Monday, March 24, 2008

Concurrent Issues with Sexual Compulsivity

When someone receives treatment for any compulsive behavior, it is common for other problematic behaviors to occur. In my work, I've helped people get their chemical use behaviors under control, only to see their sexual behaviors escalate. Once we've identified and provided interventions on the sexual behavior, a new problem such as spending, or gambling, or anger, or eating concerns arise. The problem is that treatment needs to address the entire acting out dynamic versus simply stopping negative behaviors. It is this recognition that shapes the next sections of the workbook.

Depending on your current place in life, there might be other issues that need to be addressed. This process is sometimes referred to as “triage” where an honest review of the issues occurs. The process includes prioritizing these issues, and developing treatment plans to address the most important issues first. Only you, in consultation with your support network, can prioritize the issues. It may not be wise to address the sexual compulsivity behaviors at this time if other issues are more important. At the same time, if the sexual behavior contributes to the concerns, then it may be even MORE important to address the sexual behavior.

In the list below are the issues to be addressed in the remainder of the workbook. I've tried to be complete, but I have no doubt the list is not exhaustive. If something is relevant in your life, please add it to the list. You might want to review your sex history and your sexual time line and determine to what degree some of these events are present in your time line. As you read through the list, score each topic area on a four point scale where:

1) Not a concern - (i.e., never abused as an adult or growing up.)
2) Minimal concern - (i.e., only feel anxious at certain times, I don't think it is connected to my behaviors at this time.)
3) Major concern - (i.e., my relationship is in danger of ending because of my behaviors.)
4) Emergency concern -(i.e., I'm so depressed, I wish I would die.)

If there is anything that is a "4," please seek immediate help. If you find that you are in a depressive episode, for example, you might rank it a 3. But, if you are having suicidal thoughts or feelings, the concern is an emergency and immediate intervention is necessary. Any concerns with a score of four require support and services before you address the other issues.

Once you have scored the topic areas, go back and rank the areas that are of most importance. This is simply a process of sorting out the 4, 3, 2, and 1s in an order that makes sense with you. This becomes a tentative plan about which topics should be addressed first in your treatment process.

  • Emotional Expression
  • Anger Expression
  • Communication Skills
  • Assertiveness
  • Boundaries
  • Shame
  • Masturbation
  • Fantasies
  • Intimacy
  • Touch
  • Body Image
  • Sexual Competency
  • Positive Sexuality
  • Sexual Satisfaction/Dissatisfaction
  • Safer Sex issues
  • Sexual Functioning
  • Sexual Identity
  • Chemical Dependency
  • Depression
  • Grief
  • Anxiety
  • History of Physical and/or Sexual Abuse
  • Gambling
  • Spending
  • Working
  • Eating Disorders

Sunday, March 23, 2008

Prevention Planning-Always have the end in mind.

It is important to have the end of therapy in mind. I often state in one of my first sessions with a client that my goal is to work myself out of a job. And I ask them to think about what it would look like to be done with treatment. And, honestly, people often don't have an answer. The question, nevertheless, frames the theraputic relationship as time limited, goal focused, and honors the client's overarching goal.

In the area of sexual compulsivity, I ask them to to develop a prevention plan for sexual compulsivity. This plan has three primary components. It truly shapes the content of therapy. And, it is not as easy to complete the plan as the title suggests. I will review each component.

A) Preventing the Acting out Cycle. In previous posts, I have reviewed the acting out cycle. The prevention plan is comprised of 5 of each of the important components of the cycle (thinking errors, feeling triggers and high risk situations). As treatment progresses, the client will identify many of these. I stress developing plans for each of the primary 5 issues in each area. So, if under the feelings, depression is identified as a feeling trigger, I ask the client to identify 3 plans to cope with depression. In the case of depression, the three plans could include: Taking medications, talking with my support network, and managing my physical health through diet and exercise. Thus, by the end of the treatment, the prevention plan will have up to 45 interventions that could be used. (Some interventions, may overlap. For example, if depression and anxiety are both present, taking medications may be appropriate for each).

B) The second part of the plan is to identify sexual healthy behaviors. In preventing the negative behaviors, we have to replace them with positive behaviors. In what manner will I get my sexual needs met that respects my values and boundaries? What are the issues that need to be addressed to support healthy sexuality? The difficult part for many clients is that they want me to tell them what to do; the work is for them to develop their plan.

C) Developing of a support network. This is the part of the plan that is the most difficult and results in the most avoidant behaviors by the clients. I want them to identify 3-5 people with whom they can use as a primary support network. This would be a person who can listen without judgment, support as needed, and confront when necessary. Often clients have so much shame, that they can't share anything regarding their history. It takes a lot of trust to reach out to these people. For me, a client will share his/her prevention plan with the individuals in the support network.

Taken together, these are the measures I use for when a client is done. If any part of the plan is not completed, it is imperative to examine why. Many time the issues why are the source of additional theraputic issues. When these are resolved, this phase of treatment is complete.

So, as you review the cycle, and work through additional topics, reflect on what it would look like for you to be done. These are tasks to be addressed in your process.


More professional changes, April 08

This post is to update you regarding changes in my professional life.

Part of the reason for the time lapse since the last post is due to these changes. In February, I started a part-time consulting job at Pride Institute. This is a 10 hour a week position with the responsibilities of working with the Director of Clinical Services to enhance the existing chemical dependency program. We hope to have many of the changes online by the Middle of April 2008. The second part of the job will be to develop a residential sexual compulsivity treatment program. This component will complement the chemical dependency program. We don't have a start date for this program, but our goal is by the end of summer. Watch for more details. Also, I will be working on presenting/education opportunities regarding GLBT and chemical dependency issues. In the next few weeks, I will be presenting at a local conference, and at a local hospital for their "Grand Rounds."

The other major reason for the delay in posts has been personal. During the month of February, I came down with the flu. This wiped me out for a good 10-14 days. Shortly after the recovery, I went of vacation for another 11 days. In an attempt to make up work for the illness/vacation, I've had to prioritize tasks. The blog unfortunately fell to the lower end of the list. My commitment is to return to posting on a regular basis.