The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs: Elements Behavioral Health Promises The Ranch The Sexual Recovery Institute (SRI) The Recovery Place

Myths: Sexual Addiction is not ... A symptom of a separate major mental health disorder. We first assess for ADD/OCD/Bipolar Disorders and Active Drug Abuse Poorly Researched Fun Symptomatic of Moral or Religious failing “Sex negative” or a cultural bias Fetish Behavior Same Sex Interest or Activity Crystal Meth Addiction Sexual Offending - non consensual

Typical Sex Addict Behaviors Compulsive Use of Porn (with or without masturbation) Anonymous Hook-ups (met online) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and “Sensual” Massage Parlors Cruising, Intriguing, Objectifying, Seduction Pushing Boundaries, Viewing “no” as a challenge Multiple Affairs / Anonymous Infidelity SmartPhone Hook-ups -using APPS Sexting / Abusing Social Networks / Virtual Sex Crossing Professional Boundaries Living a Double Life - compartmentalization

Addiction 2011: Current Definition Addiction is a primary, chronic disease of brain reward, motivation, memory and related circuitry. Dysfunction in these circuits leads to characteristic biological, psychological, social and spiritual manifestations. This is reflected in an individual pathologically pursuing reward and/or relief by substance use and other behaviors. ASAM 2011

Is Sexual Addiction a valid Mental Health Diagnosis ? Was in the DSM III - as a descriptor Was out of the DSM IV No longer being considered for the DSM 5 as: (Hypersexual Disorder)

The Sexual Addiction Diagnosis Follows the Characteristics of All Addictions Criteria closely parallels guidelines for assessing Substance Dependency, Alcoholism, and Compulsive Gambling: Loss of control Continuation despite adverse consequences Obsession or preoccupation The presence of all three criteria operationally define addiction to any drug or behavior

What does it mean to not have a Diagnosis Moral Judgement Religious Abuse Misdiagnosis Misdirected Treatment- often with meds Think Alcoholism prior to the 1970’s

How Can You Be Addicted to ... Sex? Increased Heart Rate Pupils Dilate Hearing More Acute Shallow Breathing Perspiration- palms, underarms, etc. “Rush” or “Intensity” Feeling Reduced Intellectual Functioning!

Sexual Addiction is the use of Intense Fantasy to Induce Neurochemical Release Serotonin - mood stability Dopamine - pleasure Adrenaline - energy, jolt Endorphins - calm Oxytocin - love/jealousy In essence it is a mechanism of neurological compensation or simply put- “a brain problem”

ADDICTS CALL IT… The Bubble The Trance Spaced Out Think ... Dissociative State Trauma Self Soothing

In 12-Step Language ... POWERLESS!

Sex Addiction is not about sex or orgasm Sex Addiction is not about sex or orgasm. It is about the search for sex and desire for orgasm. It’s a Process Addiction.

The Process Addictions Gambling Internet / Video Gaming Workaholism Binge Eating Sex Exercise Spending

Sexual Addiction Symptoms in Residential or Outpatient Clients In Assessment History Multiple abortions (females), multiple STDs (both sexes), repeated unprotected sex Previous arrest or major life consequences related to sex Drugs/Alcohol used to help tolerate or enhance sex History of previous sexual acting out in treatment Drug use fused with sexual behavior Multiple past failed relationships due to affairs or infidelity - intimacy disorder Chronic or Compulsive Masturbation with or without porn Leading an ongoing double (romantic or sexual) life

Sexual Addiction Symptoms in Residential or Outpatient Clients In Behavior Seductive Dress (especially after it is pointed out) Seeking out “special relationships” with other attractive clients or staff for advice, friendship and direction Giving “the stare”, being sexual in treatment History of CD relapse – especially females Encouraging Dependency as a form of seduction Sneaking & using porn in treatment - sharing porn in treatment. Consistent sexual references and objectification in jokes and conversation Lack of empathy about how their sexual behavior affects others. (13th step!)

Sex Addict: Countertransference Minimization – Joining in the client’s need to minimize their behavior - Unsure or uncomfortable with content Colluding with in the devaluation/blaming the spouse Disgusted- “creeped out” by client’s history and behaviors OR by their lack of affect when discussing them Angry- at client’s lack or empathy or affect Angry- because maybe you dated this client once. Over identifying with the patient’s victim stance Frustrated - “Don’t you see what you’re doing?!” Caught in your own abandonment fears Seduced by their intellect, charm & encouragement of your dependency

Brief Etiology of Sexual Addiction

How Do You Grow an (Sex) Addict? Sexual Abuse -overt and covert Early Attachment Deficits Social Anxiety- Social Avoidance Early trauma, neglect and abuse Parental Enmeshment - narcissistic parenting Pre-existing, untreated character pathology All of which keep the individual from learning to utilizing basic intimacy, socialization and support to meet healthy human dependency needs. Sex addicts seek ... Intensity vs. Intimacy

Set up Art Therapy Story “The child who is used and/or abandoned emotionally by their parent has the chance to develop his intellectual capacities undisturbed, but not the world of his emotions and this will have far-reaching consequences for his well-being.” Alice Miller: The Drama of the Gifted Child Set up Art Therapy Story

From looking out of windows to looking at porn Maladaptive, survival-based emotional coping (addiction) offers a sense of being in control when feeling needful (out of control) Self soothing Self Regulation- Calm Distraction / Dissociation Stimulation In the absence of and/or limited experience with healthier, more integrated relational means of self stability. To Show Vulnerability = SHAMEFUL From looking out of windows to looking at porn

Controllable Intimacy Most (sex) Addicts desperately seek something they can never achieve ... Controllable Intimacy

The Betrayed Spouse Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

How does he betray her right in this scene? Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

In a Primary Relationship, Active Addiction by one partner results in both Betrayal and Trauma for the other Meditation. Become present. Imagine someone very important who is not here today, maybe your most important adult -husband, wife, parent, friend. Imagine where they might be right now - where they usually are right now -at work, childcare at home. Picture them there. How does that make you feel? What are they doing? Now imagine receiving a call or text to tell you that there is a problem, that this person didn’t show up where they were supposed to be today. No one knows where they are and in fact they have been missing for a while now, but no one wanted to tell you. How would you feel? (Name feelings) What would you do (name actions) Now imagine yourself trying to find out what happened to them. Would you stay here or leave immediately. Imagine your first reactions. Now you have left here to look for them. See yourself first calling and then perhaps visiting those who might know where they are but no one seems to be able to help. No one knows where they are. From some you get conflicting answers, others tell you to stop looking, that it’s natural for this person to take some time to themselves now and then, that you’re making too big a deal out of this. Others who you know MUST have seen your loved one - deny having seen them or make up events that don’t seem to fit What do you do? How do you feel? Perhaps you find a few clues as to where they have gone-imagine yourself finding some clues at their work or at home. Perhaps in a desk drawer you find a credit card receipt, a cell phone bill or on the computer you see something in the online history - how does that feel? What do you do once you find out some information, but not enough? Would you look further? How would you feel?

Betrayal is the greatest source of pain to an addict’s spouse Betrayal is the greatest source of pain to an addict’s spouse. It’s not so much the addict’s drinking, using, spending, sexing etc. that causes the most hurt to a loving spouse - it’s the lying, broken promises and loss of trust.

What is the Emotional State of a Betrayed Spouse? The betrayed spouses initial emotional state is a form of trauma: Fearful of further loss and abandonment Ashamed, remorseful, self doubting and isolated Anxious and Hypervigilent - easily triggered to previous levels of trauma Worried about the future -parenting, finances, separation Having intrusive thoughts and images Often having problems w/sleeping, eating, self-care

Diagnose this client Acts out in angry, vengeful, acts superficially supportive of treatment while actually undermining it. Often shifts from idealizing her spouse, therapist and treatment - to devaluing and dismissing them. Can be demanding and boundary-less. Expresses feeling “out of control.” Engages in compulsive behaviors such as ‘detective work’ and stalking. Often seems to be on a mood ‘roller coaster’, it can hard to tell what mood will predominate, why and when. Mistrustful, suspicious, at times can be rageful and verbally abusive. Can ‘act out’ by overeating, spending and other compulsive behaviors. Inconsistent and uncommitted to looking at her part or her issues - tends to externalize and blame.

Which one is she (he)? An Axis II Diagnosis -Borderline Profoundly and inexorably co-dependent. “poor dear, she lost her ‘self’ to him”. A client who suffering from a profound life- trauma and grief reaction without meaningful support or direction. It might take a while before you know ...

At SRI & The Ranch we believe she/he is on a trauma-induced emotional roller-coaster (PTSD)

How long can it take to get off this ride? 9-18 months, post-discovery/disclosure. Provided there is an active recovery process in place in place for both.

Stay I stay or should I go? We advise: If violence or harm to spouse are family are not present, give it 6 months to a year. Considerations for leaving involve: Social and Family Resources Finances Childcare Health Commitment to Healing (on both parts)

Initial clinical concern for spouse is safety Physical health -STD’s, pregnancy Family safety - Children at risk? Specific betrayals that might overwhelm or undermine later

What are the clinical needs of this spouse? Concrete Direction regarding self-care, health issues, talking to family etc. Education about addiction, disclosure, family dynamics, support. Holding and Validation of her reality and her feelings Disclosure and clarity regarding their unknown history Social support by professionals (peers and family where useful) Structure toward moving forward Hope

At the heart of the spouses’ concerns ... How do I know if this is all there is to know? How will I know if he acts out again? How is trust re-established?

This is how we explain his or her situation to the addict . . .

Sex and Technology The Evolving Influence of Social Media and Technology on Hypersexuality

Note the increasing pace of technological change in our lifetime. Radio - 38 years to 50 million people Television - 13 years to 50 million people Internet - 4 years to 50 million people Social Networking - 16 months to 50 million Smart Phone apps - 9 months to 50 million Whatever comes next will happen nearly instantaneously and in our lives before we know or even fully understand it. So get ready ...

Online sexual content, chats and interaction has forced us to reassess sexuality in our culture. For example, today what do you consider to be… Infidelity?

Access Affordability Anonymity What are the most profound changes in our experience of sexual content & sexual contact over the past 20 years? Access Affordability Anonymity * Cooper, Del Monico et al 1998 - 1999

Sexual Content Access 2004 - Present Sexting and live video streaming from your smart phone Smart Phones with GPS & apps Social Networks (facebook, twitter, mySpace) Virtual World Sex (2nd-Life, virtual games etc) Virtual Sex and Teledildonics QR, AR codes and Chat Roulette

And some are using it to offend ... About Sexting Tell story about young offender at SRI - Exhibitionist/Voyeur Eewwwwwwwww! And some are using it to offend ...

About Ashley Madison Started as a website - now also a mobile app - perfect example of content access progression AM Slogan: “Life is short, have an affair.” AM Mission Statement: “To provide an interactive way for like-minded users to explore whether they wish to meet each other, chat with each other and/or explore extra- marital relationships” Over 16-million members internationally In May 2011 1.2 million men and women used the service to contact a sexual partner in that single month 92% of males on the site sign in as married 68% of female members sign in as married

This ad was turned down by the 2010 Superbowl Committee but airs on late night cable and you-tube

Smartphones Wow! They have built-in GPS locators that can locate you in time and space! Universal Internet access anywhere! Live video streaming to phones and pads! They use Apps, which are individualized software programs written for a specific task!

Smartphones have apps to help you find “friends” too right here! Ashley Madison Grindr Blendr Spice Dice Etc.

Now let’s take a closer look at these apps ... Ashley Madison Grindr And something to make you feel better after ...

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Smartphones have apps to help you pleasure yourself Flesh-light Companion My Pleasure-Vibrator

Teledildonics = Rudimentary Virtual Sex By hooking up the hardware components up to the two Wii-motes, wiggles and thrusts on the first Wii-mote are detected and sent via Bluetooth to a nearby computer. From there this information is sent over the Internet and reproduced by the other Wii-mote which acts as a Wii-brator on the other end,

Why Does Technological Advance Lead to Behavioral Escalation ? Increasing access means decreasing inhibitors to impulsive problem behavior It’s just so easy to find, get, have and use ... and faster! Increasing accessibility thru phones and pads means sexual acting out is easier to hide Those with preexisting social/emotional deficits (read teenagers, among others) no longer need to evolve a social skill set in order to be sexual Certain sexual behavior considered illegal/offending/consequential in the “real world” is not so online

Sexual Addiction Treatment

Elements Has Three Levels Sexual Addiction & Related Sexual Disorders Treatment Intensive (SRI) - 2 weeks day-treatment while staying in a recovery residence- Los Angeles. Residential (The Ranch) (trauma/crisis related) - sex addicts and exhibitionists, voyeurs, some child porn offenders -non- contact - Tenn. Residential (SSDP at Promises Malibu) Drug addiction program for stimulant-drug addicts with concurrent sexual behavior. - Malibu, CA

Addiction Treatment Method vs. Psychotherapy Behavioral problems REQUIRE behavioral forms of intervention and treatment This includes structured steps and tasks Problem behaviors have to be contained FIRST before psycho-dynamic therapy and trauma work begins in earnest Group work is more effective than individual Healing maladaptive attachment is the slow work of long- term therapy, living honestly and 12-step involvement (2-3 years minimum). This is where Psychodynamic, Analytic, Jungian, Somatic and other forms of therapy are most effective Discuss that the therapeutic relationship is formed by the therapist acknowledging and confronting the defenses and adaptations that no longer work.

Required Treatment Steps When Working with Sex Addicts Do a thorough psycho-sexual history/assessment Confront Denial Identify the genuine client treatment goals and co-create a sexual sobriety contract or plan aligned with those goals. Hold clients accountable to all their agreements! Have client evaluated for psychotropic medication Educate and teach relapse prevention Get them into a sex addiction group therapy Find support for the spouse Direct healthcare, family and crisis resolution Refer to long-term 12-step, therapy or faith-based group support

What is Sexual Sobriety? A mutually agreed upon clear, written and signed, behavioral contract based on client goals. Sobriety plans don’t change without prior discussion. Similar to how we handle eating disorders

Sexual Sobriety Contract List of Behaviors I Want to Stop A B C D E F List of Behaviors I Want to Add A B C D E F

The good news ... Treatment and recovery are also entering the new media frontier. We all need to be aware of these options for our clients: Tele-meetings Online 12-step Chats Face to Face Skype Meetings Face to face video sponsorship Virtual Reality de-sensitization techniques ...

12-step Support Groups for Sexual Addicts and Partners Sex Addict Support SAA SA SCA SLAA-Women SRA Partner Support S-Anon Alanon COSA CODA RCA - Couples

Sexual Addiction Information The Sexual Recovery Institute www.sexualrecovery.com The Ranch www.recoveryranch.com IITAP - International Institute for Trauma, and Addiction Professionals www.iitap.com SASH - The Society for the Advancement of Sexual Health www.sash.net E-summits www.e-summits.com Online and video learning with available CEU’s

The Assessment, Diagnosis and Treatment of Sexual Addiction in the Digital Age Robert Weiss LCSW, CSAT-S Director of Intimacy and Sexual Disorder Programs: Elements Behavioral Health Promises The Ranch The Sexual Recovery Institute (SRI) The Recovery Place