Exercise 3: Compulsive "Acting Out" Cycle

The acting out cycle is a framework to explain how people “act out” their compulsive behaviors. The entire treatment is connected to this cycle. The key to changing the cycle is first recognizing the feeling triggers, high risk settings, and thinking,” identifying “active and passive” ways of acting out, and the perceived payoffs. We will review each of these concepts in subsequent exercises. But for now, a brief review is provided to help you develop an initial understanding.

Expanding upon the cycle:

Set-ups.

Set ups are often easily recognized. Most people who struggle with sexual compulsivity can identify various feelings before they act out. For the sake of simplicity, I have reduced the types of set-ups to three: Emotional Triggers, Thinking Errors, and High Risk Situations. An example of a feeling trigger can help explain the concept. A person feels depressed, so he or she makes a call to the phone line which leads to a sexual encounter. The feeling identified in this example, depression, precedes the acting out incident. In the same example, a thinking error that might be present includes the thought “I’ll only make a phone call, it isn’t a big deal. I won’t hook-up afterwards.” The high risk situation in the example includes making a call to the phone line. As you move through the treatment process, you will start to identify additional setups that increase the risk for acting out. In the end, you’ll probably be able to identify ten to fifteen setups of each type.

Acting Out

The acting out phase of the cycle is often recognized as the sexual behavior (for example, I had sex with this person; I watched some porn). What you will recognize is that the sexual behavior is only one type of acting out. In the field of chemical addition, there is a term used called “cross-addiction.” I have worked with clients who have stopped their chemical use, but then their sexual behavior gets out of control. Once both the sexual behavior and chemical use are under control, it isn’t surprising to see another issue develop such as eating disorders, compulsive spending, and or gambling behaviors. The key to understanding the cycle is that the sexual behavior is only an expression of the cycle; you need to gain a better understanding of all the different ways you may act out. In recognizing the range of behaviors, you can then address the real problem: the cycle and avoid a band-aid approach to sexual health. As we move through the process, you will discover passive ways of acting out are as important as active ways of acting out. For example, I’ve worked with clients who will withdraw from conflict because of fear. This will result in the person feeling resentful which is a set up for explosive anger (another type of acting out).

Pay offs/Costs

Pay offs refer to the perceived outcome of the behavior. In the example above, the perceived pay off was a relief from the depression. As you can probably recognize, the payoff is usually temporary. Sometimes the perceived payoff leads to the cycle starting all over again. It is important to think strategically in this area. You might not always recognize other payoffs. Yes, the sexual behavior might be pleasurable, but another payoff might be avoiding the fear of being hurt in a relationship, so choosing a casual encounter is also “safe.” Costs are more easily recognized. In behavioral terms, we identify these as “consequences, ” examples include my partner is angry about my behavior; I was arrested; I got drunk.

Relationship between the components.

If you examine the arrows in the cycle, you will see that each is double pointed. The cycle is dynamic, meaning it is always shifting, moving and adapting. The cycle provides feedback to the individual, and the individual adapts as necessary to continue the cycle. This relationship will be reviewed throughout the exercises as well. An acting out encounter may have a consequence (cost) that sets the person up to act out again. Treatment involves working through this cycle and addressing all aspects.

Creating Sexual Health

Integrated into my treatment philosophy is an explicit goal of helping the client clarify his or her appropriate sexual behaviors. Toward this goal, it is important to understand what sexual health is. The definition of sexual health that I liked the most was published by the World Health Organization. They define sexual health as a . . .

“. . . state of physical, emotional, mental and social well-being related to sexuality; it is not merely the absence of disease, dysfunction or infirmity. Sexual health requires a positive and respectful approach to sexuality and sexual relationships, as well as the possibility of having pleasurable and safe sexual experiences, free of coercion, discrimination and violence. For sexual health to be attained and maintained, the sexual rights of all persons must be respected, protected and fulfilled” (WHO, 2002).

The definition is very complex and represents nearly 30 years of scholarship and development.(For those desiring an understanding o f the history of defining sexual health please see one of the papers that came out of my dissertation [ Edwards & Coleman, 2004]). Sexual health is more a process than a dichotomy answered by a yes or no. As treatment continues, the key is to help the client develop and improve their sexual health. I found another article helpful in framing the process toward sexual health. Robinson et al (2002), provides a model which consists of 10 components which are briefly summarized.

The Ten Components of the Sexual Health Model.

1. Talking About Sex is a cornerstone of the Sexual Health Model. This includes talking about one’s own sexual values, preferences, attractions, history, and behaviors. As you can see, the first exercise is about evaluating your ability to talk about sex.

2. Culture and Sexual Identity are instrumental to understanding one’s sense of sexual self. It is important that individuals examine the impact of their particular cultural heritage on their sexual identities, attitudes, behaviors, and health.

3. Sexual Anatomy and Functioning assumes a basic knowledge, understanding, and acceptance of one’s sexual anatomy, sexual response, and sexual functioning. Sexual health includes freedom from sexual dysfunction and other sexual problems.

4. Sexual Health Care and Safer Sex covers a broad perspective encompasses knowing one’s body, regular self-exams and responding to physical changes with appropriate medical intervention. Examination of one’s safer sex behaviors is critical.

5. Challenges and Barriers to Sexual Health include the major areas of as sexual abuse, substance abuse and compulsive sexual behavior. Other challenges might include sex work, harassment, and discrimination. Treatment must address these areas.

6. Body Image requires challenging the notion of one narrow standard of beauty and encouraging self-acceptance. Sexual health requires a development of a realistic positive body image.

7. Masturbation and Fantasy can be a healthy expression of sexuality. It is important for individuals to clarify their values on masturbation and fantasy. Too often, masturbation and fantasy are linked with shame because of the historical myths associated with sin, illness, and immaturity.

8. Positive Sexuality recognizes that all human beings need to explore their sexuality in order to develop and nurture who they are within a positive and self-affirming environment. Positive sexuality includes appropriate experimentation, sensuality, sexual competence developed through the ability to get and give sexual pleasure and setting sexual boundaries.

9. Intimacy and Relationships. Intimacy can take many forms and is a universal need that people meet through relationships. Sexual health requires knowing which intimacy needs are important for the individual and appropriate ways to meet these needs.

10. Spirituality and sexual health assumes congruence between one’s ethical, spiritual, and moral beliefs and one’s sexual behaviors. Spirituality may or may not include identification with formal religions, but always addresses moral and ethical concerns and deeper values in order to integrate a person’s sexual and spiritual selves.

Conclusion
The exercises and assignments in this blog and in my treatment work are designed to help an individual in their process toward improved sexual health as presented in the sexual health model. The process is extensive, requires significant work and effort. In my opinion, sexual health can be reduced to a process of integrity toward one’s behaviors and one’s values. Hence, the previous conversation on integrity takes one a new level of importance. I cannot define for the individual what is “sexual health.” Only the individual can do so. My commitment is to you express your sexuality with integrity.

References:

Edwards, W. M., & Coleman E. (2004). Defining sexual health: A descriptive overview. Archives of Sexual Behavior, 33(3), 189-195.

Robinson, B. E., Uhl G., Miner, M., Bockting, W. O., Scheltema, K. E., Rosser, B. R. S., & Westover, B. (2002). Evaluation of a sexual health approach to prevent HIV among low income, urban, primarily African American women: Results of a randomized controlled trial. AIDS Education and Prevention, 14(Suppl. A), 81-96.

World Health Organization (2002). Gender and Reproductive Rights, Glossary, Sexual Health, http://www.who.int/reproductive-health/gender/glossary.html.

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/.