From The Routledge International Handbook of Sexual Addiction, Dr Thaddeus Birchard shares his clinical experience of using CBT-based activities in group therapy for compulsive sexual behaviours.
Cognitive Behavioural Therapy (CBT)
Modern Cognitive Behavioural Therapy (CBT) has emerged since the publication of Cognitive Therapy of Depression (Beck et al., 1979). It combines behaviour therapy and cognitive therapy, with its emphasis upon understanding and changing the meaning of events. It is our interpretation of an event, rather than the event itself, that gives it its character and determines its impact upon our feeling states. Introductory textbooks on CBT are fond of quoting Epictetus (AD55-135), who said that ‘Men are disturbed not by things but by the principles and notions that they form concerning things’.
CBT always locates itself as an evidence-based methodology. There is evidence of the effectiveness of CBT for depression, panic, phobias, post-traumatic stress and personality disorders. CBT is the psychological therapy with a wide evidence base for efficacy and effectiveness’. Some authors contend that CBT is currently the psychotherapy with the best documented efficacy for sexual addiction. The sexual addiction programme used in our clinic is CBT, as is the content of the training programme that we have developed to train therapists to work with compulsive sexual behaviours.
CBT-based Activities and Compulsive Sexual Behaviours in Group Therapy
In the early stages of the work at The Marylebone Centre for Psychological Therapies, we use an exercise called ‘Values Clarification’. This exercise requires individuals to think about their values – things that they feel strongly about – and then consider whether their sexual behaviour contradicts or confirms these values. Although an uncomfortable task, we ask participants to make a list of all the harmful consequences of their compulsive sexual behaviour. The next stage of the treatment process is to ask individuals to draw a ‘trauma egg’. We ask participants to draw a large egg, inside which they note down events in their life history that were traumatic, non-nurturing or shaming. This is followed by a general share on the ‘trauma egg’ exercise. Shame is reduced when exposed in the presence of an understanding and ‘non-shaming’ other. This exercise encourages men to reflect on their history and to come to see that, while the behaviour exists, it did not come into being wilfully. Shame is thus reduced. Next we present a generic ‘cycle of addiction’, take people through it and then ask them to personalise it by analysing a recent or significant acting-out experience. The cycle has precursors, seemingly unimportant decisions, triggers, build up and the point of inevitability. Towards the end of the treatment programme we focus on cognitive distortions. These are thinking errors that are very common for all of us.
An immensely important part of our group treatment programme is the personal presentation. Drawing on the trauma egg, we ask each participant to prepare a presentation of a personal life story, with an emphasis on past events that were shaming and/or non-nurturing, the sexual history and the history of the sexual addiction, with an emphasis on any rock-bottom or crux point that caused them to pursue recovery. The personal presentation is normally followed by a teaching evening on sexual health.
We give patients a relapse prevention and recovery worksheet. The worksheet includes questions about their distinctive cycle of addiction. This includes questions about the individual precursors to their sexual acting out, as well as their distinctive cues and triggers. The worksheet closes with a section on relationships and how these can be improved. It also includes a section on making amends. This includes making a list of people to whom one owes amends.
The treatment plans outlined above fit well with any type of sex addiction, including internet pornography addiction. As far as I can determine, all effective programmes for the treatment of sexually-compulsive behaviour are, in fact, cognitive behavioural. They normally include a didactic element, homework exercises, a treatment plan, organised sessions and should, at least, have some way of measuring outcomes. Our treatment programme is such a programme.
Dr. Thaddeus Birchard