The Sex Addicted Client: General Advice for Clinicians
Treating sexual addiction is not for the squeamish. Sex addicts, if and when they become honest in therapy, often relate harrowing tales of abuse and acting out. Many have engaged in sexual activities that even a seasoned prostir careers, their homes, their tute would blush to hear about, and they’ve often done so with more partners than they can count. They’ve put themselves, their spouses, their sexual hookup partners, theihealth, their children, and so much more at risk—all for a quick and ultimately meaningless sexual fix. Many were either covertly or overtly sexually abused in childhood and/or adolescence, sometimes repeatedly and horrifically. They may also have a concurrent addiction, usually some form of substance abuse but occasionally another behavioral addiction or even an eating disorder (especially among women), and this too can lead the client into episodes of traumatic experience and bad behavior.
As a therapist, you must ask yourself before you agree to treat a sexually addicted client: Am I prepared—emotionally, psychologically, and through my training—to ask the detailed (but non-graphic) questions needed for assessment and proper treatment? Am I comfortable posing direct queries about masturbation, infidelity, frequency of sex, types of sex, number or sexual partners, feelings about sexual fantasies and behaviors, and the like? You must also ask yourself if you’re prepared to hear, without judgment, whatever it is that your client might tell you. And it is absolutely imperative that you answer this question honestly, because if your skin crawls when a sex addicted client tells you what he or she did in a back alley or an adult bookstore video booth last night, you’re no good to that client. In similar fashion, if you hear about the ways in which your client has used other human beings as sexual objects without regard to the other person’s emotional or psychological wellbeing, and your immediate reaction is to think of your client as a perpetrator rather than a damaged individual in need of psychotherapeutic assistance, you’re no good to that client.
If you are not prepared to ask probing questions about sex, and to hear your client’s truthful answers, then consultation with and/or referral to a certified sexual addiction treatment specialist is probably the best course of action for both you and your client. (Consultation and referral information is provided at the end of this post.)
Do You Fully Understand Sexual Addiction?
There is a great deal of misinformation about sexual addiction, even within the therapeutic community. Clinicians who treat sexual addiction need concrete knowledge about it how it manifests, its consequences, and the ways in which it can effectively be treated. And it’s not like they teach us this stuff in grad school!
Usually this lack of clinical knowledge and training causes therapists to underestimate the profound effect of sexual fantasies and activities on the day-to-day life of the addict (and those close to the addict). As a result, some clinicians may attempt to make sexually addicted clients more accepting of their behaviors—for instance, telling a compulsive masturbator that “masturbation is normal” without specifically addressing how masturbation works in that person’s life, or telling clients they can continue hooking up via “adult friend finder” apps as long as they aren’t hurting anyone, without specifically addressing they ways in which they may already be hurting people (including themselves).
If you as a therapist do not feel as if you have a solid general understanding of sexual addiction, including the ways in which it manifests, its consequences, how to assess for it, and how to effectively treat it, then consultation with and/or referral to a certified sexual addiction treatment specialist is the best course of action.
How Will You Feel When a Client Behaves Inappropriately?
Picture this: One day in therapy your sexually addicted client suddenly says, “Hey, I bet you’re great in bed,” or “Wow, you’ve got great legs,” or “If we have sex, I promise I won’t tell anyone.” How are you going to respond to this? And believe me, this sort of thing does occur with sexually addicted clients. After all, these individuals are men and women who are addicted to sexual fantasy and activity. As a result, their boundaries around sex are terrible. As a therapist, you will without doubt experience some form of countertransference if/when this type of inappropriate behavior occurs. Are you prepared for that? Are you ready, willing, and able to work through that with the client?
It is sometimes important, when thinking about these questions, to consider your own gender and sexual orientation, and the gender and sexual orientation of your client. For example, a heterosexual female therapist might feel differently about the possibility of working with a homosexual male sex addict. Yes, that sex addict may still make an inappropriate comment or advance—he’s a sex addict, after all—but his behavior might be easier to deal with than it would be if he was straight.
Are You Comfortable with Directive Forms of Therapy?
The methodologies that have proven most effective in the treatment of addictions (including sexual addiction) are highly directive, accountability-based modalities such as Cognitive Behavioral Therapy, typically coupled with psychoeducation, social learning, group therapy, and twelve step support networks. In other words, effective treatment of addiction is very different from traditional psychodynamic psychotherapy. And many clinicians are simply not comfortable with addiction’s hierarchical, directive, assignment and accountability focused work.
Because of this, clinicians can err with addicts by leaning in to more traditional forms of therapy—psychodynamic, narrative, Jungian, and the like—as a primary initial mode of work. This does not help the addict. Put simply, when a client seeks treatment because he or she is feeling and/or acting out of control, it is the job of the therapist (following a solid assessment) to help the client stop his or her problematic activities in the here and now. And this work is best accomplished using highly directive techniques like CBT, behavioral contracts, directed reading, homework assignments, referrals to specific support groups with assignments to attend those groups, various forms of accountability, etc.
By utilizing other treatment methods at the start, therapists can inadvertently or unknowingly fail to make behavior change an early priority. For example, even though a man obsessed with cybersex may have a history of childhood sexual abuse, before addressing his early-life trauma issues the therapist must first help him to stop his currently problematic sexual activity. In reality, it may be a year or even longer before this individual has the life-stability and ego strength needed to safely look in-depth at his painful past (without returning to problematic sexual behavior in the present). Yes, the client’s trauma history must be acknowledged right from the start, but when dealing with active addicts the initial focus must be on behavior change in the here and now, and this is best achieved using highly directive treatment methodologies. If you are not entirely comfortable working in this fashion, it is best to make a referral. (In a future blog, I will address the ways in which trauma work and addiction work overlap.)
Are You Ready for an Angry and Legitimately Out-of-Control Cheated-On Spouse?
When a sex addict’s (or any other addict’s) behavior has harmed another person—usually a spouse or significant other—that person should, if at all possible, be brought into counseling. Therapists, whether working with the betrayed partner individually or jointly with the addict, can usually help with boundaries, support, and direction. As is the case when working with sex addicts themselves, the initial focus should be on the here and now rather than on resolution of things like early-life trauma. Ideally, over time the clinician can help the betrayed partner and therefore the couple to move past the pain and difficulties caused by the addict’s behaviors, and also to develop more productive and honest ways of relating. But this work is never easy.
Most of the time this work is complicated by the fact that betrayed partners of sexual addicts often look and behave as if they are flat-out crazy. A clinician who fails to recognize that this client is simply caught in a moment of crisis may erroneously assess that person as borderline, bipolar, codependent, etc. In reality, betrayed spouses typically enter therapy in the midst of a deeply traumatic event, and they primarily need help with getting through their day—concrete direction in terms of healthcare, education about sexual addiction, legal information, social support, etc. What they don’t need is to have their heads examined by a therapist who focuses on their childhood and/or their relationship history. If you are not comfortable working with clients in crisis who are extremely labile, as betrayed spouses nearly always are upon learning about a sex addicted partner’s infidelity, then consultation with and/or referral to another clinician is probably the best option.
Consultation and Referral Information
There is nothing wrong with or bad about consulting another therapist or choosing to make a referral. Most psychotherapists are specialists of one sort or another. We each have different training, and we each have different methodologies that we prefer to use in the therapy room. Consider the general medical doctor who refers a patient with a compound bone fracture to an experienced orthopedic surgeon. Does this doctor feel ashamed about making a referral? Certainly not, because the generalist recognizes that the referral is in the patient’s best interest. The same is true in the therapy world. None of us knows how to treat every client, and that’s just the way it is. If we are not fully familiar with a specific type of work or a particular client population, then we should seek consultation or make a referral. (This also protects us against malpractice claims!)
This tenet is especially true when it comes to sexual addiction. The simple truth about the treatment of sexual addiction is that clients respond best to specific approaches, and to therapists who are well-trained, experienced, and able to intuitively and empathetically respond—without judgment—to their stories. Unqualified therapists can actually do more harm than good with these clients.
It is possible to refer a sexually addicted client for assessment and group work with a specialist, while continuing to see that client on an individual basis. Sometimes this actually works very well, as the highly directive, accountability based work of sexual recovery occurs best in a group setting anyway. If you as a therapist know that aspect of treatment is being dealt with, then you can focus on other client issues like anxiety, depression, and whatever else it is that you normally handle.
The websites of the International Institute for Trauma and Addiction Professionals and the Society for the Advancement of Sexual Health are both excellent sources for consults and referrals. Both groups also offer training and certification in sexual addiction treatment. The website of the Sexual Recovery Institute has a great deal of general information about sexual addiction, along with several short assessment tests that you can use in your practice. My personal website also has a great deal of sexual addiction information, including an extensive listing of resources.
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He is author of Cruise Control: Understanding Sex Addiction in Gay Men and Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction,and co-author with Dr. Jennifer Schneider of both Untangling the Web: Sex, Porn, and Fantasy Obsession in the Internet Age and Closer Together, Further Apart: The Effect of Technology and the Internet on Parenting, Work, and Relationships. He has also provided clinical multi-addiction training and behavioral health program development for the US military and treatment centers throughout the United States, Europe, and Asia.
Weiss LCSW, R. (2015). The Sex Addicted Client: General Advice for Clinicians. Psych Central. Retrieved on March 18, 2018, from https://blogs.psychcentral.com/sex/2014/11/the-sex-addicted-client-general-advice-for-clinicians/