John Berkowitz, LCSW and associates - Psychotherapist
Family Healing Center - Livingston & Teaneck, NJ
Sexual Addictions in Couples Counseling
There has been increased media coverage of celebrity relationships in recent months. Much of this questions whether sexual addiction exists or is an excuse for philandering.(1) Life Works, a UK-wide organisation that specialises in sexual addiction, has reported a 25 per cent increase in footfall at its clinic over the past six years. They put this down to increased awareness. ‘Behaviours haven’t changed in thousands of years – there just wasn’t any help before,’ says Life Works founder and chief executive Don Sarratt. In my own work as a relationship and family counsellor, supervisor and trainer, I have noticed an increase in individuals and couples presenting with sexual addiction.
Despite recent sexual addiction research(2) showing that relationship counselling plays only a small role in the treatment of sexual addiction, I would argue that sexual addiction issues are not new to couple work. In my practice it is quite common for supervisees to present issues related to sexual addiction in their couple work, requesting theoretical knowledge and practical training.
Carnes(3) defines sexual addiction as a ‘pathological relationship with a mood-altering chemical/experience’. Goodman(4) suggests that sexual addiction is characterised by two key features: ‘recurrent failure to control the behaviour’ and ‘continuation of the behaviour despite significant harmful consequences’. Other signs include:
Sexual addiction cycle
1. Preoccupation phase: the trance or mood where the addict’s mind is engrossed with thoughts of sex (often the most rewarding part of the cycle).
2. Ritualisation: the addict’s own special routines that lead to the sexual behaviour (this intensifies the preoccupation, adding to the arousal and excitement).
3. Compulsive sexual behaviour: the sexual act, the end goal of the preoccupation and ritualisation (addicts are unable to control or stop this behaviour).
4. Despair: the addict’s hopelessness about his/her behaviour and sense of powerlessness.
As well as this cycle there are often secrets and delusions that can lead to the following ethical dilemmas for both the addict and the counsellor.
These mainly occur around issues of trust, disclosure and health risks. For the client, conflict of issues such as being discovered or becoming infected can arise with high risk/excitement around multiple affairs, seductive role sex (serial conquests), paying for sex, anonymous sex, voyeurism (including pornography) and exhibitionism.
The counsellor may have dilemmas about limits of confidentiality relating to illegal sexual behaviours and professional boundaries in terms of the counsellor/client relationship. Leavitt(5) notes that secrets place the counsellor in a potentially powerful position, where one of the main dilemmas is in ‘playing God’. Thus there is a need for the counsellor to be clear about the ethical and legal limits of confidentiality. Leavitt argues that accountability with discretion is the ‘most helpful position for the couple counsellor, given the complexity of secrets, their gravity and consequences and that some secrets are better shared and some are better not’.
As my workload with sexual addiction increased I developed a way of working for practitioners, where individuals or couples present with sexual addiction within the couple context. This was done in the context of the integrative model of approach, method and technique.(6, 7)
Approach: the relational-integrative model
The theories within the relational-integrative model(6) are made up of three theoretical approaches: CBT, psychodynamic, systemic and attachment narrative therapy. These are based on the ability to:
In this way the theories can be integrated into an assessment and a six-stage therapeutic framework (developed from Relate’s five-stage model for working with adult survivors of sexual abuse within the couple context).
As it is important to locate assessment within a collaborative framework, client/s and counsellor jointly assess whether presenting issues are sexual addictions and explore options around the appropriateness of individual and/or couple work, separation work or referring on. Working ethically there is a need for the counsellor to accommodate clients in the way that best meets their needs and still work within his/her own competencies. Suitability for couple work depends on the addiction and co-addictive pre-recovery phases of the couple. Individual work may be needed prior to couple work and the eventual focus on the recovery of the relationship.
Method and technique: the six-stage therapeutic framework
In keeping with an integrated approach, the framework was developed using a circular and recursive process that allows the counsellor to operate from several stages simultaneously. This also allows the client to decide where in the process s/he wishes to begin.
1. Sexual addiction signs and cycle and the co-addictive pre-recovery stage:(8) Often the partner who presents with the sexual addiction attends counselling individually. The signs of addiction can be explored and the sexual addiction cycle drawn, with the client tracking the sexually acting out behaviours. The client’s co-addictive pre-recovery stage can also be explored. Signs/stages include:
2. Underlying factors and motivation for change: These relate to the intergenerational relational patterns and attachment styles of families of origin. Working with the couple’s family geneogram to uncover overt and covert messages about sexuality/intimacy, sexual values and gender issues is often illuminating. This can help explore couple fit and sexual connectedness. Other factors include themes of secrecy and ‘sinfulness’, early sexualisation, childhood trauma, abuse, neglect and sexual identity.
This work allows strong and painful feelings to emerge and time needs to be given to acknowledge, validate and address these. Only at this point can motivation for change be explored. This includes looking at the ambivalence and struggle between really ‘wanting to do it’ and really ‘wanting to stop’. Motivational interviewing using circular and reflexive questions(9) and paying attention to the ‘stage of determination’ is crucial. Developing hypotheses about relational patterns, lifestyles and rituals that can be changed is also important as these changes can lead to the restoration of trust and safety within the relationship.
3. Moving from ‘escape’ to ‘reality’: During counselling, sexually acting-out behaviours can become ‘live’ and need to be acknowledged and managed through transference and countertransference. As well as holding ethical boundaries it is important that the counsellor validates the client for being courageous enough to show the behaviours and invite a conversation about it. This duality helps bridge the gap for the client between ‘escape’ and ‘reality’. What happens relationally can then be connected to historical and current patterns, attachment styles and the couple fit.
4. Slips, lapses, relapses: A normal part of the recovery process which can be good learning in terms of identifying ‘danger zones’ and ‘safe zones’. Identifying healthy behaviours and what triggers movement into intermediate areas, lapses and relapses is important.
5. Re-storying intimacy: Having worked at a relational level the counsellor can invite story development through future-orientated questions and possibilities of emotional connectedness. Moving from a position of ‘I am the way I am’ to ‘I am the way I am influenced to be’, can help develop new stories of intimate communication and address fears of emotional closeness. White(10) notes that new stories can co-create and co-confirm new identities.
6. Developing healthy sexual relationships: Couple sexual counselling can be offered within the boundaries of the ‘human sexual response cycle’.11 Where there is sexual dysfunction, a referral to sex therapy may be appropriate. The couple may need to develop new understanding of sexuality and how to communicate sexually; why they behaved and acted the way they did; and what the feelings were about. They may then learn to tolerate vulnerability in themselves and each other.
Jim, a professional man in his 40s, attended individually for assessment. He presented with behaviours of seductive role sex, fantasy sex, and affairs (signs of sexual addiction). All Jim’s sexual activity was unprotected. Sarah, his wife, knew of the unprotected sexual activity, but not the affairs (secrets/ethical dilemmas). Jim worried about his distant relationship with his children, particularly with his son (underlying factors/motivation to change).
Exploring the couple’s relationship, Jim said there had been little sex because Sarah had had low sexual desire. Lately, however, Sarah had become as sexually active as Jim and his role in their relationship became one of recruiting ‘fuck buddies’ for them both (couple fit, signs, cycle of sexual addiction). The couple’s relationship appeared to be emotionally empty and Jim longed for emotional connectedness (motivation for change).
Tracking Jim’s sexual behaviours (sexual addiction cycle), his preoccupation began with the buzz of sexual fantasy and around his need to be found attractive and desirable (underlying factors). This phase triggered a mood altering experience that felt like intoxication that led to Jim ‘overdosing’ and becoming hostage to his own preoccupation. The thrill of ritualisation intensified to exhilaration when he persuaded others to break their own boundaries and values about sexual activity. Jim then described his and Sarah’s relationship as being ‘sexually on fire’. This became a shared focus of energy and excitement and appeared to cement the relationship (underlying factors/couple fit).
Sarah attended counselling individually. I wondered whether she was competing with Jim sexually (stage three/co-addictive pre-recovery) or displaying signs of her own sexual addiction. She thought her activities got Jim’s attention and, as long as no one got hurt, they could both continue their sexual behaviour. However, sex could only be achieved through fantasy (adopting a particular sexual identity) and Sarah believed that if this was given up, their sexual relationship would end and Jim might leave (underlying factors/couple fit). She was frightened to stop (motivation for change) and did not wish to continue counselling. At the same time, Jim constantly worried about being abandoned and throughout his childhood had felt alone. His father had questioned Jim’s parentage and when Jim was 11, his mother had an affair, bringing him along with her. When this became known, Jim became a tug-of-war between his older sisters and mother. Jim’s view of women split into ‘good’ and ‘bad’: women were either idealised as the ‘Madonna’ or demonised as the ‘whore’ (underlying factors).
During counselling, Jim’s sexual fantasy became ‘live’. He used sexually acting-out behaviours and tested whether he could split me into the idealised or the demonised woman. Together we explored what was happening relationally and linked our discussion to his past and present experiences (transference and countertransference). In this way, instead of sexually acting out his vulnerability, he was able to ‘be in it’ and explore his underlying emotions of insecurity and anxiety (moving from escape to reality). He gradually began to change his behaviours, no longer needing the intoxication of the addiction cycle. Nonetheless, there were moments during counselling when Jim was either tempted or lapsed into old behaviours (lapse/relapse). Exploring the triggers and underlying behaviours together with what was happening relationally within and between the couple, enabled Jim to get back on track (motivation for change). He began to co-create a new relationship with Sarah, confiding in her about his feelings and connecting with her in a more emotional and intimate way. Sarah was able to tolerate this and not hide from it (re-storying intimacy).
I invited conversations of new stories of a healthy sexual relationship and sexual identity, stories that integrate the authentic self rather than acting out (developing healthy sexual relationships). When counselling ended Sarah chose to continue with her sexual activities and Jim chose to still recruit her fuck-buddies. Jim has given up his fuck-buddies and hopes that Sarah will also. As Jim says, ‘It is a work in progress.’
This case study shows that sexual addiction can be viewed, and worked with, in the couple context. It is complex work and there is a need to embrace both the relational-integrated approach and the six-stage therapeutic framework. The six-stage framework is both flexible and adaptable enough to meet clients’ needs in either an individual or couple context. I believe that sexual addiction is very different from an excuse for philandering and if more counsellors are to work effectively in this field, then more insight and training is essential.
1.Hattersley G. News Review. The Sunday Times; 4 April 2010.
2. Bird MH. Sexual addiction and marriage and family therapy: facilitating individual and relationship healing through couple therapy. Journal of Marital and Family Therapy; July 2006.
3. Carnes PJ. Facing the shadow: starting sexual and relational recovery. Wickenburg AZ: Gentle Path Press; 2001.
4. Goodman A. Sexual addiction: an integrated approach. Madison: International University Press; 1998.
5. Leavitt J. Common dilemmas in couple therapy. London: Routledge; 2010.
6. Faris A, van Ooijen E. Integrating approaches. Therapy Today. 2009; 20(5):24-27.
7. Burnham J. Approach – method – technique: making distinctions and creating connections. Human Systems. 1992; 3(1):3-26.
8. Coombs RH. Handbook of addictive disorders. New Jersey: John Wiley; 2004.
9. Tomm K. Interventive interviewing: intending to ask clinical, circular, strategic or reflexive questions. Family Process. 1998; 27(3):1-15.
10. White M, Epston D. Narrative means to therapeutic ends. Norton USA; 1990.
11. Masters WH, Johnson VE. Human sexual response. California: Ishi Press International; 2010.
content © John Berkowitz 2015