1. Untangling the Web: Treating Sex and Porn Addiction Robert Weiss LCSW, CSAT Executive Director The Sexual Recovery Institute www.sexualrecovery.com Robert Weiss LCSW, CSAT Executive Director The Sexual Recovery Institute www.sexualrecovery.com

2. What Do These Men Have In Common? Fmr. President Bill Clinton Fmr. Senator Larry Craig Fmr. Governor Elliot Spitzer They are men whose sexual behavior MORTALLY WOUNDED their ability to lead... but what if their problem had been drinking or drugs e.g Patrick Kennedy? Fmr. President Bill Clinton Fmr. Senator Larry Craig Fmr. Governor Elliot Spitzer They are men whose sexual behavior MORTALLY WOUNDED their ability to lead... but what if their problem had been drinking or drugs e.g Patrick Kennedy?

3. Our Typical Client 38 year old married working male Wife found extensive porn or hook-ups in computer - says get help or you’re out. Married 7-10 years One or more children under age 6 Acted out with sex prior to marriage, then slowed or stopped - never informed wife Why did he return to acting out? 38 year old married working male Wife found extensive porn or hook-ups in computer - says get help or you’re out. Married 7-10 years One or more children under age 6 Acted out with sex prior to marriage, then slowed or stopped - never informed wife Why did he return to acting out?

4. Sex Addiction is Not ‣ A Moral or Religious Stance ‣ A Symptom of Underlying Axis I Illness ‣ Fun ‣ Same Sex Interest or Activity ‣ Sexual Offending ‣ Fetish / Paraphilia ‣ Sociopathy ‣ Crystal Meth Addiction ‣ The End of a Relationship ‣ A Moral or Religious Stance ‣ A Symptom of Underlying Axis I Illness ‣ Fun ‣ Same Sex Interest or Activity ‣ Sexual Offending ‣ Fetish / Paraphilia ‣ Sociopathy ‣ Crystal Meth Addiction ‣ The End of a Relationship

5. Sex addiction can be… A Stand Alone Diagnosis A Stand Alone Diagnosis

6. The Diagnosis Follows the Characteristics of All Addictions Criteria for assessing Sex Addiction 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 defines addiction to any drug or behavior Criteria for assessing Sex Addiction 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 defines addiction to any drug or behavior

7. Typical Sex Addict Behaviors Compulsive Use of Porn (with or without masturbation) Anonymous Sex (met online or in sex clubs etc.) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and Massage Parlors Cruising, Intriguing, Objectifying, Seduction Boundary Violations, Sexual Harassment Multiple Affairs / Anonymous Infidelity Abusing Power Relationships for Sex - Predatory Compulsive Use of Porn (with or without masturbation) Anonymous Sex (met online or in sex clubs etc.) Adult Bookstores and Strip Clubs Sexual Exchange (i.e. Drugs or Favors for Sex) Prostitutes and Massage Parlors Cruising, Intriguing, Objectifying, Seduction Boundary Violations, Sexual Harassment Multiple Affairs / Anonymous Infidelity Abusing Power Relationships for Sex - Predatory

10. Criteria for Sex Addiction Three out of ten… 1. Recurrent failure to resist sexual impulses in order to engage in specific sexual behaviors 2. Engaging in behaviors longer than intended (losing time) 3. Desire or unsuccessful efforts to stop, reduce, or control type or frequency of behavior. 4. Inordinate amounts of time 5. Preoccupation with sexual behavior or preparatory activities 6. Engaging in behavior when expected to fulfill occupational, academic, domestic or social obligations 7. Continuation despite persistent social, financial, psychological, physical, legal or health problems 8. Need to increase intensity, frequency in order to achieve desired effect 9. Reduction or loss of social, occupational, recreational or spiritual activities— sex more important 10. Distress, anxiety, restlessness, or irritability if unable to engage in the behavior

11. Addicted to sex? ‣ Increased Heart Rate ‣ Shallow Breathing ‣ Perspiration- palms, underarms, etc. ‣ Reduced Intellectual Functioning ‣ “Rush” or “Intensity” Feeling ‣ Increased Heart Rate ‣ Shallow Breathing ‣ Perspiration- palms, underarms, etc. ‣ Reduced Intellectual Functioning ‣ “Rush” or “Intensity” Feeling

12. Substances of Mood ‣ Serotonin ‣ Dopamine ‣ Adrenaline ‣ Endorphins ‣ Oxytocin “the cuddle chemical” ‣ Serotonin ‣ Dopamine ‣ Adrenaline ‣ Endorphins ‣ Oxytocin “the cuddle chemical”

13. ADDICTS CALL IT… ‣ The Bubble ‣ The Trance ‣ Spaced Out ‣ Think... ‣ Dissociative State ‣ Mood Alteration ‣ Trauma ‣ The Bubble ‣ The Trance ‣ Spaced Out ‣ Think... ‣ Dissociative State ‣ Mood Alteration ‣ Trauma

14. In 12-Step Language... In 12-Step Language... POWERLESS! POWERLESS!

15. Sex Addiction is not about sex, it’s about the search for sex and desire for orgasm. It’s a ‘process’ addiction.

16. Sexual Addiction Symptoms in Residential or Outpatient Clients In the Client’s 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”. History of CD relapse – especially females Encouraging Dependency as a form of seduction Sneaking Porn into treatment - sharing porn in treatment. Consistent sexual references in jokes and conversation Consistent sexual objectification. Lack of empathy about how their sexual behavior affects others. Having sex while in treatment In the Client’s 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”. History of CD relapse – especially females Encouraging Dependency as a form of seduction Sneaking Porn into treatment - sharing porn in treatment. Consistent sexual references in jokes and conversation Consistent sexual objectification. Lack of empathy about how their sexual behavior affects others. Having sex while in treatment

17. Sexual Addiction Symptoms in Residential or Outpatient Clients In the Client’s History Multiple abortions (females), multiple STDs (both sexes) 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 Chronic or Compulsive Masturbation In the Client’s History Multiple abortions (females), multiple STDs (both sexes) 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 Chronic or Compulsive Masturbation

19. What makes online sex so popular and so exciting? ‣ ACCESSIBILITY ‣ AFFORDABILITY ‣ ANONYMITY ‣ ACCESSIBILITY ‣ AFFORDABILITY ‣ ANONYMITY Adapted from the “Triple-A Engine” Al Cooper PhD. 1998

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

21. Cybersex Addiction/Compulsivity: Range of Online Sexual Activities in 1999... ‣ View and download pornography with or without masturbation ‣ Visit sexually-oriented chat rooms to voyeur or hook up with someone ‣ Exchange sexually explicit e-mails ‣ Belong to online sex clubs, sex organizations or hooker review sites ‣ Engage in real-time one-on-one masturbation ‣ Plan ahead to sexually act out on the road ‣ Offender / Predator Behaviors ‣ Hire prostitutes to perform live sexual acts on command ‣ View and download illegal or deviant sexual images And in 2009.. All of the above, only faster. on cell phones, laptops, social networking (yelp, twitter etc.) and don’t forget SEXTING ‣ View and download pornography with or without masturbation ‣ Visit sexually-oriented chat rooms to voyeur or hook up with someone ‣ Exchange sexually explicit e-mails ‣ Belong to online sex clubs, sex organizations or hooker review sites ‣ Engage in real-time one-on-one masturbation ‣ Plan ahead to sexually act out on the road ‣ Offender / Predator Behaviors ‣ Hire prostitutes to perform live sexual acts on command ‣ View and download illegal or deviant sexual images And in 2009.. All of the above, only faster. on cell phones, laptops, social networking (yelp, twitter etc.) and don’t forget SEXTING

22. What’s the big deal It’s just a guy thing… What’s the big deal It’s just a guy thing…

23. Consequences of Compulsive Cybersex ‣ Loss of time for work, family, recreation ‣ Family violence / relationship loss ‣ Loss of job because of cybersex at work ‣ Guilt and shame due to keeping secrets ‣ Decreased interest in sex with spouse ‣ Increased preoccupation with sex ‣ Increased overall sexual objectification ‣ Children potentially exposed to porn ‣ Increased interest in deviant sex ‣ Potential arrest for illegal online sex ‣ Escalation to off-line sex ‣ Loss of time for work, family, recreation ‣ Family violence / relationship loss ‣ Loss of job because of cybersex at work ‣ Guilt and shame due to keeping secrets ‣ Decreased interest in sex with spouse ‣ Increased preoccupation with sex ‣ Increased overall sexual objectification ‣ Children potentially exposed to porn ‣ Increased interest in deviant sex ‣ Potential arrest for illegal online sex ‣ Escalation to off-line sex

24. ...Spouses and Partners And now a word or two about...

25. Treatment is the Reclaiming of Reality

26. Please find a partner to your left or right, decide which of you will ask questions and who will answer and then ask the following: 1- How often you drink alcohol and how much do you drink. 2- How often you masturbate and what fantasies you use when doing masturbating? 3- How often do you pay for sex... 1- How often you drink alcohol and how much do you drink. 2- How often you masturbate and what fantasies you use when doing masturbating? 3- How often do you pay for sex...

27. Initial Sexual Addiction Treatment is... Cognitive Behavioral and Task Oriented

28. Initial Focus of Sex Addiction Treatment ‣ Stop the acting out ASAP by making contracts and plans ‣ Confronting denial and teach relapse prevention ‣ Carefully reviewing a sexual history - ‣ Providing Appropriate Tasks and Interventions ‣ Spouse, job & family crisis resolution ‣ Shame reduction ‣ Holding the client accountable! ‣ 12-step, therapy or faith-based group referral ‣ Stop the acting out ASAP by making contracts and plans ‣ Confronting denial and teach relapse prevention ‣ Carefully reviewing a sexual history - ‣ Providing Appropriate Tasks and Interventions ‣ Spouse, job & family crisis resolution ‣ Shame reduction ‣ Holding the client accountable! ‣ 12-step, therapy or faith-based group referral

29. And Sexual Sobriety is… A clear and well defined written plan A clear and well defined written plan Based on client goals Based on client goals Mutually agreed upon Mutually agreed upon Signed Signed Sobriety plans are behavioral in nature Sobriety plans are behavioral in nature Sobriety plans flow from the goals of the client Sobriety plans flow from the goals of the client Doesn’t change without prior agreement Doesn’t change without prior agreement A clear and well defined written plan A clear and well defined written plan Based on client goals Based on client goals Mutually agreed upon Mutually agreed upon Signed Signed Sobriety plans are behavioral in nature Sobriety plans are behavioral in nature Sobriety plans flow from the goals of the client Sobriety plans flow from the goals of the client Doesn’t change without prior agreement Doesn’t change without prior agreement

30. Simple Sexual Sobriety Plan List of Behaviors I Want to Stop ‣ A ‣ B ‣ C ‣ D ‣ E ‣ F List of Behaviors I Want to Stop ‣A‣A ‣B‣B ‣C‣C ‣D‣D ‣E‣E ‣F‣F List of Behaviors I Want to Add ‣ A ‣ B ‣ C ‣ D ‣ E ‣ F List of Behaviors I Want to Add ‣ A ‣ B ‣ C ‣ D ‣ E ‣ F

31. Treatment Error Treatment Error Inadequate or poorly detailed history— (Not asking about prior arrests/offending behaviors etc. Unfamiliarity with resources (porn blockers, 12-step) Normalizing problematic sexual behavior Initially employing Psycho-dynamic, Analytic, Jungian and other non-cognitive behavioral method Not identifying triggers, patterns, rituals and behavioral escape methods (relapse prevention planning) Focusing too early on trauma Inadequate or poorly detailed history— (Not asking about prior arrests/offending behaviors etc. Unfamiliarity with resources (porn blockers, 12-step) Normalizing problematic sexual behavior Initially employing Psycho-dynamic, Analytic, Jungian and other non-cognitive behavioral method Not identifying triggers, patterns, rituals and behavioral escape methods (relapse prevention planning) Focusing too early on trauma

32. Treatment Error Treatment Error Not addressing the sexual behavior as the primary initial treatment focus Not properly understanding and/or pathologizing the depth of the betrayal, grief, loss and rage of the partners and spouses NOT HOLDING CLIENTS ACCOUNTABLE Not getting supervision / consultation Not utilizing 12-step programs, faith based support groups, group therapy and psycho-education Not processing countertransference. Not addressing the sexual behavior as the primary initial treatment focus Not properly understanding and/or pathologizing the depth of the betrayal, grief, loss and rage of the partners and spouses NOT HOLDING CLIENTS ACCOUNTABLE Not getting supervision / consultation Not utilizing 12-step programs, faith based support groups, group therapy and psycho-education Not processing countertransference.

33. 12-step Groups for Sexual Addicts and Partners 12-step Groups for Sexual Addicts and Partners Partner Support ‣ S-Anon ‣ Alanon ‣ COSA ‣ CODA ‣ RCA - Couples Partner Support ‣ S-Anon ‣ Alanon ‣ COSA ‣ CODA ‣ RCA - Couples Sex Addict Support ‣ SAA ‣ SA ‣ SCA ‣ SLAA-Women ‣ SRA Sex Addict Support ‣ SAA ‣ SA ‣ SCA ‣ SLAA-Women ‣ SRA

34. Treatment and Training Information ‣ The Sexual Recovery Institute www.sexualrecovery.com www.sexualrecovery.com ‣ IITAP - International Institute for Trauma, and Addiction Professionals www.iitap.com ‣ SASH - The Society for the Advancement of Sexual Health www.sash.net ‣T‣T he Sexual Recovery Institute www.sexualrecovery.com ‣I‣I ITAP - International Institute for Trauma, and Addiction Professionals www.iitap.com ‣S‣S ASH - The Society for the Advancement of Sexual Health www.sash.net

36. Untangling the Web: Treating Sex and Porn Addiction Robert Weiss LCSW, CSAT Executive Director The Sexual Recovery Institute www.sexualrecovery.com Robert Weiss LCSW, CSAT Executive Director The Sexual Recovery Institute www.sexualrecovery.com