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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

The Marylebone Centre’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 The Marylebone Centre 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

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. Captured by the ‘happily ever after’ 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 a power but must be controlled by men, and that realizing their truest self requires 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 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, 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.

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 defense 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 behavioral health treatment centers. 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 The Marylebone Centre 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 The Marylebone Centre.  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 the Marylebone Centre 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 the Marylebone Centre 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.  


Group Cognitive Behavioural Therapy for Compulsive Sexual Behaviour

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


Clinical Director, Marylebone Centre for Psychological Therapies

C0-Editor:  The Routledge International Handbook of Sexual Addiction (2017)

Author:   Overcoming Sexual Addiction: A Self Help Guide (2017) , CBT for Compulsive Sexual Behaviour: A Guide for Professionals (2013)


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Each chapter in this comprehensive reference guide is written by leading international experts in the field of sex addiction, compulsive sexual behaviours and out of control sexual behaviours.  Complimentary and contrasting views both for and against the concept of sex addiction are included.  Multiple chapters on sex addiction presentations, aetiology, and treatment of sex addiction are written by researchers, theorists, and clinical practicioners.  Additional chapters highlight sex addiction in specific populations (MSM, adolescents, women, female partners, sex offenders, religious sector, and in professional misconduct).   This research-based collection covering diverse aspects of sex addiction includes the views of experts who challenge and present alternative clinical and social views to ‘sex addiction’.  Link to our Blog to gain more insight from our highly esteemed colleagues and handbook authors.


Virtual Reality (VR) – Questions re Compulsive Sexual Behaviours

I’ve been discussing with my therapeutic colleagues whether virtual reality (VR) cybersex provides a medium for compulsive sexual behaviour akin to forms of online pornographic content.   Or whether VR can, as has been done with nicotine and gambling, be used therapeutically with problematic sexual behaviours, (Park, et al. 2015).  Since no academic literature yet exists on VR cybersex, it would be premature and irresponsible to associate it with a ‘next wave’ of compulsive sexual behaviours.   Yet, there are similarities in the mediums.  So how does VR compare to the 24/7, on demand, stimulatory experience of internet pornography, a current online medium that for some becomes compulsive and problematic?  This is an exploratory article designed to raise questions for therapists working in the field of compulsive sexual behaviours.

Shifting Towards a Virtual World

Some of us may remember when cybersex gave us one (visual) or two stimuli (auditory) by looking at pornographic images or sexually explicit videos.  Cybersex now provides ‘engagement’ opportunities, e.g. conversations, interaction of sexual avatars,  remote teledildonics, etc..  Yet much of cybersex’s medium takes place on a ‘flat’ screen, and stimuli from the ‘real’ world (location, touch,pressure, peripheral vision, sound, smell and taste) remind us it isn’t ‘real’.  

VR provides immersion into a reality so that the user “feel[s] like they are experiencing the simulated reality firsthand.” (   Some VR experiences are more ‘passive’ taking the point of view (POV) of a participant, like riding a roller coaster.  Other VR media allow three dimensional movement of the participant within a new reality; good for fighting zombies in an apocalyptic world, or dinosaurs in a Jurassic forest.  Whether passive or active, VR completely replaces visual and auditory cues.  As a result, one’s sense of position and balance becomes congruent with the virtual, rather than the real world.  The real world shifts a little further away, akin to what Milgram envisioned in 1994 as a shift on a continuum from ‘real’ to ‘virtual’ environments.

VR Cybersex – What’s Different?

The first wave of VR pornography has been ‘point of the view’, i.e. the experience of inhabiting another’s body.  The VR user sees, as if with his own eyes, everything its new ‘body’ is doing and with whom it is doing it.  Even though the user has no ability or choice in interacting with this body or the other people in the experience, the stimulus cues provide a sense of integrating with the body and of being ‘in’ the virtual world.  

Though there are no published studies on the VR pornographic experience, first hand accounts are available.  They convey something ‘different’, a more ‘real’ experience than 2D pornography.  This shift in experience is reminiscent of Naughty America’s goals, “Our customers want to get as close to reality as they can get, without reality getting in the way,” (Hamill, 2015).  Users trying virtual pornography for the first time similarly report, “I underestimated how realistic it would be because they got very close to me,  It felt pretty real,” (BuzzFeedBlue, 2016).

Is VR pornography as easily accessible ?

With a VR headset (now free with some pay subscriptions), a virtual pornography experience is just a headset, headphones, and mobile phone away.  For those trying to overcome the technological ‘how to’, YouTube videos are already available to help the viewer get their phone VR porn ready.  For a better quality stimulatory, immersive experience, high end headsets with a higher price tag are available.  Yet, the bulky headset and the need for headphones make it unlikely VR technology at present will be easily accessible and hidden in a work or home environment.  Still, the technology does provide the opportunity for instant sexual, 24/7 access, anonymity, and the potential in the near future to be more affordable and provide a variety of sexual genres.

What issues does this raise of a partner’s experience of VR pornography?  Again, the research is yet to be carried out.  Harrison (2016) raised this issue with a non-scientific sample of couples’ perspectives of how they would feel if their partner were engaging in pornography.  I was struck by one respondent who felt that it was the interactive component of VR that made it different from 2D pornography.  Regarding VR pornography, he/she replied, “I guess it makes me uncomfortable because it’s so close to just having sex with me yet they’ve decided to do it on their own.  It’s something we could be doing together and they choose the VR.”

What does the future of VR cybersex hold?    

VR porn designed for two people is a predicted future feature, as well as watching one’s adopted body engage in sexual activity that may be controlled remotely, (Sloat, 2016).  Motion sensitive suits and teledildonics (dildonic devices synced to the virtual experience) open this field.  CIO of Naughty America, Ian Paul thinks the VR version of pornography will shift from the passive, depersonalised version to a more intimate one. (Lee, 2016).  Albeit, this could be seen as “an extremely isolating way of experiencing intimacy…and can function to reinforce unrealistic norms around bodies and sex,” (Core 77, 2016).

A therapeutic thought…

I linger with something I read by Weisel (2015) discussing media addicted (not pornography addicted) clients.  Weisel proposed that the person “immerses” himself into an alternate reality, to attempt to self heal “into new forms of being or onto another stage-set, in order to prevent the return of the trauma” (p. 205).  What the computer programme creates are symbols in the fantasy experience that become ‘relational artefacts’, i.e. virtual objects upon which the client creates an attachment.  It is this attachment, Weisel believes, that gains power because the relational artefacts “facilitate a sense of continuity which is endlessly renewed without any need for separation”, (p. 209).  A media-addicted client shows one of two defenses:  phantasy and reality are kept separate (rather than integrated into a triangular experience), or extinction of connectedness and a staying in a state of ‘non-experience’.  Rather than connecting with real-life relationships, the person develops a safe, separate, fantasy existence that becomes a repetition compulsion, and creates greater isolation from connection from self and others.  I wonder how this matches the therapist’s experience of working with problematic sexual behaviours particularly given we often see trauma and attachment issues driving management (with pornography) of negative feeling states.  

Still, without valid and reliable research, it is only conjecture that VR technology may provide a medium for compulsive sexual behaviours akin to what we see with internet pornography. There are distinct similarities in terms of accessibility and engagement.  By hijacking additional senses, VR takes the user into feeling the fantastical is “real”.  And how could we use the technology to provide therapeutic support? The psychology and neuroscience of our experience in VR is an exploration that is just beginning.

Author:  Cecily Criminale, MS, MEd, MA, MBACP (Reg)

Bibliography (2015). Virtual Reality vs. Augmented Reality. [Blog] Available at: [Accessed 25 July, 2016].

BuzzFeedBlue. (2016) People Try Virtual Reality Porn. YouTube. Available at: [Accessed 3 July, 2016].

Core 77. (2016) Will Porn Finally Make Virtual Reality Popular?  Available at: [Accessed 3 July, 2016].

Milgram, P., Takemura, H., Utsumi, A., & Kishino, F. (1994). Augmented Reality: A Class of Displays on the Reality-Virtuality Continuum. SPIE, 2351, pp. 282-292.

Hamill, J. (2015). ‘World’s First’ Virtual Reality Porn Flick Invites Men to Take part in a Simulated ORGY. The Mirror. Available at: [Accessed 24 July, 2016].

Harrison, J. (2016). How Will Virtual Reality Porn Affect Our Relationships? Avaialble at:–1323577/ [Accessed 24 July, 2016].

Lee, S. (2016). Virtual Reality Porn Lands in E3 with a Bang.  Newsweek. Available at:  [Accessed 23 July, 2016].

Park, C-B., Park, S. M., Gwak, A. R., Sohn, B. K., Lee, J-Y., Jung, H. Y, Choi, S-W, Kim, D J, Choi, J-S. (2015). The Effect of Repeated Exposure to Virtual Gambling Cues on the Urge to Gamble.  Addictive Behaviours. 41, pp. 61-64.

Sloat, S. (2016). Why Virtual Reality Sex is More Likely to Kill Pornography than Monogamy. Available at: [Accessed 24 July, 2016].

Weisel, A. (2015) Virtual Reality and the Psyche. Some Psychoanalytic Approaches to Media Addiction.  The Journal of Analytical Psychology. 60(2), pp.198-219.