Cognitive-behavioral therapy in the treatment of sex addiction

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

The philosophical basis of cognitive therapy goes back to the Stoic philosophers, who taught that it is not the external event that causes our distress, but our perception or interpretation of the event that is distressing. According to the Stoics, people are able to consider alternative perceptions or interpretations by changing the thoughts that underlie distress.

Cognitive models became popular in the early 1960s. Proponents of this school assume that client problems occur on two levels. The first is overt difficulty, such as depression or sex addiction. The second involves addressing the underlying psychological mechanisms and psychological cognitive distortions, which typically involve irrational beliefs that cause addictive behaviors.

Cognitive-behavioral therapies conceptualize psychological problems primarily in terms of maladaptive learning and are geared toward helping the individual learn more adaptive patterns of thought and action. This technique is generally related to interventions that are directive, practical, task-oriented, and educational in nature.

It is important to understand the main premise of cognitive approaches to treatment: the manifest problem (sex addiction) originates within what cognitive behaviorists call the client’s schemata. This is a person’s worldview, or core belief system. The focus of this approach is how the client maintains painful, harmful, or irrational behaviors. The main approach uses some form of debate. This involves pointing out to clients the irrationality of certain thoughts, beliefs, and perceptions and the construction and rehearsal of rational self-statements or other more functional cognitive skills and strategies.

My approach when working with a cognitive model includes:

1. The focus is on stopping unwanted sexual behavior. Behavior modification techniques (Relapse Prevention Skills) and/or pharmacotherapy are used to help clients achieve abstinence.

2. This is the “admission” stage and requires the patient to accept the existence of a problem and promise not to keep secrets from the therapist.

3. At this stage, patients are taught stress management techniques so that they no longer need to rely on sexual behavior to relieve their anxiety. I recommend physical exercise and teach a combination of breathing techniques, progressive relaxation, meditation, and hypnosis to show clients that they have some power over their internal states.

4. This may be the most important stage of the program. It consists of a cognitive therapy aimed at repudiating the irrational beliefs that underlie sexual addiction through active questioning. Allows clients to develop an awareness of beliefs. By asking questions, clients develop insight into their thought processes and how these influence their emotions and behavior. Consequently, the client becomes aware of the inappropriate beliefs and is helped to challenge them and change their behavior. The process involves asking questions that support or refute the thought, asking about possible alternative explanations. Ask about the range of consequences of the thought and its impact on the person and what would be the effects of believing the thought or changing their way of thinking.

5. Patients are trained in skills such as assertiveness and problem solving to facilitate adaptive social functioning.

6. The focus is on resolving any problems the person has had in establishing and maintaining a primary sexual relationship.

7. Learn what thought processes lead to “setting yourself up” to relapse.

8. Develop a positive attitude towards healthy sex; cultivate an appreciation for a partner’s needs, learn pleasurable skills, use sex therapy if sexual dysfunction is present.

9. Generate pleasant and sober activities and relationships: build a life worth living.

The sex addict depends on sex to satisfy emotional needs that cannot be met through healthy coping skills. Sex becomes a coping mechanism to deal with stress, shame, guilt, and isolation. It’s a way to connect without risking privacy.

However, the addiction is never satisfied because sex is unable to satisfy these needs because its source is historical and the need is too great. Furthermore, the needs of the true self can never be satisfied by sexual activity.

Patrick Carnes exposes the unconscious belief systems that all sex addicts need to refute.

1. I am basically a bad and worthless person.

2. Nobody would love me as I am.

3. My needs will never be met if I have to depend on others.

4. Sex is my most important need.

While these are the core dysfunctional beliefs, there are many more beliefs, attitudes, or “cognitive schemas” that keep the addictive cycle in place. From my experience, some of them are:

• I am unable to tolerate boredom; acting out sexually is a good way to fill the time.
• If I don’t get distracted by sex, I am filled with an intolerable feeling of emptiness.
• Men are more motivated by sex than women. As a man, I need to unleash that impulse, or I’ll go crazy.
• My sense of identity is determined by how many women are attracted to me.
• The vicissitudes of life are boring or unmanageable. There is no pleasure in everyday life except in my “secret” world.
• Sex with my partner is a numbing, mechanical process that lacks spontaneity and excitement.
• If life does not provide excitement and high stimulation, then I will be bored and depressed forever.
• When I have the need or the urge to act sexually, I must succumb to that need.
• For me to be a real man, I must have sex with as many women as I can. Also, as a man, I am responsible for my partner’s pleasure through intercourse. To fail in intercourse is to fail as a man.
• Engaging in cybersex is my only means of getting away from the stress and frustration of life.
• Sexuality is the only reliable means of relating to others.
• I depend on sex to meet emotional needs that I cannot meet through healthy coping skills.

The addiction is self-perpetuating; it feeds on itself due to ingrained core beliefs as well as each individual’s dysfunctional beliefs about sex. To change the addictive cycle, one must change the belief systems that support it.

Dysfunctional beliefs give rise to rationalization, minimization, and justification. The addict, as the disease progresses, begins to view the world through cognitive distortions designed to protect her sexual performance. His entire perspective is distorted to the point where he loses more and more contact with reality.

In treatment, changing these beliefs is key. Changing core beliefs is challenging because they were imprinted at a young age and have remained stable over time. Another reason that change is difficult is that these beliefs live in the unconscious mind. The addict lacks awareness of their self-defeating beliefs. How can you change something you don’t even know you have? The cognitive therapist will elicit these attitudes and beliefs and provide alternative ways of thinking and perceiving.

Sometimes I use hypnosis to access the subconscious mind where beliefs, attitudes, and cognitive schemas can become conscious and contested.

I highly recommend David Burn’s book “Feeling Good”. In it he lists 10 cognitive distortions and ways to dispute them. He studies cognitive distortions so you can begin to see how they operate in your life and shift them into a realistic and rational thought process.

Other reading

Kouimtsidis, C. et. para. (2007) Cognitive-Behavioral Therapy in the Treatment of Addictions. John Wiley & Sons, Ltd.

Lewis, LA (1994) Sobriety Demystified: Cleanliness and Sobriety with NLP and CBT. Publisher Kelsey & Co.

Schwartz, MF & Brasted, WS (1985) Sexual addiction. Medicine. Asp. Hmm. Sex., 19; 103-107.