Recently, my colleague Alexandra Katehakis, founder of the Center for Healthy Sex in Los Angeles, published a research-based book entitled Sex Addiction as Affect Dysregulation: A Neurobiologically Informed Holistic Treatment. Her thorough understanding of the neurobiological underpinnings of sexual addiction along with ways to address these underlying issues in the treatment process is impressive. Recently, I was able to speak with her about both her book and her theories on treating sexual addiction. A partial transcript of our conversation is presented below.

Right now there is a lot of debate about what qualifies as “addictive” sex. What are your thoughts on this?

I conceptualize addictive sexual behavior as adaptive. Sex addiction is an adaptive strategy, because humans are incredibly adaptive. Our brains are highly automatic. If somebody has an experience when they are quite young that relieves some pain or some stress and it is functional for them, it becomes adaptive. So that person will repeat that experience over and over again. Automaticity in that way is a component of dissociation, and that is what we see in sex addicts. So I would say that sexually compulsive or addictive behavior is adaptive, not necessarily a choice as some would argue. It’s a result of the automatic brain. And, as such, it is often a repetition of trauma—not in an attempt to rectify what was done, which is an old definition of trauma repetition, but as a neurobiological construct, a pattern of behavior. And these are patterns of behavior that create stress and problems in people’s lives over time. So what was once pleasurable becomes problematic. Sometimes it remains pleasurable, but it also becomes problematic. Sex addicts report that they cannot stop their behaviors, even though they’re problematic.

So sex addiction is, basically, an adaptive response to early-life relational trauma?

Yes. That’s the aspect of sex addiction that I’m most interested in—what happens when people don’t get proper attunement, usually starting in infancy, so their systems aren’t brought to fruition in the way that the brain and the body are designed to develop and operate optimally. If there’s any kind of chronic unrepaired disruption, you’re going to get distortions in the organism. If you have a mother who is highly depressed or highly anxious, or is under some sort of duress where she’s traumatized, she’s not going to be able to attune to her infant in a way that’s going to bring its systems up optimally, and therein lies the intergenerational transfer of trauma. So it’s not just psychological, it’s biopsychosocial. And it’s all environmental. In other words, part of the environment is the mother’s psychology and another part of the environment is her neurobiology. So you have this problematic attunement, and if there is any sort of trauma after that, whether it’s bullying, beating, sexual, neglect, or anything else, then you are going to have problems.

One of which could be sex addiction.

Yes, because sex addiction is an auto-regulatory strategy. Because the child isn’t getting proper and appropriate co-regulation from its caregivers, the organism itself will find ways to auto-regulate. And as an adult that can manifest as an addiction.

That’s what you’re talking about when you discuss addiction as a chronic brain disorder.

Yes, the brain will adapt. It’s highly malleable. It will organize itself according to what it needs in order to function. The organism is always trying to right itself. It’s always going to try to move toward some kind of healing, so it will adapt and do whatever it needs in order to function.

So a sex addict’s brain looks different and functions differently than a non-sex addict’s (or at least a non-addict’s) brain?

Well, I would say that’s likely, but we’d have to do more research to say that for sure. But there is already some evidence to that effect, and it’s clear that clinically and phenomenologically sex addicts present differently than non-addicts. There are many different examples. Some have to do with perception, some have to do with relatedness. With perception, sex addicts perceive all kinds of distortions because they’re only focused on getting into the sexual experience. That is where their attention is all day, every day.

It’s a little like magic. You see a magician who uses sleight of hand, and the reason that works is because our attention is on one thing that the magician wants us to see, instead of what he’s doing to fool us. We don’t have our attention on other things that the magician is doing. That’s how magic works. For sex addicts, they’re only looking for the sexual experience. If you ask a sex addict how many massage parlors there are in LA, and where they are, they’ll tell you that they’re everywhere. But if you ask a 35 year old soccer mom, she’ll tell you she’s never seen one. It’s an issue with perception.

For evidence of this we might look at the Mechelmans/Voon attentional bias study, which showed that sex addicts are similar with their focus to, say, a cocaine addict. For instance, if you put a cocaine addict in a room with a pile of cocaine on the coffee table, that’s all he will see. He won’t notice the color of the couch, or the carpet, or the walls, or anything else that a normal person would typically notice.

Yes, sex addicts are the same.

In your book you write, “Once addictive sexual behaviors have been arrested, the work of repairing and supporting neurophysiological structures through human relatedness must begin.” Can you explain what you mean by that?

That means that therapy has to be a two person relational system, where the therapist is actually engaging in a real relationship with the client. Historically, psychoanalysis has been more of a symbolic relationship with the client, where the client authentically projects onto the therapist that they’re the mother or the father or some problem figure and the therapist makes interpretations about that. With sex addiction, I believe the addict and the therapist need a real relationship. And together they work through whatever their issues are, so both of their subjectivities are being worked through simultaneously. It’s a coregulatory process where both parties are engaged, both parties are changing. There are ruptures, there are repairs. There’s a slipperiness to the process, but that’s what changes brain structure and function. In the same way, 12 step meetings are enormously valuable. It’s the fellowship, the coffee, the relationship that has addicts starting to trust other human beings again. That’s what starts addicts toward feeling they’re not alone. Twelve step recovery is a come as you are program and all are welcome, so people start to recognize that they can trust other people and they can get their needs met.

So you’re saying these hardwired reactive pathways that we build very early in life need to be rebuilt or worked around with new pathways, and that happens through relatedness?

Yes, we’re rebuilding pathways that were blighted, or that were never formed to begin with. Obviously, with people who are severely dissociated you’re talking about long-term therapy that requires resonance, closeness, safety, and trust between client and therapist so that the client’s uncoupled circuits can recouple. This is the work required for neural integration; this is the process of recovering dissociated self-states. And we really do see profound changes in people over time when they’re working in this way.

I had a guy who came to group last night who’s been in recovery for a long time who has some very serious psychological problems. But he’s worked very hard for years to restore his life. Recently, he lost his job, and he started slipping with pornography, and he felt a tremendous amount of fear about coming into group and talking about it because he didn’t want to be shamed, and he has a hard time with confrontation. To his credit, he came back anyway, and the group was really compassionate with him about what he’s struggling with. I saw a distinct shift in his level of defensiveness and fear, so that he was able to be more compassionate with himself. His pornography use was inconsequential to the group because it was clearly an auto-regulatory coping mechanism and, therefore, a regressed move he made to soothe his many anxieties. What mattered most was the relationship between the men in the group.

He may also have learned that he can come back to group any time he has a problem.

That’s exactly right. When I asked him what he needed from the group, he said, “I need for everyone to tell me that I should keep coming back.” Which is not what he learned in early life, when he was shamed and ostracized. This is exactly the type of relational work that he desperately needs.

How does your PASAT treatment model, as discussed in your book, differ from the cognitive-behavioral approach that most sex addiction therapists rely on in the early stages of treatment? Or does PASAT simply formalize the process of moving, over time, from cognitive-behavioral work to trauma and relational work?

It’s different than the traditional model of using CBT first, and then moving into deeper dynamic therapy, which is a bifurcated model. With PASAT, the actual relational work is happening during the cognitive-behavioral treatment protocol. Sex addiction therapists in general tend to ascribe to Patrick Carnes’ CBT model, which lays out a road map on how to help people get sober. But therapists have to simultaneously be working on the relational aspects. So it’s not just about giving somebody an assignment and processing the assignment with them, it’s about co-regulation—tracking all the nonverbal cues of the client while the therapist is also paying attention to his or her own somatic countertransference, and tracking the client’s affect, gesture, and autonomic cues. So the therapist is in an “experience near” relationship with the addict, meaning both parties have a felt sense of each other, are processing their experience of each other while also processing cognitive material.

So it’s an integration of the relational work with the behavioral work?

Correct. It’s a holistic model. It brings everything in at the same time. Historically we’ve had addiction therapists and then we’ve had psychodynamic therapists, and never the twain shall meet. I’m proposing that we play all those notes at the same time, requiring the therapist to bring all of himself or herself into the mix. When we do this, we’re affecting and changing both parties’ neuropsychobiology. We’re working the left brain and the higher cortical functions, but we’re also working from the body up. It’s a much more integrated model that’s geared toward regulation and integration. We might also call it the affect regulating “cure” for addictive trauma.

Alex Katehakis’ book, Sex Addiction as Affect Dysregulation, is available on Amazon.com at this link.