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Article Excerpt
Seventeen to 37 million Americans struggle with sexual addictions (P. Carnes, 1994b; A. Cooper, D. L. Delmonico, & R. Burg, 2000; B. Morris, 1999; J. L. Wolf, 2000), yet traditionally trained addictions and offender counselors often find themselves unprepared to assist clients who are sexually addicted. This article provides a general overview of the disorder, explores the ongoing definition debate, and offers clinically proven treatment protocols.
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The suggested prevalence of sexual addiction is staggering. An estimated 17 to 37 million Americans struggle with this addictive disorder (Carnes, 1994b; Cooper, Delmonico, & Burg, 2000; Morris, 1999; Wolfe, 2000). These figures are greater than the combined number of Americans who are addicted to gambling or have eating disorders (National Center on Addiction and Substance Abuse at Columbia University, 2003; Potenza, Fiellin, Heninger, Rounsaville, & Mazure, 2002; Shaffer & Korn, 2002; Tenore, 2001). In addition to the prevalence, the incidence of sexual addiction is rising, due in part to the affordability, accessibility, and anonymity of sexually explicit material available on the Internet (Cooper et al., 2000). The prevalence of sexual addiction is predicted, based on current trends, to continue rising at a rapid rate (Cooper, 2004).
Because of the lack of qualified counselors, many addicted individuals turn to self-help groups, all of which are administered by nonprofessionals without for-real education and training in treating sexual addiction (Haugh, 1999; Myers, 1995; Wolfe, 2000). Of the 73 nationally known 12-step, self-help support groups, 8 distinct groups are dedicated to individuals seeking assistance in managing their sexually addictive behaviors. This number of sexual addiction support groups is more than any other 12-step group addressing an addictive disorder and may reflect the large number of individuals who are sexually addicted. Despite steadily increasing self-referral and participation in 12-step, self-help groups such as Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sex Addicts Anonymous, Sexual Compulsives Anonymous, and Sexual Recovery Anonymous, the treatment community lacks the resources and funding to address this growing population (National Council on Sexual Addiction and Compulsivity, 2000). Although the increase in the number of 12-step groups specific to the treatment of sexual addiction is a commendable step, there is a growing need for addictions and offender counselors to respond to the needs of the population of clients who are sexually addicted. Although a very limited number of articles related to sexual addiction have been published, these articles have typically been published in journals specific to other clinician groups. For example, Carnes (1990) presented his early findings in the American Journal of Preventive Psychiatry & Neurology, Goodman (1993) offered a definition and some treatment suggestions in the Journal of Sex and Marital Therapy, and Myers (1995) explored the impact of addictive sexual behavior in the American Journal of Psychotherapy. A specific journal, Sexual Addiction & Compulsivity, was created in 1993 to provide a forum for authors and researchers to provide information regarding sexual addiction (e.g., Delmonico & Griffin, 1997; Goodman, 2001; Manley & Koehler, 2001; Ragan & Martin, 2000). Whereas this demonstrates the importance and timeliness of information pertinent to treating clients who are sexually addicted, this information has been disseminated to most clinician groups, with the exception of addictions and offender counselors. Psychiatrists, sex and marital therapists, psychotherapists, even those working specifically with sexual addicts, all have the necessary scholarly resources at their disposal to aid in their work with this client population. As of yet, no meta-analysis defining sexual addiction and outlining the recommended treatment protocols has been published for addictions and offender counselor generalists who are not specialists working exclusively with couples or persons who are sexually addicted. Concomitantly, no meta-analysis defining sexual addiction has been published in the Journal of Addictions & Offender Counseling. Therefore, the intent of this article is to (a) define this disorder according to the existing literature; (b) establish the need for professionals working in the addictions and criminal justice fields to know about sexual addiction; and (c) offer clinically proven treatment protocols to assist with the assessment, diagnosis, and treatment of clients who are sexually addicted.
Defining Sexual Addiction
Patrick Carnes (1994b), a pioneer in the sexual addiction field since 1976, noted that compulsive sexual behaviors resembled the progressive and chronic compulsive behaviors commonly found with other addictions. For this reason, Carnes chose to use the term sexual addiction to describe a set of maladaptive behaviors that were uncontrollable, that brought negative consequences upon the addicted individual, and that harmfully affected those involved with the addicted individual. He further noted that, similar to the early days when public education on alcoholism spurred both ignorance and prejudice, controversy about the use of the term sexual addiction was to be expected.
Controversy has indeed ensued. Terminology and diagnostic criteria for sexual addiction have undergone considerable scrutiny and debate (Apt & Hulbert, 1995; Coleman, 1990; Goodman, 2001; Schneider & Irons, 1996). Although scholarly debate can be an impetus for improved training and treatment regimens, it can also impede the delivery of necessary resources to individuals in crisis: This has occurred in the debate over sexual addiction. The resources and energy needed for training new counselors, conducting empirical research, and creating new treatment protocols and facilities have been stymied over the legitimization of the disorder (Goodman, 2001; Manley & Koehler, 2001; Wolfe, 2000).
Before treatment protocols are explored, the continuing debate must be addressed to help validate our suggestions. Therefore, we explore (a) the addictive disorder; (b) criteria development for the designation of an addictive disorder; and (c) the literature-based debate over the use of the term addiction to describe maladaptive, compulsive-like sexual behaviors.
The Addictive Disorder
The model on which this article is based is that of the addictive disorder (Carnes 1994b; Goodman, 2001). This model assumes that compulsive-like behavioral manifestations that meet criteria similar to those for chemical dependency are in fact addictive behaviors. Researchers (Goodman, 1998; Griffin-Shelley, Sandier, & Lees, 1992; Raviv, 1993) have stressed the importance of understanding addiction in a broader context than that of strictly chemical dependency. Although some researchers and counselors in the addictions field (Apt & Hulbert, 1995; Barth & Kinder, 1987; Levine & Troiden, 1988; Rachlin, 1990) believe that the term addiction should be applied only to circumstances that involve chemical substances, similar diagnostic criteria have been applied to a number of problem behaviors, often called "process addictions." These addictions include those related to sex (Abouesh & Clayton, 1999; Carnes, 1992, 1994a, 1994b; Fischer, Williams, Byington, & Lonsdale, 1996; Goodman, 1993, 1998, 2001; Levin, 1999), gambling (Buchta, 1995; Griffiths, 1992), eating (Baker, 1995; Sheppard, 1995), work (Robinson, 1998, 2000), television (Mcllwraith, 1998), shopping (Lee, Lennon, & Rudd, 2000), exercise (Cockerill & Riddington, 1996), the Internet (Armstrong, Phillips, & Saling, 2000; Young, 1999), and video games (Griffiths, 1991, 1997).
Diagnostic criteria for addiction are often applied to provide a framework for treatment because clients seldom present with a singular addictive disorder (Das, 1990; Merta, 2001; Rowan & Galasso, 2000). It seems prudent, as well as cost-effective, to treat multiple addictions simultaneously so as not to repeat therapeutic interventions for each disorder (Juhnke, 2002). Because the same interventions used with chemical dependency have proven effective in treating other addictive disorders (Griffin-Shelley et al., 1992), and given that many who are chemically addicted also meet sexual addiction criteria (Black, Kehrberg, Flumerfelt, & Schlosser, 1997; Carnes, 1992; Delmonico & Griffin, 1997), it follows that those trained to treat chemical dependency should also be trained to treat the commonly comorbid sexual addiction.
Criteria Development for the Addictive Disorder
In working toward defining the addictive disorder, Carnes (1992), Goodman (1998, 2001), Levin (1999), and Young (1999) suggested that one begin by identifying the key elements used to identify chemical dependency. The fact that neither tolerance nor withdrawal is necessary for designating a behavior or substance as addictive (American Psychiatric Association [APA], 2000; O'Brien, 1996; Potenza et al., 2002) is an issue that we address in more detail later in this article. Therefore, we begin with the conditions that are both necessary and sufficient for the diagnosis of a dependence/addictive disorder.
Goodman (2001) suggested that the two criteria necessary and sufficient for the designation of drug addiction are "(1) recurrent failure to control the use of one or more drugs, and (2) continuation of drug use despite substantial harmful consequences" (p. 195). To arrive at a concise definition of an addictive disorder, Goodman (a) substituted the word behavior for drug in the above conditions and (b) added key elements from those arguments asserting that addictive behaviors are better defined within the context of a compulsion or an impulse control disorder. An addictive disorder can therefore be defined as
A behavior that can function both to produce pleasure and to reduce painful affects is employed in a pattern that is characterized by two key features: (1) recurrent failure to control the behavior, and (2) continuation of the behavior despite substantial harmful consequences. (p. 195)
Similar definitions have been applied to designate gambling (Blaszcynski, Buhrich, McConaghy 1985; Buchta, 1995; Griffiths, 1992; Potenza et al., 2002), the Internet (Armstrong et al., 2000; Young, 1999; Young, Pistner, O' Mara, & Buchanan, 1999), and eating disorders (Baker, 1995; Flood, 1989; Sheppard, 1995) as addictive disorders.
If one accepts the merits...
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