The rationale for initial abstinence is that, early in recovery, individuals who have been using sexual behavior addictively may be incapable of selectively eliminating the self-regulatory functions from their sexual behavior; and, to the extent that they continue to use sexual behavior to regulate their affects and/or self-states, they are less likely to benefit from treatment.
Meanwhile, refraining from behaviors that could be used addictively pushes the individual into greater self-awareness. Therapeutic use of this enhanced self-awareness to undermine denial and rationalization, to stabilize identity and sense of self, and to integrate healthy superego functions then brings patients to a point where they are more capable of distinguishing healthy from pathological sexual behavior. Abstinence from sexual behavior, though not a goal of treatment for sexual addiction, can on occasion be a helpful therapeutic technique.
Treating Character Pathology
Stage III is the period during which the therapeutic focus can turn to psychodynamic psychotherapy as the therapeutic modality that is most effective in treating character pathology. Psychodynamic psychotherapy, however, is not equally effective in all cases. Both the need and the capacity for psychodynamic therapy vary among individuals who use sexual behavior addictively. In addition, the effectiveness of psychodynamic treatment often depends also on the "goodness of fit" between the patient and the therapist, and on the nature of their relationship. Initiation of psychodynamic psychotherapy does not, of course, mean that relapse prevention is no longer needed. Urges to engage in symptomatic sexual behavior can be evoked or exacerbated by affects that emerge in the course of psychodynamic therapy.
Relapse prevention skills not only help to limit undesirable behaviors, but also enhance the effectiveness of psychotherapy by increasing the likelihood that inner states will be communicated in words rather than actions. The therapist must thus be able to shift sensitively among exploratory and supportive psychodynamic therapy, and relapse prevention in response to the patients' changing needs.
Couples or family therapy, when it is indicated, is most likely to have positive results if it is deferred until Stage III. I consider couples and family therapy to be treatment not for sexual addiction per se, but for the interpersonal issues and dysfunctional relationship patterns associated with sexual addiction. Indications for couples or family therapy in the context of sexual addiction are not significantly different from what they are in the context of other psychiatric disorders, unless the addict's addictive sexual behavior directly involves the couple or members of the family. As is the case when treating individuals who suffer from psychiatric conditions other than sexual addiction, couples and family therapy is likely to help most after the individual's major disorder has stabilized and, if significant character pathology was part of the presenting picture, after character healing is underway.
The identified patient's mate or children often require time to stabilize and, occasionally, individual psychotherapy is necessary, before they can productively engage in conjoint therapy. However, couple or family intervention may be necessary earlier in treatment if the couple or family is in crisis. Self-help groups, such as 12-step groups, are typically most helpful during Stages I and II and early in Stage III. A good self-help group-one that is composed of relatively healthy, growing individuals with whom the patient fits well-can also be helpful in Stages III and IV.
To date, no studies have been conducted to evaluate the effectiveness of this integrated approach to treating sexual addiction. In fact, empirical research on almost every aspect of sexual addiction is sorely lacking: neurobiology, psychometrics, family history, diagnostic criteria (reliability, coverage and predictive validity) and response to treatments. This deficit may have been due to the unavailability, until recently, of clear and meaningful diagnostic criteria for sexual addiction. It also may have been due to a reluctance by many to consider sexual addiction as a fit subject for scientific study. Hopefully, this and the previous article will redress these conditions and stimulate the empirical research that this new field so desperately needs.