Relapse and Healing

Obviously, no one likes to relapse. It often feels like a failure. Rather then emphasize the failure, the process of change can take a relapse and learn from it. When you examine the conditions that occurred in a relapse, you might uncover an unknown issue; or, you might recognize an issue you were avoiding is more important than you previously believed. Similarly, you might recognize you need to develop a different plan on a topic that you thought you addressed.

What kind of cookie are you making? Understanding Cross Compulsivity

A metaphor to understand cross-compulsivity is the process of making a cookie. One of the first things you do in making cookies is to review the list of ingredients. Typically this list includes flour, eggs, water, sweetener, fat, and a raising agent. Beyond the basics, most of the other ingredients reflect the type of cookie you are making. If you’re making chocolate chip cookies, you need chocolate chips. If you want oatmeal raisin, you need those ingredients. White-chocolate, macadamia with cran-raisin requires those ingredients.

Using the metaphor further, a person can make a slight change in the ingredients and achieve different results. For example, there are many options in the type of fat to use. If you use butter, you get a soft, creamy cookie. Margarine gives you are smaller, harder cookie. (In the cooking field, these nuances are a big deal!) Each of the different types of fat results in slightly different taste and textures.

Coming back to cross-compulsivity, many of the ingredients between cross-compulsive behaviors are the same. Whether it is sex, drugs, eating, spending, or other form of acting out, there are overlapping ingredients. It is the specific behavior that adds the type of cross-compulsivity similar to the types of ingredients that define the type of cookies (chocolate vs oatmeal vs sugar vs peanut butter, and so on). Drugs create the flavor of drug addiction; sex means sexual compulsivity; eating means eating disorders and so on. This similarity helps explain why a person might address or “fix” one problem behavior, and simply switch to a different problem area. It also helps why addressing the underling cycle is important. Similar to the cookie, there are similar ingredients within the acting-out cycle. In my approach I use thoughts, feelings and high-risk situations as the ingredients to the acting out cycle. It is important to identify the basic ingredients to your acting out cycle versus only focusing on the problematic area. Otherwise, you risk simply changing the type of cookie you are making in your life.

It’s not about the sex.

I was asked if someone could/would engage in cybersex behaviors without actually meeting a partner in real time/face to face as Rep. Weiner acknowledged. The short answer is, “yes.” The reason is that the cybersex behavior isn’t always about the sex. Why do it then? To that question, there is no easy answer. Below is a list of other reasons that people might use to engage in cybersex behaviors.

1) Boredom
2) Loneliness
3) Fear of cheating
4) Shame
5) Jealousy
6) I didn’t cheat since I didn’t meet
7) It’s a break from the hard work of the day.
8) Horny
9) My partner isn’t around
10) It’s just a fantasy, it’s not real.
11) No one will find out.
12) Excitement

One of the tasks in treatment is to figure out the deeper motives that shape an individual’s behavior. It is a process of discernment and discovery. In the workbook, we highlight 3 groups of reasons: thinking errors, feeling triggers, and high risk situations. Each then becomes a source to intervene in the cybersex beahviors.

Topic 12: Behavioral Analysis

--I apologize...the formatting didn't transfer from the table. Please feel to contact me via email for a copy of the document.

Clients often report they don’t know why they did what they did. And to a large degree, I believe them. I often challenge my clients to tell me the steps necessary to drive a car. As they do, I playfully trip them up by asking questions about this or that. What they come to realize is that driving a car is a remarkably complex task that calls for multiple thought processes and requires you need to pay attention to details. In psychology, this term is called “automaticity:” the ability to complete complex behaviors without active cognitive thinking –like a habit. Much of the ritual in Internet sexual compulsivity is automatic. People fall into a trance, and simply don’t know why they are doing what they are doing. A helpful tool in identifying thinking errors, feeling triggers and high-risk situations is the completion of a behavioral analysis. This is a step-by-step examination of what happens in an acting-out experience. The goal is to help you identify additional relevant issues, so you should examine all details, no matter how small you think they are. The behavioral analysis is a way to slow down and uncover the contributing factors. In the process of completing the analysis, you will identify a number of places to intervene and interrupt the cycle.
• You will learn to recognize and then contradict thinking errors. Challenging negative thinking through corrected thoughts or using affirmations (if you are familiar with the 12-step tradition) is a start.
• You will be able to address your feelings. Identifying ways you can connect with others in a healthy way, for example, allows you to help address feelings of loneliness. If your sadness and depression are significant and long lasting, medications or therapy might be helpful.
• High-risk situations are recognizable. Too much free time can make you vulnerable to a high-risk situation. Finding ways to engage in healthy fun is another way to intervene on the cycle.
In each of the behavioral analyses, I talk about an escalating pattern of behaviors that sets the stage for the next trip through the cycle. When working with clients, I call these trips “micro-cycles,” because you may experience multiple trips through the cycle within a given time period. The example below highlights multiple ways you may have failed to cope with the setups throughout a given time period. The key then is to identify ways you can interrupt any and all of the various parts of the cycle.
Assignment
• Using the template below, complete a behavioral analysis of an acting-out encounter. What feelings triggers (see page XX) thinking errors (see page xx) or high-risk situations (see page xx) did you identify? Update the current lists, as appropriate.
Instructions
To complete the analysis, it may be helpful to work backwards. Start with the acting-out incident. Answer the question “What happened?” Then ask, “What happened right before that” and so on. Stay focused on what happened while you work backward. Don’t give up to early, but you can always add more if you remember parts of the cycle. It’s like tracing the last domino’s fall back to the first domino. Once you have a good start at what happened, complete the other columns by adding the corresponding thinking errors/thoughts, feeling triggers and high-risk settings. Try to fill each column, but if you can’t you can always come back to it. At the end of the process, summarize the behavioral analysis. Every item in the analysis becomes a place to develop an intervention plan.
---Start Here---
What happened?
Include Payoffs or Consequences Thoughts
What was I thinking?
What reason did I use?
Feelings
What was I feeling? High-risk Situation
When, where, who, what?
I hooked up with someone I did it again. Shame.
Hopelessness. Isolation. Avoid my support network.
Late night
No support
I drove over to their place He/she is attractive. Sex will be great.
Why do I keep doing this? Excited, happy, numb, distracted. Going to other peoples house.
Not establishing boundaries.
No support network
Keeping secrets
I was chatting online Maybe I can connect with someone.
My partner is already asleep, no one will know.
My partner isn’t available Lonely, excited, aroused Cruising.
Online late
Online in “bad” places
I start looking at porn. No one will know
It’s only pictures
I earned it after how bad today was. Justified, entitled,
Bored No supervision online.
Porn sites
I was checking my email I have to see what else needs to be done on the project. Lonely, tired, sad. Working too late
Using work to give me an excuse to use the internet
“Work-aholic”
I was heading to bed Can’t talk to anyone.
I’m alone.
No one cares Sad, depressed, lonely, tired. Isolation.
Tired
Overworked
I had a fight I can’t do anything right.
My partner doesn’t understand.
It’s my fault Fear, sadness, shame, guilt. Seeing someone angry.
Conflict
Lack of assertive skills
I missed dinner My partner doesn’t care; he/she didn’t’ wait for me. Hungry Not eating well
Not keeping a schedule
Life not in balance
I come home late I had to get this project done.
Maybe my boss won’t be mad at me if I’m done.
It’s not a big deal. Stress
Guilt/Shame
Fear Working late
Not keeping a schedule
Trying to please others.
I had a project to complete at work. Oh no. I’m in trouble.
I should know better.
I have to do it myself.
No one will help.
It has to be done today.
I’m going to get fired. Worried, anxious.
Stress Made a mistake.
Not talking with others.
Not being honest.
Isolating.
Not asking for help.
Lots of conflict at work. Better be careful or my boss will turn on me.
I’d better not screw up. Worried/fearful that someone is angry.
Shame/Fear Someone is angry
Conflict
Consequences at work.
My boss yelled at me. I did it again
I’m in trouble
I can’t do anything right.
I told myself I wouldn’t do that again. Tired.
Fearful
Shame/Guilt Conflict
Doing things I said I wouldn’t
I came in late because I overslept Frustrated that I didn’t sleep well.
I did it again Tired. Hooking up the night before (complete and/or continue the analysis)
Summary of the analysis Catastrophizing.
Minimizing.
Justifying.
Blaming.
I can’t make a mistake.
I’m in trouble.
I can’t tell anyone.
I’m going to get fired.
I’m alone. Lonely.
Guilt.
Tired.
Worried.
Anxious.
Fearful.
Sad.
Depressed.
Lonely.
Shame.
Hopelessness.
Excited.
Stress. Not sleeping well.
Making a mistake.
Isolation.
Being online.
Working from home.
Working late.
Overwork.
Drinking.
Cruising.
Chatting online.
Looking at porn.
Conflict.

Anger as a feeling trigger

Anger is a difficult topic to address because of the relationship to so many topics. It is a robust topic with multiple meanings and ways it is expressed. I will summarize a number of issues regarding anger as may relate to the acting out cycle. If these are relevant, please work with your network to obtain support and additional resources.

Anger as a primary feeling
What makes anger so difficult to understand and treat is the confusion around the phrase“ I’m angry.” Feelings of anger, mad, rage, frustrated and disappointment reflect different intensities of anger. What may trigger anger varies.

Anger as a secondary feeling
It is worth repeating: What makes anger so difficult to understand and treat is the confusion around the phrase “I’m angry.” Sometimes anger is a response to other feelings. The concept of “flight or fight” highlights this difficulty. When someone experiences fear, they typically want to run away or attack the source of the fear. In these cases, anger is actually a response to the fear. Treatment should focus on the source of fear. Another example as highlighted in the Payoffs for Sex is that anger may be in response to hurt. I’ve worked with clients whose acting out behavior is a form of revenge to hurt the partner or other person. These two examples highlight the importance of understanding why you are angry. If your feelings of anger are in response to a response to another feeling, it is important to identify and address the primary feeling instead.

Anger as part of a process
In the topic on Feelings of Grief, the stages of grief highlight how anger is a normal part of the grieving process. In circumstances where you experience loss, understanding how anger is expected as part of that process is helpful. Treatment for coping with anger in this example will address the process of coping with loss and grief.

Strategies for coping with anger
I mentioned in the section on Anxiety how I like the “_____ for dummies” series of books. They also have a book Anger Management for Dummies book that may be helpful In addition to reading additional material in coping with anger, the following strategies may be helpful.

Mindfulness: In the topic on the Power of Thought, I raised the topic of becoming aware of your body, thoughts and feelings. This skill is also helpful in coping with and expressing anger.

Time outs: Giving yourself a brief break from the situation can reduce unhealthy expressions of anger. I have my clients say “I need 15 minutes to settle down and think about what I need to say.”

Assertive communication: Review the upcoming topic on assertiveness. Learning how to assertively communicate when you feel anger is important.
Relaxation: Reducing overall stress and identifying ways to relax creates opportunities to focus on what is important and how you want to respond.

Meditation/Journaling: The ability to reflect on an encounter where you felt anger can improver your ability to understand the source of your reaction. Assessing your behavior can improve future responses.

Reaching out: Reaching out to your support network for support, coaching, feedback and advice when you feel anger is also helpful. A different perspective is sometimes what it takes.

Anger as an issue for follow-up
In the topic on Cross Addiction/Compulsivity, I highlighted different forms of acting out such as chemical use or spending behaviors. Anger can be a form of acting out as well. Every once in a while, I have a client who has significant problems regarding expressing, managing, and coping with anger. In some circumstances, client will be abusive toward others. Most often this shows up as verbal abuse, but in some situations, the client will engage in physical abuse. It is NEVER acceptable to express anger in this way. If you find that you struggle with coping with the anger, or that you continue to escalate after using the strategies above, I recommend further follow-up for additional support. This may include anger management classes/training or ongoing therapy.

Assignment
• Describe the circumstances when you felt anger.
• When you find yourself angry, what other feelings may be the associated with the anger.
• What are your plans to improve your ability to express anger in healthy ways?
• Review your sex history. Examine how anger is related to the acting out behaviors. Might how you express anger be a form of acting out? Highlight any relevant examples.

Sexual Avoidance

Over the past few weeks, I’ve been working on updating the workbook. One major topic that is now included is the following concept.

Sexual Avoidance

One of the more difficult aspects of sexual avoidance is recognizing the problem. Therapists in this field often focus on behaviors that are measurable. Most of this workbook focuses on what a client does in the realm of sexual behaviors. Individuals can easily recognize how many partners they had, or acknowledge, “I did this behavior,” and so on. Less recognized and as a result less treated is the question of sexual avoidance. Some professionals use the term sexual anorexia. There is not agreement on a term that adequately describes the concern. For some people, obsessive thoughts are the problem; other individuals engage in sexual avoidance or have strong reactions such as of sexual aversion. In some cases the time between sexual contact and/or any significant relationships can be years. In a few circumstances, the comment from a client is that he or she hasn’t had sex in a decade or more. The key for many of these people isn’t that lack of sex, but the motivating factor in why they haven’t had sex. Thoughts and feelings of shame, fear, and hopelessness often shape why a person avoids sexual contact. Often the underlying dynamic for sexual avoidance is similar to the dynamic for sexual compulsivity. It is important for you to assess the pattern that results in the possibility of sexual avoidance. Examine your sexual history; there are a few questions relating to sexual avoidance. In each of those circumstances, review how the acting out cycle may have been present. You might be caught in the acting out cycle through a passive behavior (avoidance) versus an engagement behavior (compulsive). If you see this pattern, include sexual avoidance as part of your treatment plan.

Questions to consider.

1. Describe any circumstances where you have intentionally avoided sexual contact with a partner or significant other. Include any underlying thoughts and feelings.

Topic 4: Immediate Short-Term Prevention Plan

Occasionally, I receive feedback from colleagues that leads to a new topic. A friend suggested that he has worked with clients who need an immediate behavior plan to help them radically interrupt the acting out cycle. Of course, I responded. While it was implicit in the workbook, the conversation lead to a new topic. For those who have the workbook, consider this assignment topic 3.5.


Topic 4: Immediate Short-Term Prevention Plan
Often what brings a person to therapy is the fact that there are immediate behaviors that are interfering in one’s life. These behaviors need to be stopped right away before any additional consequences (legal, emotional, relational) occur. This assignment is to help you clarify what your immediate problem behaviors and develop immediate plans. (By the end of the workbook, you will develop long-term sexual healthy behavior plans.)

To begin with, answer the following questions:
1) Review what brought you into treatment. What are the problematic behaviors?
2) Review the sexual timeline. What are the behaviors that are of immediate concern?
3) Think forward into the future, what current behaviors do you want to stop?

Your assignment is to identify which behaviors you want to stop and to develop the short-term plan to help you meet you goals. For this assignment, these are the most important behaviors that need to stop now. In medical triage, you treat the most important issues first. When someone is bleeding for example, you don’t worry about a temperature until after the bleeding has stopped. Now, think about the plan for the next week, 30 days, or even 90 days. This plan is short term and is meant to help you build on short-term successes. I’ve included some examples of interventions that might be helpful.

1) I will not go online to internet sex sites.
2) I will not go to public sex sites
3) I will not have sex outside my relationship.
4) I will not have sex for the next week (or the next 30 days).
5) I will not masturbate to unhealthy fantasies for the next week.
6) What do I need to put in place to help me succeed


There is a high probability that you might fail. Interrupting and stopping the cycle is difficult. If it was as easy as saying “I’m not going to do this anymore” you would have already stopped! The key is to keep trying and address the issues why you fail. If and when you fail, completing a behavioral analysis (discussed at the end of stage 1)is important. You will be able to use what you learn from the process to uncover your unique components to the acting out cycle (which is addressed next) and help you strengthen your plans.

Behavioral Analysis of the Acting out Cycle

A helpful tool in identifying thinking errors, feeling triggers and high risk situations is the completion of a behavioral analysis. This is a step-by-step examination of what happened. The level of detail is on the minutia. The goal is to help identify additional relevant issues to be addressed. I often challenged my clients to tell me how to drive a car. As they do, I will playfully trip them up by asking questions about this or that. What they come to realize is that driving a car is a remarkable complex task, with multiple cognitions, and items to be aware of. psychology the term is automaticity: the ability to complete complex behaviors without active cognitive thinking. Much of the ritual in sexual compulsivity is automatic. The behavioral analysis is a process to slow down and uncover the contributing factors. The following table is helpful.

What happened	Thoughts	Feelings	High Risk Situation
Woke up tired/Didn’t sleep well	Frustrated that I’m not sleeping well	Tired	Not Sleeping Well
Went to work		Tired
Boss angry (and not even at me)	Better be careful or she’ll turn on me. I better not screw up	Worried Fearful that someone is angry
I make a mistake	Oh no. I’m in trouble now. I should know better. I can’t tell anyone. I’m going to get fired.	Worried/Anxious	Made a mistake Not talking with others Not being honest
I hide the mistake	Maybe they won’t find out	Paranoid/Fearful again	Lying
Boss mad at me	I can’t do anything right.	Fear/Sad/Shame/Guilt
I shut down	Can’t talk to no one. I’m alone	Sad, depressed, lonely, tired	Isolating
I head over to the bar after work	Maybe I can meet some of my friends	Lonely, tired. Sad	Bar setting
Drink too much	At least I won’t feel anything for a while	Relaxed/calm	Drinking
Start Cruising at the bar.	Maybe I can connect with someone.	Lonely. Excited	Cruising behaviors
Bring someone home. Unsafe Sexual contact (no condom).	Wow. He/she is attractive. Sex will be great.	Excited. Happy. Numb Distracted	Unsafe Sex Not establishing boundaries.
Wake up tired	Frustrated that I did it again

Summary of the analysis	Catastrophizing Minimizing I can’t make a mistake I’m in trouble I can’t tell anyone I’m going to get fired I’m alone	Lonely Tired Worried Anxious Fearful Sad Depressed Lonely Excited	Not sleeping well Making a mistake Isolating Being in a bar Drinking Cruising Unsafe Sex

In the process of completing the analysis, you now have a number of places to start intervening to stop or interrupt the cycle. Learning to recognize and then contradict thinking errors is part of this process. Challenging negative thinking through corrected thoughts, or affirmations if you’re familiar with the 12-step tradition is a start.

Addressing the feelings are important. Identifying ways that you can connect with others in a healthy way allows you to help address feeling lonely. Perhaps if the sadness and depression is significant enough, and long term enough, medications or therapy might be helpful. Finding ways to engage in healthy “sober” fun is another way to intervene on the cycle.

In each of the high risk behaviors, I talk about an escalating pattern of behaviors that sets the stage for the next trip through the cycle. Working with clients, I call this a “micro-cycle” which suggests that the whole day can be a cycle, but in each attempt to cope or failure to cope, I engaged in a pattern of unhealthy behaviors. The key then is to identify ways that you can interrupt any and all of the aspects of the cycle addressed in this chart.