Posted by: futureissoon | September 12, 2011

Cognitive-Behavioral Therapy in the Treatment of Sex Addiction


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“Men are disturbed not by things that happen, but by their opinion of the things that happen.” Epictetus (c. 50 – 120)

The philosophical basis for cognitive therapy goes back to the Stoic Philosophers who taught that it is not the external event that causes our distress, but rather our perception or interpretation of the event that is distressing. According to the Stoics, people are capable of considering alternative perceptions or interpretations by changing the thoughts that underlie the distress.

Cognitive models became popular in the early 1960’s. Proponents of this school assume the client’s problems occur at two levels. The first is the overt difficulty, such as depression or sex addiction. The second involves addressing underlying psychological mechanisms and psychological cognitive distortions, usually involving irrational beliefs that cause the addictive behaviors.

Cognitive-behavioral therapies conceptualize psychological problems primarily in terms of maladaptive learning, and are oriented toward assisting the individual to learn more adaptive patterns of thinking and acting. This technique typically relies on interventions that are directive, practical, task-oriented and educative in nature.

It is important to understand the major premise of cognitive approaches to treatment: the overt problem (sex addiction) originates within what cognitive behaviorists call the client’s schemata. This is a person’s world view, or core belief system. The focuses of this approach is on how the client maintains painful, harmful, or irrational behaviors. The primary approach utilizes some form of debate. This involves pointing out to clients the irrationality of certain thoughts, beliefs and perceptions and the construction and rehearsing of rational self-statements or other more functional cognitive strategies and skills.

My focus when working with a cognitive model includes:

1. The focus is on stopping the undesired sexual behavior. Behavioral modification techniques (Relapse Prevention Skills) and/or pharmacotherapy are employed to help clients achieve abstinence.

2. This is the “admission” stage and requires the patient to accept the existence of a problem and to promise to keep no secrets from the therapist.

3. In this stage, patients are taught stress management techniques so they no longer need to rely on sexual behavior to alleviate their anxiety. I recommend physical exercise, and teach a combination of breathing techniques, progressive relaxation, meditation and hypnosis to show clients that they do have some power over their inner states.

4. This may be the most important stage of the program. It consists of cognitive therapy directed towards repudiating the irrational beliefs that underlie sexual addiction through active questioning. It allows clients to develop an awareness of beliefs. By asking questions clients develop an insight into their thought process and how these influence their emotions and behavior. Accordingly the client becomes aware of inappropriate beliefs and is helped to challenge them and change their behavior. The process involves asking questions that support or refute the thought, asking about possible alternative explanations. Questioning about the range of consequences of the thought and it’s impact upon the person and what would be the effects of believing the thought or of changing their thinking.

5. Patients are trained in such skills as assertiveness and problem solving in order to facilitate adaptive social functioning.

6. Focus is on resolving whatever problems the individual has had in establishing and maintaining a primary sexual relationship.

7. Learning what thought processes lead to “setting oneself up” for a return to relapse.

8. Developing a positive attitude towards healthy sex; cultivating an appreciation for the needs of one’s partners, learning pleasuring skills, using sex therapy if there is a sexual dysfunction.

9. Generating pleasurable sober activities and relationships – building a life worth living.

The sex addict depends on sex to meet his emotional needs which he is unable to meet through healthy coping skills. Sex becomes a coping mechanism for dealing with stress, shame, guilt and isolation. It is a way to connect without risking intimacy.

However, the addiction is never satisfied because sex is unable to meet these needs because their source is historical and the need is too great. In addition, the needs of the true self can never be met by sexual activity.

Patrick Carnes sets out the unconscious belief systems that all sex addicts need to refute.

1. I am basically a bad, unworthy person.
2. No one would love me as I am.
3. My needs are never going to be met if I have to rely on others.
4. Sex is my most important need.

While these are the core dysfunctional beliefs, there are many more beliefs, attitudes, or “cognitive schema” that keep the addictive cycle in place. From my experience, some of them are:

    • I am unable to tolerate boredom; sexual acting out is a good way to fill in the time.
    • If not distracted by sex, I am filled with an intolerable sense of emptiness.
    • Men are more sex-driven than women. As a man, I need to discharge that drive, or I’ll go crazy.
    • My sense of self is determined by how many women are attracted to me.
    • The vicissitudes of life are either boring or unmanageable. There is no pleasure to be had in day-to-day life except for my “secret” world.
    • Sex with my partner is a mechanical, deadening process which lacks spontaneity and excitement.
    • If life does not provide excitement and high-stimulation, then I’ll be bored and depressed forever.
    • When I get an urge or impulse to act out sexually, I must succumb to that urge.
    • In order for me to be a real man, I must have sex with as many women as I can. Furthermore, as the man, I am responsible for my partner’s pleasure through intercourse. Failing at intercourse is failing as a man.
    • Engaging in cybersex is my only means of getting away from the stress and frustration of living.
    • Sexuality is the only trustable means of relating to others.
  • I depend on sex to meet emotional needs which I am unable to meet through healthy coping skills.

Addiction is self-perpetuating; it feeds on itself because of ingrained core beliefs as well as each individual’s dysfunctional beliefs about sex. In order to change the addictive cycle, one must change the belief systems that underlie it.

Dysfunctional beliefs give rise to rationalization, minimalization and justification. The addict, as the disease progresses, starts to see the world through cognitive distortions designed to protect his sexual acting out. His whole perspective becomes distorted to the point where he becomes increasingly out-of-touch with reality.

In treatment, changing these beliefs is key. Changing core beliefs is a challenge because they were imprinted at an early age and have remained stable over time. Another reason change is difficult is that these beliefs live in the unconscious mind. The addict lacks awareness of his self-defeating beliefs. How can you change something you don’t even know you have? The cognitive therapist will elicit these attitudes and beliefs and provides alternative ways of thinking and perceiving.

I sometimes use hypnosis to gain access to the subconscious mind where the beliefs, attitudes and cognitive schemas can be brought to awareness and disputed.

I highly recommend David Burn’s book “Feeling Good”. In it he lists 10 cognitive distortions and ways to dispute them. Study the cognitive distortions so you can begin to see how they operate in your life and change them to a realistic, rational thought process.

Further Reading

Kouimtsidis, C. et. al. (2007) Cognitive-Behavioral Therapy in the Treatment of Addiction. John Wiley & Sons, Ltd.
Lewis, L.A.(1994) Sobriety Demystified: Getting Clean and Sober with NLP and CBT. Kelsey & Co. Publishing
Schwartz, M.F.and Brasted, W.S. (1985) Sexual Addiction. Med. Asp. Hum. Sex., 19;103-107.

Dorothy C. Hayden, LCSW, MBA, CAC is a Manhattan-based analytic therapist who specializes in sex therapy and sex addiction. Having received her MSW from New York University, she studied psychoanalysis at the Post Graduate Center For Mental Health and The Object Relations Institute. After studying hypnotherapy at the Milton Erickson Society for Psychotherapy and Hypnosis, she became a certified NLP practitioner. She is currently studying couples counseling at The Training Institute for Mental Health. She can be reached at dorothyhayden1231@gmail.com ( http://www.sextreatment.com )


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