“The loss of the daughter to the mother, the mother to the daughter, is the essential female tragedy.”
– Adrienne Rich

On a dark November afternoon, I received an unusual phone message from a woman in Southern California. She had gotten my name from her daughter, and she wanted to come and see me. When I called her back, I heard an anxious, strained voice, “Thanksgiving brought it all up again, as the holidays do every year. There is a rupture in our family that tears me apart.”

For the mothers I have seen, being a mother had been their life, and having been a good mother a vital midlife concern. Their great fear is that they were not good mothers. It has been the norm to vacillate between extremes of guilt and defensiveness. Finally, what I have seen is that something about their childhoods has prepared them for the role of being caught in the middle, a role which they have played for years in the incest family.

She introduced herself as Betty and proceeded to tell me a bit of the story. Her daughter, after uncovering her sexual abuse, had broken off contact with Betty and her husband. This woman had not seen her daughter in four years; they had not spoken in almost two. She desperately missed her daughter, Sarah. Sarah, who had been in couple’s therapy with me some time ago, had asked her to call me to see about the possibility of their doing some work together.

I was intrigued. This woman was proposing to fly up weekly or biweekly, pay for the sessions, and work to heal their divided family. “She’s my daughter,” she almost wailed. Thus began my journey of mother-daughter work with women from families coping with incest.

As long as I have been working with survivors of childhood sexual abuse, I have observed that grief about the mother is among the deepest wounds to be healed. Along with rage at the mother, this grief tends to be far greater than any feelings about the perpetrator of the abuse. I have also seen the most extreme denial, and an urgency about trying to preserve an image of the ideal mother, including survivors saying barely tongue in cheek “My mother was perfect.” When they begin to see her more clearly, they feel truly orphaned. How could she not have noticed? Why didn’t she stand up for me? How could she have stayed with him? These questions haunt and torture them.

The complex mix of anger, hurt, longing, fear, love and desperate relief were a bittersweet variation on the Prodigal Son. It was the Prodigal Daughter, or the Prodigal Mother, and one of those privileged moments in psychotherapy that feel really too intimate as to include the therapist. It took my breath away.

The first session was with Betty alone, and it seemed to be an act of maternal heroism. This was the first time she had flown in an airplane by herself, and she navigated from the airport to an address in a strange city. She was a 50’s mom with the look of a farm girl. Active in her church and involved with her social service job, she was kindly and well meaning. She and her husband had been in therapy briefly when Sarah had originally raised the issue of the abuse, working with a therapist who had a decidedly “false memory syndrome” perspective. Betty was otherwise not particularly psychologically minded. She needed to check me out. She knew that I specifically work with survivors of trauma and she was not sure if I would view her as a villain.

The objective of the first session for me, besides building rapport, is to explore the motivation for the work and the nature of the hoped-for outcome. Some mothers are looking to make the problem go away. I need to let them know that this therapy will not be an argument about “what really happened”. It will not be a process for one or the other to make a case for what is the truth, and attempt to prove it. If that is the desired outcome, then we know right there to go no further. So far that has not happened. Betty said she was willing to “do anything to bring Sarah home.”

I described to her how I work. I use the same approach I use for working with couples, which involves a structured format called “Intentional Dialog” adapted from Harville Hendrix’s Imago Relationship Therapy. We also discussed logistics, how we might set things up to take into account the time and expense of her travel. We agreed to meet for weekly ninety minute sessions to start.

Betty and I seemed to make a connection, although I quickly realized that my neurological answers to her questions about traumatic memory were not what she really needed. Clearly, the process would be one of learning how to forgive one another and cope with having different memories and beliefs about the family’s truth.

The Character of the Mothers

What sort of women marry and stay with men who molest their daughters? Some themes have emerged over time through my work with these women. They tend to be children of neglect, often the unchosen among siblings. Betty was the “Ugly Duckling” among superstar sisters, although she never seemed to arrive at swan-dom. She suffered through her life within a brittle sense of worthlessness. Easily dominated, she was well prepared for a relationship of swallowing what she was dealt.

Often the women have their own experience of childhood trauma or witnessing trauma. Accustomed to neglect and minimizing of their own devastating experiences, they may resent or simply fail to understand why their daughter is “making such a big deal about the molest.” Spoken or unspoken, they may harbor a judgment of “I put mine behind me, why can’t you just get over it?” Yet for some reason they are here.

As is common with neglect, there may be a tendency toward some degree of dissociation. This may account for their capacity to not consciously know when the abuse was occurring. The mothers I have worked with have been strangers to their own feelings. Unaware of their other-directedness, they have to be taught how to talk about themselves, or how to even notice when they are not, let alone learning to become aware of their own emotions. They grew up in families where feelings were not discussed, so there was hardly a category for even feeling them. Betty was distressed and ashamed by her frequent tears in our sessions. To her it was a “breaking down” or “losing it,” that she would then apologize for.

For the mothers I have seen, being a mother had been their life, and having been a good mother a vital midlife concern. Their great fear is that they were not good mothers. It has been the norm to vacillate between extremes of guilt and defensiveness. Finally, what I have seen is that something about their childhoods has prepared them for the role of being caught in the middle, a role which they have played for years in the incest family.

Mother Daughter Therapy

In general, I have seen four core clusters of issues to be worked through in the mother-daughter therapy. From the daughter’s point of view they would be: You knew; You chose him; Do I really want to know who you are and understand how this could have happened; and the question of forgiveness. The first two, intimately entwined together, are the deepest wounds that survivor daughters tend to bring. They are incomprehensible and heartbreaking to imagine. Sarah lamented, “even if my kitten is under the weather I notice something is wrong. I was depressed, I cut myself, I was isolated and sad all the time, I didn’t eat and got emaciated. Even if you did not see the abuse, which is also unimaginable to me, how could you not have noticed that something was wrong?” It adds up to the most profound sense of annihilation and insignificance: “I did not exist for you. Invisible, I did not matter at all.”

Of course, if the mother did know then she clearly chose, whether actively or by default, to side with the father. If the daughter was significant enough or visible enough to be noticed, then the failure to protect, or the choice to turn a blind eye and maintain status quo, was intentional. Either is a profound rejection and unspeakable injury. Arriving at the point of being able to speak of such things is monumental. This is what the daughter has waited years to be able to say.

Finding words to describe these feelings, many of which have resided and ached within the survivor for decades, is Sisyphean at best. She both fears destroying the mother with them, or being ignored again. Either is tantamount to dying. The preparation is painstaking.

For Sarah and Betty, our work took some time. Our first session in which the two laid eyes upon one another for the first time in four years was a moment of awe. The complex mix of anger, hurt, longing, fear, love and desperate relief were a bittersweet variation on the Prodigal Son. It was the Prodigal Daughter, or the Prodigal Mother, and one of those privileged moments in psychotherapy that feel really too intimate as to include the therapist. It took my breath away. Sarah had dressed up, and looked more beautiful than I had ever seen her. Betty was a warrior woman having marched triumphantly in from the airport shuttle. The first session or two was a tentative, frightening and thrilling reunion, filled with looking at each other and catching up on news of their and their families’ lives.

From there it was a natural progression and important ground work for Betty to share stories with Sarah about her own childhood. As is generally true with neglected children, Betty did not even really know she had a story to tell. She certainly had no experience of the power and connection of sharing that story, especially with her daughter. She also told Sarah about the early years of her marriage with Sarah’s father, the financial pressure, the shame around the idea of a second divorce, the demand of Sarah’s disabled little sister on her time and reserves of patience and energy. Mother and daughter were creating a new connection which allowed them to get to know each other in ways they never had. For the purposes of the therapy, we were creating a context that might help Sarah ultimately make sense out of her mother’s failing her. It also created more balance in the therapy, depathologizing Sarah. If Betty’s story was also important to the work, Sarah felt less the “problem child” when she described her own. We were also creating a safe container, in the relationship with me and in the structure of the therapy.

Once under way, the work became difficult immediately. Betty had a strange suspicion of some sort of secrecy. Somehow she had unconsciously transformed the question “you knew” into a fear that Sarah suspected she was hiding something. She rather franticly tried to dispel this, but it was hard for Sarah to understand.

Sarah wanted for Betty to understand her feelings and how the trauma had affected her whole life. But somehow this sounded to Betty like a return to the argument about what really happened, and the court-like questions of blame and guilt. At this stage it seemed untenable to work less than once a week. There was not enough object constancy in the context of so much fear. The intense feelings, particularly Sarah’s emerging anger, would have been too much to hold for more than a week at a time, and there would not have been enough momentum to sustain hope for change.

There was another difficulty particular to this work. Betty went home each week to her husband, this same husband who had molested Sarah. For her it was like moving between one reality and another, one world and another. She struggled to keep her footing in both. Even though she was not discussing the therapy with her husband, she was returning to the world of denial, the world of his defensive, if unspoken, rage. It confused and ungrounded her.

With her inexperience with therapy and foreignness to feelings, Betty interpreted her frequent tears and Sarah’s and her anger as “the therapy not working.” As her hope waned, she began to complain about the trips and the expense. So, with some hesitation on my part, we began to meet once or twice a month for three or four hour sessions. Often my schedule did not allow full three or four hour blocks, so there might be a break of an hour or 90 minutes that gave Sarah and Betty a bit of a push to go out and do something together, have a meal or go shopping in my Rockridge neighborhood. When they began to return to the office with clothes and things that Betty had bought for Sarah, or doggy bags from enjoyable lunches, I began to see what an inadvertent and vitally important component these breaks were: they were structuring and dosing normal time together into the therapy session.

As time went on, both of their deepest objectives seemed organically, gradually to be met. What both really wanted most of all was to be seen. For Sarah, it had been, “Mom, I want you to understand me, and how my life has been.” For Betty it had been, “Sweetheart I want you to understand that I am not a bad person or a bad mom. I want you to see who I am and that I have really loved you.” This was happening quietly through the dogged exercise of the dialog, which by definition lands each momentarily in the other’s shoes. The incest was ceasing to be the focus of the connection and disruption of connection of these two women.

A Word About the Dialog

The role of Intentional Dialog in this work must not be underestimated. Daniel Siegel and Alan Schore, big names in current attachment research, are understanding more and more about the neuroscience of early attachment experience, and how the interaction between mother and infant affects the biology of the child’s developing brain. It is unclear what the possibilities are about healing early neurobiological attachment deficits later in life. Siegel and Schore are hopeful that it is possible.

Siegel cites research that identifies the primary cross-cultural element of healthy attachment and subsequent mental health as the good- enough mothering sequence referred to as “Contingent Communication.” In this sequence, there are four elements: when the infant emits a signal, the mother perceives it accurately, makes sense out of it, arrives with the appropriate response, and does so promptly. Contingent communication soothes and teaches self-soothing to the infant, and facilitates development in the structure of the brain where affect regulation occurs. It is simple attunement, and yet painfully rare among our traumatized and neglected clients.

The structure of Intentional Dialog, which involves mirroring, summarizing, making empathic sense out of, and responding in the same predictable format, essentially replicates the process of contingent communication. Perhaps, in effect, Sarah and Betty were repairing the dysregulated attachment sequence of both of their early lives. I like to think that is part of what makes this work so powerful.

Changing the Ending

As time went on, Sarah and Betty were e-mailing and phoning each other between sessions. Betty began to plan longer trips around our sessions, where she might spend a weekend with Sarah and her husband. They began planning a trip across the country for a relative’s wedding. It was becoming clear that they needed me less and less.

Interestingly, it is not unusual for the perpetrator to become curious around this time. Perhaps they want to “find out who this Ruth is,” or explore their own possibilities in the family healing. Sometimes I have met with them, and the process has continued. But that would be another story.

A last hurdle for Sarah, as for many survivors, was about letting go of the trauma. What does it mean to see how this could have happened? What would it mean to accept her mother as she is, her love with her failings, Betty’s own childhood injury with her massive betrayal as a mother? Would seeing her as who she is mean the abuse was OK? Does it excuse her from her part in Sarah’s lifetime of Post Traumatic pain and life disruption? Does it mean defeat? These are all questions that a survivor must contend with in this work. Is forgiveness a kind of denial, giving in, or might it be a loving, spiritual high ground? For each survivor and each mother-daughter pair, this question and its answers may be different.

For Betty, a final hurdle was about reintegrating Sarah into the family without a disavowal or a recanting of the “heinous accusation.” Would that mean that Sarah “won”? Would that mean that all the pain, rage and shame of the rest of the family would fade away like a war without a monument? What would it mean to allow the family to change? Would that once again be “Sarah controlling the whole family”? These are questions the incest mother must wrestle with, especially if she continues to share a life with the perpetrator. They are no small thing. I view this as profound spiritual work. There is no right answer. Sarah and Betty, and others I’ve seen, have been moved by love (and of course they are the select few that find their way into a process like this) to end a legacy of tragic unconsciousness and heartbreak.

Lately it is not uncommon for me to get an emotional phone call, where the breathless voice on the line says “I’m a sex addict! My partner threw me out! Can you help me?” The anguish is palpable and my heart goes out to both the caller and the partner. Of course I want to help. This article is an attempt to elucidate my thoughts on the subject of “sex addiction.”

Sex therapist, physician and author Charles Moser’s main complaint about the “sex addiction” designation is twofold. First he believes it is that it is a catch-all term for all sorts of behaviors, completely lacking in diagnostic precision. For some it may be an expression of OCD, a set of ritualized behaviors to manage anxiety and inner chaos, and in effect self soothe. For others it may be an expression of ADD (attention deficit disorder,) or a way to stimulate, focus or wake up the brain. It may reflect an anxiety disorder or depression. Or some other possibility. Moser’s complaint is that all these diverse diagnostic categories that call for different approaches to treatment, are lumped together under one unflattering umbrella label. Precision in treatment of the actual problem is lost. It’s lousy medicine.

What is “Sex Addiction?” That is the $64,000.00 question. No one knows. Is it looking at pornography on the internet? How much looking constitutes addiction? How do we define “pornography?” Is it compulsive pursuit of prostitutes? Serial affairs? Is it about quantity of sex? Is it about specific sexual activities? Risk taking? Or simply about not being able to stop? What do we mean by this term? As of yet, science has not given us an answer.

The “sex addiction” treatment industry has an answer. (And quite an industry it is, that has mushroomed around this “diagnosis” in recent years.) Programs offer both inpatient and outpatient treatment, largely in the image of chemical dependency treatment. They charge a lot of money for their programs so they stand to gain significantly by having the public buy their definition.

What is Addiction?

Chemical dependency or substance addiction has over the last 50 or 60 years, been studied and precisely defined. Prior to this time, alcoholism was viewed as a terrible moral flaw and character defect. In the 1950’s a pair of brilliant and desperate alcoholics discovered that although they seemed to be unable to stop drinking on their own, together they managed to do it. They then found that if they went on to help still other alcoholics to stop drinking too, it helped them to stay sober. They developed a program that evolved into what we now know as the 12 Steps of Alcoholics Anonymous (AA.) This was truly the best and most effective method ever to come along, for people addicted to alcohol to become sober. It quickly spread around the world. Before long it became apparent that the 12 Steps as they were utilized by alcoholics, were equally effective for those addicted to other drugs. So Narcotics Anonymous followed in the footsteps of AA, and similar miracles and transformed lives followed.

Obsession is an agony as is behavior that one cannot control. Sexual problems create a very particular kind of relationship hell. It is easy for partners to take it personally when pictures on a screen, prostitutes or other people compel the sexual attention and time of their mates.

On the heels of AA and NA came true scientific research about addiction and what it actually is. Science began to uncover a whole physiology that went along with the much observed psychology and behaviors of addiction. We got a precise definition, and a precise “phenomenology.” Phenomenology means a picture that is objective, based on observable characteristics from many angles. It specifically leaves out the subjective, or perceptual biases based on morality, religion, philosophy, culture or personal taste or point of view.

We also got a precise nosology, (nosology is the branch of medicine that deals with the classification of diseases.) making alcohol and drug addiction diagnosable by known specific criteria. This did not happen overnight of course. But by the middle 1980’s there was a sophisticated and growing field of study in both medicine and psychology about addiction.

The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official text for diagnosis, utilized by health care providers and insurance companies. Being at least allegedly research based, it evolves with history as culture and the general knowledge base grows and changes. For example barely thirty years ago, homosexuality was listed in the DSM as a diagnostic category, and practitioners were working hard to “cure” those “afflicted.” Young people born after these changes might find it absurd or hard to believe that being gay was considered a “mental disorder” not that long ago. Those of us who have been around for a while, lived through the changes and perhaps even witnessed the effort required to remove homosexuality from the DSM. This is a clear example of how science blurs with politics and morality in the murky world of diagnosis. Bessel van der Kolk, veteran researcher, clinician, academician and author says it plainly “Diagnosis is a political instrument.”¹

In the DSM, there is a precise list of criteria for the diagnosis of Substance Dependence, the clinical jargon for addiction. The list includes: tolerance, which means progressively increased amounts of the substance are required to achieve the desired effect; withdrawal, which is a characteristic syndrome of physiological and psychological symptoms that appear when the substance is removed; persistent desire (ie craving) and unsuccessful efforts to cut down substance use; much time and preoccupation spent on obtaining and using the substance, even to the neglect of important social, occupational or recreational activities; and continued use in spite of consequences.² Although there is a lengthy chapter detailing variations on these themes, there is a uniform, agreed upon diagnostic tree that clinician or client can consult to ascertain whether the diagnosis fits.

Alcohol and drug treatment programs assess and diagnose with precise criteria, and generally treat the addiction with a combination of detoxification, which means safely withdrawing the person from the substance with medical support if needed; drug and alcohol education so clients have a clear understanding of the nature of addiction and recovery; individual and group counseling or therapy; general healthcare including good food, exercise, sleep perhaps supplements, and attention to whatever health deficits may have resulted from the addiction. A major component of most programs is 12 Step which is still considered to be the most effective path to recovery and certainly a centerpiece of the “aftercare” plan.

Relapse prevention is of course an important aspect of the education component in addiction recovery, as relapse is one of the most insidious aspects of chemical dependency. Shorter-lived returns to substance use are referred to as “slips” and relapse is the full blast return to active use. It is essential to learn how to guard against either.

About “Sex Addiction?”

The last 20 years brought the internet, and with it the proliferation of widely available erotic and sexually explicit materials of every imaginable and unimaginable stripe. No longer did anyone have to skulk naughtily or shamefully into an “adult” bookstore or video store to find “girly” magazines or movies. In the comfort and privacy of one’s own home, virtually everything could be had. Al Cooper coined the term “the Triple A Engine”: Anonymous, Affordable, and Available, to explain what appeared to be a new order of magnitude of its use.³ As technology advanced so did the complexity and variety of available services and visual opportunities. We all began to hear stories of individuals spending numerous hours of day and night (often while on the clock at their places of employment,) engaged with these materials. Money was spent, relationships jeopardized. Therapists began to get the desperate calls.

In the psychology and the sex therapy field there is much debate about whether in fact there is such a thing as “sex addiction.” One key expert in the sex therapy field, Eli Coleman in his brilliant, brief article “Compulsive Sexual Behavior: What to Call It, How to Treat It?” makes a strong case against the language of addiction. Says Coleman “Although the term ‘addiction’ may be an interesting metaphor, it obviates the essential understanding of the etiology of compulsive sexual behavior.”⁴ He views sexual compulsivity as a “disorder of regulation,” physiologically very similar to OCD (obsessive compulsive disorder).

By disorder of regulation, he means the nervous system is in effect “wired” too high or too low, with anxiety and/or depression. Self-regulation is the attempt to manage emotion and arousal such as to get comfortable in one’s skin. Disorders of regulation can be caused by physiological irregularities, life experiences, or both. This means trauma, neglect, genetics, medical factors, or some combination of them all, may add up to the irregularities. The impact is a greater or lesser urgency of the need to calm down or breathe life into the nervous system. Some people use alcohol or drugs to this end, some use food or work, exercise, gambling, shopping, thrill seeking, sleep, etc. Some like the OCD sufferer use rigidly ritualized, uncontrollable behaviors. The possibilities are limitless. Coleman sees what he calls “compulsive sexual behavior (CSB) as being within this spectrum.

To Coleman Using the rubric of addiction suggests “once an addict, always an addict,” which as of yet is an unanswered research question about CSB. It also implies that the only solution is a rigorous spiritual program like AA. Perhaps most significantly, however, the world of addiction treatment and recovery has traditionally been strongly biased against medications. Coleman’s research shows that sufferers from CSB often respond quite favorably to pharmaceutical treatments, often those used for OCD, ADD or depression. In many cases medications can be decisive in who does and who does not succeed at putting the unwanted behaviors to rest.⁴ I have indeed observed pivotal impact and success with medications in many of my clients as well.

Sex therapist, physician and author Charles Moser’s main complaint about the “sex addiction” designation is twofold. First he believes it is that it is a catch-all term for all sorts of behaviors, completely lacking in diagnostic precision. For some it may be an expression of OCD, a set of ritualized behaviors to manage anxiety and inner chaos, and in effect self soothe. For others it may be an expression of ADD (attention deficit disorder,) or a way to stimulate, focus or wake up the brain. It may reflect an anxiety disorder or depression. Or some other possibility. Moser’s complaint is that all these diverse diagnostic categories that call for different approaches to treatment, are lumped together under one unflattering umbrella label. Precision in treatment of the actual problem is lost. It’s lousy medicine.

Secondly, in order to understand, diagnose and treat safely and effectively we need to consider not only the behavior itself, but its context and meaning. From there we can determine a diagnosis and treat that. Behavior alone, taken out of context does not yield a diagnosis. Himself a busy physician, Moser says he might easily wash his hands fifty times a day, between patients and between procedures. In some cases washing one’s hands 50 times a day might be the symptom of an irrational fear of germs or a ritualized OCD behavior. In that case the problem is not really the handwashing behavior itself, (although to be sure the behavior may be distressing). The real problem to be treated is the irrational fear and the anxiety. For the busy physician with a seemingly identical behavior, there may be no problem to be treated at all. Moser views the sexual addiction recovery model as falling short in this way. It lacks an understanding of context, meaning and therefore a treatment approach that addresses the real issues.⁵

I agree with both Coleman and Moser. I think I would add that the designation of “sex addiction” has a tone of shame that other obsessive and compulsive afflictions don’t, or at least not as much. Perhaps it is my own association. Perhaps not. I believe the archaic prejudices about weakness of character, or sordidness associated with the word “addict,” linger.

This sense of prejudice extends into some of the other language used in the “sex addiction” world. Bulimia is another compulsive disorder. When a bulimic has a recurrence of the problematic behavior it is viewed as a relapse. When a “sex addict” practices the unwanted behavior it is referred to as “acting out.” In my childhood, “acting out” was a term used with unruly children being told they, or their behavior are “bad.” In the mental health world, disturbed people displaying their feelings in dramatic misbehavior rather than words are described as “acting out.” Again, the language is pejorative, unsympathetic and smacking more of a moral defect than a painful difficulty. For me these add up to prejudices that do not help the person struggling with sexual compulsivity, and definitely contribute to partners believing “My partner is a pervert. What is wrong with me?”

Dopamine

Dopamine is one of the predominant neurotransmitters or brain chemicals. Where many people are familiar with serotonin, they might be less so with dopamine. Seratonin is the chemical more associated with a sense of well-being. Dopamine is associated with excitement, pleasure, reward, and also seeking behaviors. Dopamine is stimulated by some of life’s pleasures like eating and of course sex. Some thrilling or risk taking activities activate dopamine.

Irregularities of the dopamine system may impel behaviors that will stimulate or increase it. For some people gambling, shopping, sky diving or activities involving uncertainty or excitement are used to attempt to self regulate this system. And the dopamine rush may be self re-enforcing. That is to say the linkage between a behavior and the pleasure of the dopamine reward, may inspire the impulse to continue the behavior.

Individuals who spend time looking at erotically stimulating materials and masturbating may get a dopamine surge at orgasm. The practice of looking and the pleasure of the dopamine high may get wired together in their brains or psyches. The dopamine reward may impel the urge to do it again, and even again and again and again. Does this constitute addiction?

As an endurance athlete I get very high from intense exercise. I love to ride my bicycle and I usually know exactly when the dopamine kick will hit. I go back again and again for that joy. It is not the only thing I like about riding my bike, but it is a definite perk. When I go on a long ride, I get as high as a kite, and I know I can count on riding to change my mood. So I repeat these activities as often as I can. Although I have had a couple of serious accidents, I have always returned to riding, more careful perhaps, but undeterred. And admittedly sometimes I take unintelligent risks. For example, the first time I rode 200 miles in one day, the temperature was 105 degrees. I was not willing to give it up. Am I an addict? Some might say a resounding yes. Some say they admire my “discipline!” I know it is certainly not that. Others just think I’m a nut. And what am I addicted to? Dopamine? Bicycling? Is it even compulsive?

All these questions come to my mind as I contemplate the loose and incomplete logic and definitions around the question of sex addiction. Clearly dopamine is involved and often a pivotal factor in compulsive behaviors. Compulsive sexual behavior is no exception. Does it add up to meeting the criteria for addiction as defined in the DSM?

Recovery

None of this is to minimize the pain and suffering of compulsive sexual behavior. Obsession is an agony as is behavior that one cannot control. Sexual problems create a very particular kind of relationship hell. It is easy for partners to take it personally when pictures on a screen, prostitutes or other people compel the sexual interest, attention and time of their mates. As with most compulsive activities, the world of the compulsion is compartmentalized and hidden from the rest of life. Often in these relationships there is a snowballing deceit so there is a terrible dynamic of betrayal and guilt that spans many levels. Because compulsions may be relentless and difficult to disarm, often a couple goes through more than one go-around of confrontation or “coming clean,” attempting to stop, and the patterns silently and insidiously creeping back.

My belief is that disorders of compulsivity are painful and destructive, and definitely hard to beat. In our culture anything related to sex is likely to carry an additional weight of shame, guilt and disgust. I prefer to use language that is precise and unstigmatizing. I work hard to understand specifically what is the context and meaning of the behavior, and of course to help clients clearly connect the behavior with its impact on their own lives and the lives of significant others. And we attempt to tailor treatments very specifically to the real problem.

Elements of a Solid Treatment Approach

We begin with a careful assessment, taking into account the whole person and the person’s whole life. What is the unwanted behavior? What are the patterns? When did it start? Is it related to trauma? Anxiety? Depression? Or something else? We seek to piece together the context and meaning. Is the behavior an attempt to calm down, to escape, to feel alive, to relate to others? Is there a sexual problem that it is an attempt to bypass or compensate for? A relationship problem? An attachment disorder? There are so many possible diagnoses that may lead in different treatment directions.

Of course we seek to link the behavior to its to consequences. One of the hallmark agonies of compulsivity is how behaviors persist in spite of the havoc they wreak. Somehow the person or the brain fails to learn from experience. It is essential to face up to the damage, and in most cases stop the behavior.

In general a solid treatment net includes individual therapy for deep self-exploration. Whatever the specific diagnosis, the deeper layers need to be uncovered and processed. Often medications are a tremendous help. Again a precise diagnosis is required. For some people, antidepressants are the medication of choice, and often the SSRI’s (the Prozac family of drugs) which also have libido suppressing properties, are a welcome relief. For others who are more in the anxiety/OCD spectrum, it is anti-anxiety medication that helps manage the compulsion to self-soothe with the unwanted behaviors. For still others, the behaviors may be a symptom of Attention Deficit Disorder, and an attempt to enliven the nervous system. In these cases the ADD medications may be a godsend. As I’ve said, sometimes the right medication makes all the difference.

Couple’s therapy is essential for those who have partners. Often relationship is an area of great difficulty for the CSB sufferer anyway. And as the compulsive sexual behaviors persist and “progress,” relationship and family takes a strong hit, with dishonesty, distance, often sexual problems or impasses in the partnership, etc. However, I have never yet seen a couple who did not have other problems besides the problem of sexual compulsivity between them. Perhaps both believe that all their conflict is a result of that but I have never seen this to be true. It is however a very hard sell, as generally the CSB sufferer feels so much guilt, shame, remorse and fear; and the partner feels so much betrayal, rage, hurt and righteous indignation, that both are entrenched in that belief. There are many couple’s dynamics to sort, process and renegotiate, in the course of repairing the broken trust. This is no small feat. And as I said, it is imperative.

Group support is also tremendously helpful. The benefit of 12 Step recovery is that it is imminently available and free. It is excellent for breaking the isolation which is endemic; coming out of “hiding” among others who may have similar stories and feelings; and facilitating the process of self examination and self reflection. The 12 Steps are compassionate while also directly confronting the damage to self and others that the compulsive behaviors wreak. My complaint about the 12 Step application to sexual compulsivity is its rather moralistic stance, and its adherence to the language of addiction. Yet for many it is the core of a successful recovery package. If not 12 Step groups, some other supportive therapy group around the issues of sexual compulsivity are a necessary treatment element.

Of course general self care around health is important: good nutrition sleep and exercise. Sexuality like perhaps nothing else is at the interface of body mind and relationships. We must carefully attend to all of them!

The rest is an unrelenting commitment to honesty and growth; a willingness to make recovery the centerpiece and top priority of one’s life for a good while; and time. It may be the hardest thing one ever undertakes, and unquestionably the most valuable.

Currently the DSM is up for revision, as it is every few years. There is wide disagreement and debate about whether to create a new diagnostic category of “sex addiction” in the new tome, expected to appear in 2012. Experts are working hard, attempting to come to agreement and also answer these tough questions. As van der Kolk says, we want the DSM to reflect the best and the most current science.⁶ What do you think?