Addictive sexual behavior is addressed through behavioral symptom management, which consists primarily of relapse prevention and other cognitive-behavioral techniques. Meanwhile, the addictive process is addressed primarily through psychodynamic psychotherapy, therapeutic groups and psychiatric pharmacotherapy. Relapse prevention strategies help individuals who use sexual behavior addictively to recognize factors and situations that are associated with an increased risk of acting out sexually, to cope more effectively with sexual urges, to recover rapidly from episodes of symptomatic behavior and to use such "slips" as opportunities to learn about how their recovery plans can be improved.
Relapse prevention conceptualizes urges to engage in addictive sexual behavior as signals of disruptive affect states, for which the addict needs to develop healthier, more adaptive management. In thus shifting the focus from controlling the behavior to understanding the affects, relapse prevention provides a natural bridge from behavior management to psychodynamic psychotherapy.
Cognitive-behavioral techniques other than relapse prevention comprise directive, didactic procedures that focus not on symptomatic sexual behavior, but on other aspects of a person's life that predispose him or her to rely on symptomatic behavior to cope with distressful affects and unmet needs. Applicable cognitive-behavioral techniques may be divided into two groups: skills training, which helps patients to learn thoughts and behaviors that will result in more effective management of their affects and meeting of their needs (e.g., anger management, assertiveness training); and lifestyle regeneration, which helps patients learn to achieve and maintain a healthy, balanced lifestyle.
The primary goals of psychodynamic psychotherapy in the treatment of sexual addiction are to enhance individuals' self-regulation and to foster their capacity for meaningful interpersonal connections. The fabric of psychodynamic psychotherapy is woven from three strands: understanding, integration and internalization.
Three Strands of Psychodynamics
Understanding focuses on the relationship between addictive sexual behavior and impaired self-regulation. When we understand that addictive behaviors typically are patients' attempts to regulate their affective states, which threaten to overwhelm them because their built-in regulation systems are impaired, our focus shifts from behavior to affect. Affects then guide our explorations: What affects are emerging? What events triggered the affects? What core beliefs, inner conflicts and personal history are involved?
Integration refers to the patient's personality. Automatically, without conscious intent or awareness, we engage in a variety of mental processes that function to protect us from emotional trauma. Most of these self-protective processes can be understood as ways of keeping out of our awareness material that we unconsciously imagine would be overwhelmingly painful or dangerous if we were to become aware of it.
The cornerstone of integration in psychotherapy is the fostering of patients' awareness of such material: their affects, needs, wishes, fears, inner conflicts, core beliefs and automatic ways of protecting themselves from emotional pain. Psychotherapeutic work tends to be most effective when it addresses issues in the here-and-now. In psychotherapy, the most here-and-now issues are those that concern the relationship between the patient and the therapist. Hence, these often are the most productive issues to address.
As a significant relationship develops between the patient and the therapist, the patient's basic inner models become activated, and the psychological factors that influence the patient's other significant relationships begin to affect how the patient perceives, experiences and acts toward the therapist. The therapeutic relationship then provides a safe environment in which the patient and the therapist together can explore the patient's basic inner models in "real time."