I have been working in the field of sexual compulsivity for almost twenty years and during that time I have seen a shift in the attitudes and education of medical and clinical professions. For a long time, sexual compulsivity was seen as an unsubstantiated disorder. It was not legitimized by clinical trials, research studies, or even more profound, recognized in the Diagnostic and Statistical Manual of Mental Disorders. However, in recent years the attitudes and treatment is shifting both professionally and culturally. These changes are positive, but still, I pause. I believe we can do better. Diagnosing and assessing sexual disorders is challenging. Not for the client whose behaviors are overt, having been caught with evidence in hand. This disorder can be a pattern of complex interactive behaviors that often leave the professional perplexed.
Or even more profound leave them believing they have a complete assessment of the subjective world of the addict. At The Meadows extended care treatment specifically for sexual disorders, Dakota we have seen clients, (mixed gender population) who were not diagnosed with sexual disorders. Fortunately, skilled clinicians saw signs or red flags and were astute enough to refer them to Dakota.
Consider this case. A female patient came into primary care with the following presenting issues: depression, alcohol abuse, self-reported “flirting” while drinking. A skillful clinician was able to see the indicators of a sexual disorder. By the time the client has been discharged from extended care the client’s list of sexual behaviors included; compulsive masturbation, masturbation to the point of injury, erotic literature, sexual fantasy, seductive role sex, Internet pornography including sadomasochism and rape sites.
Consider the case of a 31-year-old female. Her presenting issues upon admission included; depression, Post Traumatic Stress Disorder, and love addiction. After five weeks in extended care, she had disclosed sexual behaviors including; working as a prostitute and stripper, seductive role sex, phone sex, affairs, anonymous sex (sex clubs and swinging), working as a dominatrix, use of urination and defecation for sexual arousal and sexually exploited by the boss.
The same is true for men. This is especially true in cases where men have had same-sex encounters but identify as heterosexual. The confusion and shame are so overwhelming they do not disclose, keeping it a secret. They may be willing to talk about a pornography stash or act out with prostitutes but complete sexual disclosure is something they are unwilling to risk.
As we all know with addiction, it is the secrets that kill. It is the shame associated with the secrets that compel compulsive lying. It is vital that we as clinicians create a safe and healing environment for the client to unburden themselves with the truth.
I often say this work is not for the faint at heart. Sexual addiction can lead our clients into very dark, socially unacceptable behaviors that can be both shocking and disturbing. It is our responsibility as clinicians to hold that safe place for our clients to heal.
This may seem like a rudimentary statement but consider the previous case; it is much easier and or comfortable to explore issues of love addiction than the dark and seedy reality of a client who views defecation as sexually gratifying.
I like the idea that it is my responsibility as a therapist to hold temporarily for the client the burden of this shame. I respectfully and skillfully urge the client to describe his or her shame and the behavior it has generated. The client hands it off to me for storage until that time in our therapy when I can hand it back to him or her for inspection. At that point, the client has grown able to appreciate that he or she is not endemically evil, but is the victim of abuse.
I am able to hold the shame, the anxious hope, whatever belief system, or whatever emotion the client is feeling, and say to this suffering and trusting person, “You know what? I believe you can work through this, and that you can and will become even more than you now believe is possible. And I will hold all the shame or other emotion for you while we are doing this work together.”
What can make for successful interventions is becoming the solid ego state against which the wounded ego can collide, yet survive. I mirror for them the respect, understanding, and safety they have never known. The wounded part begins to heal. The therapist becomes a good parent. The client internalizes that identity. The healing takes place within the therapeutic relationship.
The goal of early treatment is to help clients trust that I respect them in their full humanity, even the darkest parts. I want them to understand that I can deal with their demons and find the healthy soul trapped within. This is the beginning of the healing.
