs to eat, just in a manner that is healthy for that individual—recovering sex addicts work in treatment to co-define (with their treatment team, in written contracts) which of their sexual behaviors are healthy and which of those behaviors work against their individual life, career, family, and relationship priorities. They then commit to engaging in the healthy behaviors moderately and appropriately, with supportive direction, while eschewing the problematic behaviors. As long as the client doesn’t return to his or her bottom-line problem sexual behaviors he or she is sober in treatment and in 12-step sex and relationship recovery. Again, the definition of “problematic” varies from one individual to the next depending on each person’s specific life circumstances.
Inpatient Sex Addiction Rehab
For many, an initial step on the path to healing is inpatient or residential recovery. The recommended length of stay at The Ranch in Tennessee, a gender-separate treatment program specializing in sexual and romantic addiction (along with substance addictions and other psychological disorders) is 35 days. However, with sex addiction rehab (as with drug and alcohol rehab) the length of stay varies from facility to facility and even patient to patient.
One common misconception about treatment/rehab centers is that the addict in treatment will be fully cured by the time he or she completes his or her inpatient stay, that the addict will never again struggle with problematic sexual behaviors. And while long-term sexual sobriety is always the primary goal, “finding a cure” is not what inpatient treatment is about. Instead, the main goals of inpatient sex addiction rehab are:
• To temporarily separate the addict from people, places, and things integral to his or her problematic sexual behaviors
• To help the addict delineate which sexual behaviors are problematic (and which are not)
• To reduce denial by helping the addict gain insight into the full extent of his or her past dependency on sexual fantasy and behavior for emotional distraction and self-stabilization
• To educate the addict as to the full extent of the consequences of his or her sexual acting out, looking at harm to the addict and other people
• To thoroughly educate the client about addiction triggers and relapse prevention tools that he or she can use when triggered to sexually act out
• To coach and support the client into building ego strength, social skills, and an ongoing social support network
• To break down the addict’s resistance to participation in lifelong, ongoing recovery from sexual addiction
In much the same way that drug detox is the first step in recovery from substance abuse, residential sexual addiction treatment can be a first step on the road to long-term sexual sobriety and a satisfying life. Once again, inpatient treatment is not a “cure” for sexual addiction. Instead, it is a significant interruption of long-established compulsive behavior patterns and a structured opportunity to begin the process of building the awareness and coping mechanisms needed for long-term recovery. As we sometimes tell our clients: “Treatment prepares sex addicts for the necessary longer-term outpatient therapy to come.”
What Clients Should Not Expect from Treatment Settings
Another common misconception about sexual addiction inpatient treatment is that the primary focus of the work will be to identify and resolve the client’s childhood trauma. Certainly trauma resolution is one focus of inpatient treatment, but it’s only one among many, as helping patients gain insight into childhood concerns probably won’t provide them the concrete tools they need to cope with day-to-day life without returning to the obsessive and compulsive use of sexual fantasy, urges, and behavior to self-soothe and self-medicate. To borrow an old AA mantra: first things first. And the first thing to do in sexual addiction treatment, beyond a thorough bio-psycho-social-sexual assessment, is identify and stop the problematic sexual behavior. Later, after the sex addict has established sobriety, the therapist can delve more deeply into childhood trauma and other underlying psychological issues. The timing of this varies from individual to individual.
When early treatment does choose to address past trauma, the main goal is shame reduction—helping the client come to terms with his or her past behavior patterns and related losses/consequences without causing the individual to end up more deeply mired in self-hatred and shame (which are usually primary triggers for sexual acting out). Basically, addicts need to hear, “Yes, you made some bad choices in your adult life AND you are responsible for the outcome/consequences of those actions (divorce, arrest, disease, etc.), but you didn’t act this way because you are a bad person. You ended up in treatment because your sexual problems are the logical outcome of how you learned to connect, which is something all human beings need to do.” In this way a trauma history is acknowledged, but it does not become the focal point of treatment until the client has developed the emotional and social resources and stability to not act out when faced with uncomfortable feelings. Only then can the deeper work can begin.
What Does Happen in Sex Rehab
When an individual enters any reputable sex addiction treatment facility, the first thing that occurs is a series of thorough psychiatric, physical, and bio-psycho-social-sexual assessments. Careful evaluation will explore and evaluate nearly every aspect of that person’s life, looking at the entire person, including all that they have been through and all aspects of their lives, work, relationships, etc. In this way clients are simultaneously assessed for other addictions, mental and physical health issues, along with relationship, family, legal, work, social, recreational, and financial concerns. A complete and thorough sexual history is taken and reviewed throughout treatment to help the client and staff members understand how the client’s past issues relate to current problems.
After evaluation, early treatment typically focuses on two main issues: separating the addict from his or her harmful sexual or romantic behavior patterns, and breaking through the denial used to make that behavior acceptable. The most effective tools for accomplishing these early tasks are Cognitive Behavioral Therapy (CBT) and Group Therapy. CBT differs significantly from traditional models of talk therapy that examine how the past affects the present, relying instead on a more directive approach. With CBT the clinician and client look at the people, places, and things that trigger and reinforce sexually addictive thoughts, urges, and behaviors, and then identify ways to recognize and short-circuit the process. Basically, the cognitive approach teaches sex addicts to interrupt compulsive sexual thoughts and behaviors by thinking about and/or doing something else. Instead of wallowing in sexual fantasy that ultimately leads to problematic sexual behavior, the addict learns to engage in other, healthier behaviors such as calling a sponsor, going to a meeting, exercising, or finding an enjoyable hobby. CBT clinicians are directive and reality based, focusing on the here and now rather than on exploring and resolving past trauma. In sum, the inpatient therapist’s role is to implement a task-oriented, accountability-based methodology geared toward containment of the addict’s problematic sexual behaviors.
During inpatient treatment, CBT focuses on three major issues:
1. Identification of the Problem. Close questioning and observation help the clinician and patient identify the specific behaviors that make up the problematic sexual addiction pattern.
2. Behavioral Contracting. The clinician and patient work together to define, in written terms, specific problem sexual behaviors to be eliminated.
3. Relapse Prevention. The clinician and patient work together to identify and reduce patterns of experience and interaction that support or trigger acting out behaviors.
Recovering sex addicts nearly always require external reinforcement and support if they wish to permanently eliminate deeply ingrained behavior patterns. To this end, addiction-focused group therapy is also a highly significant component of both residential and outpatient sex addiction treatment. In group therapy and psycho-education, treatment specialists work with anywhere from six to ten addicts. In these facilitated group settings, patients are able to see—often for the first time—that their problem is not unique and they are not alone. This helps to reduce the shame, remorse, and guilt associated with sexual acting out (all of which can be triggers for further sexual acting out). The group format is also ideal for confronting the denial, rationalization, and justification common among sex addicts. Group-level confrontations are powerful not only for the individual being confronted, but for the addicts doing the confronting. Through such interaction, everyone present can learn how rationalization and justification sustain addiction. Last but certainly not least, in a group therapy setting clients are able to learn and reinforce with one another what interventions and coping mechanisms are most effective, based on their own and other members’ experiences.
The Next Stage
Residential treatment is only the beginning of the journey for recovering sex and relationship addicts. At the conclusion of their stay, many feel as if they’ve got their problem licked, but once they’re away from the safe, highly structured, accountability-based treatment cocoon and back in the real world they inevitably are confronted with the very same problems and temptations that led them into treatment in the first place. As such, careful, structured, contracted aftercare planning is imperative. Putting an external safety net in place before the client goes home is an essential part of every inpatient client’s exit strategy. Most people need continued work with a sexual addiction treatment specialist, often both in individual and group therapy. Those in relationships will also require therapeutic support for spouses/partners.
It is important to remember that every sex addict’s pathway to long-term sexual sobriety is different. Each individual arrives in treatment with a specific set of problematic sexual behaviors and a unique background, and each addict needs a program of recovery designed to meet his or her individual needs. The most likely path to long-term success for those lucky enough to experience inpatient treatment is for the inpatient facility to establish contact with a licensed sex addiction treatment therapist in the addict’s hometown before the client is released from inpatient care. In this way, the new therapist can become familiar with the addict’s issues in advance of their first meeting, and a personalized plan of action can be formulated and implemented before the temptations of home can take effect.
Robert Weiss LCSW, CSAT-S is the author of three books on sexual addiction and an expert on the juxtaposition of human sexuality, intimacy, and technology. He is Founding Director of the sex addiction treatment program The Sexual Recovery Institute and Director of Intimacy and Sexual Disorders Services at The Ranch and Promises Treatment Centers. Mr. Weiss is a clinical psychotherapist and educator. He has provided sexual addiction treatment training internationally for psychology professionals, addiction treatment centers, and the US military. A media expert for Time, Newsweek, and the New York Times, Mr. Weiss has been featured on CNN, The Today Show, Oprah, and ESPN among many others. Rob can also be found on Huffington Post and on Twitter at @RobWeissMSW.
Weiss LCSW, R. (2012). Sex Addiction Treatment: Addressing Hypersexual Behavior in a Rehab Setting. Psych Central. Retrieved on April 18, 2015, from http://blogs.psychcentral.com/sex/2012/09/sex-addiction-rehab-treatment/