There’s a well-known sentiment in the therapy world about addiction: It’s the hardest diagnosis to treat. And, there’s another well-known sentiment within the world of addiction: Sexual addiction is the hardest of all the addictions to treat. Sexual addiction is the hardest of the hardest populations to work with as a therapist (or so it’s said). I don’t know why those notions didn’t scare me off of the work (that’s another article for another day, probably), but they didn’t. So, here we are. After six years of sexual addiction treatment training and as many years working directly with that population, here’s what I can tell you to expect from sexual addiction recovery therapy.
Yes, Sobriety Matters (But Probably Not as Much as You Think)
One of the taglines of twelve-step programs is this: Sobriety is only 10% of the work. In other words: Sobriety is an important early step in recovery, AND it is only one step. A step that needs to be taken before most of the other steps can, but a single step of a long journey nonetheless. When I start working with a new sexual addiction client, I check in around sobriety (How long has it been since you acted on your addiction? What’s the typical pattern of behaviors? How long have you been able to maintain sobriety in the past?) and then I deliberately pay attention to other areas of recovery. I intentionally widen the focus and spread the burden of recovery over several factors, taking most of that heavy weight off the shoulders of sobriety and letting other parts of recovery carry their share. Because so much of sexual addiction becomes focused on the unwanted behaviors (affairs, pornography use, solicitation, etc.), and because those behaviors have likely never felt in control since the onset of the addiction, there is often a pervasive sense of disempowerment, hopelessness, and shame. Spreading out the responsibility of recovery among many factors, with sobriety being only one of them, creates a new perspective that many clients find hopeful and empowering, especially at the beginning of treatment.
Right at the beginning of sexual addiction treatment, much as I do in betrayal trauma treatment, I assess the client’s support system. Who knows about your addiction? Who have you turned to for help? Who might be able to support you? I also outline the benefits of group work and recommend clients join a twelve-step program immediately if they’re not already participating in one. Twelve-step groups are profoundly useful in the beginning of sexual addiction treatment, helping clients get out of the darkness and into the light. As they face their reality more head-on, a client new in recovery also simultaneously experience parts of their reality they had often never considered: They aren’t alone. Other people are struggling in similar ways. And, other people are succeeding in ways the client has yet to experience, maybe yet to even imagine. Sometimes it takes a new client several weeks to get to a meeting – that’s alright. I use the structure of therapy to hold them accountable and if they keep showing up with me, eventually they show up in twelve-step.
Map Out the Addiction
In the earliest stages of sexual addiction treatment, we begin to map out the history of the addiction. I ask how the client has attempted to manage their addiction so far. Like most people, sexual addiction clients come to therapy often as a last resort, which means they’ve tried everything they can think of before they walk through my door. These attempts range from white-knuckling and/or shame-based behavior change (either self-induced or other-induced, often both) to a twelve-step program or religious counseling. Some clients use online forums for support. Others use smartphone apps to track their behaviors. It helps me to understand where they’ve been and what they’ve tried, and it really helps clients to drop any remaining denial regarding their addiction to list out all the ways they’ve attempted unsuccessfully to recover.
It’s important to note that this is the beginning of creating a full history of the addiction. I meet the client where they are, using their language to describe the addictive behaviors. Clients often use euphemisms and are very uncomfortable with direct sexual language; I note this for myself and don’t expect it to change on its own or anytime soon. For clients new to recovery, just coming to see me for addiction treatment is often very shameful. Which brings me to the next bit of this early work.
It is important that from the very first session, therapy is a source of hope. I can’t control how clients experience me or our work together, and I know it is unlikely that therapy will be a source of hope and ONLY hope, but I keep my eye on that prize. Hope has to be a part of it. In early sexual addiction recovery, as in many other types of therapy, hope comes in the form of information. From the very beginning, I offer clients bits and pieces of the research around shame, addiction, neuroscience, attachment, and sexuality. I repeat myself often, knowing that the sexually-addicted brain cannot hold onto new information as well as a healthy brain can. I use psychoeducation to normalize the shame clients feel just by coming to see me. I use the experience of finding my information, making initial contact, scheduling the first session, budgeting for the cost of therapy, driving to the office, sitting in the lobby, waiting to meet me for the first time – I use all of those micro-experiences to flesh out, at a surface level (because it’s way too soon for deep work), the overarching, life-dominating, macro-experience of shame, humiliation, desperation, and hopelessness that accompanies addiction. The simple act of normalizing all of this in the context of addiction is incredibly powerful. I validate, normalize, and inform. Rinse and repeat. Rinse and repeat again.
Good Old-Fashioned Cognitive Behavioral Therapy
Giving new clients an hour of experiencing themselves and their addiction in new ways is powerful, but it’s only an hour out of their week. They have to go manage the 167 remaining hours before I see them again on their own, or at least without my direct help. This is why I offer some concrete tools right at the beginning. Clients new to recovery are desperate for what to do. Yes, it helps them to be treated like whole people who deserve to be healthy, and, yes, hope matters. But they all want to walk out of that first session with a clear action plan, even if they don’t think they can or don’t actually intend to do it. Validation, normalization, and psychoeducation provide a sense of hope for the present; leaving session with concrete tools lends hope for the future. Most of the time, the concrete tools are something like these: 1. Join a twelve-step group and go at least once before I see you again. 2. Download a meditation app and try it at least once before I see you again. 3. Pick out a notebook for journaling and journal at least once before I see you again. 4. Come back to therapy. These are cognitive-behavioral tools that can help the brain start the healing process, and they also have the benefit of being measurable. All human brains like to keep score, but especially the addicted brain, which helps explain the fixation on sobriety: We want to know where we stand and how much progress we’ve made.
Predict the Future
In the first session and periodically throughout the course of sexual addiction treatment, I offer predictions. At the beginning, the predictions are based on my general expertise, and say things like, “Active recovery takes anywhere from one to five years. We’ll start with some behavior modifications that are not focused on sobriety as well as getting you some solid support outside of therapy. We’ll move slowly into emotional work and eventually trauma work. If there’s a relationship to heal, we’ll bring in couples therapy. I’ll adjust our treatment plan as we go and as I get to know you and your needs better.” As we work together and collaborate more, I am able to tailor my predictions for the specific client. When treatment starts, though, what really matters is that the client understands they’re at the beginning of a difficult process, that I know where to take them and how, and that other people have travelled this road and are travelling the same road now.
Therapy for sexual addiction recovery really isn’t that different from most types of therapy: Everyone who comes into my office wants to change something about their lives or themselves. Everyone who comes into my office has some experience with trauma. Everyone who comes into my office is experiencing some desperation, some hopelessness, some shame. It is my honor and my privilege to help guide them through the shifts they crave and, hopefully, through the shifts they need. I have come to see sexual addiction as a symptom of an unmet need, unwanted sexual behaviors as cries for help, recovery as a window into healthy, peaceful living and deep, safe relationships.
Leave your questions in the comments below, and, as always, thank you for being here.