Accordingly, to the extent that affect regulation is enhanced, the frequency and intensity of addictive urges are likely to diminish. Meanwhile, greater stability of psychobiological functioning is associated with better behavioral control and improved assessment of reality. Interventions that enhance affect regulation and behavioral inhibition can thus be expected to reduce the symptomatic expression of sexual addiction.
Tailoring and Timing
The specific functional impairments, needs and inner resources that individuals who use sexual behavior addictively bring to the treatment situation vary from individual to individual. Functional impairments also vary within the same individual from one point during treatment to another. Treatment for sexual addiction is most likely to be effective when the treatment plan for each patient is individually tailored and evolves as the patient progresses through recovery.
Recovery from sexual addiction is a developmental process that can be understood to proceed in four overlapping stages:
- Stage I, Initial Behavior Modulation
- Stage II, Stabilization (of behavior and affect)
- Stage III, Character Healing
- Stage IV, Self-Renewal
Certainly, these stages constitute a heuristic device that oversimplifies the picture. Behavior, affect, character and self can be considered also as dimensions of a person, which are concurrent and interrelated. At different times in treatment, one dimension or another may be the most prominent, or may receive the most therapeutic attention, but all the dimensions are involved at all points in the developmental process. This multidimensional understanding applies also to the therapeutic modalities.
During Stage I, most individuals who use sexual behavior addictively can begin to modulate their addictive behavior by means of a combination of inner motivation, psychological support and affect-regulating medication. Many sex addicts do not require affect- regulating medication; but some who are able to modulate their behavior without medication may still benefit from the medication's attenuation of addictive urges and from its alleviation of the affective distress that often accompanies the initial modulation of addictive behavior.
While the core of treatment for sexual addiction is constituted by relapse prevention and psychodynamic psychotherapy, the benefit that sex addicts derive from these treatment modalities is likely to be limited until they have achieved some control over their addictive sexual behavior. For some individuals who use sexual behavior addictively, the combination of inner motivation, psychological support and affect-regulating medication may be insufficient to enable achievement of behavioral control. In such cases, behavior modification and/or antiandrogen pharmacotherapy may be necessary before comprehensive treatment can proceed.
The progressive modulation of addictive sexual behavior marks the transition from Stage I to Stage II. At this point, the therapeutic focus can shift to relapse prevention as the primary modality for stabilizing abstinence from addictive behavior. Supportive psychotherapy may be helpful at this time, but exploratory-expressive psychotherapy is likely to be more beneficial in most cases if it is deferred until the latter part of Stage II, when behavior and affect are more stable. Meanwhile, psychodynamically oriented interventions may be needed during Stages I and II to address psychodynamically based resistances to pharmacological, behavioral and cognitive-behavioral interventions, lest the entire treatment be disrupted.
Moreover, unlike psychoactive substance addictions, sexual addiction involves the addictive use of a behavior that is part of normal living. Consequently, recovery from sexual addiction is not a matter of complete abstinence from sexual behavior, but of learning 1) to distinguish between those forms of sexual behavior that are high-risk and those that are low-risk, and to refrain from engaging in high-risk forms of sexual behavior; and 2) learning to engage in sexual behavior in ways that are healthy rather than pathological. Learning the first type can usually be addressed in relapse prevention, but learning the second type often requires psychodynamic psychotherapy.
Early in recovery, when the sex addict's judgment is still significantly distorted by a combination of denial, rationalization, vague or fragmented identity, and superego pathology, distinguishing healthy from pathological sexual behavior can be exceedingly difficult. During this initial period, some patients might benefit from total abstinence from any kind of sexual behavior.