Cognitive Behavioural Therapy in the Treatment of Sex Addiction

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In a complex world, cognitive therapy and other forms of talk therapy have become a necessary and effective support system for many conditions; one of which is the treatment of sex addiction. The foundations of cognitive therapy date back to the early 3rd century and the work of the Stoic Philosophers. They believed it is not acts, actions or events which cause us psychological turmoil but our responses to them. Furthermore, if we want to reduce psychological strain, we can do so by altering these responses and the motivations behinds them.

“Men are disturbed not by things that happen, but by their opinion of the things that happen.” Epictetus (c. 50-120)

During the early 1960s, cognitive behaviour therapy and its techniques remerged as an exciting ‘new’ approach to patient counselling. Adopters of the method viewed their patients as people two layers of dysfunction. First, there is the clear and obvious problem (addiction, depression, anger issues, etc). Beneath this, there are the fundamental reasons for the problem’s existence (insecurity, anger, irrational beliefs, etc). It is the job of the cognitive therapist, they believed, to penetrate the first layer and uncover these deeper truths.

Essentially, cognitive therapists believe harmful or dysfunctional behaviours and responses are caused by learned habits. This is known as ‘maladaptive learning’ and it extends to persistent thought patterns, illogical beliefs, skewed perceptions and dysfunctional ways of thinking and acting that may seem normal to a patient because their lived habits and experiences correspond.

Cognitive behaviour therapy strives to help these patients unlearn harmful habits and dysfunctional ways of thinking so that they can be replaced with healthier responses. It uses methods which lean heavily on directive, practical, educative and task oriented processes.

When treating a sex addiction, for example, cognitive therapy says the addiction itself is not the real target. It cannot be changed unless the underlying habits and thought patterns which have enabled it are corrected. In this context, the addiction (or other issue) is referred to as the ‘overt problem’ and psychologists look for underlying explanations in the patient’s ‘schemata’ or cognitive behaviours.

One way to look at ‘schemata’ is as a world view. We all have a core belief system which colours our responses to people, places, events, cultural phenomena and more. By exploring this belief system at depth, a therapist hopes to uncover the parts of it that have allowed dysfunctional responses to flourish. This process normally involves a substantial amount of talk therapy. The cognitive therapist identifies harmful or illogical beliefs, thought patterns or perceptions and helps the patient come to an understanding of why they are unhealthy. Part of this technique may involve the replacement of unhealthy statements with more rational alternatives and a certain degree of repetition until the new versions seem more familiar.

My method for supporting patients using cognitive therapy is as follows:

Stage 1 – The first priority is to prevent or limit the consequences of the harmful addiction, behaviour or other problem. We may not be able to stop it right away which means, in the interim, pharmaceuticals or behaviour modification techniques or ‘relapse prevention skills’ must be employed to keep the patient safe.

Stage 2 – This stage is known as ‘admission’ (sometimes ‘acceptance’ or ‘acknowledgement’) and involves the patient recognising the presence of a problem. Sometimes, they are asked to make a sincere promise to the therapist to be completely transparent about this problem and the difficulties it causes them.

Stage 3 – The next stage teaches the patient some alternative behaviours to their destructive ones. Again, this does not fix the problem but it, hopefully, limits the damage caused. As the majority of dysfunctions and addictions involve some degree of stress or anxiety (particularly feelings of loss of control), the therapist provides healthier forms of stress management (for instance, instead of indulging in risky sexual behaviours, try meditation or exercise).

I personally recommend the use of exercise as an alternative, constructive form of stress management. When combined with deep breathing and various types of meditation and self-reflection, it is a great way to regain power over urges or thoughts which feel out of control.

Stage 4 – This is arguably the most critical part of the therapeutic process. It’s when the cognitive therapy (and its focus on correcting underlying issues) really begins. The goal is to replace illogical or harmful thought patterns by, first, exploring the reasons why they are inappropriate.

In the case of sex addiction, this process starts with in depth discussions about the patient’s core beliefs and values. The therapist asks personal questions to find out what the patient thinks and/or feels and whether this is irrational or harmful. As discussions continue, the patient is encouraged to question these values and challenge their supposed ‘normality.’ Are they normal or have they just become familiar to the patient? Would they be normal for a mentally healthy person? Are these thoughts or beliefs contributing to addictive behaviours?

Stage 5 – The therapist supports the patient as they learn problem solving skills and develop the confidence to try alternative, healthier solutions.

Stage 6 – This phase of therapy focuses on the patient’s difficulties in maintaining or establishing successful relationships. The goal is to find solutions for each of these obstacles.

Stage 7 – The patient is encouraged to acknowledge harmful thought patterns that are contributing to their need for addictive behaviours and may lead to relapse.

Stage 8 – The patient is provided with the support they need to replace harmful thought patterns with healthier perceptions about sexual activity and relationships. The therapist focuses on the need to recognise a partner’s desires, how to fulfil these desires and why these desires are as just important as personal ones to the success of the relationship.

Stage 9 – The final stage of the process sees the patient develop healthy routines and emotional and physical outlets which don’t involve the addiction.

In the case of sex addiction, a patient uses sexual activity and scenarios to fulfil an emotional need within themselves. If they can identify this need and find alternative (healthier) ways to meet it, they can start to overcome the problem. Commonly, sex addiction is a dysfunctional coping method for anxiety, shame, guilt or isolation. It allows the patient to fulfil a need for closeness without exposing themselves to the risk of rejection.

Crucially, the addiction can never successfully fulfil the need because it doesn’t stem from a desire to have sex. The real goal is intimacy, only the patient is afraid to pursue it in healthy ways because they come with a risk of additional pain.

According to Patrick Carnes, the same negative thought patterns are observed in most sex addict patients. If these can be broken and replaced with healthier ways of thinking, a full recovery is likely.

  • I am a bad person who is unworthy of love.
  • I am unlovable in my current state.
  • I do not want to rely on anybody. It is too risky/painful/unfulfilling.
  • Sex is the strongest, most important need in my life.

I see these negative thought patterns in my patients all the time and, until they can be corrected, the likelihood of therapy being success is low. Fortunately, cognitive therapy is designed to uncover these harmful perceptions even if they are buried beneath many layers of obfuscating and damaging behaviours. Some other common thought patterns I see in sex addict patients include:

I need sex to distract me.

  • When I am not having sex, I am consumed by emptiness.
  • As a man, I’m more sexually oriented than women. My sexual behaviour is a natural response to a high libido.
  • My worth is defined by how many people find me attractive and want to have sex with me.
  • I find everyday life boring. Sex is the most exciting part of my existence because it is ‘taboo,’ ‘illicit’ or ‘forbidden.’
  • My sexual partner can no longer fulfil me. Our relationship is lacking in passion and spontaneity. Illicit sexual activity helps me avoid feeling depressed and bored.
  • I am a man. It is my job (biologically) to pursue sex with many women. I have a duty to prove my sexual prowess.
  • I cannot fulfil my emotional needs through healthy channels. Sex is a way to connect with people without having to give too much of myself.

The thing to remember about sex addiction – all addictions, in fact – is they can become a self-fulfilling prophecy. Often, the patient pursues casual, emotionless sexual acts to protect themselves from the emotional risks that come with all healthy relationships. Yet, of course, the behaviour only fuels their loneliness and isolation which, in turn, drives them to maintain the addiction.

It is a self-perpetuating problem and, until a part of this cycle of dependence and desire is broken, the addiction will continue. This is why cognitive talk-based therapies are such an effective tool. They target the underlying negativities allowing the addiction to continue.

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