Couple’s Therapy: Deconstructing the Myths

Relationships can be extremely rewarding and fulfilling, however, sometimes they present challenges we don’t feel prepared to overcome. In these occasions, many people don’t seek help from a therapist because they have wrong preconceived notions about couple’s therapy.

We thought that gathering the most common misconceptions we have come across through years of experience in this field and deconstructing them would help you make an informed decision about couple’s therapy.

My Partner’s Problem, Not Mine

Relationship and couple’s therapy works with the relationship.

— The focus is on the dynamics —

Though partners in the relationship may gain individual insight about themselves, the focus is on the dynamics that create the problematic situations.  In order to work on these issues in the relationship, it’s important that all partners have an opportunity to express how they feel, their wants and needs.  Partners entering relationship and couple’s therapy come to therapy for the mutual purpose of exploring the relationship dynamics which they are part of.

It’s Too Late

Relationship and couple’s therapy helps you decide where you are in terms of your willingness to work on, or continue, the relationship.

— In some cases, partners find that with therapeutic support they are able to develop skills that allow them to continue in the relationship in a healthier way. For others, they are ready to leave the relationship —

Therapy can provide a safe space to express the need to move on, and can provide a supportive way to create a more positive ending.  It can also be used to help couples discuss and communicate issues arising around practical issues involved in a separation or ending of relationship.

My partner won’t change OR  My partner will realize what they are doing and will change.

Just like people, relationships can change. Partners in the relationship have the option to make individual changes that are healthier for themselves, as well as options for individual change that benefit the relationship.

— Therapy provides an option for each person to examine their role in the relationship and decide what they would like to change —

Partners may be tired of their role and would like a more balanced relationship.  Therapy facilitates this discussion, as well as the option for how to enact these changes.

My partner won’t listen to a therapist.

Couple’s therapists support you and your partner(s) to express how you are feeling, what you want and to help you find the language and actions to get there.  The therapist helps create a healthy and constructive discussion by introducing skills and techniques to aid the relationship goals.

— It is not the role of our therapists to tell a person what to do to change —

Rather, the therapist facilitates the opening up of the person’s experience so they can explore themselves.  In situations where one person in the relationship is not willing to engage in therapy, it is difficult to help resolve the issues in the relationship.  The therapist will address this with you and decide whether this type of therapy is productive and what other options exist for support for the individuals involved.

The therapist won’t really see what my partner is doing.

In a professional setting, therapists get to know your relationship and you.

— Safe place —

The therapy rook becomes a safe place for each partner to express their perception and feelings of what is going on.

The therapist will help us get back to the way we were.

You may recall happier days earlier in the relationship and have a strong desire to get back to those positive feelings.  If you and your partner(s) are working to develop a healthier relationship, then what you reflect, explore, and practice in couple’s therapy may improve the relationship dynamic and how you feel about each other.

— Going forward —

We like to think of going ‘forward’ with new skills in a more developed, rich relationship, than ‘backwards’ to a time when you might have had fewer coping strategies.

More information can be found here: Couple’s Therapy at Dr Thaddeus Birchard & Associates for Psychological Therapies

For further questions or assistance, please contact us on 020 7224 3532 or send us an e-mail at 


Sex Addiction, the Twelve Steps, and Therapy

Timothy D. Stein, MA and Patrick Carnes, PhD. present us with their summary of the chapter 4.4 Sex Addiction, the Twelve Steps, and Therapy of the Routledge International Handbook of Sex Addiction.

Rex had consistently avoided 12 step meetings.

When he reluctantly walked into the room for the first time, he found a room of men who shared his struggle. He listened to readings, hearing numerous phrases that described his pain, his fear, and his situation. He heard men share their experiences while others nodded their heads with understanding and support. He realized that no one at the meeting was interested in who he was outside of the room. No one was interested in “outing” him or his behaviours. Instead, they were focused on changing their lives and helping others do the same.

During the meeting, Rex mustered up the courage to share his struggle with pornography and masturbation. He talked about his desire for things to be different. He talked about how he had tried to “control” and “manage” his life unsuccessfully. And then, when he started to talk about his wife and kids and the impact his behaviour had on them, the walls came down. Tears streamed down his face. His voice cracked. His words came out in choppy and difficult to understand bursts. He dropped into the pain he had been avoiding for so long. The facade he had unconsciously created decades earlier, to show the world a strong, capable, successful, handsome, “got his shit together” image of a man, cracked.

The men in the room created a safe place and allowed Rex to be vulnerable. They became his community; the community that helped him stop isolating and open up to a solution larger than himself.

Rex’s therapist took advantage of the acceptance Rex began to feel in his new community by integrating the principles of the 12 steps as a way to create traction in Rex’s therapy. She supported Rex’s 12 step work and used it as a springboard into the deeper issues and patterns in his life. She was able to intertwine the work done in therapy sessions with the 12 step work Rex was doing in the recovery community, and this intermingled process of recovery became a gestalt, a process for change larger than the sum of its parts.

The steps do not focus on stopping the problematic behavior.

Instead, the message embodied in the 12 steps is that by focusing on something larger than yourself and trusting something larger than yourself, change and healing can happen. In fact, the only step that mentions the behavior is step one, and then only to admit powerlessness over it. Steps 2 through 12 do not mention the addictive behavior or even an attempt to stop or change the behavior. Instead, those steps focus on spirituality; they guide addicts into connecting with their Higher Power and allowing that Higher Power heal them.

Because of this, the 12 steps are often referred to as a spiritual solution to a behavioral problem. Carl Jung, the well-known psychiatrist, influenced this idea. In correspondence with one of the co-founders of AA, Bill W, he suggested that an alcoholic’s “craving for alcohol was the equivalent, on a low level, of the spiritual thirst of our being for wholeness, expressed in medieval language: the union with God” (Jung, 2001).

Critics sometimes cite a low percentage of consistent sobriety by members of 12 step groups as evidence that they are ineffective. However, research that culminated in the book Don’t Call It Love (Carnes, 1991) shows that the 12 step process is a significant piece of the long-term sobriety puzzle. According to this research, sex addicts who have the most success with sobriety have a number of factors in common, three of which are:

  • They worked with a primary therapist
  • They were involved in group therapy
  • They attended 12 step meetings.

More recent research also supports the 12 step model of treatment. Hartman et al. (2012) tell us those sex addicts in residential treatment who also participate in 12 step programs show improved sexual impulse control and self-reported quality of life at six months follow up. Plus, they are more likely to attend aftercare. While there currently is a paucity of research in this area, these studies show that incorporating the 12 steps as an adjunct to therapy can lead toward positive client outcomes.

In the 1970’s, problematic sexual behavior was hitting a saturation point, and 12 step organizations addressing this issue started to spring up. Currently, active “S” programs include Sex and Love Addicts Anonymous (SLAA), Sex Addicts Anonymous (SAA), Sexaholics Anonymous (SA), Sexual Compulsives Anonymous (SCA), and Sexual Recovery Anonymous (SRA). These programs have adapted the 12 steps of Alcoholics Anonymous so they can address problematic sexual behavior rather than alcoholism.

Step work and therapy are both powerful processes.

Rob Weiss, a noted sex addiction expert, has said, “The 12 steps are where I grew up. Therapy is where I went to school” (Weiss, 2012). With an understanding of the 12 steps, weaving 12 step ideas into therapy is only limited by the therapist’s willingness to discuss these concepts and their creativity.

In chapter 4.4 Sex Addiction, the Twelve Steps, and Therapy of the Routledge International Handbook of Sex Addiction we highlight a variety of ways step work can be integrated into therapy.  We also discuss significant milestones that sex addicts in recovery will face during their step work and explain how therapists’ awareness of these milestones can be beneficial to their clients’ recovery and work in therapy.

About the Authors: Timothy D. Stein and Dr Patrick Cranes

Timothy D. Stein, MA, is a well-known expert in the field of sex addiction. His work as a clinician, lecturer, consultant, supervisor and author keeps him on the cutting edge of sex addiction treatment.

Tim is a regular presenter at national and international conferences and is dedicated to offering information, providing clinical and recovery guidance, and advocating for the understanding and treatment of sex addicts and their partners.

Tim’s professional life is guided by his passion to heal the lives and relationships of individuals and families impacted by sex addiction. Through his writing, lecturing, and clinical work, Tim strives to help those impacted by sex addiction to find self-love, emotional resilience, integrity and joy in recovery whether this is through personal insight or information and tools Tim provides to other professionals.

Tim is a co-founder of Willow Tree Counseling in Santa Rosa, CA and was integral in the development and evolution of their treatment programs for sex addicts and partners of sex addicts.

More information can be found on his website

Patrick J. Carnes, PhD, is an internationally known authority and speaker on addiction and recovery issues. He has authored over twenty books including the bestselling titles Out of the Shadows: Understanding Addiction Recovery, Betrayal Bond, Don’t Call It Love, The Gentle Path Through the Twelve Steps and The Gentle Path through the Twelve Principles.

Dr. Carnes’ research provides the architecture for the “task model” of treating addictions that is used by thousands of therapists worldwide and many well-known treatment centres, residential facilities, and hospitals.

More information can be found on his website


The Role of Sexual Fantasies in Sexual Addiction

I take the view that the mind comes equipped with many profound and ingenious resources which are partly the endowment of evolution, whilst also referencing metaphysical realities that pass beyond our current understanding. These latter may always elude our primate cognitive capacities, and therefore I do not believe that what we cannot now understand must eventually succumb to the overweening methods of science. Epistemological modesty therefore allows me to make provisional judgements about what is real, and for me this includes the products of the imagination understood symbolically, and a superordinate Self that offers us the opportunity to experience an intimation of wholeness via individuation. For me, a dialectical, intrapsychic relationship between consciousness and the unconscious promotes the journey of individuation, but this rests on successful experiences of relationship in our developmental years. It is also effortful. Without the cooperation of consciousness in the form of reflective functioning – an achievement for many of us, the unconscious mind may simply offer us analgesic strategies for our dysphoria, enabling us to tolerate our arrested developmental teleology, to ‘tread water’ while the universe waits.

Sexual fantasies and even sexual acting-out may begin as analgesic, but compulsive recourse, and a developmental imperative, ultimately make them empty and painful activities. Those who question the concept of an endogenous developmental imperative may ask folk who have spent their whole lives disappointing themselves and others why they have been disappointed. Discarding the trivial social constructionist answer that there must be a failure to socially conform and thus gain the approval of convention, we are left with something more profound and yet inspiring. There is a direction of travel; Jung called it individuation.

Part of the thesis in my chapter The Role of Sexual Fantasies in Sexual Addiction is an exploration of what, developmentally, blocks the meta-cognitive level of functioning. The research of Dutra et al (Lyons-Ruth) 2009 on pathways to dissociation showed that ‘small t’ relational trauma, for example a lack of positive maternal emotional involvement and poor communication, without the abuse associated with disorganised attachment, is also associated with dissociative symptoms. Of course, some sex addicts may have experienced abuse, but the Lyons-Ruth research appears to describe the aetiology of fearful-avoidant attachment, a developmental disturbance suffered by the majority of sex addicts (Zapf et al 2008). So Bancroft’s (2008) observation that sexual addiction often seems to involve dissociative states may be corroborated through this connection.

The distinguished Jungian author Jean Knox follows a similar trajectory in her 2005 article on sexual fantasies. She erects a framework of levels of self-agency, with the highest levels representing meta-cognitive and meaning-making processing. For her, the role of sexual fantasies is to rescue the vulnerable and relationally wounded – perhaps shamed, conscious self from painful awareness of dependency and relationship needs. She speaks of this process as eliminating reflective functioning and as a ‘defensive attempt to become mindless and so to eliminate a separate identity and sense of self, with the accompanying need for a loving relationship’. Another effect is to inhibit the dialectical relationship between conscious and unconscious, the meaning-making function Jung called the ‘transcendent function’. For me this is dissociative, but rooted in developmental relational deficits and disturbances.

I further explore in my chapter the Winnicottian idea of the ‘mind object’, a false-self constellation that is used to displace mother’s care, or lack thereof. Corrigan & Gordon (1995) assert that the mind object ‘is an omnipotently created object always available for mastery and control of internal objects so that dependence and the feelings it generates – anxiety, frustration, anger and envy – can be obliterated’. Again, a dissociative manoeuvre. Winnicott saw the false self as a defensive process emerging from relational and other forms of early trauma, but all is constructed from internalisations of primary object relations. For Jung, and the brilliant Donald Kalsched, whose books bring Jung into our contemporary world, there is a mytho-poetic inner world ‘just as primary, just as foundational, as the infant-mother relational world through which it is (usually) transformed’ (Kalsched 2013, p. 269). I have personal experience of the truth of this. This opens up the transformative possibilities of our unconscious minds, that transpersonal realm. But for effective communion with this pre-existing part of ourselves we need a paradigm of successful relationship gained through external connection and love. Therapy beckons where early attachment has been disturbed. Otherwise, the resourceful mind will help us to dissociate from what we fear may not be available.


About Richard Newbury

Richard has considerable experience as a supervisor for Relate and more recently he has worked as Clinical Lead for a branch of Mind. His interest in Jung stems from a long Jungian analysis and the success of Jung’s ideas in his own life and work. His focus on sexual addiction arises from working with Thaddeus Birchard to treat sufferers, as well as an admiration for Thaddeus’s books.

Accredited Diploma in Sex Addiction Therapy

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Compulsive Sexual Behaviours  – How often is it presenting in your therapy room?

We hear from therapists around the country that even though it might not be the presenting problem, compulsive sexual behaviours are being disclosed in therapy.  It isn’t just the person feeling the compulsion, but more partners coming forward looking for support after feeling the trauma and shock of discovery.  Compulsive sexual behaviours don’t discriminate based on gender or sexual orientation.  Yet seeking support may vary based on one’s perceptions of social messages and acceptability.  The psychological, relational, and social impacts are very real for all impacted by it.  Psychosexual therapists are also now adding prolonged pornography use to the list of associated and/or causal factors in erectile dysfunction, a trend seen more frequently in young men.

Gaining Confidence and Competence to Work with Compulsive Sexual Behaviours

Dr Thaddeus Birchard & Associates’s Diploma in Sex Addiction Therapy is accredited by Middlesex University, approved by The Association for the Treatment of Sexual Addiction and Compulsivity (ATSAC), and is approved for 69 CPD hours with The College of Sexual and Relationship Therapists (COSRT).  We blend theory, therapeutic tools, and practical application to give you greater confidence and competence in working with your clients around their experiences of sex addiction and compulsive sexual behaviours.

Client Access to Therapeutic Support

The number of ATSAC Qualified Members specialised in working with compulsive sexual behaviours is still very small. Clients in more remote areas report long waiting lists or having to travel large distances to find a therapist capable of providing support.  Our London Diploma course is the longest-standing of it’s kind in the UK.  To help therapists in the North and in Europe access this training, we also provide the Diploma course in Edinburgh, Scotland.

Enrol for Fall 2018 Diploma Course

We keep our Diploma numbers low so that you feel a part of a group where each voice is heard.   Learn more about our course structure, dates, fees, and requirements from our downloadable brochure.  Apply online to enrol for a CPD training that gives you the skills to address the issues that may already be presenting in your therapeutic practice.


Note:  This course delivered by Dr Thaddeus Birchard & Associates can lead to the award of credit points by Middlesex University.  This course does not result in the award of a Middlesex qualification.

The Importance of Individualized Attention in Couple’s Therapy for Sex Addiction


In my work as a sex addiction counselor, I am a big believer in individualized attention for both the addict, and the partner. Both have some serious issues they need to work through, and I believe they should both be given the time and space to do that.

When a couple begins seeking treatment to help cope with a sex addiction, I should make it clear that I am not often visited by a couple at first. More often than not, it is the addict’s partner who contacts me because she has recently discovered the extent of her partner’s problem.

In this moment, I am looking at a partner in distress, and an addict in despair. My first order of business is triage. I will talk to the partner, get as much information as I can, and then begin recommending a treatment plan. The most important aspect of this plan is that each partner receive individualized attention.

Yes, eventually our goal will be to have both partners present during the same counseling session, but at first, the needs of the addict and the needs of the betrayed partner are tremendously different. It can actually be counterproductive to get these two people into the same room when tensions and emotions are still running so high.

This is where my work truly begins. I arrange for the partner (a female, in the vast majority of cases I see) to work with a female therapist in our practice. I will keep in continual contact with her therapist, so that the two of us can coordinate treatment and progress with one another.

Meanwhile, I will begin to work with the sex or porn addict personally. I myself am in recovery from sex and porn addiction, and my personal experiences give me a unique opportunity to speak directly to an addict in a language, and on a level that he understands. As stated in the chapter on couples’ therapy in The Routledge International Handbook of Sexual Addiction:

I do individualized work with the sex addict to address his compulsion, using my book Breaking the Cycle: Free Yourself from Sex Addiction, Porn Obsession, and Shame (Collins, G., 2011) as a template for the recovery programme. Compulsion is at the heart of the addiction. The addict feels powerless to stop acting out. He may understand intellectually that his addiction is destructive to himself and everyone around him, yet he continues his behaviour pattern nonetheless. It generally helps him to hear that, although he has displayed behaviour that has been harmful and he must be held accountable for his actions, this doesn’t mean he must be accountable for every bad thing that has happened in his relationship.

Once the addict has entered treatment, I am faced with the prospect of introducing this “regular guy” to some pretty huge concepts that are not always easy to absorb at first. For instance, I borrow from the teachings of Eckhart Tolle to begin convincing the addict that he is not his mind, he is not his story, and he is not his addiction. Yes, sometimes it takes a while for the truth behind these lessons to crystallize for the addict, but once they do, they become the basis for my work, and the scaffolding upon which he can build his own recovery.

To help create that important sense of separation between the addict and his addiction, I ask him to engage in practice called “dialogue.” This activity requires the addict to sit down with a pen and paper, or at their computer with a blank document open, and to actually write out a dialogue between himself and his addict sub-personality. Here is an example of what that might look like:

George: Addict, are you there?

Addict: (no response)

George: Addict, are you there? (This could go on for five or six times, and then finally…)
George: Come on, addict, I need to talk to you!

Addict: Get lost!

George: I need to talk to you about our addiction. I’m going to lose my marriage.

Addict: I like what I’m doing, I don’t want to stop.

George: You might not like my marriage, but I do.

This is a very empowering exercise, because it helps the addict realize that he is in control. He thought that he was at the mercy of his compulsions, but he has the ability to take that control back for himself anytime he wants. I like to use the term “the tail is wagging the dog,” because it helps to illustrate that this small portion of his mind has been allowed to control everything about him. Once he comes to the realization that he is not his addiction, he can regain power over himself. He can begin living the life he actually wants to live.

It is so important that a sex or porn addict be given this individualized attention so that he has the opportunity to sift through these processes and ideas in a safe and understanding environment. If he is ever going to move past his compulsive behaviors, he needs the opportunity to see them for what they are.

For a more complete description of the healing process for both partners, please refer to my chapter in The Routledge International Handbook of Sexual Addiction.

About the author:  George Collins


George Collins is the founder and director of Compulsion Solutions, a centre in the San Francisco Bay Area established to treat sex addiction and porn addiction. George earned a Master’s Degree in Counseling Psychology (with a Transpersonal Specialization) from John F. Kennedy University. He has been a guest on local, national, and international radio and television shows as a recognized expert on sexually compulsive behaviour. Through the process of healing his own sex addition, he developed the methods and techniques for overcoming sexually compulsive behaviour that are used at Compulsion Solutions and presented in his book Breaking the Cycle: Free Yourself From Sex Addiction, Porn Obsession and Shame. He also co-authored A Couple’s Guide to Sexual Addiction: A Step-by-Step Plan to Rebuild Trust & Restore Intimacy.

Overview of Presentations of Sexual Addiction

By Ralph Earle (PhD, ABPP) and Rick Isenberg (MD, CSAT)

In the human experience, sexual expression takes a myriad of forms, limited only by the bounds of imagination. As the field of human sexuality progresses, more and more sexual behaviours have been catalogued and acknowledged as normal variants. As myriad as the range of sexual behaviours are the various manifestations of sexual addiction. Addiction, with its obsession, compulsion, tolerance, cravings and withdrawal, may distort any form of human sexual and romantic expression, and turn what is potentially joyful and intimate into something compulsive and problematic.

Much work has been done to understand the various manifestations of sexual addiction. It is apparent that certain behaviours present in clusters that may accompany specific forms of psychopathology. In this chapter, we review the various common presentations of the disorder, considering first those medical and psychological disorders that present similarly and must be ruled out before making the diagnosis of sexual addiction.

Differential Diagnosis of Sexual Addiction

In the field of mental health, despite our reliance on the Diagnostic and Statistical Manual (DSM) (American Psychiatric Association, 2013), not everything that quacks like a duck is truly a duck. We learn from our colleagues in medicine that a practitioner must always consider a differential diagnosis before making and acting upon a diagnosis. We have come to understand that when presented with depression, for instance, we must rule out hypothyroidism, syphilis, Lyme disease, post-concussion syndrome and drug effects, among many other disorders. So it is, too, with patients presenting with problematic, compulsive sexual behaviour. Especially in light of the shame, discrimination and contempt showered by our society on men and women with sexual addiction, we as clinicians must be discerning in our application of the label. Not all that quacks like a sexual addict is a sexual addict.

Definition of Sexual Addiction

In keeping with the nomenclature applied to substance use disorders and gambling disorder, Carnes has proposed ten criteria for the diagnosis of sexual addiction, which include elements of obsession, compulsion, risk-taking, tolerance, withdrawal, cravings, unsuccessful efforts to stop and social impairment. It is important to recognize that there are conditions that present with only some of the diagnostic criteria that must be separated from the rubric of sexual addiction, and other medical and psychological disorders that largely mimic sexual addiction and must be excluded before a diagnosis is made. We next explore these ‘rule out’ conditions.

Medical Conditions that May Mimic Sexual Addiction

Hypersexual behaviour has been associated with a range of neurological and psychiatric disorders. Before making a diagnosis of sexual addiction, consideration must be given to these medical disorders that are associated with sexual behaviour that is compulsive, inappropriate, uncharacteristic or excessive: Traumatic Brain Injury, Stroke and Neurosurgical Injury, Dementia, Autism Spectrum Disorder, Parkinson’s Disease, Bipolar Disorder, and Substance Abuse. The diagnosis of sexual addiction should not be made when these disorders are present without extensive consideration.

Non-Pathological Behaviours

In this discussion of conditions subject to misdiagnosis as sexual addiction, it is important to emphasize that the concept of healthy sexuality may include sexual behaviours that are frequent or different from the norms of the prevailing culture (such as homosexuality, BDSM, polyamory, etc). The clinician would do a disservice by reflexively labelling such behaviour as addictive. Such behaviors would not qualify as addictions unless all the criteria of obsession, compulsion, risk-taking, tolerance, withdrawal, cravings, unsuccessful efforts to stop and social impairment are present.

The Clinical Presentations of Sexual Addiction

In recent years, multiple typologies have been proposed for sexual addiction.

The most extensive characterization of the phenotypes of sexual addiction has been performed using latent profile analysis of a large database of patient self-reported data obtained through use of the Sexual Dependency Inventory (SDI-4.0).

As described by Carnes, close to two hundred different sexual behaviours have been catalogued as part of the development of the SDI. Using the statistical technique of factor analysis, these behaviours are found to cluster in distinct types, each with characteristic acting-out behavioural patterns. In the derivation of the SDI-4.0, 20 behavioural clusters were identified. It is common for sexual addicts to endorse behaviours in multiple categories. Details are provided in the book chapter.

These behavioral clusters include:

  • Fantasy Sex
  • Pornography Use
  • Phone Sex
  • Use of Inanimate Objects
  • Anonymous Sex
  • Conquest and Seduction
  • Group Sex
  • Relationship Addiction
  • Humiliation & Domination
  • Pain-Exchange Sex
  • Paying for Sex
  • Power Exchange Sex
  • Intrusive Sex
  • Voyeurism & Covert Intrusions
  • Exhibitionism
  • Exploitation of Trust
  • Sexual Exploitation of Children
  • Production of Pornography
  • Compulsive Sexuality with Drug Use


Sexual addiction presents in a myriad of ways with recognizable clusters of behaviour. The clinician facing a client with problematic, compulsive or excessive sexual behaviours must be mindful of the medical and psychological conditions which resemble sexual addiction and must be differentiated, with appropriate specific treatment provided. Multicultural sensitivity is necessary, especially when working with sexual minorities.

About the authors:

ralph-earle_photo  Ralph Earle is a noted marriage and family therapist and psychologist, author and lecturer.  He holds a Masters of Divinity from Harvard Divinity School, and a PhD in Pastoral Psychology.  He is a Diplomate of the American Board of Professional Psychology (ABPP) and a Licensed Marriage and Family Therapist, as well as a Certified Sex Addiction Therapist.  He is a past national President of the American Association for Marriage and Family Therapy (AAMFT). He is a national authority on sexual addiction with over 40 years’ experience working with sexual problems.  Dr. Earle is an ordained minister and served on the Board of Directors of the Interfaith Sexual Trauma Institute of St John’s University, Minneapolis.  He has numerous media credits and is the author of several books, including Lonely All the time:  Recognising, Understanding and Overcoming Sex Addiction and Come Here, Go Away.  He is he co-author of Sex Addiction: Case Studies and Management, and Healing Conversations: Therapy and Spiritual Growth, and The Pornography Trap: Setting Pastors and Laypersons Free from Sexual Addiction.  He is the founder of Psychological Counselling Services (PCS) in Scottsdale Arizona that specialises in the PCS intensive Outpatient Therapy Program model.  He is a Certified Supervisor of Sex Therapy for the American Association of Sexuality Educators, Counsellors and therapists (AASECT) and a Certified Supervisor for AAMFT.

RIsenberg_photo  Rick Isenberg serves as medical director at Psychological Counselling Services, a premier outpatient treatment centre for sexual and other process addictions. He is also the executive director of the American Foundation for Addiction Research (AFAR) and a certified sex addiction therapist (CSAT).  Dr. Isenberg is pursuing a Master’s degree in clinical counseling. Dr Isenberg is a licensed obstetrician/gynaecologist.  He has 16 year’s experience in clinical research, having directed research programmes and Johnson & Johnson, Wyeth Pharmaceuticals, Ventana Medical Systems and Regenesis Biomedical.  Dr Isenberg has served on the medical faculties of the University of Pennsylvania and Thomas Jefferson University.  He has authored original research and review articles in the medical literature on subjects including addiction, pain management, wound healing and complications of surgery.


The Face of Female Sexual Addiction, by Dr. Alexandra Katehakis

Female Sex & Love Addiction (FSLA)

While the term sex addiction (SA) has a decidedly male ring to it, female sex and love addiction (FSLA) echoes a romantic component seen as essentially feminine. Deprived of early parental mirroring and care, both SAs and FSLAs ache to be seen and loved. But unlike their male counterparts, most FSLAs identify their loneliness and hurt and have, consciously or unconsciously, spent a lifetime trying to abate them through love addiction instead of the love avoidance characterizing SA. Cultural messages that women’s life goal is to couple, and greater social acceptance of their expressing that desire, both permit and perpetuate their view of aloneness as a privation rather than a point of pride, as SAs often construe it.

‘Happily Ever After’

Captured by the myth, a desperately lonely girl, whether straight or gay, will very early conjure a rescue fantasy and wait for ‘the one’ to save her. Without attachment figures to regulate and soothe her, she embroiders that device of dissociative fantasy in adulthood. Her own attachment difficulties inevitably draw her to problematic partners, leaving her alone, again. In fact, the more grandiose her fantasy, the lower the likelihood she will create a real connection.

Most FSLAs blend flagrant behaviour with self-effacement, perpetuated by Western culture’s contradictory messages that their sexuality is powerful but must be controlled by men and that realizing their truest self, requires a relationship with a male. Without an integrated sense of self, the FSLA constructs one from an incongruous amalgam of parental expectations and patriarchal, soft-porn advertising and paints herself into a narrow corner of derivative sexuality. ‘Sexually codependent’ (Kasl, 1989), she cannot find safety and validation from another’s desire and grows lonelier and more self-loathing.

While addictive sexual behaviour (including its avoidance) is an obvious symptom of FSLA, the single-minded pursuit of sex, ‘falling in love’ or both bespeak their essence as the profound inability to attach securely. The FSLA who comes to your office typically sounds as if she is seeking a real relationship. But the dopaminergic surge from the chase, extreme fantasy, the delusion of all-consuming love, or compulsory orgasm generates a false sense of control which masks from her, but marks for you, her dissociation from others and herself.

As for male SAs, FSLAs’ (whether predatory or passive) preoccupation that sometimes incapacitates them for work or daily tasks is the organizing force of their life. Her addictive cycle is composed of compulsion, continuing despite negative consequences, tolerance leading to escalating behaviours, hyperfocus to escape emotional discomfort, rituals (including grooming) to increase excitement and finally, acting out sexually.

Ironically, the FSLA has difficulty talking about her sexual issues due to her lifelong, global shame. That shame may also block her from disclosing collateral damage that would facilitate your assessment: surprisingly common anorgasmia or vaginismus, unwanted pregnancies, STDs, partner abuse, loss of female friendships from rivalry, a financial disaster from affairs with bosses or coworkers, poor work performance or overspending on wardrobe and grooming. In fact, she may present as glamorously dressed and toned (perhaps through shopaholism and over-exercising) because she defines her inner self by outward perfection, including possessions, looks and sex appeal.

Hyperarousal and Hypoarousal

Alternatively, an FSLA may ‘act in’, depriving herself by sexual aversion, staying in an exploitative job, isolating, locking herself into an online primary ‘relationship’ or suffering from other addictions or eating disorders. But whether seemingly self-assured or shy, her presentations cover up disruptions in early development. Thus she will likely present as moderately to severely dissociated. Fear-based hyperarousal appears as accelerated speech, scrambled thinking and emotional flooding, while shame-based hypoarousal announces itself with slow speech and a detached manner. And all presentations demonstrate not just dissociation but compartmentalization – the major defence against dysregulation and a hallmark of any addiction – and automatism, or unconscious activations bubbling up behaviourally as unacknowledged gestures, vocalizations or facial expressions. So an FSLA usually presents as incapable not only of maintaining relationships but also of describing current or past ones. In other words, she lacks an affectively coherent narrative, and that deficit stamps both her attachment style and her reflection about attachments. In brief, despite superficial achievements, her depression, anxiety, low self-esteem, incapacity to bond with friends or lovers, loneliness and helplessness indicate active FSLA.

When it comes to healing FSLAs, therapists must confront the falsity of both enmeshed familial roles and the commodified, competitive, shame-based sexuality of contemporary culture, and help them discover the self-knowledge, self-compassion, and self-determination that invites true connection with another.

About Alexandra Katehakis, PhD

Alexandra Katehakis, Ph.D., is a licensed Marriage, Family Therapist, and Founder and Clinical Director of Center for Healthy Sex in Los Angeles, California, USA. She serves on the core faculty of the International Institute of Trauma and Addiction Professionals (IITAP), and consults for behavioural health treatment centres. Dr Katehakis is a Clinical Sexologist, Certified Sex Addiction Therapist/Supervisor and Certified Sex Therapist/Supervisor. She is author of numerous publications and books including Sex Addiction As Affect Dysregulation: A Neurobiologically Informed Holistic Treatment, (2016), published by W.W. Norton & Co., co-author of the 2015 AASECT award-winning Mirror of Intimacy: Daily Reflections on Emotional and Erotic Intelligence (2104), contributing author to the Clark Vincent award-winning Making Advances: A Comprehensive Guide for Treating Female Sex and Love Addicts, in M. Feree (Ed.), (2012), and author of Erotic Intelligence: Igniting Hot Healthy Sex After Recovery From Sex Addiction (2010).

Existential Perspectives on Working with Sexual Addiction

Alex Smith provides some existential perspectives on sex addiction.  The following is extracted and adapted from ‘Existential Perspectives on Working with Sex Addiction’ in the Routledge International Handbook of Sexual Addiction.

From an existential perspective, sex addiction is not understood as a pathological condition with attendant predictable causes, symptoms and involuntary behaviours that afflict the sufferer and over which he has no control. Since sex addiction (or indeed any other addiction or compulsivity) is assumed to not be a disease, it is also assumed that it cannot have an aetiology, such as cancer or malaria might. Instead, the behaviours associated with sexual compulsivity are understood as a manifestation of a person’s free will, a personal way of relating and responding to one’s lived experience that is chosen by an individual and for which he is responsible.

Accordingly, an addiction is understood as a learnt habit rather than as a disease. Thomas Szasz, a psychiatrist and psychoanalyst who practised in the existential tradition,  saw “getting hooked” on an object of addiction as ‘simply an aspect of the universal biological propensity for learning, which is especially well-developed in man’ (Szasz 1977: 33). He described it as a fundamental characteristic of all of us that we become habituated (which for Szasz was the same process as becoming addicted) to all manner of things, which might range from narcotics to orange juice to sex. As our habituation (addiction) develops, we acquire an increasing tolerance to that to which we are habituated and our craving for it grows. The habit can be broken if we want to break it but it may well be that, for whatever reason, we do not want to break it (Szasz, 1977). Since addiction is a completely natural process of learning and one that we can choose to unlearn, there can be no question of it being a disease that renders the addict powerless.

While proponents of the disease model of addiction will insist that recent advances in neuroscience have proved that addiction is a disease of the brain stripping the addict of his agency, the same scientific findings can be shown to provide compelling evidence (Lewis, 2015) that this is not the case and that Szasz’s view of addiction is correct. Neuroscience does show, however, that it becomes increasingly difficult for the addict to be able to think of other responses to the desire to feel better, other than turning to the object of addiction, as his tolerance and craving for it increases. While this is demonstrably true, it does not mean that if someone becomes addicted, he loses the freedom to choose how he might respond in a given situation and to be responsible for the choices he might make.

In line with this, one can argue that living a life of addiction is a paradigm case of what Jean-Paul Sartre, the most famous of the existentialists, describes as being in ‘Bad Faith’. Sartre insists we are both free and responsible. In fact, he describes us as being condemned to be free and responsible for everything we do. We define who we are by what we do, through the choices we make on the basis of what we assume, believe, understand and value. This is not to say that how we define ourselves at any particular time will necessarily continue to define us thereafter (our values, beliefs, understandings and assumptions might change). ‘Human conduct cannot be finally defined by patterns of conduct’, Sartre declares in Being and Nothingness (Sartre 1958: 64). Familiar behavioural responses ‘consistent with one’s personality’ must be chosen again and again in relation to each new situation in which an individual finds himself. Being human therefore involves a constant choosing of oneself out of nothingness. This is burdensome. It is a heavy responsibility that every person would like to avoid. Sartre says each of us longs to become massif, to possess the solidity of things. For if we were to possess the solidity of things, we would then be complete and there would be no more choosing to do. We would be defined once and for all and this would remove the anguish of the responsibility that our never-ending, ineliminable freedom brings.

Despite it being an ontological impossibility, we therefore frequently pretend we are massif. In Bad Faith, we pretend that we have no choice but to be the way we are or to do the things we do, or we imagine that the choices we do have are much more limited than they actually are. From this perspective, the sex addict is choosing his sexual behaviours again and again, and distracting himself from the recognition that he could choose differently. If he accepts the medical model of addiction, he might also be denying responsibility for his actions, and insisting that responsibility for them lies at the door of disease he is convinced he has. Often he will say, ‘I know what I’m doing is harmful to me’, or, ‘What I’m doing contravenes all my values’. Yet, again and again, his brave attempts to desist because of the consequences fall away as his desire gets the better of him and he feels like he has no choice other than to ‘act out’. Ultimately, he chooses to go down this dangerous path because its attractions in the moment hold something for him that is more desirable than anything else he can think of. In that moment, he is completely focused. There is no uncertainty or anxiety. He is what he is: massif.  At the same time, he bestows powerlessness on himself…

Lewis, M. (2015) The Biology of Desire: Why Addiction is not a Disease, New York: PublicAffairs.

Sartre, J.P. (1958) Being and Nothingness (Translation: Barnes, H.E.), London: Routledge.

Szasz, T. (1977) The Theology of Medicine, New York: Harper Colophon Books.

Photo on 03-11-2016 at 20.00  Alex Smith (BA, MA (Distinction), ADEP, UKCP Registered Psychotherapist and Approved Supervisor, Reg MBACP) is an existential-phenomenological psychotherapist and clinical supervisor with nearly twenty years of experience working in a variety of settings. Alex is a relational therapist who works with a wide range of presenting issues including identity, sex addiction and bereavement. He is also a course leader and lecturer at the internationally renowned School of Psychotherapy and Psychology at Regent’s University London. Alex is a published author on existential psychotherapy and a Senior Associate of Dr Thaddeus Birchard & Associates for Psychological Therapy.

Written in the Scars: Sex Addiction as an Attachment Disorder

John Beveridge (UKCP, ATSAC) discusses how disrupted attachment impacts core beliefs and sexual behaviours associated with sexual addiction, and how this manifests in the therapeutic realm.  

Having trained in attachment theory, when I assess sex addicts coming into therapy, I look for experiences of early relational trauma, abuse, and abandonment.

‘Attachment Theory is in essence a spatial theory: when I am close to my loved one I feel good, when I am away I am anxious sad or lonely’ (Holmes 1993: 67). There is a biological imperative for animals to stay attached to the herd, and so it is for humans. Mitchell and Black (1995) write that John Bowlby recognised that babies come pre-programmed with attachment behaviours including: sucking, smiling, clinging, crying, and following.  These are designed to elicit an emotional response so that caregivers form relationships with us, upon which our survival depends.

If parents do not attach, unattended children are naturally at risk of accident or predation, and, since this knowledge is wired into us, fear of abandonment persists across the lifespan. We do not like to think of the emotional damage that might result from different kinds of abuse and parental neglect, ranging from the abandonments of emotional absence, to the gross impingements of physical and sexual abuse. Ronald Fairbairn, a contemporary of Bowlby, recognised that children who are abused need to cling to the belief that their parents are good people.  In order to preserve this illusion, they must develop a ‘moral defence’, which Greenberg and Mitchell, describe thusly, ‘The child separates and internalises the bad aspects of the parents – it is not they who are bad, it is he. The badness is inside him; if he were different, their love would be forthcoming’. (Greenberg & Mitchell 1983: 170).

This raises an important question for our work, namely why are unpleasant experiences, early conflicts, not dropped and forgotten, but instead become restructured systematically throughout life? Mitchell and Black write that: ‘The child bonds to the parents through whatever forms of contact the parents provide, and those forms become lifelong patterns of attachment and connection to others’ (Mitchell & Black 1995: 115).

Relational bonds can be broken through disaster, accident or misfortune, such as; parental death, adoption, separations through hospitalization, operations, and illness, or children being born prematurely. When these events occur at a pre-verbal age, it can make later historical description of distress in therapy impossible because it is inconceivable in language and may only be retained as body memories. The most sacred bonds of trust are always broken when children are sexually abused. In families where there are powerful sexual secrets caused by incest, or illegitimacy, or the raising of a sibling’s child by the parents as their own, or adults having affairs and secret addictions to porn, then atmospheres are created where nothing is really as it seems.

Core beliefs are formed in infancy which affect how people see themselves and how they believe they are going to be responded to in relationships. For addicts, the knowledge of their separation anxiety and the risk of losing their original caregivers has to remain out of awareness, so distractions have had to be intense and dramatic. In a sex addict’s early life, engaging in sexual activities, which bring escape, intensity, numbing, and distraction, might seem like a creative solution to emotional problems, but the relief it provides only approximates to the advantages of being held in a secure attachment. To avoid feeling vulnerable, which is inevitable in relationship, many sex addicts retreat from intimate involvement with family or friends who they see as impediments to their secret lives. Sexually addicted people are attracted to all-or-nothing thinking and the excitement of high-risk behaviour. I keep telling my patients, “Exciting does not always mean pleasant”.

Sexual acting out is often used by people who feel shame around having any emotional needs. Addicts survive in the present, by literally, ‘making a drama out of a crisis’. They can then be in a state of powerlessness over their addictive behaviour, believing that they have only themselves to blame, particularly when damaging and self-defeating consequences become apparent. This seems baffling, masochistic, and perverse, even to those engaging in it. The wells of self-hatred, fear, and self-loathing run deep. Sometimes therapy becomes necessary when the client may have an experience with loss, or they encounter an external crisis, which provides an emotional ‘live link’ to the place in their relational history where they felt most helpless and vulnerable. This can be caused by; the threat of separation, or divorce, or illegal activity, or public disgrace, and, in some cases, all of the above.

As animals, we are conditioned to react to threat by fighting, fleeing, or pretending to be dead. In recovery we are dealing with the depressive effects of low self-esteem, which has deepened in the addictive vortex of trying to recover alone and failing to make progress.

It has to be recognized that, under threat, just thinking about sex produces dopamine which has an immediate sensory payoff. Because acting out to regulate unwanted feelings has become a ‘default setting’, recovering addicts will experience stress when they are expected to be intimate, open and honest. There has to be a desire to relinquish intensity and excitement, which is a big ask in an instant culture where waiting, being still and holding on to feelings which offer no ‘quick return’ is actively discouraged. Psychodynamic support is needed to find the dysfunctional relational dynamics which continue to trigger anxiety when the addictive payoffs no longer work.

People feel at the mercy of their emotions if, when growing up, their feelings were not explained to them. Now, in therapy, the addict might revisit their traumatic relational past which, as an infant, they had to survive alone. The field of addiction therapy is largely populated by therapists who are recovering addicts themselves and I believe that we cannot take people to, or be with them in, places we have not been willing to visit ourselves. If a therapist has not encountered this experience then, triggered by the client’s emotional vulnerability, they might behave in the same way that the original caregivers did, who abandoned or abused the child. Therapists can be drawn into present day problem-solving, feeling under pressure to help the client escape their terrifying feelings and they might try to hurry the patient through this process.

IMG_4857  John is an attachment based Psychoanalytic psychotherapist working in North and Central London in private practice. Trained at the Bowlby Centre London and in Supervision at SAP (Society of analytical psychology) John has also trained at The Institute for Group Analysis (IGA) He has studied PIT Trauma Reduction and Sex Addiction at the Meadows Arizona, trained in sex addiction with Paula Hall and with Thaddeus Birchard.  He teaches therapists in training at and runs groups for sexually compulsive men at Dr Thaddeus Birchard & Associates.  John enjoys spreading understanding about Sex addiction through writing and public speaking. He is the author of ‘The Exclusion Zone’ chapter to The Therapeutic Frame in the Clinical Context.  (2003, Maria Luca Ed.), and ‘The Tangled Web’ in  Love in the Age of the Internet. Attachment in the Digital Era. (L. Cundy, Ed.) re-edited for The Politcal Self: Understanding the Social Context for Mental IIlness. 2017 (R. Tweedy, Ed.)  John can be contacted via the ATSAC website, via telephone (+44 (0)7979 862 765) and via email


Working with Female Partners

Joy Rosendale (MA (Dist) Cert Ed, Accredited with COSRT, UKCP, ATSAC) writes about interventions used in group programmes for female partners of men with sex addiction and sexually compulsive behaviours. 

Although there has been a rise in understanding and treatment of sex addiction over the past few decades, the situation of partners of sex addicts has not been given a similar degree of attention. Most partners are traumatised by the revelations of the sex addict, yet historically they have been omitted from the treatment processes and so suffered from losing the relationship they thought they had, and then losing their spouse to recovery.

My experience has been that most women feel ambivalent when deciding to join a group offering support and education about sexual addiction and its impact on partners. Feelings of isolation, powerlessness, shame, sadness, fear and indignation that it is not their problem, all feature in the often desolate emotional landscape.

All addictions make a couple dynamic problematic, but when sexual energy is diverted compulsively outside of the relationship, it strikes at the heart of femininity. Some members think their partner’s acting out is just bad behaviour, using expressions such as ‘he can’t keep his trousers up’. However, increasingly, since 2013 especially, participants are reading more of the literature and recognising that it may be worth exploring the concepts of an intimacy disorder, a generational addiction pattern or frozen early emotional development.

Sue arrived in the office, white with fatigue and with the shocked, traumatised appearance sadly familiar to me from other partners in a similar situation. She had discovered more pornography on her husband’s computer that morning, despite a showdown three days earlier when her partner, Doug, disclosed a secret life of visiting dominatrix sex workers. Doug had become careless of late and had left a mobile phone in a jacket. Sue had taken to checking his things routinely as she had felt his absence from the relationship in the last year but had not been able to make her intuitions concrete. There had been some missing time in his work schedule and she had once found a stocking in his suitcase.

In this initial session I reassured Sue that, as her life committed to reality again, rather than existing in the denial of addictive patterns, she would be in a place to make decisions about whether to stay in or leave the marriage, and that in six months it might be time for some evaluation.

Sue felt extremely apprehensive before the first group meeting and almost couldn’t get in the car to drive there. She paired up with Sarah for the introductions and was shocked to hear that Sarah’s husband, a city lawyer, went ‘dogging’ frequently, sometimes disappearing for days and returning dishevelled, with his shoes muddy and ruined. Sarah’s baby was only 18months old. When Sue though of this back at home after the meeting she cried for Sarah, for herself and for all the women who had been humiliated and exposed.

My observation, anecdotally, is an outcome of ‘thirds’: in a typical group, one third will leave the relationship, one third will ‘stay stuck’ (remain together but with problems unresolved) and one third go on to have a different and often improved closeness with their partner.

A therapeutic modality that I have to be of benefit when facilitating partner groups at Dr Thaddeus Birchard & Associates is Transactional Analysis, which is humanistic in its philosophy, believing we all have worth and value (I’m Ok, You’re Ok). The three main TA concepts I explore in this chapter are Ego States, The Drama Triangle, and Life Scripts, all of which I find help partners better understand and shape the dynamics of their own relationships.

The group facilitator will need to be willing and able to sit with the profound trauma, anger and sadness in the room and should never accept the invitation to join the ‘aren’t men awful’ game. Finally, hope must always be held for the future for partners. This is a learning that would never had been chosen, but whether going forward in the couple, or continuing alone, it can be a positive wake-up call for one’s life.

joy-rosendale_500  Joy specialises in working with partners of those struggling with sexually compulsive behaviours www.joyrosendale.comShe initiated the Partners’ programme at Dr Thaddeus Birchard & Associates in 2005 and the groups continue, offering support and education. She also teaches on the Sex Adddiction Training Diploma and has contributed to books on the subject including being a contributing author to the Routledge International Handbook of Sexual Addiction.  Joy has been practising psychotherapy for 27 years and trained with Relate as a relationship and sex therapist, and with Patrick Carnes in Arizona for sex addiction.   She likes Transactional Analysis as a modality (I’m ok, you’re ok) and offers a kind and holistic approach to self development.