Saturday, August 9, 2008

Acting out and Cross compulsivity/addiction

Warning...this is a longer post.

When examining the acting out cycle, it is important to recognize other behaviors that may be related to the sexual behavior. Often the sexual behavior is not the first level of acting out, but rather the culmination of a number of behavior cycles. For example, a client wakes up late and is anxious about getting yelled at by the boss. In response, he lashes out in anger at his partner and the two of them have a fight. At work, he is yelled at by his boss so on the lunch break has a cocktail to help himself relax. Somehow surviving the rest of the afternoon, he goes to the bar to be with friends. There he starts to drink and picks up a sexual partner. In this dramatized case, the cycle be a review of the sexual acting out in the evening, but you could trace other cycles throughout the day including coping with anxiety, anger expression, alcohol use, and isolation. Now, for many people it might be rather easy to identify differences within the exact details of the example, but the variations are easily recognizable. A number of classic forms of acting out are examined here in a brief manner. Should you find that some of these are relevant, please work with your therapist and support network .

Chemical Dependency

Chemical dependency is another treatment issue in of itself. I cannot overstate the importance of addressing this issue in the creation of chemical dependency. The purpose of this topic is to help you recognize any connections between your sexual behavior and chemical dependency. My goal is to very briefly review some of the indicators of chemical dependency, provide a screening tool and then highlight possible relationships between chemical dependency and sexual behavior.

Typically, when a clinician interviews someone for indicators of chemical dependency, he or she looks for some of the following signs:

  • A maladaptive pattern of substance use leading as manifested by one (or more) of the following.
  • Problems at completing responsibilities at work, school, or home as a result of chemical use
  • Using chemicals when it is physically hazardous (such as driving an automobile)
  • Recurrent substance-related legal problems
  • Continued substance use despite having persistent consequences
  • Tolerance, as defined by either of the following: (a) A need for markedly increased amounts of the substance to achieve intoxication or the desired effect or (b) Markedly diminished effect with continued use of the same amount of the substance.
  • Withdrawal, as manifested by either of the following: (a) The characteristic withdrawal syndrome for the substance or (b) The same (or closely related) substance is taken to relieve or avoid withdrawal symptoms.
  • The substance is often taken in larger amounts or over a longer period than intended.
  • There is a persistent desire or unsuccessful efforts to cut down or control substance use.
  • A great deal of time is spent in activities necessary to obtain the substance, use the substance, or recover from its effects.
  • Important social, occupational, or recreational activities are given up or reduced because of substance use.
  • The substance use is continued despite knowledge of having a persistent physical or psychological problem that is likely to have been caused or exacerbated by the substance

In the field there is also a distinction between chemical use, abuse and dependency. If I use alcohol, of example, there is nothing wrong with it. But there might be times when I’ve done unhealthy, risky or unwise behaviors. If it happens rarely, this might qualify for chemical abuse. If my level of use is higher, or I engage in a number of risky behaviors, or if the number of symptoms is higher, this might qualify for a diagnosis of chemical dependency. The idea is that chemical use is put on a continuum of use-abuse-dependency. The process is to help the individual identify where he or she may lie on that continuum. Treatment also depends on the placement on that continuum. The more severe the level of use, the more intensive the treatment intervention will need to be. A classic alcohol use screen that is helpful is the “CAGE” questionnaire deriving the name from the four questions:

  • Have you ever felt you ought to Cut down on your drinking?
  • Have people Annoyed you by criticizing your drinking?
  • Have you ever felt bad or Guilty about your drinking?
  • Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eyeopener)?

According to the NIAAA, higher scores are indicative of alcohol problems and a total score of 2 or more is generally considered clinically significant and warrant further assessment (NIAAA, 1995).

A similar drug screen questionnaire is 20 questions and can be found at the following link.

The screening tests are provided for your information. If your scores are higher, I strongly recommend that you seek additional assessment and treatment if necessary.

The classic paradigm is that someone may use alcohol, and then make poor choices which leads to sexual behavior. Another paradigm to consider is that the alcohol use is a response to a previous cycle which then leads to a series of sexual behaviors. Some clients have VERY restrictive values or thoughts regarding sexuality. These thoughts lead to a behavior of “shutting down” or repressing sexuality. Once they use the chemicals, the ability to repress the thoughts and feelings decreases. Hence, chemical use appears to lead to sexual behavior. In the second paradigm, however, the restrictive sexual thoughts would be the primary problem with the chemical use being a secondary problem.

To highlight the need to accurately assess the primary treatment issue, I have worked with clients who have completed multiple chemical dependency treatments. With one client who could never maintain periods of chemical sobriety longer than a few months, it became clear that the sexuality issues are primary with the drug use a result of the sexuality issues.


National Institute on Alcohol Abuse and Alcoholism. (1995). Assessing alcohol problems: A
guide for clinicians and researchers
(NIH No. 95-3745). Bethesda,MD:National Institute of Health

SHIELDS, A. & CARUSO, J. (2004) A RELIABILITY INDUCTION AND RELIABILITY GENERALIZATION STUDY OF THE CAGE QUESTIONNAIRE. Educational and Psychological Measurement,64(2) ,254-270 DOI: 10.1177/0013164403261814

Welcome to the Drug Abuse Screening Test (DAST) (2008)

Eating Disorders

When the topic of eating disorders is raised, the primary thought that often comes to mind is an adolescent female or young woman throwing up to reduce their weight because of bad body image. And while this is a primary population (about 90%) men are a growing population who also suffers from eating disorders. And among gay men, the number of men with the disorder appears to be higher than the general population.

Typically eating disorders fall into two or three types. These are anorexia nervosa, bulimia nervosa and Eating Disorder NOS. Often simply referred to as anorexia, anorexia nervosa is typically exhibited through the failure to eat or maintain proper nutrition. Bulimia nervosa is typically exhibited through purging behaviors such as throwing up or laxative use. Most often, however, you will not find a person with an either/or diagnosis, hence the combined diagnosis of eating disorder, not otherwise specified; sort of a “misc,” “other” or catch all diagnosis.

Symptoms of eating disorders include some of the following:

  • Significant changes in weight.
  • Depression
  • Eating more than a typical person does in a typical mean
  • Constantly thinking about food
  • Constantly thinking about body image.
  • Constantly thinking “I’m fat.”
  • Purging after eating.
  • Over-exercising
  • Taking excessive laxatives.

While it is difficult to accurately diagnose eating disorders, there is a body of research looking at helping individuals identify if they are at risk. One research article identified four questions that may be helpful. These questions are:

  • · Do you worry that you have lost control over how much you eat?
  • · Do you make yourself sick when you feel uncomfortably full?
  • · Do you currently suffer with or have you ever suffered in the past with an eating disorder?
  • · Do you ever eat in secret?

According to their research, if you answer yes to three of the questions, it is recommended that you seek further assessment. I tend to be more cautious, so if you have at least two “yes” responses, consider the possibility that your eating behavior may be a concern. It is very difficult to treat individuals who suffer from eating disorders. The interrelated issues related to treating eating disorders are similar to the interrelated issues as identified in this workbook. I’d be willing to be bet you could do a massive “search and replace” sexual health with eating disorder and many of the topics would be appropriate. The reason the topic is included in this workbook is because it is necessary to review how your eating behaviors are associated with your sexual behavior. Part of addressing eating disorders will also require you to address the questions of body image which is a different topic. Review your sex history and the timeline. The following questions are examples of things to consider. Is there any correlation between sexual behavior, frequency, thoughts and feelings and eating behaviors? Might an eating disorder episode precede or succeed sexual behaviors? Might sexual behaviors trigger shame that is transferred to eating behaviors?

Cotton, M. Ball, C., & Robinson, P (2003) Four Simple Questions Can Help Screen for Eating Disorders Journal General Internal Medicine, 18(1): 53–56 .doi: 10.1046/j.1525-1497.2003.20374.x.

Prevalence of Eating Disorders found at:

Gambling whoops…to be finished.

Another area of concern for some individuals is to evaluate their gambling behavior. The ongoing theme is to assess any relationship between gambling behaviors as a reaction to sexuality or sexuality a reaction to gambling. To begin with, review the referenced South Oaks Gambling Screen located at:

Review your sexual timeline. Is there any relationship between your sexual behavior and/or gambling behaviors.


Lesieur, H. & Blume, S. (2008) The South Oaks Gambling Screen (SOGS) located at:


Spending behavior also has a the possibility of being related to sexual behavior. Like many of the similar cross compulsive behaviors, each of these issues may require treatment in their own right.

Some questions to consider (IIAR, 2008)

  • Shopping or spending money as a result of feeling disappointed, angry or scared.
  • Shopping or spending habits are causing emotional distress in one’s life.
  • Having arguments with others about one’s shopping or spending habits.
  • Feeling lost without credit cards.
  • Buying items on credit that would not be bought with cash.
  • Feeling a rush of euphoria and anxiety when spending money.
  • Feeling guilty, ashamed, embarrassed or confused after shopping or spending money.
  • Lying to others about purchases made or how much money was spent.
  • Thinking excessively about money.
  • Spending a lot of time juggling accounts or bills to accommodate spending.

Another research (Edwards, 1993) developed a screening questionnaire. She highlighted 5 factors that may highlight compulsivity spending behaviors. These factors are:

  • Factor 1: A person has a tendency to shop and spend in binges or "buying episodes".
  • Factor 2: Some people have a preoccupation, compulsion, and impulsiveness in shopping and spending patterns.
  • Factor 3: Some people engage in compulsive spending because they enjoy the shopping and spending activity.
  • Factor 4: Some individuals experience significant life functioning issues surrounding and resulting from his or her shopping and spending behavior.
  • Factor 5: Many compulsive spenders experience feelings of remorse, regret, and shame.

As you examine your spending behavior, review the questions above. Are you engaging in behaviors that could be considered compulsive? Might compulsive spending precede sexual behavior? Or might compulsive sexual behavior be an attempt to “cope” with spending behavior?


Illinois Institute for Addiction Recovery (2008) What behaviors indicate compulsive shopping and spending?

Edwards. E (1993) Development of a New Scale for Measuring Compulsive Buying Behavior Financial Counseling and Planning, 4, 67-85

Compulsive Working

Compulsive working, or even simply job stress can contribute to problematic sexual behaviors. As with many of the compulsive behaviors, the degree of the problem is often on a continuum of severity. And again, it is provided here to jumpstart your treatment process in order to review how work and sexual behaviors overlap. In some cases, the reality is that we simply don’t recognize the compulsive patterns. Strangely, I couldn’t find much academic research in the area. Rather, I found a basic website addressing some questions for consideration.

  • If you treat your home as the second office, and you regularly take work home to finish.
  • If you take office work with you on a vacation or take smart devices like laptops, cell phones and pagers to keep in touch.
  • If you are a social recluse preferring to be isolated and buried in your work shunning all forms of social activity and you brush it aside as `trivial'.
  • If work patterns are the cause of problems in your family life. When you can't enjoy the returns in terms of success or money just because you are too `caught up' with work
  • If you are physically run down because of overwork and stress and you can't be bothered.

Applying the concepts of the acting out cycle, example the motivations behind your work by looking at the thoughts and feelings you have before, during or after work. Your reaction to work can trigger thinking errors that can be used to justify your sexual behavior. You might use sexual behavior to help escape work, or identify how hard you worked as justification for a sexual contact.


Are you a workaholic? (2008)

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