Can one undergo therapy for sexual addiction?

This wonderful question was forwarded by one of our readers. There are many treatments offered today for sexual addiction. Here, we will look at this from the point of view of a psychodynamic therapy: ISTDP.
When someone presents with a sexual addiction, the first thing to remember is this: sexual addiction is a symptom! Rather than get focused entirely on the symptom, we want to find out what feelings he struggles with in relationships, where his anxiety is discharged, and what defenses he uses. Then we can see how his defenses create his symptom of sexual addiction.
On the simplest level, as the psychoanalyst Heinz Kohut pointed out decades ago, a sexual addiction is often a compulsive mechanism to discharge unregulated anxiety. Thus, helping this group of patients recognize anxiety in session and regulate it can be an essential step in gaining control over this defense. Then they can recognize and regulate their anxiety rather than discharge it through compulsive masturbation or sexual activity.
Since they are so focused on their sexual addiction, they do not usually recognize their anxiety in session. So it’s important to block their defenses of discharge in session to draw their attention to their anxiety.
1) “Notice how your voice is racing? That’s often a sign of anxiety. If we slow down for a moment, where do you notice feeling anxiety in your body right now?”
2) “Notice how you just talked over me (impulsive speech)? That’s often a sign of anxiety. If we slow down for a minute where do you notice feeling anxiety in your body right now?”
3) “Notice how you are jumping from one topic to another? That’s often a way to talk over what makes us anxious. If we pause for a moment, could we see where you are experiencing anxiety in your body right now?”
I find that therapists often ignore these defenses of discharge which avoid anxiety and which are the precursors to using sexual activity to ignore anxiety.
When the patient can see his anxiety and regulate it, then we start exploring the feelings underneath his anxiety IN THE SESSION. Why with the therapist? The patient is anxious with the therapist, using racing speech, impulsive speech, raising his voice, or diversifying, all to ignore the anxiety triggered by feelings with the therapist. Thus, we want to find out what feelings are triggered in the therapy relationship that evoke his anxiety, and lead to discharge.
If he can learn to identify what he feels without flooding with anxiety, his defense of sexual acting out is no longer necessary!
Sexual addiction is a way to discharge and ignore anxiety when feelings rise in relationships. Rather than tolerate the gradual rise of mixed feelings that always occurs in romantic relationships, this group of patients rushes to sex to get rid of the anxiety. But rushing into sexual relationships, a defense, creates an entirely new set of problems. And since anxiety keeps rising in relationships, sex keeps getting used as the defense to discharge that anxiety.
These patients mistakenly think they simply have a “large sex drive.” But the size of one’s sex drive does not explain impulsivity, compulsivity, anxiety, and the patterns of feelings, anxiety, and sexual defenses. They do not have a “large sex drive”, they have a large amount of anxiety which requires a large amount of sex to discharge it.
Now let’s go back to an old post of mine on “the universal addiction.” We are all addicted to not being here now with what we feel. Drugs, booze, and sex are all ways we try to get rid of what we are feeling. So, in that sense, sex is not really the addiction. Sex is just a tool this group of patients uses to deal with their fundamental addiction: help me not feel what I am feeling right now!
Since the patient is unable to bear the feelings that rise quickly in relationships, he uses sex as a way to discharge anxiety and to distract himself from psychological intimacy through pursuing an alienated form of physical contact.
And since this happens in most of his relationships, the same feelings and anxiety will be aroused in the therapy. Initially the patient will be anxious. Then we will see rapid speech. Then talking over you. Then talking about his sexual partners. And then perhaps even talking about sexual feelings toward you. What you see here is an escalating series of defenses that become more primitive the more his anxiety rises. Thus, it becomes essential to block defenses, and then identify and regulate anxiety as soon as you can to stop the escalation of anxiety and regression of defense in the session.
As you identify and regulate his anxiety, help him identify the feelings that trigger his anxiety. Once he can identify feelings without having to use the defense of sexualization, you will have decreased his impulsivity a great deal. Be careful, though! When you block his defenses and identify his anxiety, his anxiety may go into cognitive/perceptual disruption. This group of patients has a very low capacity to bear feelings and anxiety. That’s why they resort to sexual acting out. So when you block their impulsive speech, anxiety will rise and may go into cognitive/perceptual disruption, and then you can regulate his anxiety using the graded approach that I have described in Co-Creating Change.
Keep your focus on anxiety regulation and identification, so the patient can pay attention to and regulate his anxiety. Gradually increase his capacity to bear feelings without have to use discharge or acting out to rid himself of those feelings. As you increase these capacities, the patient’s use of primitive defenses will decrease and eventually disappear.
All models of treatment of sexual addiction realize that we must build capacity in the patient to bear feelings without acting out. Hopefully, this outline I have provided here gives you the rational and techniques we use when helping this vulnerable population.

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