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 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).