By Dr. Victor B. Cline
[Editor's note: In this article, Dr. Cline describes strategies that he has found useful in treating sexual addicts, particularly those addicted to pornography, and that might be helpful to other professionals counseling sexual addicts. Others interested in the nature of sexual addiction may also find it informative.]
In over 25 years I have treated approximately 350 males afflicted with sexual addictions (or sometimes referred to as sexual compulsions). In about 94% of the cases I have found that pornography was a contributor, facilitator or direct causal agent in the acquiring of these sexual illnesses. I note that Patrick Carnes, the leading U.S. researcher in this area, reports similar findings. In his research on nearly 1000 sex addicts, as reported in his Don't Call it Love: Recovery from Sexual Addictions (Bantam Books, 1991): "Among all addicts surveyed 90% of the men and 77% of the women reported pornography as significant to their addiction."
I found that nearly all of my adult sexual addicts' problems started with porn exposure in childhood or adolescence (8 years and older). The typical pattern was exposure to mild porn early with increasing frequency of exposure and eventual later addiction. This was nearly always accompanied by masturbation.
This was followed by an increasing desensitization of the materials' pathology, escalation to increasingly aberrant and varied kinds of materials, and eventually to acting out the sexual fantasies they were exposed to. While this did on occasion include incest, child molestation and rape, most of the damage was through compulsive infidelity (often infecting the wife with Herpes or other venereal diseases) and a destruction of trust in the marital bond which in many cases led to divorce and a breaking up of the family.
Many wives found their husband preferring fantasy sex (they would catch them masturbating to pornography) to making love with their partner. This had devastating effects on the marriage. One wife, in great pain, confronted her husband, "What do you see in those two-dimensional faceless women that I can't give you as a loving wife who is flesh and blood, a real person and committed to you??" The men never had an answer. To some extent they enjoyed sexual relations with their wives but most preferred the fantasy with masturbation because "these women" could do anything and were perfect in form and appearance!
I found that once addicted, whether to just the pornography or the later pattern of sexual acting out, they really lost their "free agency." It was like a drug addiction. And in this case their drug was sex. They could not stop the pattern of their behavior, no matter how high-risk for them it was.
My 25 years' clinical work, as well as frequent reviews of the literature, convince me that at least one avenue leading to the creation of these kinds of addictions is through a process of masturbatory conditioning. The work of R.J. McGuire, et. al ("Sexual Deviation as Conditioned Behavior," Behavior Research & Therapy, 1965: vol. 2, p.185) suggests that exposure to special sexual experiences (which could include pornography), and then masturbating to the fantasy of this exposure, can sometimes later lead to participation in deviant sexual acts.
As McGuire explains it, as a man repeatedly masturbates to a vivid sexual fantasy as his exclusive outlet, the pleasurable experiences endow the deviant fantasy (rape, molesting children, injuring one's partner while having sex, etc.) with increasing erotic value. The orgasm experienced then provides the critical reinforcing event for the conditioning of the fantasy preceding or accompanying the act. McGuire indicates that any type of sexual deviation can be acquired in this way, that it may include several unrelated deviations in one individual and that it cannot be eliminated even by massive feelings of guilt.
Other related studies by D.R. Evans ("Masturbatory Fantasy & Sexual Deviation," Behavioral Research & Therapy, 1968: vol.6, p.17) and B.T. Jackson ("A case of Voyeurism Treated by Counter Conditioning," Behavioral Research & Therapy, 1969: vol.7, p.133) support this thesis. They found that deviant masturbatory fantasy very significantly affected the habit strength of the subject's sexual deviation.
In my treatment of hundreds of primarily male patients with sexual pathology (paraphilias) I have consistently found that most men are vulnerable to the effects of masturbatory conditioning to pornography with a consequence of sexual ill health, because we are all subject to the laws of learning with few or no exceptions. In my experience as a sexual therapist, any individual is at risk of becoming, in time, a sexual addict, as well as conditioning himself into having a sexual deviancy and/or disturbing a bonded relationship with a spouse or girlfriend when this occurs.
A frequent side effect is that their capacity to love is also dramatically reduced (e.g. it results in a marked dissociation of sex from friendship, affection, caring and other normal healthy emotions and traits which help marital relationships). This sexual side becomes, in a sense, dehumanized. Many of them develop also an "alien ego state" (or dark side), whose core is antisocial lust devoid of most values. Raw id, in a sense. In time, the "high" obtained from masturbating to pornography becomes more important than real life relationships.
It has been commonly thought by health educators that masturbation has negligible consequences, other than reducing sexual tensions. Moral objections aside, one exception would appear to be in the area of repeatedly masturbating to deviant pornographic imagery, either in memories in the mind or as explicit pornographic stimuli which risks (via conditioning) the acquiring of sexual addictions and/or other sexual pathology. It makes no difference if one is an eminent physician, attorney, minister, athlete, corporate executive, college president, unskilled laborer, or an average 15 year old boy. All can be conditioned into deviancy. The process of masturbatory conditioning is inexorable and does not spontaneously remiss.
The course of this illness may be slow and is nearly always hidden from view. It is usually a secret part of the man's life, and like a cancer, it keeps growing and spreading. It rarely ever reverses itself, and it is also very difficult to treat and heal. Denial on the part of the male addict and refusal to confront the problem are typical and predictable, and this almost always leads to marital or couple disharmony, sometimes divorce, and sometimes the breaking up of other intimate relationships.
One researcher, Stanley Rachman ("Experimentally induced sexual fetishism," The Psychological Record, 1968: vol.18, p.25), demonstrated in the laboratory how sexual deviations could be created in adult male subjects. He was actually able to condition, in two separate experiments, 100% of his male subjects into sexual deviancy (fetishism).
There are many approaches to treatment, which usually involve individual work with a psychotherapist who has skills in treating this kind of illness, plus being put into a 12-step group such as Sexaholics Anonymous. There are no costs to be in such a group, which is patterned after the original A.A. model.
I have personally found the following approach to yield the most successful outcomes for at least the type of patient population which I work with: males 15-70 from mainly middle social class backgrounds, often religious, and motivated to change (because of the threat of divorce, loss of job, prison, etc.).
1. If the patient is married I attempt to have the wife participate in treatment. She has been traumatized repeatedly by the husband's problem and broken promises, and usually has a huge trust issue with him and may be debating divorce. I see them together so that the wife knows everything that goes on in treatment; and we address her fears, depression, the kinds of acting-out, as well as their stressed marriage.
2. In the first interview I have the husband outline the problem and ask him what he wants me to do. He needs to take the initiative in his healing. I then turn to the wife and ask if she has anything to add or correct or if she wants to say what her goals for therapy are. If on the verge of divorce, I determine if she wants out or wants to stay and help.
3. I talk about the importance of the wife being a part of the healing team. It goes faster if both are involved. Both are wounded. Both need help. However, there is one unchangeable rule: NO SECRETS. I tell them that secrets "kill you. They take away your power." They create shame and guilt. And even though there might be some relapses (usually minor) during treatment, these need to be talked about openly in therapy; they are wasting their money if these are not disclosed and worked with. I tell them that most people I know who are kicking the cigarette habit quit 12 times before they really quit. Anything hidden, the spouse always sooner or later finds out about it. So right to begin with: no secrets!
4. I next take a history of the man's exposure to pornography and masturbation to it (or masturbation with no pornography) and sexual acting out. I do this in the wife's presence, which helps her understand more clearly that in some ways her husband was a victim usually starting at an early age. I next inquire about possible sexual abuse or early seduction of the husband as a child or as an adolescent, which have eroticized him prematurely. In taking this history, I start with his first memory of exposure to pornography--what its form was (magazine, video, phone sex, etc.) and if he masturbated to it--and continue with the history up to the day of interview. Then I establish a sobriety date (the date of last exposure) for all the different forms of porn or sexual acting out that he was involved with, as well as the last time he masturbated. At each succeeding visit I recheck these sobriety dates. If there has been relapse then I do relapse prevention work with him, identify triggers that set him off, and seek ways to circumvent these.
5. I next explain to the wife that her husband has lost his free agency. And that's why promises don't work. Good intentions mean nothing. Her husband may mean well and really want to quit because of the terrible painful consequences, but he literally cannot do this by himself yet. He has to have highly specialized help. Most therapists do not know how to treat sexual addictions. Self control and self discipline or a rational approach generally don't change anything. With most people I see who are deeply addicted, prayers and scripture reading are usually not enough to solve the problem even though I believe that God could instantly cure the problem if He so chose. In most cases He lets the individual work it through the long way probably because he will in the future be more likely to resist temptation.
6. I tell both husband and wife about the "wave" which periodically hits the patient and overwhelms him with temptation. This is something most men cannot resist. One of the goals of therapy is to prepare the man to face and defeat the wave. These waves vary in frequency from several times a day to once a year or even less. Between the waves the man feels at peace and has the mistaken notion that he has his power and can resist anything. But this is an illusion and is only temporary until the next wave hits him.
I explain to the couple that as a therapist I'm like a guide to Mount Everest. I can show them how to get there but they have to walk every step of the way. They have to do all the work. I assure them they can heal. But like alcoholics when sober, sexual addicts must be careful not to expose themselves in the future to high-risk situations. I also explain that they are not mentally ill in the classical sense but that they have an addiction which powerfully controls their lives, somewhat like being on crack cocaine. And the journey to freedom will not be easy. It will require an enormous commitment on their part to become whole again.
7. I assign both husband and wife to read Patrick Carnes' book, Out of the Shadows, and Stephen Kramer's book, Worth of a Soul.
8. I have the husband begin attending S.A. (Sexaholics Anonymous) which is a 12-step group, spiritually based...There are chapters in nearly every city in America. They are free. To find where and when one meets, call Alcoholics Anonymous (in all the phone books). They will know. The client-addict may start with a newcomers group first, and then graduate to the step-study group after a few months. Wives that have been badly traumatized by their husband's behavior may wish to attend S-Anon (for spouses of offenders) or even later join with their husbands at their S.A. meetings if allowed. The client-addict needs to attend 90% of his weekly meetings for this to work and be truly healing. If the individual is relapsing at high rates, they may need to attend up to three or four nights a week in order to achieve sobriety and break the stranglehold of their addiction.
9. At these S.A. meetings, they need in time to locate a "sponsor," who is someone who has been sober (no relapses) for a lengthy period of time who they can call (phone) in an emergency, which is an occasion when the wave hits and they are strongly tempted to act out. Their sponsor can help them stay sober; he's like a life guard.
[Editor's note: Some churches and other overtly religious organizations also provide special support groups for sexual addicts. Unlike S.A. groups, these organizations typically approach the problem from a particular religious perspective.]
10. Because the compulsion to act out is so overpowering, I give them a mental set to just stay sober one day at a time. They must think only of making it today. If they focus on a longer time period they may be setting themselves up for failure.
11. Through close interviewing, the addicts must identify triggers which activate the wave (e.g. looking at porn, seeing girls in skimpy clothes, after a fight with their spouse or the spouse being out of town, driving by an adult bookstore, walking into any video store, viewing hard-R or X films, looking at ladies bra and panty ads) and then plan strategies to avoid these or deal with them. Example: if going on a business trip and staying in a hotel with access to porn movies, request the front desk, when checking in, to block out those channels. Call their wives at 9:00 P.M. each evening when away.
12. "Thought-stopping." When the addict is stimulated or aroused by sexual fantasy which can lead to masturbation and the acting out cycle, I tell them that they have only three seconds to block or stop the thought or imagery. At the top of their voice they should yell STOP (or scream silently if others are nearby) and visualize a policeman with handcuffs approaching, holding a big sign with the words STOP on it. This will kick the offending imagery off the mind screen briefly. But then they have to bring to mind an event in their life that has very powerful emotional significance (either positive or negative) which they can ruminate about. In other words, they fight fire with fire, a strong sexual fantasy with another totally different kind of memory, such as the time they helped their team win the game, a surprise birthday party, or even the death of a very close friend. But it must be something powerful emotionally.
13. "Fire drills." I present to them imaginary situations which they might have to face in real life which would expose them to temptation. How would they handle it? I process their responses in great detail so if something like this should happen in real life they would be mentally prepared to deal with it. Example: a friend at work wants to show them his porn. How would they handle it? The wife, of course, is listening to all of this and participating as she chooses.
14. No more masturbation. Stop masturbating. This risks further conditioning into deviancy. The goal of no masturbation may be difficult and not even possible immediately. I have them keep a calendar record of those days when they masturbate and urge them to strive for reducing its frequency but especially, if they do slip, to refrain from fantasizing about deviant sexual imagery. In contrast, I have them imagine loving their spouse. I check their calendar record at each session to determine whether the frequency of masturbation has been reduced, with the ultimate goal of being free of this habit.
15. Marriage counseling. I tell them to do things that will help improve their marital relationship. I give them assignments to have fun together and improve intimacy, take marriage seminars, participate in sports together, be friends, etc.
16. Stress reduction therapy. If they have financial problems, I help them work out solutions or refer them to agencies that can help. If they have out-of-control children, I give them support in dealing with this. Or if the wife suffers greatly, I recommend a program to provide her with a support group and place where she can be nurtured.
17. When relapses occur, I don't "beat them up." I point out that relapses are just part of a growth experience and explain what can be learned from the relapse that will protect them in the future. I try to give them hope. I point out the progress already made and the good things done.
18. I have them keep a daily journal in which they record fantasies and behaviors. I then review and process these during therapy.
19. I give them further books to read, such as Patrick Carnes' later books, Contrary to Love, and Don't Call It Love. I also recommend the Sexaholics Anonymous Big Books, include case histories and biographies of recovering addicts.
20. Other techniques I use include apology sessions; medications to temporarily reduce the sex drive, including eliminating sex fantasies; autobiography; covert sensitization; family of origin work; developing a sobriety contract; healthy sexuality education, and social skills work.
21. And lastly, if an inappropriate image or tempting thought appears on the client's mind, I have him close his eyes and say, "Thank you God. I appreciate your reminding me of my weakness. This will help me get well!!!"
22. Therapy must be tailored to the special needs of the couple. I choose only those techniques that best fit my client's special needs.
Printed with permission from ObscenityCrimes.org.