This article was downloaded by: [University of Sussex Library] On: 16 January 2015, At: 20:46 Publisher: Routledge Informa Ltd Registered in England and Wales Registered Number: 1072954 Registered office: Mortimer House, 37-41 Mortimer Street, London W1T 3JH, UK
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Sexual Addiction: Designation and Treatment Aviel Goodman Published online: 14 Jan 2008.
To cite this article: Aviel Goodman (1992) Sexual Addiction: Designation and Treatment, Journal of Sex & Marital Therapy, 18:4, 303-314, DOI: 10.1080/00926239208412855 To link to this article: http://dx.doi.org/10.1080/00926239208412855
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Sexual Addiction: Designation and Treatment
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
A V I E L GOODMAN
While there is general agreement that the pattern of behavior described as “sexual compulsivity ” or ‘Sexual dependency” or “sexual addiction” does exist, considerable controversy surrounds the issue of how this syndrome should be designated. The principle candidates-compulsiuity, dependency, and addiction-re examined, and addiction is found to be the most suitable term. Addiction is then clearly &fined, and diagnostic criteria for addictive disorder are specified. After the definition of and diagnostic criteria for sexuul addiction are presented, arguments against the concept of sexual addiction are reviewed and answered. Implications of this concept for treatment are then explored. Over 100 years ago, Krafft-Ebbing’ described a condition in which a person’s sexual appetite is abnormally increased to such an extent that it permeates all his thoughts and feelings, allowing of no other aims in life, tumultuously, and in a rutlike fashion demanding gratification without granting the possibility of moral and righteous counter-presentations, and resolving itself into an impulsive, insatiable succession of sexual enjoyments. . . . This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom and even his life. (pp. 70-71) While there is general agreement that the pattern of behavior that corresponds to this description does exist,* considerable controversy surrounds the issue of how it should be designated. T h e principle candidates include “sexual compulsivity,” “sexual dependency,” and “sexual addiction.” Examination of these terms reveals that the one most suitable for designating this syndrome is sexual addiction. T h e definition of and diagnostic Address correspondence to Aviel Goodman, M.D., Director, Minnesota Institute of Psychiatry, 1347 Summit Avenue, St. Paul, MN 5510.5-2219.
Journal of Sex & Marital Therapy, Vol. IS, No. 4, Winter 1992 0 BrunnerlMazel, Inc. 303
304
Journal of Sex t 3 Martla1 Therapy, Vol. 18, No. 4, Winter I992
criteria for sexual addiction are presented, followed by a review of arguments against this concept. Finally, implications of the sexual addiction concept for treatment are considered.
COMPULSIVITY,DEPENDENCY,OR ADDIClION? Compulsivily (or compulsion) refers to behavior motivated by an attempt to evade or avoid an un leasurable/aversive internal state. Quadland3 and Weissberg and Levay have argued in favor of designating the condiDownloaded by [University of Sussex Library] at 20:46 16 January 2015
r
tion described above as compulsive sexual behavior, or sexual compulsivity. They emphasize the defensive function of the sexual activity, how it operates to reduce anxiety or some other painful affect. And they note that when sexual activity is blocked, the individual suffering with this condition experiences discomfort. T h e definition of compulsive behavior, however, also entails “behavior that is not enjoyed o r seen as an end in i t ~ e l f(p. ’ ~ 21). As Coleman‘ has observed, many of these sexual behaviors cannot be considered compulsive “because compulsion is currently defined as a compelling activity from which the person derives no pleasure” and people with this condition “often describe great pleasure before and during the sexual activity itself’ (p. 8). l h e DSM-Ill-R’ explicitly stated, “Some activities, such as eating (e.g., Eating Disorders), sexual behavior (e.g., Paraphilias), gambling (e.g., Pathological Gambling), or drinking (e.g., Alcohol Dependence or Abuse), when engaged in excessively may be referred to as ‘compulsive.’ However, the activities are not true compulsions because the person derives pleasure from the particular activity, and may wish to resist it only because of its secondary deleterious consequences” (p. 246). Dependency (or dependence) refers to behavior motivated by an attempt to achieve a pleasurable internal state via gratification of needs, basic or derived. While the concept of sexual dependency is consistent with the pleasure people derive from the sexual activity, it neglects the defensive character of the behavior-its function in averting painful affects. T h e pattern of sexual behavior with which we are here concerned involves both gratification and escape from internal discomfort. Hence, neither cornpulsivity nor dependency is adequate to characterize it. The concept of d i c t i o n suffers from lack o f a generally recognized definition that is clear and meaningful. This issue will be addressed in the following section. For the purpose of the present discussion, it is sufficient to observe that addiction refers to a behavior pattern essentially characterized by 1) loss of control, and 2) continuation despite harmful consequences. Addictive behavior is moreover distinguished by the capacity both to produce pleasurable effects and to provide a means for evasion of painful internal states. Addiction thus entails a synthesis of dependency and compulsivity, and is alone among these terms in its ability t o adequately characterize a pattern of sexual behavior which involves both gratification and escape from internal discomfort.
Sexual Addiction
305
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
DEFINITION OF SEXUAL ADDICTION Carnes’ defined addiction as “a pathological relationship with a moodaltering experience” (p. 4). This formulation represented an advance from earlier definitions, since it implied that:l) the basis of addiction is not a substance or a behavior but an alteration of the emotional state (consistent with the discussion in the preceding section); and 2) whether a behavior pattern qualifies as an addiction is determined by how it relates to the individual’s life (“pathological relationship”). Carnes’s definition, however, is susceptible to the criticism most often directed against the concept of addiction: that it is vague and imprecise, and so all-inclusive as to leave the term virtually devoid of pragmatic value. Unless this definition of addiction is followed by a specific definition of “pathological relationship,” it does not provide enough information to be useful in a scientific context. In recent paper^,^.'^ I introduced a definition of addiction that shared the advantages of Carnes’s definition, yet was sufficiently specific to be scientifically useful. Addiction was defined as a disorder in which a behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the behavior, and 2) continuation of the behavior despite significant harmful consequences. This definition is, in part, comparable to the initial statement in DSM-III-R’ regarding Psychoactive Substance Dependence: “The essential feature of this disorder is a cluster of cognitive, behavioral, and physiologic symptoms that indicate that the person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences” (p. 296). T h e definition of addiction was supplemented by a set of diagnostic criteria for addictive disorder, which were presented in a format similar to that of DSM-III-R: Addictive Disordtr (or Addiction) A. Recurrent failure to resist impulses to engage in a specified behavior. B. Increasing sense of tension immediately prior to initiating the behavior. C. Pleasure or relief at the time of engaging in the behavior. D. At least five of the following: 1) frequent preoccupation with the behavior or with activity that is preparatory to the behavior 2) frequent engaging in the behavior to a greater extent or over a longer period than intended 3) repeated efforts to reduce, control, or stop the behavior 4) a great deal of time spent in activities necessary for the behavior, engaging in the behavior, or recovering from its effects 5 ) frequent engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations
3 06
Journal of Sex U Marital Therapy, Vol. 18, N o . 4, Winter 1992
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
6) important social, occupational, or recreational activities given up or reduced because of the behavior 7) continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior 8) tolerance: need to increase the intensity or frequency of the behavior in order to achieve the desired effect, or diminshed effect with continued behavior of the same intensity 9) restlessness or irritability if unable to engage in the behavior E. Some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a long period of time. ’The definition of and diagnostic criteria for sexual addiction are then derived from the definition of addiction and the list of diagnostic criteria for addictive disorder by substituting “sexual behavior” for “behavior.” Accordingly, sexual addiction is defined as a disorder in which a sexual behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the sexual behavior, and 2) continuation of the sexual behavior despite significant harmful consequences. T h e diagnostic criteria are as listed below: Sexual Addiclion A. Recurrent failure to resist impulses to engage in a specified sexual behavior . R . Increasing sense of tension immediately prior to initiating the sexual behavior. C. Pleasure or relief at the time of engaging in the sexual behavior. D. At least five of the following: 1) frequent preoccupation with the sexual behavior o r with activity that is preparatory to the sexual behavior 2) frequent engaging in the sexual behavior to a greater extent or over a longer period than intended 3) repeated efforts to reduce, control, or stop the sexual behavior 4) a great deal of time spent in activities necessary for the sexual behavior, engaging in the sexual behavior, or recovering from its effects 5) frequent engaging in the sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations 6) important social, occupational, or recreational activities given u p or reduced because of the sexual behavior 7) continuation of the sexual behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the sexual behavior 8) tolerance: need to increase the intensity or frequency of the sexual behavior in order t o achieve the desired effect, or diminished effect with continued sexual behavior of the same intensity
307
Sexuul Addiction
9) restlessness or irritability if unable to engage in the sexual behavior E. Some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a longer period of time.
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
REVIEW OF ARGUMENTS AGAINST T H E CONCEPT OF SEXUAL ADDICTION Arguments against the concept of sexual addiction may be organized into four categories: sociological, conventional, moral, and scientific. Each will be reviewed in turn. Sociologzcal
Sociological arguments against the concept of sexual addiction revolve around the idea that “addiction” is no more than a label for behavior that deviates fro’m social norms. This viewpoint is represented by statements of Levine and Troiden’l that “sexual addiction and sexual compulsion represent pseudoscientific codifications of prevailing erotic values rather than bona fide clinical entities” (p. 349) and that “psychosexual disorders are social constructions: that is, stigmatizing labels attached to sexual patterns that diverge from culturally dominant sexual standards’’ (p. 355). As Coleman‘ observed, sociological theorists are concerned that “this concept can potentially be used to oppress sexual minorities . . . because they do not conform to the moral values of the prevailing culture (or therapist)” and that “mental health professionals using such conceptualizations have become simply instruments of such conservative political views and have made people who d o not fit into a narrow, traditional sexual lifestyle feel bad, immoral, and, now mentally ill” (p. 8). These are cogent and powerful criticisms, but they are not applicable to sexual addiction as formulated in the preceding section. This definition of sexual addiction is quite consistent with Levine and Troiden’s” statement that “there is nothing inherently pathological in the conduct that is labeled sexually compulsive or addictive” (pp. 355-356). Contrary to their assumptions, no form or pattern of sexual behavior is in itself defined as an addiction. Any sexual behavior that can function both to produce gratification and to provide escape from internal discomfort has the potential to be engaged in addictively, but constitutes a sexual addiction only to the extent that it occurs in a pattern that meets the diagnostic criteria outlined above. It is not the type of behavior, its object, its frequency, or its social acceptability that determines whether a pattern of sexual behavior qualifies as sexual addiction; it is how this behavior pattern relates to and affects the individual’s life, as specified by the diagnostic criteria. Other sociological arguments are less readily dismissed. Coleman‘ noted that “no matter how one defines sexual compulsivity or addiction, there seems to be an implicit comparison to normalcy” (p. 8) and that
journal of Sex &? Marital Therapy, Vol. 18, N o . 4 , Winter 1992
308
global assessment concepts such as preoccupation, out of control, unmanageability, and negative conse uences are potentially subjective and value-laden assessments. Orford’ observed that control/uncontrol is not a dichotomy but a continuum with arbitrary cut-off points, and reiterated Kinsey’s argument that “it is impossible to separate normal and abnormal in other than an arbitrary way”* (p. 302). Levine and Troiden” emphasized that these distinctions depend on the therapist’s value orientation and purposes, as well as culturally induced perceptions of what constitutes sexual impulse control. There is no question that all the assessments specified or implied in the diagnostic criteria for sexual addiction represent continua rather than dichotomies, and that the distinctions between “pathological” and “healthy” are ultimately arbitrary and reflect the values of the culture and the therapist. These points are, however, no more applicable to sexual addiction than to addictive disorders involving other behaviors, and indeed to virtually all medical diagnoses. T h e distinctions in medicine between disease and health are sociohistorically relative (not absolute) points on continua, and reflect the underlying assumptions and values of the culture and the p h y ~ i c i a n . ’ ~ . ’ ~
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
9
Conventional
A number of arguments against the concept of sexual addiction emerge from conventional assumptions about addiction. A frequent objection is based on the idea that addiction is a physiolo ical condition and must be physiologically defined. Levine and Troiden“ argued that “sex is not a form of addiction. Strictly speaking, addiction is ‘a state of physiological dependence on a specific substance arising from habitual use of that substance.’ They further objected that “abrupt withdrawal from sexual behavior does not lead to forms of physiological distress” (p. 356). However, as Coleman6 observed, “Our conception of addiction has changed over the years and is no longer as physiologically defined” (p. 8). DSMI I I-R diagnostic criteria for substance dependence, the prototypal addiction, are formulated in behavioral and experiential terms that are actually less restrictive than the diagnostic criteria for addictive disorder presented in the preceding section. Physical withdrawal symptoms are not necessary for the diagnosis of dependence on any substance (as long as three of the other seven criteria on the list are fulfilled) and are generally not observed during withdrawal from a number of addictive substances, including cannabis, psychedelics, and phencyclidine (PCP). Current psychobiological theories of addiction to alcohol and other drugs tend to emphasize emotional effects the addicts wish to achieve15 and the activation of centrally coded affect systemsl6 rather than unmediated chemical effects or physical withdrawal symptoms. Objections of the sort raised by Levine and Troiden may also be answered at a more basic level. Their arguments presuppose a dichotomy between psychological conditions and physiological conditions, and claim that the sexual syndrome belongs to the former class while addiction belongs to the latter. Meanwhile, contemporary psychiatric and philosophical theory affirms an essential ”
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexuul Addiction
309
unity of psychological and physiological, in which every psychological process is identical to o r correlated with some physiological process.” Thus, it is not meaningful to speak of dependence or distress that is psychological but not physiological. Other arguments against sexual addiction derive from assumptions about what is implied by the term “addiction.” Coleman6 stated, “The danger of describing sex as an addiction is that it presupposes that the individual is addicted to all forms of sexual behavior rather than a specific sexual object or set of sexual behaviors, and following this model, suggests abstinence as a treatment goal” (p. 7). T h e first assumption, that sexual addiction presupposes addiction to all forms of sexual behavior, is comparable to the statement that drug addiction presupposes addiction to all types of drugs. These statements are valid only to the extent that addiction is understood as a process involving a propensity to engage in a behavior in addictive ways, and not as actual addictive manifestation of the behavior itself. A sexually addicted person will tend to “specialize” in only one or a few types of sexual behavior, much like a drug addicted person will tend to specialize in only one or a few types of drugs. And, similar to drug addiction, in which drugs other than the drug of choice retain the potential to be used addictively, forms of sexual behavior that are not the sex addict’s act of choice remain in the domain of the addictive process. It is, however, not the case that a sexually addicted person by definition addictively engages in all types of sexual behavior, any more than a drug addict by definition addictively uses all types of drugs. T h e assumption that treatment of an addictive disorder necessitates lifelong abstinence also merits a closer look. There is a flurry of research in the field of alcoholism concerning whether a person who once used alcohol addictively can ever drink in moderation. This is mentioned without endorsement of a position on either side of this question, only to illustrate that the necessity of lifelong abstinence is an issue of science to be evaluated empirically, not an issue of dogma to be affirmed without question. We can also observe that what is said to constitute abstinence for an alcoholic or drug addict may entail some arbitrary distinctions, since people recovering from addiction to alcohol or controlled substances are not always required to abstain from nicotine and caffeine (which are also mood-altering, potentially addictive drugs). Finally, o u r approach to understanding the concept of abstinence in sexual addiction can benefit from looking at its meaning in the context of addictive use of food, which is more similar to sexual addiction than is alcoholism and other drug addictions in that absolute lifelong abstinence from natural processes like ingesting food or engaging in sexual behavior is rarely a reasonable option. We can see that:l) a person may use some foods in addictive ways (to escape internal discomfort as well as to provide gratification) and some foods in healthy ways (to nourish the body as well as to provide gratification); 2) which foods are used in which way may vary from person to person; and 3) which foods are used in which way by one person may change over time. Hence, what constitutes abstinence in recovery from food addiction depends on which foods are being used
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
310
Journal of Sex k? Marital Therapy, Vol. 18, No. 4 , Winter 1992
in addictive ways, and how addictive use of food may be distinguished from healthy use of food for that individual. At this time, abstinence in recovery from sexual addiction tends to be defined in one of three ways: 1) according to arbitrary but meaningful distinctions between acceptable and unacceptable sexual behaviors (as in the support group Sexaholics Anonymous); 2) according to which sexual behaviors are being used in addictive ways (as in Sex Addicts Anonymous); or 3) according to how addictive use of sex may be distinguished from healthy use of sex for that individual (as in Sex a n d Love Addicts Anonymous). I n no case is lifelong abstinence from all sexual behavior a goal of treatment or a condition of recovery. Moral Moral arguments against the concept of sexual addiction a r e based o n a concern that the designation of this pattern of sexual behavior as an addiction undermines individuals’ responsibility for their behavior. This concern is shared by groups at opposite ends of the political spectrum. Those at the conservative end fear that the concept of sexual addiction may be employed to absolve individuals of responsibility, that sex addicts will not be held accountable for the consequences of their behavior. Meanwhile, those at the liberal e n d fear that the concept of addiction may be used to deprive individuals of personal responsibility a n d freedom of choice, defining sex addicts as victims who must be saved, even i f they d o not want to be.” These concerns reflect a failure to grasp a basic principle of medical care, which is captured in the Alcoholics Anonymous aphorism, “ T h e alcoholic is not responsible for his disease, but is responsible for his recovery.” Like alcoholics a n d d r u g addicts, sex addicts a r e not responsible for having their addiction, nor for the feelings, fantasies, and impulses it entails; but they a r e responsible for what they do about their addiction and for how they act in response to their feelings, fantasies, and impulses. This distinction-between responsibility for the disease and responsibility for recovery-also applies to other medical conditions, and failure to appreciate it has been a major factor in undermining the medical model. In the treatment of sexual addiction, responsibility actually plays a central role. Responsibility for consequences of their addictive sexual behavior is usually what propels sex addicts into treatment and provides the wedge to break through their denial. Also, sense of responsibility for their own recovery is much of what sustains sex addicts’ willingness t o continue in a growth process that is often challenging and painful. Scicn t ijic
What are here termed the scientific arguments against the concept of sexual addiction were enumerated by Coleman.6 T h e first, a philosophical or semantic argument, is that free use of the w o r d “addiction” has
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexual Addiction
311
rendered the term meaningless, so all-inclusive that it lacks pragmatic value. This problem with the term is what rompted the proposed definition and diagnostic criteria for addiction8O cited in the preceding section. T h e proposed definition is scientifically meaningful, and the diagnostic criteria are more restrictive (less inclusive) than comparable criteria in DSM-111-R. T h e next, a clinically based objection, is that many of the people who are treating those with sexual addiction have not been properly trained. To whatever extent this may be valid, it is not an argument against the concept of sexual addiction, rather an argument in favor of better training. Effective treatment of sexual addiction requires understanding not only of addictions, but also of psychodynamics, family systems theory, group dynamics, and cognitive-behavioral therapy. The ability to recognize major mood disorders and psychotic disorders is also necessary, as is a high level of self-awareness and ability to manage in healthy ways one’s own issues and feelings. T h e scarcity of this combination of qualities may suggest that reassessment of education in the mental health fields is indicated, but it is no indictment of the sexual addiction concept. Coleman’s6 final scientific argument concerns the lack of research “which documents the existence of such a conceptualization” (p. 8) and the lack of research which documents the effectiveness of treatment methods derived from these concepts. This paper was intended to address the first concern and to indicate not only the concept’s existence, but also its value. T h e second concern represents not an argument against sexual addiction, but a call for treatment effectiveness research. This is a critical need in the field of sexual addiction, as it is in the mental health fields generally, particularly in view of third party payers’ eagerness to deny reimbursement for mental health treatment. IMPLICATIONS FOR TREATMENT ‘The designation of this condition as an addiction entails two primary sets of implications for treatment. T h e first set derives from the recognition that addiction involves both compulsion (motivation to evade or avoid an unpleasurable/aversive internal state) and dependence (motivation to achieve a pleasurable internal state). Optimal treatment thus requires that both compulsion and dependence processes be addressed. It is necessary to treat the internal discomforts from which the sexual behavior had provided escape by means of pharmacotherapy (antidepressants, stabilizers such as lithium and carbamazepine, and more rarely antipsychotics or anxiolytics) or psychotherapy (to promote resolution of internal conflicts, enhanced ego and superego integration associated with improvement in regulation of affect and self-esteem, and so on), or a combination of pharmacotherapy and psychotherapy. It is also necessary to foster the individual’s development of healthier, more adaptive means for meeting the needs that the addictive sexual behavior was intended to gratify. In addition to individual psychotherapy, twelve-step groups and other supportive or therapeutic groups may be particularly valuable in
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
312
Journal of Sex
W
Marital Therapy, Vol. 18, No. 4 , Winter 1992
this regard. A further corollary is that treatment methods that fail to address both the compulsive and the dependent components of this syndrome, including antiandrogen drugs and aversive conditioning to sexual stimuli, are unlikely to be effective unless combined with other modalities that d o address these processes. T h e second set of implications concerns the relationship between sexual addiction and other addictions, and relates to treatment of addiction generally. T h e diagnostic criteria for addictive disorder presented above are general and not specific to any particular form of behavior. They represent a set of relationships between a pattern of behavior and certain other processes or aspects of a person’s life. Addiction is essentially detined as a pattern of behavior characterized by loss of control and continuation despite harmful consequences. This pattern is common to all addictions, by definition, whatever the behavior involved. T h e inference system of medical science suggests that similarities in patterns of symptomatic relationships are likely to reflect similarities in an underlying disease process. We may then hypothesize that the different addictive disorders have in common an underlying disease process, in other words, that the set of addictive disorders is most accurately described, not as a variety of addictions, but as a basic underlying addictive process, which may be expressed in one or more of various behavioral manifestations. This hypothesis concerning an underlying addictive process is continuous with an inte rative approach to etiology and the treatment of addictive disorders!’ In the course of healthy growth, people develop effective, adaptive means of regulating their feelings and their sense of self. When some combination of genetic and environmental factors interferes with development of these self-regulatory processes, people are more vulnerable to being overwhelmed by intense feelings or by loss of selfcoherence. And they may learn that they can ward off these traumatic states by taking in a substance (like food, or alcohol, or other drugs) or by engaging in some other rewarding activity (like sex, or gambling, or stealing). T h e essential process, the addictive process, is the compulsive dependence on an (apparently self-initiated and self-controlled) external action in order to regulate the internal state. Once this process has been developed, the intelligent human organism has the flexibility to shift among various actions or to combine them, according to the requirements and limitations of the situation. Sexual addiction is thus not a bizarre aberration, nor a new fad, nor even a unique disease. I t is simply the addictive process being expressed through sex, the compulsive dependence on some form of sexual behavior as a means of regulating one’s feelings and sense of self. An effective program for the treatment of a person who wants to recover from sexual addiction, or from any addictive syndrome, must consequently address not only the addictive behavior, but also the underlying addictive process. This is particularly important when the behavior used addictively also plays a role in healthy functioning, for example, eating or sexual behavior. Lifelong abstinence from all forms of the behavior is then neither a realistic nor a desirable goal. T h e all-or-nothing
313
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexual Addiction
orientation typical of addicted people is then inapplicable, and it is necessary for the individual to undergo the changes in personality that enable healthy moderation. Progress in recovery from addiction is a function of development of healthy, adaptive means for managing feelings, getting needs met, and resolving inner conflicts. This, in turn, depends on awareness of feelings, needs, and inner conflicts, as well as identification and challenging of maladaptive core beliefs. Treatment, thus, first of all requires abstinence from addictive behavior, which would otherwise operate to distort or prevent this inner awareness. What constitutes abstinence from addictive behavior for a given person depends on which behaviors are being used addictively and on how addictive use of a behavior may be distinguished from healthy use of a behavior in that individual. Treatment itself may then be conceptualized as three interrelated processes: 1) fostering awareness of feelings, needs, inner conflicts, and core beliefs, particularly as they arise in the context of interpersonal relationships; 2) encouraging development of more healthy, adaptive means for managing feelings, getting needs met, and resolving inner conflicts; and 3) more directive, cognitive-behavioral teaching of effective strategies for maintaining abstinence from addictive behavior.
CONCLUSION This essay began with a search for the most appropriate term to designate a maladaptive pattern of sexual behavior. Consideration of the alternatives indicated that “sexual addiction” is the most suitable. Addiction was defined as a process whereby a behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the behavior, and 2) continuation of the behavior despite significant harmful consequences. A formal delineation of diagnostic criteria for addictive disorder was also presented, specified in a format similar to that of DSM111-R.After a definition of and diagnostic criteria for sexual addiction were derived from those for addiction and addictive disorder, arguments against the concept of sexual addiction were reviewed and answered. T h e final section explored theoretical and practical implications concerning treatment of sexual addiction and of addictive disorders generally. What emerged constitutes a true actualization of the biopsychosocial model of illness and health, indicating a practical as well as conceptual integration of addictionology, biological psychiatry, psychodynamic theory, cognitive-behavioral psychology, family systems theory, and group dynamics.
REFERENCES 1 . Krafft-Ebbing R: Psychopathia sexualis (F.J. Kebrnan translation), New York, Paperback Library, 1965 (first edition, 1886). 2. Orford J : Hypersexuality: Implications for a theory of dependence. Br J Addict 73:299-310, 1978.
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
314
Journal of Sex E3 Marital Therapy, Vol. 18, No. 4, Winter 1992
3. Quadland MC: Compulsive sexual behavior: Definition of a problem and an approach LO treatment.] Sex Marital Ther 11(2):121-132, 1985. 4. Weissberg J H , l m a y AN: Compulsive sexual behavior. Med Asp Hum Sex 20(4):127-128, 1986. 5 . Barth R J , Kinder BN: T h e mislabeling o f sexual impulsivity. J Sex Marital Ther 13(1): 15-23, 1987. 6 . Coleman E: Sexual compulsion vs. sexual addiction: T h e debate continues. SIECUS Rt/10rlJuly:7-11, 1986. 7. American Psychiatric Association: Diuposlic and stalkfical manual of m n h l disora’ers (3rd ed, rev). Washington, DC, APA, 1987. 8 . Carnes P: Out of the shadows: Understanding sexual addiction. Minneapolis, CompCare, 1983. 9. Goodman A: Addiction: Definition and implications. BrJ Addicl85: 1403-1408, 1990. 10. Goodman A: Addiction concept involves theoretical and practical issues. Psychiatric Times 8(6):29-33, 1991. 1 1 . 1,evine MP, l’roiden RK: T h e myth of sexual compulsivity../ Sex Res 25(3):347-363, 1988. 12. Orford J: Excessive appetifes: A psychologd view of addiction. Chichester, Wiley, 1985. 13. Agich GJ: Disease and value: A rejection of the value-neutrality thesis. Theor Med 4:27-4 I , 1983. 14. King 1,s: What is disease? Phil Sci 2 1 : 193-20, 1954. 15. C o x W M , Klinger E: A motivational model of alcohol use.JAbnPsych 97(2):168-180, 1988. 16. Baker T I % ,Morse E, Sherman JE: T h e motivation to use drugs: A psychobiological analysis of urges. In PC Rivers (ed), Nebraska symposium on motivation: Vol. 34. Alcohol and addictive behavior (pp. 257-323). Lincoln, University o f Nebraska Press, 1987. 17. Goodman A: Organic unity theory: T h e mind-body problem revisited. AmJ Psychiatry f48(5):553-563, 199 1. IS. Szasz T: Ceremonial chemisfly. Garden City, Anchor Press/Doubleday, 1974. 19. Goodman A : T h e addictive process: A psychoanalytic understanding. J AmPr Ac Psychoanal, in press.
Journal of Sex & Marital Therapy Publication details, including instructions for authors and subscription information: http://www.tandfonline.com/loi/usmt20
Sexual Addiction: Designation and Treatment Aviel Goodman Published online: 14 Jan 2008.
To cite this article: Aviel Goodman (1992) Sexual Addiction: Designation and Treatment, Journal of Sex & Marital Therapy, 18:4, 303-314, DOI: 10.1080/00926239208412855 To link to this article: http://dx.doi.org/10.1080/00926239208412855
PLEASE SCROLL DOWN FOR ARTICLE Taylor & Francis makes every effort to ensure the accuracy of all the information (the “Content”) contained in the publications on our platform. However, Taylor & Francis, our agents, and our licensors make no representations or warranties whatsoever as to the accuracy, completeness, or suitability for any purpose of the Content. Any opinions and views expressed in this publication are the opinions and views of the authors, and are not the views of or endorsed by Taylor & Francis. The accuracy of the Content should not be relied upon and should be independently verified with primary sources of information. Taylor and Francis shall not be liable for any losses, actions, claims, proceedings, demands, costs, expenses, damages, and other liabilities whatsoever or howsoever caused arising directly or indirectly in connection with, in relation to or arising out of the use of the Content. This article may be used for research, teaching, and private study purposes. Any substantial or systematic reproduction, redistribution, reselling, loan, sub-licensing, systematic supply, or distribution in any form to anyone is expressly forbidden. Terms & Conditions of access and use can be found at http://www.tandfonline.com/page/termsand-conditions
Sexual Addiction: Designation and Treatment
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
A V I E L GOODMAN
While there is general agreement that the pattern of behavior described as “sexual compulsivity ” or ‘Sexual dependency” or “sexual addiction” does exist, considerable controversy surrounds the issue of how this syndrome should be designated. The principle candidates-compulsiuity, dependency, and addiction-re examined, and addiction is found to be the most suitable term. Addiction is then clearly &fined, and diagnostic criteria for addictive disorder are specified. After the definition of and diagnostic criteria for sexuul addiction are presented, arguments against the concept of sexual addiction are reviewed and answered. Implications of this concept for treatment are then explored. Over 100 years ago, Krafft-Ebbing’ described a condition in which a person’s sexual appetite is abnormally increased to such an extent that it permeates all his thoughts and feelings, allowing of no other aims in life, tumultuously, and in a rutlike fashion demanding gratification without granting the possibility of moral and righteous counter-presentations, and resolving itself into an impulsive, insatiable succession of sexual enjoyments. . . . This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom and even his life. (pp. 70-71) While there is general agreement that the pattern of behavior that corresponds to this description does exist,* considerable controversy surrounds the issue of how it should be designated. T h e principle candidates include “sexual compulsivity,” “sexual dependency,” and “sexual addiction.” Examination of these terms reveals that the one most suitable for designating this syndrome is sexual addiction. T h e definition of and diagnostic Address correspondence to Aviel Goodman, M.D., Director, Minnesota Institute of Psychiatry, 1347 Summit Avenue, St. Paul, MN 5510.5-2219.
Journal of Sex & Marital Therapy, Vol. IS, No. 4, Winter 1992 0 BrunnerlMazel, Inc. 303
304
Journal of Sex t 3 Martla1 Therapy, Vol. 18, No. 4, Winter I992
criteria for sexual addiction are presented, followed by a review of arguments against this concept. Finally, implications of the sexual addiction concept for treatment are considered.
COMPULSIVITY,DEPENDENCY,OR ADDIClION? Compulsivily (or compulsion) refers to behavior motivated by an attempt to evade or avoid an un leasurable/aversive internal state. Quadland3 and Weissberg and Levay have argued in favor of designating the condiDownloaded by [University of Sussex Library] at 20:46 16 January 2015
r
tion described above as compulsive sexual behavior, or sexual compulsivity. They emphasize the defensive function of the sexual activity, how it operates to reduce anxiety or some other painful affect. And they note that when sexual activity is blocked, the individual suffering with this condition experiences discomfort. T h e definition of compulsive behavior, however, also entails “behavior that is not enjoyed o r seen as an end in i t ~ e l f(p. ’ ~ 21). As Coleman‘ has observed, many of these sexual behaviors cannot be considered compulsive “because compulsion is currently defined as a compelling activity from which the person derives no pleasure” and people with this condition “often describe great pleasure before and during the sexual activity itself’ (p. 8). l h e DSM-Ill-R’ explicitly stated, “Some activities, such as eating (e.g., Eating Disorders), sexual behavior (e.g., Paraphilias), gambling (e.g., Pathological Gambling), or drinking (e.g., Alcohol Dependence or Abuse), when engaged in excessively may be referred to as ‘compulsive.’ However, the activities are not true compulsions because the person derives pleasure from the particular activity, and may wish to resist it only because of its secondary deleterious consequences” (p. 246). Dependency (or dependence) refers to behavior motivated by an attempt to achieve a pleasurable internal state via gratification of needs, basic or derived. While the concept of sexual dependency is consistent with the pleasure people derive from the sexual activity, it neglects the defensive character of the behavior-its function in averting painful affects. T h e pattern of sexual behavior with which we are here concerned involves both gratification and escape from internal discomfort. Hence, neither cornpulsivity nor dependency is adequate to characterize it. The concept of d i c t i o n suffers from lack o f a generally recognized definition that is clear and meaningful. This issue will be addressed in the following section. For the purpose of the present discussion, it is sufficient to observe that addiction refers to a behavior pattern essentially characterized by 1) loss of control, and 2) continuation despite harmful consequences. Addictive behavior is moreover distinguished by the capacity both to produce pleasurable effects and to provide a means for evasion of painful internal states. Addiction thus entails a synthesis of dependency and compulsivity, and is alone among these terms in its ability t o adequately characterize a pattern of sexual behavior which involves both gratification and escape from internal discomfort.
Sexual Addiction
305
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
DEFINITION OF SEXUAL ADDICTION Carnes’ defined addiction as “a pathological relationship with a moodaltering experience” (p. 4). This formulation represented an advance from earlier definitions, since it implied that:l) the basis of addiction is not a substance or a behavior but an alteration of the emotional state (consistent with the discussion in the preceding section); and 2) whether a behavior pattern qualifies as an addiction is determined by how it relates to the individual’s life (“pathological relationship”). Carnes’s definition, however, is susceptible to the criticism most often directed against the concept of addiction: that it is vague and imprecise, and so all-inclusive as to leave the term virtually devoid of pragmatic value. Unless this definition of addiction is followed by a specific definition of “pathological relationship,” it does not provide enough information to be useful in a scientific context. In recent paper^,^.'^ I introduced a definition of addiction that shared the advantages of Carnes’s definition, yet was sufficiently specific to be scientifically useful. Addiction was defined as a disorder in which a behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the behavior, and 2) continuation of the behavior despite significant harmful consequences. This definition is, in part, comparable to the initial statement in DSM-III-R’ regarding Psychoactive Substance Dependence: “The essential feature of this disorder is a cluster of cognitive, behavioral, and physiologic symptoms that indicate that the person has impaired control of psychoactive substance use and continues use of the substance despite adverse consequences” (p. 296). T h e definition of addiction was supplemented by a set of diagnostic criteria for addictive disorder, which were presented in a format similar to that of DSM-III-R: Addictive Disordtr (or Addiction) A. Recurrent failure to resist impulses to engage in a specified behavior. B. Increasing sense of tension immediately prior to initiating the behavior. C. Pleasure or relief at the time of engaging in the behavior. D. At least five of the following: 1) frequent preoccupation with the behavior or with activity that is preparatory to the behavior 2) frequent engaging in the behavior to a greater extent or over a longer period than intended 3) repeated efforts to reduce, control, or stop the behavior 4) a great deal of time spent in activities necessary for the behavior, engaging in the behavior, or recovering from its effects 5 ) frequent engaging in the behavior when expected to fulfill occupational, academic, domestic, or social obligations
3 06
Journal of Sex U Marital Therapy, Vol. 18, N o . 4, Winter 1992
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
6) important social, occupational, or recreational activities given up or reduced because of the behavior 7) continuation of the behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the behavior 8) tolerance: need to increase the intensity or frequency of the behavior in order to achieve the desired effect, or diminshed effect with continued behavior of the same intensity 9) restlessness or irritability if unable to engage in the behavior E. Some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a long period of time. ’The definition of and diagnostic criteria for sexual addiction are then derived from the definition of addiction and the list of diagnostic criteria for addictive disorder by substituting “sexual behavior” for “behavior.” Accordingly, sexual addiction is defined as a disorder in which a sexual behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the sexual behavior, and 2) continuation of the sexual behavior despite significant harmful consequences. T h e diagnostic criteria are as listed below: Sexual Addiclion A. Recurrent failure to resist impulses to engage in a specified sexual behavior . R . Increasing sense of tension immediately prior to initiating the sexual behavior. C. Pleasure or relief at the time of engaging in the sexual behavior. D. At least five of the following: 1) frequent preoccupation with the sexual behavior o r with activity that is preparatory to the sexual behavior 2) frequent engaging in the sexual behavior to a greater extent or over a longer period than intended 3) repeated efforts to reduce, control, or stop the sexual behavior 4) a great deal of time spent in activities necessary for the sexual behavior, engaging in the sexual behavior, or recovering from its effects 5) frequent engaging in the sexual behavior when expected to fulfill occupational, academic, domestic, or social obligations 6) important social, occupational, or recreational activities given u p or reduced because of the sexual behavior 7) continuation of the sexual behavior despite knowledge of having a persistent or recurrent social, financial, psychological, or physical problem that is caused or exacerbated by the sexual behavior 8) tolerance: need to increase the intensity or frequency of the sexual behavior in order t o achieve the desired effect, or diminished effect with continued sexual behavior of the same intensity
307
Sexuul Addiction
9) restlessness or irritability if unable to engage in the sexual behavior E. Some symptoms of the disturbance have persisted for at least one month, or have occurred repeatedly over a longer period of time.
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
REVIEW OF ARGUMENTS AGAINST T H E CONCEPT OF SEXUAL ADDICTION Arguments against the concept of sexual addiction may be organized into four categories: sociological, conventional, moral, and scientific. Each will be reviewed in turn. Sociologzcal
Sociological arguments against the concept of sexual addiction revolve around the idea that “addiction” is no more than a label for behavior that deviates fro’m social norms. This viewpoint is represented by statements of Levine and Troiden’l that “sexual addiction and sexual compulsion represent pseudoscientific codifications of prevailing erotic values rather than bona fide clinical entities” (p. 349) and that “psychosexual disorders are social constructions: that is, stigmatizing labels attached to sexual patterns that diverge from culturally dominant sexual standards’’ (p. 355). As Coleman‘ observed, sociological theorists are concerned that “this concept can potentially be used to oppress sexual minorities . . . because they do not conform to the moral values of the prevailing culture (or therapist)” and that “mental health professionals using such conceptualizations have become simply instruments of such conservative political views and have made people who d o not fit into a narrow, traditional sexual lifestyle feel bad, immoral, and, now mentally ill” (p. 8). These are cogent and powerful criticisms, but they are not applicable to sexual addiction as formulated in the preceding section. This definition of sexual addiction is quite consistent with Levine and Troiden’s” statement that “there is nothing inherently pathological in the conduct that is labeled sexually compulsive or addictive” (pp. 355-356). Contrary to their assumptions, no form or pattern of sexual behavior is in itself defined as an addiction. Any sexual behavior that can function both to produce gratification and to provide escape from internal discomfort has the potential to be engaged in addictively, but constitutes a sexual addiction only to the extent that it occurs in a pattern that meets the diagnostic criteria outlined above. It is not the type of behavior, its object, its frequency, or its social acceptability that determines whether a pattern of sexual behavior qualifies as sexual addiction; it is how this behavior pattern relates to and affects the individual’s life, as specified by the diagnostic criteria. Other sociological arguments are less readily dismissed. Coleman‘ noted that “no matter how one defines sexual compulsivity or addiction, there seems to be an implicit comparison to normalcy” (p. 8) and that
journal of Sex &? Marital Therapy, Vol. 18, N o . 4 , Winter 1992
308
global assessment concepts such as preoccupation, out of control, unmanageability, and negative conse uences are potentially subjective and value-laden assessments. Orford’ observed that control/uncontrol is not a dichotomy but a continuum with arbitrary cut-off points, and reiterated Kinsey’s argument that “it is impossible to separate normal and abnormal in other than an arbitrary way”* (p. 302). Levine and Troiden” emphasized that these distinctions depend on the therapist’s value orientation and purposes, as well as culturally induced perceptions of what constitutes sexual impulse control. There is no question that all the assessments specified or implied in the diagnostic criteria for sexual addiction represent continua rather than dichotomies, and that the distinctions between “pathological” and “healthy” are ultimately arbitrary and reflect the values of the culture and the therapist. These points are, however, no more applicable to sexual addiction than to addictive disorders involving other behaviors, and indeed to virtually all medical diagnoses. T h e distinctions in medicine between disease and health are sociohistorically relative (not absolute) points on continua, and reflect the underlying assumptions and values of the culture and the p h y ~ i c i a n . ’ ~ . ’ ~
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
9
Conventional
A number of arguments against the concept of sexual addiction emerge from conventional assumptions about addiction. A frequent objection is based on the idea that addiction is a physiolo ical condition and must be physiologically defined. Levine and Troiden“ argued that “sex is not a form of addiction. Strictly speaking, addiction is ‘a state of physiological dependence on a specific substance arising from habitual use of that substance.’ They further objected that “abrupt withdrawal from sexual behavior does not lead to forms of physiological distress” (p. 356). However, as Coleman6 observed, “Our conception of addiction has changed over the years and is no longer as physiologically defined” (p. 8). DSMI I I-R diagnostic criteria for substance dependence, the prototypal addiction, are formulated in behavioral and experiential terms that are actually less restrictive than the diagnostic criteria for addictive disorder presented in the preceding section. Physical withdrawal symptoms are not necessary for the diagnosis of dependence on any substance (as long as three of the other seven criteria on the list are fulfilled) and are generally not observed during withdrawal from a number of addictive substances, including cannabis, psychedelics, and phencyclidine (PCP). Current psychobiological theories of addiction to alcohol and other drugs tend to emphasize emotional effects the addicts wish to achieve15 and the activation of centrally coded affect systemsl6 rather than unmediated chemical effects or physical withdrawal symptoms. Objections of the sort raised by Levine and Troiden may also be answered at a more basic level. Their arguments presuppose a dichotomy between psychological conditions and physiological conditions, and claim that the sexual syndrome belongs to the former class while addiction belongs to the latter. Meanwhile, contemporary psychiatric and philosophical theory affirms an essential ”
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexuul Addiction
309
unity of psychological and physiological, in which every psychological process is identical to o r correlated with some physiological process.” Thus, it is not meaningful to speak of dependence or distress that is psychological but not physiological. Other arguments against sexual addiction derive from assumptions about what is implied by the term “addiction.” Coleman6 stated, “The danger of describing sex as an addiction is that it presupposes that the individual is addicted to all forms of sexual behavior rather than a specific sexual object or set of sexual behaviors, and following this model, suggests abstinence as a treatment goal” (p. 7). T h e first assumption, that sexual addiction presupposes addiction to all forms of sexual behavior, is comparable to the statement that drug addiction presupposes addiction to all types of drugs. These statements are valid only to the extent that addiction is understood as a process involving a propensity to engage in a behavior in addictive ways, and not as actual addictive manifestation of the behavior itself. A sexually addicted person will tend to “specialize” in only one or a few types of sexual behavior, much like a drug addicted person will tend to specialize in only one or a few types of drugs. And, similar to drug addiction, in which drugs other than the drug of choice retain the potential to be used addictively, forms of sexual behavior that are not the sex addict’s act of choice remain in the domain of the addictive process. It is, however, not the case that a sexually addicted person by definition addictively engages in all types of sexual behavior, any more than a drug addict by definition addictively uses all types of drugs. T h e assumption that treatment of an addictive disorder necessitates lifelong abstinence also merits a closer look. There is a flurry of research in the field of alcoholism concerning whether a person who once used alcohol addictively can ever drink in moderation. This is mentioned without endorsement of a position on either side of this question, only to illustrate that the necessity of lifelong abstinence is an issue of science to be evaluated empirically, not an issue of dogma to be affirmed without question. We can also observe that what is said to constitute abstinence for an alcoholic or drug addict may entail some arbitrary distinctions, since people recovering from addiction to alcohol or controlled substances are not always required to abstain from nicotine and caffeine (which are also mood-altering, potentially addictive drugs). Finally, o u r approach to understanding the concept of abstinence in sexual addiction can benefit from looking at its meaning in the context of addictive use of food, which is more similar to sexual addiction than is alcoholism and other drug addictions in that absolute lifelong abstinence from natural processes like ingesting food or engaging in sexual behavior is rarely a reasonable option. We can see that:l) a person may use some foods in addictive ways (to escape internal discomfort as well as to provide gratification) and some foods in healthy ways (to nourish the body as well as to provide gratification); 2) which foods are used in which way may vary from person to person; and 3) which foods are used in which way by one person may change over time. Hence, what constitutes abstinence in recovery from food addiction depends on which foods are being used
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
310
Journal of Sex k? Marital Therapy, Vol. 18, No. 4 , Winter 1992
in addictive ways, and how addictive use of food may be distinguished from healthy use of food for that individual. At this time, abstinence in recovery from sexual addiction tends to be defined in one of three ways: 1) according to arbitrary but meaningful distinctions between acceptable and unacceptable sexual behaviors (as in the support group Sexaholics Anonymous); 2) according to which sexual behaviors are being used in addictive ways (as in Sex Addicts Anonymous); or 3) according to how addictive use of sex may be distinguished from healthy use of sex for that individual (as in Sex a n d Love Addicts Anonymous). I n no case is lifelong abstinence from all sexual behavior a goal of treatment or a condition of recovery. Moral Moral arguments against the concept of sexual addiction a r e based o n a concern that the designation of this pattern of sexual behavior as an addiction undermines individuals’ responsibility for their behavior. This concern is shared by groups at opposite ends of the political spectrum. Those at the conservative end fear that the concept of sexual addiction may be employed to absolve individuals of responsibility, that sex addicts will not be held accountable for the consequences of their behavior. Meanwhile, those at the liberal e n d fear that the concept of addiction may be used to deprive individuals of personal responsibility a n d freedom of choice, defining sex addicts as victims who must be saved, even i f they d o not want to be.” These concerns reflect a failure to grasp a basic principle of medical care, which is captured in the Alcoholics Anonymous aphorism, “ T h e alcoholic is not responsible for his disease, but is responsible for his recovery.” Like alcoholics a n d d r u g addicts, sex addicts a r e not responsible for having their addiction, nor for the feelings, fantasies, and impulses it entails; but they a r e responsible for what they do about their addiction and for how they act in response to their feelings, fantasies, and impulses. This distinction-between responsibility for the disease and responsibility for recovery-also applies to other medical conditions, and failure to appreciate it has been a major factor in undermining the medical model. In the treatment of sexual addiction, responsibility actually plays a central role. Responsibility for consequences of their addictive sexual behavior is usually what propels sex addicts into treatment and provides the wedge to break through their denial. Also, sense of responsibility for their own recovery is much of what sustains sex addicts’ willingness t o continue in a growth process that is often challenging and painful. Scicn t ijic
What are here termed the scientific arguments against the concept of sexual addiction were enumerated by Coleman.6 T h e first, a philosophical or semantic argument, is that free use of the w o r d “addiction” has
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexual Addiction
311
rendered the term meaningless, so all-inclusive that it lacks pragmatic value. This problem with the term is what rompted the proposed definition and diagnostic criteria for addiction8O cited in the preceding section. T h e proposed definition is scientifically meaningful, and the diagnostic criteria are more restrictive (less inclusive) than comparable criteria in DSM-111-R. T h e next, a clinically based objection, is that many of the people who are treating those with sexual addiction have not been properly trained. To whatever extent this may be valid, it is not an argument against the concept of sexual addiction, rather an argument in favor of better training. Effective treatment of sexual addiction requires understanding not only of addictions, but also of psychodynamics, family systems theory, group dynamics, and cognitive-behavioral therapy. The ability to recognize major mood disorders and psychotic disorders is also necessary, as is a high level of self-awareness and ability to manage in healthy ways one’s own issues and feelings. T h e scarcity of this combination of qualities may suggest that reassessment of education in the mental health fields is indicated, but it is no indictment of the sexual addiction concept. Coleman’s6 final scientific argument concerns the lack of research “which documents the existence of such a conceptualization” (p. 8) and the lack of research which documents the effectiveness of treatment methods derived from these concepts. This paper was intended to address the first concern and to indicate not only the concept’s existence, but also its value. T h e second concern represents not an argument against sexual addiction, but a call for treatment effectiveness research. This is a critical need in the field of sexual addiction, as it is in the mental health fields generally, particularly in view of third party payers’ eagerness to deny reimbursement for mental health treatment. IMPLICATIONS FOR TREATMENT ‘The designation of this condition as an addiction entails two primary sets of implications for treatment. T h e first set derives from the recognition that addiction involves both compulsion (motivation to evade or avoid an unpleasurable/aversive internal state) and dependence (motivation to achieve a pleasurable internal state). Optimal treatment thus requires that both compulsion and dependence processes be addressed. It is necessary to treat the internal discomforts from which the sexual behavior had provided escape by means of pharmacotherapy (antidepressants, stabilizers such as lithium and carbamazepine, and more rarely antipsychotics or anxiolytics) or psychotherapy (to promote resolution of internal conflicts, enhanced ego and superego integration associated with improvement in regulation of affect and self-esteem, and so on), or a combination of pharmacotherapy and psychotherapy. It is also necessary to foster the individual’s development of healthier, more adaptive means for meeting the needs that the addictive sexual behavior was intended to gratify. In addition to individual psychotherapy, twelve-step groups and other supportive or therapeutic groups may be particularly valuable in
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
312
Journal of Sex
W
Marital Therapy, Vol. 18, No. 4 , Winter 1992
this regard. A further corollary is that treatment methods that fail to address both the compulsive and the dependent components of this syndrome, including antiandrogen drugs and aversive conditioning to sexual stimuli, are unlikely to be effective unless combined with other modalities that d o address these processes. T h e second set of implications concerns the relationship between sexual addiction and other addictions, and relates to treatment of addiction generally. T h e diagnostic criteria for addictive disorder presented above are general and not specific to any particular form of behavior. They represent a set of relationships between a pattern of behavior and certain other processes or aspects of a person’s life. Addiction is essentially detined as a pattern of behavior characterized by loss of control and continuation despite harmful consequences. This pattern is common to all addictions, by definition, whatever the behavior involved. T h e inference system of medical science suggests that similarities in patterns of symptomatic relationships are likely to reflect similarities in an underlying disease process. We may then hypothesize that the different addictive disorders have in common an underlying disease process, in other words, that the set of addictive disorders is most accurately described, not as a variety of addictions, but as a basic underlying addictive process, which may be expressed in one or more of various behavioral manifestations. This hypothesis concerning an underlying addictive process is continuous with an inte rative approach to etiology and the treatment of addictive disorders!’ In the course of healthy growth, people develop effective, adaptive means of regulating their feelings and their sense of self. When some combination of genetic and environmental factors interferes with development of these self-regulatory processes, people are more vulnerable to being overwhelmed by intense feelings or by loss of selfcoherence. And they may learn that they can ward off these traumatic states by taking in a substance (like food, or alcohol, or other drugs) or by engaging in some other rewarding activity (like sex, or gambling, or stealing). T h e essential process, the addictive process, is the compulsive dependence on an (apparently self-initiated and self-controlled) external action in order to regulate the internal state. Once this process has been developed, the intelligent human organism has the flexibility to shift among various actions or to combine them, according to the requirements and limitations of the situation. Sexual addiction is thus not a bizarre aberration, nor a new fad, nor even a unique disease. I t is simply the addictive process being expressed through sex, the compulsive dependence on some form of sexual behavior as a means of regulating one’s feelings and sense of self. An effective program for the treatment of a person who wants to recover from sexual addiction, or from any addictive syndrome, must consequently address not only the addictive behavior, but also the underlying addictive process. This is particularly important when the behavior used addictively also plays a role in healthy functioning, for example, eating or sexual behavior. Lifelong abstinence from all forms of the behavior is then neither a realistic nor a desirable goal. T h e all-or-nothing
313
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
Sexual Addiction
orientation typical of addicted people is then inapplicable, and it is necessary for the individual to undergo the changes in personality that enable healthy moderation. Progress in recovery from addiction is a function of development of healthy, adaptive means for managing feelings, getting needs met, and resolving inner conflicts. This, in turn, depends on awareness of feelings, needs, and inner conflicts, as well as identification and challenging of maladaptive core beliefs. Treatment, thus, first of all requires abstinence from addictive behavior, which would otherwise operate to distort or prevent this inner awareness. What constitutes abstinence from addictive behavior for a given person depends on which behaviors are being used addictively and on how addictive use of a behavior may be distinguished from healthy use of a behavior in that individual. Treatment itself may then be conceptualized as three interrelated processes: 1) fostering awareness of feelings, needs, inner conflicts, and core beliefs, particularly as they arise in the context of interpersonal relationships; 2) encouraging development of more healthy, adaptive means for managing feelings, getting needs met, and resolving inner conflicts; and 3) more directive, cognitive-behavioral teaching of effective strategies for maintaining abstinence from addictive behavior.
CONCLUSION This essay began with a search for the most appropriate term to designate a maladaptive pattern of sexual behavior. Consideration of the alternatives indicated that “sexual addiction” is the most suitable. Addiction was defined as a process whereby a behavior that can function both to produce pleasure and to provide escape from internal discomfort is employed in a pattern characterized by 1) recurrent failure to control the behavior, and 2) continuation of the behavior despite significant harmful consequences. A formal delineation of diagnostic criteria for addictive disorder was also presented, specified in a format similar to that of DSM111-R.After a definition of and diagnostic criteria for sexual addiction were derived from those for addiction and addictive disorder, arguments against the concept of sexual addiction were reviewed and answered. T h e final section explored theoretical and practical implications concerning treatment of sexual addiction and of addictive disorders generally. What emerged constitutes a true actualization of the biopsychosocial model of illness and health, indicating a practical as well as conceptual integration of addictionology, biological psychiatry, psychodynamic theory, cognitive-behavioral psychology, family systems theory, and group dynamics.
REFERENCES 1 . Krafft-Ebbing R: Psychopathia sexualis (F.J. Kebrnan translation), New York, Paperback Library, 1965 (first edition, 1886). 2. Orford J : Hypersexuality: Implications for a theory of dependence. Br J Addict 73:299-310, 1978.
Downloaded by [University of Sussex Library] at 20:46 16 January 2015
314
Journal of Sex E3 Marital Therapy, Vol. 18, No. 4, Winter 1992
3. Quadland MC: Compulsive sexual behavior: Definition of a problem and an approach LO treatment.] Sex Marital Ther 11(2):121-132, 1985. 4. Weissberg J H , l m a y AN: Compulsive sexual behavior. Med Asp Hum Sex 20(4):127-128, 1986. 5 . Barth R J , Kinder BN: T h e mislabeling o f sexual impulsivity. J Sex Marital Ther 13(1): 15-23, 1987. 6 . Coleman E: Sexual compulsion vs. sexual addiction: T h e debate continues. SIECUS Rt/10rlJuly:7-11, 1986. 7. American Psychiatric Association: Diuposlic and stalkfical manual of m n h l disora’ers (3rd ed, rev). Washington, DC, APA, 1987. 8 . Carnes P: Out of the shadows: Understanding sexual addiction. Minneapolis, CompCare, 1983. 9. Goodman A: Addiction: Definition and implications. BrJ Addicl85: 1403-1408, 1990. 10. Goodman A: Addiction concept involves theoretical and practical issues. Psychiatric Times 8(6):29-33, 1991. 1 1 . 1,evine MP, l’roiden RK: T h e myth of sexual compulsivity../ Sex Res 25(3):347-363, 1988. 12. Orford J: Excessive appetifes: A psychologd view of addiction. Chichester, Wiley, 1985. 13. Agich GJ: Disease and value: A rejection of the value-neutrality thesis. Theor Med 4:27-4 I , 1983. 14. King 1,s: What is disease? Phil Sci 2 1 : 193-20, 1954. 15. C o x W M , Klinger E: A motivational model of alcohol use.JAbnPsych 97(2):168-180, 1988. 16. Baker T I % ,Morse E, Sherman JE: T h e motivation to use drugs: A psychobiological analysis of urges. In PC Rivers (ed), Nebraska symposium on motivation: Vol. 34. Alcohol and addictive behavior (pp. 257-323). Lincoln, University o f Nebraska Press, 1987. 17. Goodman A: Organic unity theory: T h e mind-body problem revisited. AmJ Psychiatry f48(5):553-563, 199 1. IS. Szasz T: Ceremonial chemisfly. Garden City, Anchor Press/Doubleday, 1974. 19. Goodman A : T h e addictive process: A psychoanalytic understanding. J AmPr Ac Psychoanal, in press.
