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1. If the patient is married I attempt to have the wife participate in treatment. She has been traumatized repeatedly by the husband's problem and broken promises, and usually has a huge trust issue with him and may be debating divorce. I see them together so that the wife knows everything that goes on in treatment; and we address her fears, depression, the kinds of acting-out, as well as their stressed marriage.
2. In the first interview I have the husband outline the problem and ask him what he wants me to do. He needs to take the initiative in his healing. I then turn to the wife and ask if she has anything to add or correct or if she wants to say what her goals for therapy are. If on the verge of divorce, I determine if she wants out or wants to stay and help.
3. I talk about the importance of the wife being a part of the healing team. It goes faster if both are involved. Both are wounded. Both need help. However, there is one unchangeable rule: NO SECRETS. I tell them that secrets "kill you. They take away your power." They create shame and guilt. And even though there might be some relapses (usually minor) during treatment, these need to be talked about openly in therapy; they are wasting their money if these are not disclosed and worked with. I tell them that most people I know who are kicking the cigarette habit quit 12 times before they really quit. Anything hidden, the spouse always sooner or later finds out about it. So right to begin with: no secrets!
4. I next take a history of the man's exposure to pornography and masturbation to it (or masturbation with no pornography) and sexual acting out. I do this in the wife's presence, which helps her understand more clearly that in some ways her husband was a victim usually starting at an early age. I next inquire about possible sexual abuse or early seduction of the husband as a child or as an adolescent, which have eroticized him prematurely. In taking this history, I start with his first memory of exposure to pornography--what its form was (magazine, video, phone sex, etc.) and if he masturbated to it--and continue with the history up to the day of interview. Then I establish a sobriety date (the date of last exposure) for all the different forms of porn or sexual acting out that he was involved with, as well as the last time he masturbated. At each succeeding visit I recheck these sobriety dates. If there has been relapse then I do relapse prevention work with him, identify triggers that set him off, and seek ways to circumvent these.
5. I next explain to the wife that her husband has lost his free agency. And that's why promises don't work. Good intentions mean nothing. Her husband may mean well and really want to quit because of the terrible painful consequences, but he literally cannot do this by himself yet. He has to have highly specialized help. Most therapists do not know how to treat sexual addictions. Self control and self discipline or a rational approach generally don't change anything. With most people I see who are deeply addicted, prayers and scripture reading are usually not enough to solve the problem even though I believe that God could instantly cure the problem if He so chose. In most cases He lets the individual work it through the long way probably because he will in the future be more likely to resist temptation.
6. I tell both husband and wife about the "wave" which periodically hits the patient and overwhelms him with temptation. This is something most men cannot resist. One of the goals of therapy is to prepare the man to face and defeat the wave. These waves vary in frequency from several times a day to once a year or even less. Between the waves the man feels at peace and has the mistaken notion that he has his power and can resist anything. But this is an illusion and is only temporary until the next wave hits him.
I explain to the couple that as a therapist I'm like a guide to Mount Everest. I can show them how to get there but they have to walk every step of the way. They have to do all the work. I assure them they can heal. But like alcoholics when sober, sexual addicts must be careful not to expose themselves in the future to high-risk situations. I also explain that they are not mentally ill in the classical sense but that they have an addiction which powerfully controls their lives, somewhat like being on crack cocaine. And the journey to freedom will not be easy. It will require an enormous commitment on their part to become whole again.
7. I assign both husband and wife to read Patrick Carnes' book, Out of the Shadows, and Stephen Kramer's book, Worth of a Soul.
8. I have the husband begin attending S.A. (Sexaholics Anonymous) which is a 12-step group, spiritually based...There are chapters in nearly every city in America. They are free. To find where and when one meets, call Alcoholics Anonymous (in all the phone books). They will know. The client-addict may start with a newcomers group first, and then graduate to the step-study group after a few months. Wives that have been badly traumatized by their husband's behavior may wish to attend S-Anon (for spouses of offenders) or even later join with their husbands at their S.A. meetings if allowed. The client-addict needs to attend 90% of his weekly meetings for this to work and be truly healing. If the individual is relapsing at high rates, they may need to attend up to three or four nights a week in order to achieve sobriety and break the stranglehold of their addiction.
9. At these S.A. meetings, they need in time to locate a "sponsor," who is someone who has been sober (no relapses) for a lengthy period of time who they can call (phone) in an emergency, which is an occasion when the wave hits and they are strongly tempted to act out. Their sponsor can help them stay sober; he's like a life guard.
[Editor's note: Some churches and other overtly religious organizations also provide special support groups for sexual addicts. Unlike S.A. groups, these organizations typically approach the problem from a particular religious perspective.]
10. Because the compulsion to act out is so overpowering, I give them a mental set to just stay sober one day at a time. They must think only of making it today. If they focus on a longer time period they may be setting themselves up for failure.
11. Through close interviewing, the addicts must identify triggers which activate the wave (e.g. looking at porn, seeing girls in skimpy clothes, after a fight with their spouse or the spouse being out of town, driving by an adult bookstore, walking into any video store, viewing hard-R or X films, looking at ladies bra and panty ads) and then plan strategies to avoid these or deal with them. Example: if going on a business trip and staying in a hotel with access to porn movies, request the front desk, when checking in, to block out those channels. Call their wives at 9:00 P.M. each evening when away.
12. "Thought-stopping." When the addict is stimulated or aroused by sexual fantasy which can lead to masturbation and the acting out cycle, I tell them that they have only three seconds to block or stop the thought or imagery. At the top of their voice they should yell STOP (or scream silently if others are nearby) and visualize a policeman with handcuffs approaching, holding a big sign with the words STOP on it. This will kick the offending imagery off the mind screen briefly. But then they have to bring to mind an event in their life that has very powerful emotional significance (either positive or negative) which they can ruminate about. In other words, they fight fire with fire, a strong sexual fantasy with another totally different kind of memory, such as the time they helped their team win the game, a surprise birthday party, or even the death of a very close friend. But it must be something powerful emotionally.
13. "Fire drills." I present to them imaginary situations which they might have to face in real life which would expose them to temptation. How would they handle it? I process their responses in great detail so if something like this should happen in real life they would be mentally prepared to deal with it. Example: a friend at work wants to show them his porn. How would they handle it? The wife, of course, is listening to all of this and participating as she chooses.
14. No more masturbation. Stop masturbating. This risks further conditioning into deviancy. The goal of no masturbation may be difficult and not even possible immediately. I have them keep a calendar record of those days when they masturbate and urge them to strive for reducing its frequency but especially, if they do slip, to refrain from fantasizing about deviant sexual imagery. In contrast, I have them imagine loving their spouse. I check their calendar record at each session to determine whether the frequency of masturbation has been reduced, with the ultimate goal of being free of this habit.
15. Marriage counseling. I tell them to do things that will help improve their marital relationship. I give them assignments to have fun together and improve intimacy, take marriage seminars, participate in sports together, be friends, etc.
16. Stress reduction therapy. If they have financial problems, I help them work out solutions or refer them to agencies that can help. If they have out-of-control children, I give them support in dealing with this. Or if the wife suffers greatly, I recommend a program to provide her with a support group and place where she can be nurtured.
17. When relapses occur, I don't "beat them up." I point out that relapses are just part of a growth experience and explain what can be learned from the relapse that will protect them in the future. I try to give them hope. I point out the progress already made and the good things done.
18. I have them keep a daily journal in which they record fantasies and behaviors. I then review and process these during therapy.
19. I give them further books to read, such as Patrick Carnes' later books, Contrary to Love, and Don't Call It Love. I also recommend the Sexaholics Anonymous Big Books, include case histories and biographies of recovering addicts.
20. Other techniques I use include apology sessions; medications to temporarily reduce the sex drive, including eliminating sex fantasies; autobiography; covert sensitization; family of origin work; developing a sobriety contract; healthy sexuality education, and social skills work.
21. And lastly, if an inappropriate image or tempting thought appears on the client's mind, I have him close his eyes and say, "Thank you God. I appreciate your reminding me of my weakness. This will help me get well!!!"
22. Therapy must be tailored to the special needs of the couple. I choose only those techniques that best fit my client's special needs.
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See also: "Best Advice" - a Compendium