A program of integrity versus a rigorous program.

A recent phone call prompted this post. The end result of the conversation was feedback that my program wasn’t “rigorous enough.” When I asked how things might be different, the individual wasn’t able to answer. When I reflect on the question and my response, I came to a clarifying insight. I affirm that my approach to treatment is not “rigorous.” Rather, my treatment approach emphasizes integrity.

Let’s expand on the two terms, rigorous and integrity. Merriam -Webster defines rigorous as: “1): harsh inflexibility in opinion, temper, or judgment: severity (2): the quality of being unyielding or inflexible: strictness (3): severity of life: austerity b: an act or instance of strictness, severity, or cruelty.” Explicit in this definition are the concepts of cruelty, inflexibility, and emphasis on rules and procedures.

Applying this definition to a treatment program, it is easy to imagine how many people desire the clinician to be in charge. I can’t tell you how many times that I’ve been asked “Tell me what to do.” “Is this OK?” or “what should be my bottom line behavior?” As a clinician I will provide feedback and suggestions, but I impose very few behavioral restrictions. When I do, the restrictions are usually around legal, ethical or health consequences. I might say “Remember Sen. Larry Craig? Engaging in public sex like you just described probably isn’t helpful.” Or, “Using the work computer to look at porn will get you fired.” And as a final example, “Unsafe sex puts you at risk.” To fall into the trap of “rigorous treatment,” in my opinion, sets up the therapist as the external control which is bound to fail. In motivational psychology, a long term consequence of external control is a decrease in compliance to the external limits. Slowly, resentment builds as the individual “fights” with the external limits. Eventually a total break might occur where the client’s resistance causes a rupture in the therapeutic relationship. One of my critiques of the “sexual addiction” approach is the risk of imposing an external code to create sobriety through rigorous compliance. This code is usually reflects narrow Christian values. Simply complete a web search and you’ll find many therapists treating sexual addiction using a 12-step approach with a Christian evangelical approach. In the long run, it is my opinion that this treatment approach will fail.

Instead, I emphasize integrity in my treatment approach. Merriam-Webster defines integrity at “1: firm adherence to a code of especially moral or artistic values: incorruptibility; 2: an unimpaired condition: soundness; 3: the quality or state of being complete or undivided.” Implicit in this definition are the ideas of wholeness, completeness, and unity. The approach also implies an internal local of control. Research in motivational psychology has repeatedly demonstrated that individual’s will create profound possibilities when internally motivated. When a person is internally motivated, they will do things not thought possible; they will run marathons for example because they want to make a difference in the world. Think for a moment of someone who has inspired you; their source of motivation was probably internally focused. My treatment approach is designed to help the individual create integrity in their life. The goal is to help identify behaviors, attitudes and goals that lead to wholeness, completeness and unity. This approach, however, is more work and intensive than simply following a list of rules. It also requires some trial and error which results in reassessment of the internal purpose. Following this approach, a client who has created an internal moral code of sexual health will be happier, more effective and ultimately “whole.” This is what I create in my treatment approach.

Furthermore, my commitment is to provide my services with integrity. My internal purpose evokes from me a level of interest in your progress that goes beyond the therapeutic hour. I try to help you develop a parallel internal purpose as defined by you. My role is to be a coach, advisor, teacher, and supporter. And it requires direct honest feedback which may sometimes feel harsh. But, paradoxically, you’ll be amazed at how often I’m “thanked” for being honest with my clients. In the end, my treatment approach requires from you a transformation versus a compliance with a set of rules. And in this transformation, unlimited possibilities are possible.

References/resources

Merriam-Webster Dictionary retrieved from http://www.m-w.com/

Visual Thesaurus retrieved from http://www.visualthesaurus.com/.

Exercise 2: Completing a Sex History.

A natural progression from talking about sex is the exercise of talking about your sex history. As you begin the process of addressing sexual compulsivity, it is important to accurately describe your past sexual behavior. You cannot treat that which is not identified. The assignment is to complete the questions as thoroughly as possible. I often suggest that see this document as a "living document" which means it might be helpful to periodically return to the assignment and add material as you remember pieces of your history.

As you work through the sex history, it is important to be as honest and thorough as possible. At first, you may not want to put everything on paper or answer honestly because of what others might think. However, when you are open and honest, in the long run, you have a better sense of what needs to be dealt with in your treatment process.

When you have completed the inventory, please share the responses with another person. At this time, it not recommended to disclose this information to your primary partner (that disclosure will happen near the end of stage 2 and the beginning of stage 3). It is also recommended that the persons with whom you disclose the information be trustworthy and non-judgmental. Typically these individuals are therapists, sponsors, or members of a group process.

Masturbation:
1) At what age did you first masturbate?
2) How did you learn about masturbation?
3) What messages did you hear about masturbation while growing up?
4) What were your beliefs and feelings about masturbation while growing up?
5) What are your beliefs about masturbating today?
6) How often do you masturbate currently?
7) When was the last time you masturbated?
8) What thoughts did you have when you last masturbated?
9) Where have you masturbated besides in your home? Describe the circumstances.
10) When you masturbate, what objects have you used to enhance your level of sexual arousal (e.g. items of clothing, vibrators, magazines, “sexual toys”, items to inflict pain). Describe the items and when you began to use them for sexual stimulation.

Fantasy
1) Describe your three most arousing current sexual fantasies?
a. How do you feel about these fantasies?
2) What messages and beliefs did you hear about fantasy?
3) What beliefs do you have about fantasy today?
4) Have you ever masturbated to sexual fantasies of rape? If so, describe the fantasy (including your relationship to the victim, the frequency of the fantasy, and the length of time since the last rape fantasy).

Sexual Behavior
1) At what age did you first have sexual intercourse?
2) How old was your partner?
3) How did you feel about the experience?
4) How many sexual partners have you had?
a. Fill out a table including each partner to the best of your ability. For example

Your age	Partners Age	Type of Sexual Contact	Length of Relationship
16	15	Vaginal Sex, Oral Sex	Dated for 12 months
22	21	Vaginal Sex	1 encounter

b. If the number of partners is too high to count, complete the table by examining periods of your life and estimating the number of contacts. Pick periods that make sense to you. For example,
i. Upto Age 14 (pre-adolescence), number of partners______
ii. Age 15-18, Number of partners _________
iii. College, age 19-24, Number of partners ________
iv. First Job, Number of partners ________
v. First Relationship Number of partners ________
vi. Divorce and/or end of first relationship, Number of partners ________
vii. Lived at a particularly address, city, Number of partners ________
c. Describe what behaviors occurred (be explicit and thorough)
(for example, anal sex, vaginal sex, mutual masturbation, kissing, touching, etc)
d. What was the length of the relationship?
(one night stand, casual, dating a few months or longer relationship, partnership,
e. What percentage would you estimate were “one night stands”?
f. How many sexual partners have you had of the same sex as yourself?
i. How did you feel about it then
ii. How do you feel about it now?
g. How many of these sexual encounters occurred while using drugs and/or alcohol? Describe the circumstances.
5) How many times have you had a sexual affair while you were married or while in a committed relationship with someone? Describe the circumstances.
6) Describe the nature of any sexual contacts or behaviors between members of your family.

Dating Behavior
1) At what age did you begin to date or go out with girls/boys your own age?
2) Describe your level of self confidence regarding dating.
3) How comfortable did you feel?
4) Did you think you were attractive to girls/boys?
5) Did your self esteem improve or decrease as you dated more frequently?

Other patterns of sexual behavior
1) How many times have you paid money for sex or traded drugs for sex?
2) If you used prostitutes in the past, describe the types of sexual activities you engaged in.
3) Have you engaged in prostitution yourself?
4) How many times have you had sexual touch with an animal? Describe the circumstances.
5) How many times have you exposed your genitals to someone you did not know or to someone without their consent? Describe the circumstances.
6) How many times have you spied or peeked at someone in order to see if they are undressing or being sexual? Describe the circumstances.
7) Describe the types of sexual magazines and sexual movies you view for sexual stimulation.
8) How many times have you used threats of violence, physical force, or any weapon to make someone perform a sexual act (other than during your current offense)? Describe the circumstances.
9) How many times have you participated in consensual use of restraints or bondage? Describe the circumstances.
10) How many times have you ever participated in group sex? Describe the circumstances.
11) What other alternative or kinky behaviors might you have participated in?

Technology
1) How many times have you made sexual phone calls or used a 1-900 sex line? Describe the circumstances.
2) How many times have you used the internet to meet sexual partners? Describe the circumstances.
3) How many times have you used the internet for “virtual” sex.
4) How many times have you searched the internet for pornography or pictures? Describe the circumstances.
5) How many pictures/videos have you downloaded?
6) Have you downloaded pictures of explicit child sexual material? If so, describe the circumstances.

Health Concerns
1) What physical problems have you experienced which effect your ability to be sexual (such as difficulties achieving or maintaining erections, difficulties having orgasms, a lack of interest in sex, difficulties in delaying ejaculation)? Describe the circumstances.
2) Describe the sexually transmitted illnesses you have had. Describe the circumstances how this illness was transmitted.

Abuse
1) When were you ever sexually touched or forced to engage in sexual behavior against your will as a child? Describe the circumstances.
2) When were you ever sexually touched or forced to engage in sexual behavior against your will as an adult? Describe the circumstances.

Children
1) Describe any sexual contact you have had with children while you have been an adult.
2) Describe the content of sexually explicit pictures of children you have seen or possessed. How often have you viewed these pictures?
3) Have you masturbated to fantasies of children? If so, describe the details.

Legal
1) Describe any legal consequences of your sexual behavior.
2) Describe the frequency of legal consequences.

General
1) Describe any sexual behaviors or practices which were not addressed in the above questions. 2) Which three questions above which were the most difficult to answer.
a. Why did you select these three questions
b. What made them so difficult to answer?

Exercise 1: Talking About Sex

To start addressing questions of sexual compulsivity, it is important to reflect on your ability to talk about sex. The goal for this exercise is to 1) To assess your ability talk about sex and sexuality with others. and 2) To identify people with whom you can talk about sex.

As you start this process, it is important to examine how comfortable are you talking about your sexuality and sexual behavior. I am confident that as you progress through the work, your comfort level will increase. It is not uncommon, however, to be nervous, embarrassed, feel guilt and/or shame about the information to be reviewed.

Exercise 1

Answer the following questions.

YES/NO 1) I avoid talking about sex.

YES/NO 2) I talk about my sexuality with my friend(s).

YES/NO 3) I find many sexual matters too upsetting to talk about. (R)

YES/NO 4) I talk about my sexuality with my sexual partner(s).

YES/NO 5) I talk about my sexual feelings.

YES/NO 6) I usually feel comfortable discussing my sexual values.

YES/NO 7) I usually feel comfortable discussing topics of a sexual nature.

YES/NO 8) In general, I usually feel comfortable discussing my sexuality. (R)

YES/NO 9) Talking about sex is usually a positive experience.

YES/NO 10) It bothers me to talk about sex. (R)

YES/NO 11) I usually feel comfortable discussing my sexual behavior.

YES/NO 12) There will be negative consequences if I talk about sex. (R)

Score 1 point for each yes (# 1, 2, 4-7, 9, 11)

Score 1 point for each no (# 3, 8, 9, 12)

More than 8 points, suggests a difficulty talking about sex.

Exercise #2.

1) Reflect on the above questions, explain your responses.

2) Name three people you could start talking to about sexuality. This could be pastor, friends, colleagues, sponsor, therapist, partner/spouse, etc.

3) Write one paragraph summarizing what you would like to share with each of the individuals at this time regarding your questions of sexual compulsivity. Share as appropriate.

What is sexual compulsivity?

A definition and universal term is perhaps the most difficult dilemma in the field of sexual compulsivity. How do we define a concept that has been widely misused and overused? Simply looking at the concept, there are multiple terms to describe the same phenomenon including sexual compulsivity and sexual addiction. These terms are the most prevalent; however additional terms that are used include sexual impulsivity, sexual obsession, sexual anorexia, sexual compulsion, out of control sexual behavior, sexaholism and, finally but certainly not the last, love addiction. As you can see, the field itself is far in agreement on a universally accepted term. And, each term reflects a different theoretical foundation and treatment approach. While the differences are varied, nevertheless, there is perhaps more overlap when talking about the concept, even if there is not agreement on the terminology. Generally, I prefer the term sexual compulsivity. It is the term that I use in my work. Part of the rationale of my choice of the term reflects a behavioral model over an addiction model.

A large number of resources ranging from websites, journal articles to self-help books discussing sexual compulsivity exist. Simply complete a web search, and the number of hits is about 2 million. My goal here is not to replicate what is already available. In this venue, I’ve chosen to summarize and simplify the definition. Remember, my goal is not a theoretical treatise, or academic journal article. My goal is to identify a definition that works in the majority of circumstances to provide a resource for individuals struggling with sexual compulsivity.

The definition of sexual compulsivity that I use has two parts. The first part is a subjective level. On some level, the individual recognizes that his/her sexual behavior interferes with his/her life. The second level is an objective level. The interfering sexual behaviors sometimes will breach an external boundary with consequences.

Each part requires additional exploration. On the first part, the individual recognizes that their sexual behavior is a problem. Sexual compulsivity is when as any sexual behavior or thought violates your personal values and boundaries. These behaviors often lead to negative feelings of guilt, shame, and self-recrimination. In psychology we call this egodystonic. In my treatment approach, there is a failure of integrity between what they say they want and what they do. The vast majority of people seeking help realize they need help. Because of the recognition by the individual that he or she has a problem, it is usually sufficient to focus on the first part of the definition in my work.

The second part of the definition allows external feedback to the person regarding the impact of their sexual behavior on others. In some cases this can be a legal consequence such as an arrest. In other cases, the behaviors create financial consequences. And yet in some other cases, relationships end because of the violation of the boundaries. This objective part of the definition may not always be present, but is useful when the level of denial regarding the individual’s internal awareness is so great that they fail to recognize the impact of the behavior.

Two of the dilemmas with this definition are what some critics of the field say is sex negativity, and labeling of many types of sexual expression as sexual compulsivity as a form of social control. A classic example is how homosexuality was previously illegal or an illness; now control is exerted by labeling homosexuality a sin. I am aware of these concerns. In later posts, I will write about sexual positive and sexual health.

What behavior is considered compulsive is hard to define. Often the answer is “depends.” Often, the answer will depend on the presence of consequences, your values, your agreements with others (i.e., marriage/partnership). The basic premise I have is that YOU define healthy and unhealthy behaviors in relationship to others. At the same time, there are behaviors that automatically raise questions. For example, researchers in the field suggest that spending 11 or more hours a week checking out Internet Pornography is one threshold of Internet Sexual Compulsivity. This number, however, does not answer the question with any sense of finality. As you work through the workbook, you may find that the same behavior may or not be compulsive depending on the day, your mood, and other circumstances.

Just to note, sexual compulsivity is not the same as sexual promiscuity or pedophilia. Sexual compulsivity also can occur in the absence of sexual behavior (obsessive thoughts, fear of sex). Sexual compulsivity is also not the same as pedophilia (defined as an attraction to children). And while they may sometimes (rarely!) overlap, the two issues are separate therapeutic concerns.

In the end, the goal of this post was to help people recognize the concept of sexual compulsivity. The key component is the individual’s recognition that their sexual behavior creates a problem in their life. The key to treatment, however, requires additional information as to why, what, who, when, and where the problem lies.