Treatment of Sex Addiction: Relapse Prevention

Therapy for Sex Addiction

Relapse Prevention for Sex Addicts Overview Relapse in sexual recovery is a reality. While all addictions are relapse prone, it is the sexual recovery community who suffer most from the demoralization of repeated relapse. After all, we can live without ever being around alcohol or drugs, but our sexuality is ever-present. Because ours is a sexualized culture, triggers, cravings, urges, cues, and high-risk situations are everywhere. The sex addict, despite his best efforts to achieve continuous abstinence, may find himself continually returning to his addiction despite the knowledge of the damage it inflicts on him -- disease, damage to primary relationship, social disapproval, financial loss, and decreased self-esteem. In times of stress, the lure of immediate gratification (the pleasure, "high", tension reduction, relief of distress) calls him and he responds, puppet-like, to the perceived inevitability of relapse. When caught in the addiction cycle of preoccupation, fantasies, euphoria, urges, cravings and the intense, and driving need for comfort and gratification, retreat into the comfort of the "erotic haze" is the only coping mechanism available to him at the time. The erotic haze is a dissociative state that allows the very real negative consequences of his behavior to recede from consciousness as the imperious need for immediate gratification becomes his exclusive focus. Most sex addicts state that the sexual act itself is inconsequential. Hours spent in the dissociative "erotic haze" meet certain non-sexual needs. It is this euphoric self-state that the person is really addicted to. With orgasm, the "bubble" breaks and reality sets in. Feelings of defeat, shame, hopelessness and demoralization are common. Because his only way of coping with distressing feelings is sexualization, he returns to the addiction for relief of the pain that's caused by the addiction because he doesn't see any alternatives. He blindly goes to the source of the pain for relief of the pain. Thus we see the vicious, never-ending cycle of active addiction. We keep returning to the source of the suffering for relief from the suffering which creates more suffering so we again go to the source of the pain and so on and so on.

But there is hope. Addicts repeatedly return to their addiction because it's what they know. The result of long-term addiction is a gradual erosion of the ability to choose different alternatives to deal with life. An addict just entering treatment is in a state of nil-choice. A relapse prevention program helps people who use sexual behavior addictively (1) to recognize factors and situations that are associated with an increased risk of acting out; (2) to cope effectively with sexual urges; (3) to recover rapidly from episodes to symptomatic behavior; and (4) to use such "slips as opportunities to learn about how their recovery plans can be strengthened. You'll learn new coping skills, new options and new cognitive strategies to cope with external and internal stressors. You'll become very familiar with the warning signs of your personal relapse process and learn that you can intervene at many points in that process with a healthy coping mechanism. Change a thought - and you're out of the downward spiral. Do something different from you used to do - and you're propelled out of the erotic haze into reality. Ingrained sexual habits can be transformed into behaviors that are under the regulation of higher, more mature mental processes involving awareness and responsible decision-making. You can begin to make a variety of choices that ultimately lead to the enjoyment of pleasurable experiences that are nonsex related and have no negative consequences. The goal of Relapse Prevention (RP) is the restoration of the ability to choose, an increase in the client's awareness and choice about their behavior, to develop coping skills and self-control capacities, and to generally develop a greater sense of confidence, master, or self-efficacy in their lives. Working an individualized relapse prevention program is not part of treatment per se, but maintaining a relapse prevention (RP) program is probably the most critical element involved in staying sexually abstinent. If the person believes that the only goal of treatment is abstinence, then little attention is paid to the perils and demands of the journey towards the maintenance of abstinence and continued growth as a person. In the process of recovery you'll be faced with a plethora of temptations and stressors. The pull of powerful old habit patterns will beckon you. Failure to anticipate and plan for the stressors of recovery will result in immersion in the addiction cycle. The phases of this cycle consist of preoccupation, dissociation, entering into the "erotic haze", ritualization and sexual acting out, followed by despair, shame and guilt. The addict, because he has not developed ways of coping with overwhelming emotions, sees his only option for relief from the shame and self-loathing as the return to the beginning of the cycle. With time, the addiction cycle may escalate, with greater intensity, more frequency, more risk and greater loss of control.

Relapse prevention intervenes before the client enters into the addiction cycle. While behavioral or cognitive interventions are still possible in the preoccupation and dissociation stages, once the client enters into the "erotic haze", it is almost impossible to stop the process. Motivation - Values and Goals The cultivation of meaningful, realistic goals and clarification of personal values should precede the development a RP program. To counteract the pull of the addiction, you need to know why you're motivated to work for recovery. You will your own life goals and enduring values that can guide you, as the North Star, towards restoration, recovery, and the achievement of a satisfying and meaningful life. Most sex addicts want to achieve real connection with others and not the mere illusion of connection. They want to build the genuine self-esteem that comes from living out one's most cherished ideals and values and from the ability to regulate their feelings and behaviors. They want to stop the lies, secrets and deceptions that keep them in a perpetual state of fear, shame and self-doubt. Luckily, these goals are attainable. What it Takes Working a RP programs requires three things of you. Motivation. You need to be consistently aware of the negative consequences of unregulated sexual behavior. Remembering the pain and suffering of being in active addiction can be a great motivator to change. Another motivator to staying active in the recovery process and knowing that you're working towards your life goals that would be unachievable if you're involved in active addiction. The process of continuously doing what you've committed to do is itself a strong motivator. Active addiction gradually erodes your moral fiber and betrays your essential values. Knowing what makes life meaningful to you and re-committing to your essential values will be the motivational force and the foundation for the work ahead. Mindful awareness of your inner processes. Enhanced knowledge and awareness of inner processes (see article on "Mindfulness Meditation.") is necessary for most aspects of recovery, but more so in RP. Most of the warning signs of relapse occur unconsciously. Mindful awareness brings them into consciousness where they can be dealt with in adaptive ways. Mindfulness meditation fosters a sense of detachment between addictive behavior and your personal identity. Cultivating a "witness consciousness" that is balanced and non-judgmental trains you to become your own mind-scientist. With mindful awareness, you can see the warning signs of relapse as

they happen so you can take proper action. Through mindful awareness and with the help of your therapist, you'll learn to think about your thinking and observe and detach from painful emotional processes. A willingness to learn new responses to old stimuli, an openness to new ways of behaving and thinking and a continuing determination to practice new skills until they become automatic is essential to making your relapse prevention program work for you. One definition of "determination" is the ability to stay the course regardless of thoughts andfeelings. You just keep doing the next right behavior on your recovery plan, regardless of your feelings or your perceived discomfort. Treatment means nothing if it's not used as a springboard for taking healthy, constructive actions to replace the addiction. The Basics First you figure out what thought processes, high-stress situations and behaviors lead to the endpoint of acting out. Sexual relapse is the end-point of a relapse process that may have begun last week, last month, or last year. You don't get "struck" acting out. Sexual enactments don't come out of the blue. There are many, many steps that lead to being in relapse mode. Cultivating mindful awareness of the warning signs of your particular relapse process is essential. As you learn new recovery skills (or healthier coping mechanisms), you'll be able to use one of them as an intervention at various places in the addiction cycle. When you become aware of the warning signs of relapse, you immediately do something different than you've always done that will disrupt the pull towards acting out. When an addict has used immersion in the "erotic haze" as a coping mechanism to avoid pain and deal with life stressors for an extended period, it becomes his exclusive way of coping with life. However, the coping mechanism is maladaptive because it leads to suffering-inducing consequences. An RP program teaches adaptive coping skills that generate new behavioral alternatives, new ways of thinking, new choices, new experiences and, combined with other treatment modalities, offers a radically different way of being in the world. How it Works The Ball and Chain When I work with clients on a RP program, I use the metaphor of a behavioral chain that has many links. The bottom of the chain is relapse. Each link in the chain represents a relapse

warning sign that you can observe as it happens and immediately intervene with one of your newly learned coping skills. Even though it seems as though relapse descends upon you, a force beyond your control that comes "out of the blue", in fact, there is a long chain of events that lead you there. You can learn to find and control the chain of events that represent your particular relapse process. Clients learn how to go back in time to reconstruct all the internal and external links of the chain (thoughts, feelings, behaviors, urges, fantasies and external events) that have that led to relapse in their past. Following is an example of one of a client's behavioral chain that led to relapse: • Two days before his relapse, he went to the gym. • At the gym, he thought members of the staff looked at him in a strange way. • He interpreted their looks as judgments about himself. • He felt both embarrassed and hopeless. He felt hopeless because it seems that would never feel normal in any of the places he wanted to belong • He went directly home without doing her errands because he didn't want to be seem by anyone. • Lying on the couch while watching TV, he became sexually aroused and distracted from his earlier feelings of embarrassment and helplessness. • He went to the computer and looked for a site with free porn pictures. • After his orgasm, he felt ashamed that he had look at porn after he had promised himself he wouldn't do that again. • He felt hopeless and depressed and thought about what a loser he was. • He thought about how no one would ever love him. • He thought he would go crazy if he couldn't be loved and sexually satisfied by a woman. • He thought he has to prove himself that he could have sex with a woman and that he was not a loser. He thought he needed to regain his self-control. This client's chain brought him to a brothel where he had sex with a prostitute. Following his experience, he felt an immediate sense of demoralization and shame. If uninterrupted, the displeasure of the feelings of demoralization and shame will bring him right back to the beginning of the addiction cycle. This is an ordinary example of how you can end up doing exactly what you didn't want to do. When your personal behavioral chain is pulling and you don't try to break it until it's too late, then you've gone and gotten yourself just in the place you've been trying to avoid.

Again, the relapse didn't descend upon him as a cruel fate. It didn't just happen. It took a few dozen steps for this client to arrive at relapse. At each of those steps, (or links in the chain) he could have intervened with a cognitive change or a healthy behavior to prevent the relapse. You need to become very aware of the links in the chain, especially when warning signs go off. The next step is to look at each link in the chain and come up with alternatives (also called coping mechanisms) that are ways to get out of the chain when you are caught in it. Change a thought, you've off the chain. Do an alternative behavior, you're off the chain. These are the ways to free yourself from becoming tangled up in the chain. An alternative is something you do instead of your usual response in a situation. An alternative makes it possible for you to think and behave in a different way that you did before ( You might want to pick up a copy of "Living Sober" (AA Worldwide) that provides plenty of ideas of alternative, pleasurable behaviors and activities. As you look at the sample behavioral chain, you can see a series of emotions, thoughts and actions. You're not asked to do anything about the emotions just now. Feelings come and go. Just notice that how you feel affects how you think and what you do at a given time. You can't directly change feelings, but you can become aware of them and how they affect the other parts of your life. What you can change directly is how you think about things and what you do about them. First you look for every cognitive distortion on your chain and come up with alternatives ways of thinking that might be more in line with reality. Go through the chain, replacing the thoughts that led you down the dark sexual alternatives with better alternatives (Sbraga et al., 2000). Next you look at the behaviors in you chain and come up with realistic alternatives. If you find yourself in a high-risk situation, what could you have done instead? Write out a list of alternative behaviors that will instantly get you off the chain. Think of lots of options, particularly options that are give non-sexual pleasure with no negative side effects. Write your new coping mechanisms on a card and carry them with you. Research has shown that people lapse, it is usually in response to negative feelings and to interpersonal conflicts. These events should always to consider high risk. You learn how to be good at using you coping skills to stop your relapse progression by practicing. You are creating new, positive habits for yourself. These are habits that will take you towards your goals instead of stealing away the best years of your life.

Managing Feeling-States All addicts have problems with tolerating distressing inner states. Research shows that two types of situations are especially high-risk for relapse: Negative emotional states and situations involving an inter-personal conflict with a closed one. People go to any length to avoid certain feelings such as shame, fear, anger, loneliness, emptiness, depression and so on. Addicts avoid feelings through sexual acting out. You might consider other ways you have to not sit with feelings. It is possible to control feelings for a bit of time, but they surface and fade away. Handling feelings is essential in relapse prevention because how you feel has a lot to do with sexual control problems. Sex addicts try to manage their emotions with sex. Think for a moment how many times you have gone out looking for sexual satisfaction when you were feeling hurt, lonely, rejected, sad, angry, disrespected, anxious, depressed, fearful or unloved? And, of course, sex makes you feel better - for a brief period. Unfortunately, this strategy of managing feelings just doesn't work. If you really did a cost-benefit analysis of sexual acting out, you might see that the benefit is fleeting and the costs...well, you know what they are. The reality is that if having all the sex you wanted could make you feel better or create a better life for you; don't you think it would have happened by now? The problem is that sex, despite its allure and the false promises it offers you, cannot make you feel better in a real or lasting sense. The authentic self is not nourished or healed through sex. So if you can't change your feeling and they just happen, what are we to do about painful feelings? Here's the deal: DO ABSOLUTELY NOTHING ABOUT YOUR FEELINGS! Feelings, if you don't try to get rid of them, come and go rather quickly. When people try to control their emotions, the feelings don't get the chance to dissolve as they should. They just keep coming back. FEELINGS DON'T KILL - THEY WILL NOT ANNIALATE YOU. THEY ARE NOT DANGEROUS. They create discomfort, and then they pass away. The important thing is to remember that you can handle any of your feelings that come up. You have a choice about whether or not to act out sexually and create more suffering. In the same way, what do you do when you're triggered, hot, horny, aroused and amorous? The answer is the same: DO NOTHING. Sex addicts have a false belief that they must do something about it no matter what. This is a lie. People feel aroused all the time and don't act on the feelings. Happily married people are sometimes attracted to other people, but they don't have

affairs. Priests and nuns feel sexual arousal but they honor their vows. Certain engaged young people choose to postpone sex until after marriage. Somehow, they all survive without acting on sexual urges. Learning to tolerate sexual arousal without being sexual is a gift you give to yourself. Urges and cravings Urges and cravings are physiological responses to internal or external triggers. You experience being pulled by the wish for immediate gratification. An RP program teaches you urgemanagement techniques. You are taught to anticipate and accept these reactions as a normal part of getting sober. You are taught to dies-identify with the urge and to view it dispassionately as an alien force. I use hypnosis to set up imagery work with the client and ask him to imagine it as a wave, watching it rise and fall as an observer and not to be "wiped out" by it. This imagery technique is called "urge surfing" and refers to visualizing the urge or craving as a wave that crests and then washes on to a beach. In so doing, the client learns that rather than building until they become overwhelming, urges and craving peak and subside rather quickly if they are not acted on. The client further visualizes not being "swept away" but rather can see himself riding the wave on a surf board. This imagery fosters detachment from the urges and reinforces the temporary, fleeting nature of these phenomena. Lapse Management Despite planning and precaution, many clients committed to abstinence will experience a lapse after initial abstinence. Lapse-management techniques strategies focus on halting the lapse to prevent an uncontrolled relapse. I contract with the client to contact me as soon as possible after the lapse, and to evaluate the situation for clues to the factors that triggered the lapse. The client is instructed to leave the lapse-inducing environment and we immediately structure the experience as a slip-up, a mistake. Furthermore, the client is taught to reconceptualize the episode as a single, independent event and to see it as a mistake and not a disaster that can never be undone. I find that clients who place the blame for the lapse on themselves and see it as a dead-end, a treatment failure and experience shame and defeat are more like to move into full relapse mode. Other clients who view the lapse as a mistake that needs correcting and an opportunity to learn

what needs to be changed in their RP strategy fare better in resisting the entrance back into the addiction cycle (Gorsky et.al., 1986). Sexual Fantasy as a Trigger Sexual fantasies have to do with a wish for something. For you to discuss a sexual fantasy is to admit that you have an unfulfilled sexual wish. There can be shame associated with having that type of longing. Getting rid of a sexual fantasy isn't really possible. Once again, I challenge you to handle sexual fantasies by DOING NOTHING. People often try to get rid of their sexual fantasies or pretend they don't have them. But trying not to think about them may give them more energy. Fueling fantasies to give a higher level of excitement isn't the way to go either. By "feeding" I mean to make them longer, more detailed and stronger than they started out. People fuel fantasies to work toward an inner "perfection." But it can take over your life. You check out of reality and check into your fantasy. If you start holding real-life situations and people up to the standards of your fantasies, there is no way they can measure up. When fantasizing takes the place of reality, it's very unhealthy. Remember a fantasy is a fantasy precisely because there are no downsides to it. There are no costs involved. Real life does not work that way. A fantasy can be dispelled by discussing and understanding it with your therapist. I have also found that the fantasy life leaves a person as he matures and is getting satisfaction from real living. The fantasies will simply fall away. Lifestyle Regeneration A focus on learning to achieve and maintain a healthy, balanced life-style is key. This is based on the principle that a healthy, balanced life-style decreases one's vulnerability to change warning signs into new behaviors and promotes mental and physical well-being in general. Issues addressed should include diet, exercise, rest, recreation and the balance between work ("the shoulds") and play ("the wants."). Your lifestyle should be balanced with the "wants" and the "shoulds". Life stressors need to be balanced by genuine pleasure, shared activities and just plain old fun. Stress Management (Relaxation Training)

Stress is the silent killer for all of us -- more so for those involved in an addiction recovery program. Learning to deal with stress is critical. There are a number of relaxation trainings and stress management procedures I can draw upon to provide the client with a global increased perception of control, thereby reducing the stress "load" that any given situation may pose. Such procedures as progressive muscle relaxation training, recreational reading, yoga, meditation, exercise and self-hypnosis are useful in dealing with the hassles of daily life. Also, through engagement in stress-management techniques, you will gain mastery over arousal states and emotions which before were believed to be beyond personal control. An important component of relaxation skills is that you will learn the skill of "self-soothing" which can give an experience of being able to generate within that which you've been seeking from without. Skills Acquisition Depending on each need, different clients need to be taught different skills. These may include: Social Skills Assertiveness Training Communication Skills Relationship Skills Healthy Sexuality Dating Skills Positive Self-talk Problem-Solving Coping skills for dealing with life Cognitive Re-framing (Marlatt et.al., 1985) References Relapse Prevention by Marlatt and Gordon, 1985

Staying Sober by Gorsky and Miller, 1986 The Sex Addiction Workbook by Sbraga and O'Donohue, 2000