For many therapists with no specialised training in psychosexual therapy or addiction treatment, a client’s pronouncement that they are a sex addict might cause alarm bells to ring. A number of questions are likely to spring to mind: does such a diagnosis actually exist? If it does exist, how do we recognise it? And, what is the most effective way of treating it?
The jury is still out on whether sex addiction can be seen as a true addiction or even mental disorder. The World Health Organization recently included ‘compulsive sexual behaviour disorder’ as an impulse-control disorder in the International Classification of Diseases (ICD-11),1 but the American Psychiatric Association failed to recognise it in the latest version of the Diagnostic and Statistical Manual of Mental Disorders (DSM-5).2 There was disappointment among many sex addiction therapists at this omission from the DSM-5, as, on a daily basis, they come face to face with individuals who suffer greatly as a result of their out-of-control sexual behaviour. For some clients, this might take the form of prolific pornography use, while for others, it might be weekly visits to escorts or a never-ending stream of one-night stands.
It is not the behaviour per se that is the marker of sex addiction, but rather the negative impact that it has on the individual’s life. For these clients, rather than being a pleasurable experience, sex is used compulsively to relieve negative emotional states and, as a result, often causes significant distress.3 Despite this distress, they feel unable to stop the behaviour. Clients usually only walk into the therapist’s consulting room once the addiction has become completely unmanageable, for example because it has resulted in loss of employment due to pornography use on work computers, financial ruin due to numerous escort visits or marriage breakdown due to multiple affairs.
Whether or not we wish to use the term ‘sex addiction’, or prefer to refer to this as out-of-control sexual behaviour, hypersexuality or sexual compulsivity, what is clear is that it poses a significant problem for an ever-growing number of people. The availability of free online pornography and hook-up apps has done nothing to alleviate the problem. We are likely, therefore, to see an increasing number of clients walking through our doors for whom out-of-control sexual behaviour causes mental and emotional distress.
Most sex addiction treatment strategies are based on a cognitive-behavioural approach.3 Sex addiction therapists will typically work with clients to help them to identify their addiction cycle, recognise the triggers for acting out, understand the harmful consequences for themselves and those around them, uncover the core beliefs that fuel the behaviours, and put in place a plan for sobriety, eventually resulting in the development of a healthy relationship with sex. This approach has proven very effective. However, it may be that it overlooks a particularly important aspect of sex addition.
Sex addiction and attachment
Increasingly, addictions are being recognised as attachment disorders.4 Studies across a range of different substance and behavioural addictions have shown addicts to be more likely to have an insecure attachment style than non-addicts.5 A small number of studies have focused specifically on the relationship between insecure attachment and sex addiction.6–8 In these studies, over 90 per cent of sex addicts displayed an insecure attachment style.7,8 This is in marked contrast to the population at large, where under 45 per cent of individuals are insecurely attached.9,10
If addiction is viewed as an attachment disorder, then perhaps there is some merit in considering the place of attachment in the treatment of addiction. Some researchers have certainly recognised the value of such an approach, arguing for attachment-based treatment approaches to substance abuse,11 alcohol abuse12 and gambling disorder.13
However, to date, very little work has been done on the relevance of an attachment-based approach to the treatment of sex addiction (with the exception of an excellent book by Alexandra Katehakis).14 In order to discover more about how such an approach might work, I interviewed six sex addiction therapists in the UK, the US and Australia who include a focus on attachment dynamics in their work with clients suffering from sexual compulsivity. I analysed the interview data to explore whether there were any common themes or approaches in the therapists’ work that might form the basis of a tentative attachment-based approach to treating sexual compulsivity.
My study, which has been published in full in the Journal of Sexual Addiction and Compulsivity,15 identified three common overarching attachment themes in the therapists’ work: (i) regulating closeness and distance in the therapy room; (ii) affect regulation; (iii) risking connection in the outside world. The remainder of this article explores how each of these themes might be addressed when working with sexually addicted clients. I also provide a clinical vignette to demonstrate how I have integrated these findings into my own work.
Regulating closeness and distance in the therapy room
As a result of their insecure attachment style, sex addicts generally lack the ability to enter into close, intimate relationships with other people. Due to their attachment history, such relationships seem fraught with danger, and the addict therefore keeps people at arms’ length. While these individuals may seem to have close family and friends, their addiction prevents true intimacy, as it is kept hidden through continual lies and deception. At the same time, these clients may engage in intense sexual relationships with people with whom they have no real attachment, allowing them a brief semblance of connection without the attendant danger of real intimacy.
Bearing this in mind, the idea of entering into an intimate therapeutic relationship can seem overwhelming and dangerous for the sex addict. They may well have come to therapy as a result of an ultimatum from a distraught partner who has discovered the addiction. It may, therefore, prove very difficult to create a therapeutic alliance with them. These clients are likely to shrink away from all attempts at truly getting to know them; they may end therapy prematurely or miss sessions without warning. It is important to remember that they are often caught in a paradox: they are longing to get close, in order to have their pain soothed by another, and yet closeness feels so dangerous that they dare not approach. The therapist, in turn, is faced with a conundrum; they need to be able to draw close to their client in order for the real work to begin, and yet, in doing so, they may scare the client away.
The therapist must therefore attempt to meet the client where they are, rather than where the therapist may want them to be. In order to do this, they will need to work sensitively in the here and now of the therapeutic relationship, looking out for any openings for connection, however miniscule these may be. This may be slow, painstaking work
One of the most important advances in attachment theory over the past few decades has been the understanding that it is a theory not only about relationships but also about affect regulation.16 We develop our models for affect regulation at a very early age, with infants programmed to seek out attachment to their primary caregivers. The caregiver’s role is to soothe the infant’s emotions and help them to self-soothe. If they fail in this task, the individual does not learn how to adequately regulate their own emotions and also cannot turn to others for emotional regulation. Instead, they look outside themselves to control their emotional state, and drugs, alcohol, food, gambling and sex can all step in to fill this void.
The role of the therapist is, therefore, to help the client to understand that they are capable of experiencing and regulating their emotions, rather than acting out in order to escape them. The first challenge for the therapist in this process is that sex addicts often suffer from alexithymia and are unable to identify their emotions, having cut themselves off from them at an early age. Somatic awareness is a key route to reconnecting the client with their emotional state, helping them to focus on what they feel in their body. The therapist will need to pay close attention to the client’s somatic cues and draw attention to them, helping them to move firstly towards self-awareness and then to self-regulation, for example through breathing and relaxation exercises.
Affect regulation has two complementary parts: self-regulation and co-regulation. In order to help the client experience co-regulation, the therapist will need to be attuned to their own thoughts, feelings and bodily sensations, using them as a compass for how the client is feeling. For example, if the client is in an anxious state, breathing shallowly, the therapist can adjust their own breathing and help to ground the client. As the client learns how to experience both co-regulation and self-regulation, their need for addictive behaviours lessens.
Risking connection in the outside world
Achieving a connection with the client in the therapy room is only the first step towards secure attachment. For change to really occur, this new way of relating then has to be transferred to the outside world. The addict has used their addiction as a replacement for close relationships; if they are to truly recover, they will need to begin to forge relationships, trust others and maintain an emotional connection with them.
Groupwork plays a key role in helping recovering sex addicts to risk connection in the outside world. In group, whether it is a 12-step group such as Sex Addicts Anonymous (SAA) or a therapeutic community for recovering sex addicts, the addict learns to reveal who he is underneath the false exterior. Being in the presence of others in similar positions, they learn that they can disclose the more shameful parts of themselves without humiliation. They receive understanding from other group members who can share their experiences. Secure attachments begin to form between group members, many of which may become enduring bonds that last a lifetime.
The couple relationship often comes into crisis as a result of sex addiction being uncovered. The partner often experiences trauma as a result of discovering that their life with their spouse is based upon lies and deception. They may feel that they don’t know their partner at all. They may need individual therapy, and the couple, if they decide to try to mend the relationship, will also need to engage in couple therapy.
If sex addiction is found to be predicated upon attachment ruptures in early childhood, part of the therapeutic work may need to focus on healing these traumatic attachments in the present. Attachment traumas might include rejection, abuse, abandonment and neglect. It is vital to obtain a comprehensive history of the client’s attachment patterns, both as a child and adult, as well as exploring any attachment trauma within the wider family. The therapist will need to help the client work with attachment traumas in order to grieve loss, as well as to repair relationships, where this is relevant. This can allow the client to revise their internal working models, both of themselves and of others, enabling them to risk intimacy and move towards developing more securely attached relationships.
Case study: Jake
When Jake entered my therapy room, he appeared stiff and formal. He sat up straight in his chair and refused to make eye contact. He told me that his wife, Sarah, had insisted that he come for therapy. As I tried to probe gently into what he might want from our work together, he appeared at times defiant, professing that he did not need help, while at others defeated, muttering that he was beyond help. At times, in our early sessions, I doubted that we would ever be able to form a therapeutic alliance, but I sat listening to him quietly and non-judgmentally and, little by little, he began to let me see him. I was careful to go at his speed and not try to get too close too quickly.
It took a few sessions for Jake’s story of addiction to unfold. He explained to me that Sarah had opened a letter from the bank and discovered that they had defaulted on their mortgage repayments. The bank was on the verge of repossessing the house. When Sarah confronted Jake, he pleaded ignorance, but as Sarah uncovered more evidence of their financial situation and his exorbitant spending, he eventually broke down and admitted to her that the money had been spent on strip clubs, prostitutes and gambling. Sarah had gone into deep shock and depression. As Jake gradually revealed all this to me, I listened to him without judgment, showing him that I could bear the weight of his admissions without also being shocked. This was the beginning of modelling a new attachment experience for him.
I began the work with Jake with the traditional CBT tools, helping him to put into place a plan for managing his addictive behaviours, identifying triggers, challenging unhealthy thought processes, and replacing the acting out with new healthy behaviours. As we worked together in this very practical way, I sensed his trust in me growing. I was able to recommend local Sex Addicts Anonymous (SAA) and Gamblers Anonymous (GA) groups, which Jake soon began to attend on a weekly basis.
Although the recovery went well in the first few months, Jake would come to some sessions on the verge of acting out. We would try together to identify the emotional triggers. In one session, I noticed a hollow feeling in my stomach, which did not seem to relate to my own emotional state. I told Jake what I was sensing and wondered whether it seemed pertinent to our work. He was quickly able to identify a similar sensation in his own body and together we were able to name it as loneliness. Recognising and naming his emotions was a new process for Jake, and one which he found very uncomfortable. I taught him some mindfulness techniques, which helped him to acknowledge and accept his emotions without acting out. We also discussed how connecting with some of the people he had met in SAA might help to alleviate the feeling. Jake also had to learn how, when he was experiencing difficult emotions in the relationship, he could allow himself to be vulnerable and discuss them with Sarah, rather than running away and seeking solace in sex and gambling.
As our relationship strengthened, I was able to take a full attachment history, with a view to identifying and working on attachment trauma. Jake’s father had suddenly disappeared when he was three. His mother sank into depression and so neither parent was available to help soothe his distress. His older brother had a stash of porn magazines, which Jake discovered when he was 13. Soon, he found that looking at the magazines and masturbating helped to ease his sense of loneliness and insecurity. As Jake grew up and went to work in the City of London, visits to strip clubs and escorts seemed the norm among his colleagues, who also drank heavily. Jake soon found that any difficulty in his professional and private life could be effectively obliterated with a potent mix of sex, alcohol and gambling. When he met Sarah, he vowed to himself that he would stop. He was successful until they had their first argument, at which point he immediately turned back to his old habits in order to soothe himself. This then became his normal way of dealing with any problem in their relationship, particularly after their son, Sam, was born and Sarah no longer seemed to have any time or energy for Jake.
As a result of his attachment history, Jake had developed an internal working model that he was not good enough (after all, his father left him) and others were unreliable (neither his mother nor his father were there to ease his pain). After many months of work, Jake decided that, as part of his recovery process, he wanted to make amends with his mum, from whom he was estranged, understanding that she had done her best under difficult circumstances.
Much of Jake’s concern within therapy was the restoration of his relationship with Sarah. She had entered individual therapy and, six months into their work, both of them decided that they were ready for couple therapy. I referred them to a couple therapist specialising in treating sex addiction. Even though Sarah had been unaware of the addiction, it had pervaded their relationship from the start. Both of them had to relearn how to be in relationship with each other without the addiction present, to form a secure attachment. The couple work centred around rebuilding trust, re-establishing sexual intimacy and emotional co-regulation.
Eighteen months later, Jake and I still see each other on a weekly basis, and he still attends weekly SAA and GA meetings. He and Sarah have repaired and strengthened their relationship, and Jake is no longer acting out. Sarah is now pregnant with their second child, and Jake and I are exploring how this shift in the family may once again trigger difficult emotions. This time, Jake is armed with the emotional resilience and communication tools that will hopefully allow him to manage the transition without seeking solace in sex and gambling. For Jake, the addictions had indeed been a misguided search for a secure base.
An attachment-based approach to sex addiction treatment provides the client with a new attachment experience within the therapy room, which they can use as a model for forging new types of relationships in the outside world. It is a twoperson, immersive process that occurs at a physical and emotional level. This approach requires a complex array of individual therapy, couple therapy (if the client has a partner) and group therapy. It is long-term work and this can be one of the greatest challenges for the addict. These clients are used to seeking an immediate response to difficult emotions, a response that prevents them from ever having to feel their emotions too deeply. Therapy is difficult for them because it is a slow, painful process, in which they are brought face to face with their emotions in order to learn that they can face them and feel them without the need to act out.
Joanna Benfield is a psychosexual and couple therapist in private practice in Kingston upon Thames. She has an MA in counselling and psychotherapy and a postgraduate diploma in psychosexual and relationship therapy. Joanna is author of Three in a Bed: conversations with a sex therapist and co-editor of the Routledge International Handbook of Sexual Addiction. She is a registered member of BACP and an accredited member of the College of Sexual and Relationship Therapists (COSRT). Joanna is also editor of the BACP Healthcare Counselling and Psychotherapy Journal.
1. World Health Organization. International Classification of Diseases (ICD-11) – maintenance platform. [Online.] WHO; 2018. https://icd.who.int/ dev11/l-m/en#/http://id.who.int/icd/entity/1630268048 (accessed 6 August 2018).
2. American Psychiatric Association. Diagnostic and statistical manual of mental disorders (5th edition). Washington, DC: DSM; 2013.
3. Kafka M. Hypersexual disorder: a proposed diagnosis for DSM-5. Archives of Sexual Behaviour 2010; 39: 377–400.
4. Birchard T. CBT for compulsive sexual behaviour: a guide for professionals. Hove: Routledge; 2015.
5. Gill R (ed). Addictions from an attachment perspective: do broken bonds and early trauma lead to addictive behaviour? London: Karnac; 2014.
6. Faisandier K, Taylor J, Salisbury R. What does attachment have to do with out-of-control sexual behaviour? New Zealand Journal of Psychology 2011; 40(3): 19–29.
7. Leedes R. Theory and praxis: a heuristic for describing, evaluating and intervening on sexual desire disorders when sexual expression interferes with humanistic expression. Sexual Addiction and Compulsivity 1999; 6: 289–310.
8. Zapf J, Greiner J, Carroll J. Attachment styles and male sex addiction. Sexual Addiction and Compulsivity 2008; 15: 158–175.
9. Bartholemew K, Horowitz LM. Attachment styles among young adults: a test of a four-category model. Journal of Personality and Social Psychology 1991; 61: 226–244.
10. Hazan C, Shaver P. Romantic love conceptualized as an attachment process. Journal of Personality and Social Psychology 1987; 52(3): 511–524.
11. Flores P. Addiction as an attachment disorder. New York: Jason Aronson; 2012.
12. Vetere A. Alcohol misuse, attachment dilemmas, and triangles of interaction: a systemic approach to practice. In: Gill R (ed). Addictions from an attachment perspective. London: Karnac; 2014 (pp 57–68).
13. Karter L. Gambling addiction: seeking certainty when relationship is the risk. In: Gill R (ed). Addictions from an attachment perspective. London: Karnac; 2014 (pp 119–124).
14. Katehakis A. Sex addiction as affect dysregulation. New York: WW Norton & Company, Inc; 2017.
15. Benfield J. Secure attachment: an antidote to sex addiction? A thematic analysis of therapists’ experiences of utilising attachment-informed treatment strategies to address sexual compulsivity. Sexual Addiction and Compulsivity 2018; doi 10.1080/10720162.2018.1462746.
16. Schore JR, Schore AN. Modern attachment theory: the central role of affect regulation in development and treatment. Clinical Social Work Journal 2007; DOI 10.1007/s10615-007-0111-7.