Yes, It Is Time to Finally Move on From Sex Addiction
A new clinical approach is gaining ground as a rival to the sex addiction model.
Posted May 08, 2016
I have just come back from Chicago, where I presented my latest research at the Society for Sex Therapy and Research (SSTAR) Annual Conference.The presentations were all uniformly excellent, but in particular, I was most struck by what I consider to be the groundbreaking work of clinicians Doug Braun-Harvey and Michael Vigorito and their approach to "out of control sexual behavior" or (OCSB). OCSB? What is that? Well, you may recognize this concept as "sex addiction," which in my view is a problematic term that I've critiqued both here and here. So, the first thing to understand about these two guys is that they are working with the same sets of behaviors as sex addiction counselors, but without the addiction lens. Why is this so significant? Let's take a look.
One of the most salient concepts from their talk is the central importance of therapist self-awareness. In other words, especially in the field of sexuality, it is very easy for any clinician to get carried away with one's own prejudices and biases, which of course will inevitably interfere with treatment, often likely even causing great harm. This kind of bias may lead to a "premature evaluation", in which a pre-established label (such as sex addict) is automatically assumed and foisted onto the client, stigmatizing him (and it's often a "him") for life. Braun-Harvey and Vigorito urge us to never assume etiology, instead approaching each client as a unique individual who has his own needs, beliefs, and values.
Most importantly DBH and Vigorito approach their work from a sex-positive lens, first defining sexual health rather than jumping the gun into an eager search for pathology. In many ways, this encompasses a central conflict in the training of therapists. They learn to "meet clients where they're at," yet have to wade through a mammoth book of diagnostic labels in order to brand clients with a reimbursable code. It's madness really, and the subject of much debate within the field. At any rate, DBH and Vigorito have developed a six-fold model of Sexual Health Principles:
Safe (ie protection, condoms,etc)
Let's examine each one in turn. As I've written about before, consent is one of the key criteria in the new DSM 5 to differentiate between paraphilias and paraphilic disorders, and is really a clear demarcation between sexuality of any stripe and sex offending. In these cases, offending clients are referred out to sex offender specialists. Looking at #2, sexuality can be consensual but exploitative. In other words, someone can provide consent but feel manipulated or coerced in some form. Sex with subordinates, clients, or vulnerable individuals may certainly be consensual, but are often indeed exploitative. I won't delve deeper into #3 safe sex, as I am a sex therapist, not educator, but suffice it to say, protected sex must always be a given, especially with strangers and in casual situations.
Honesty, #4, is a big one since many folks show up as self-identified sex addicts because of discovered affairs. In this case, we want to take a look at what DBH and Vigorito call "sexual narcissism," a type of exploitativeness and lack of empathy which only appears contextually in sexual situations. It is this narcissism, rather than "addiction", which is often the cause of infidelity and sexual deceit.
Shared values, #5, is important especially in this day and age, in which folks can identify in any number of ways that do not include monogamy, including polyamory and swinging. In my mind, this is closely aligned with honesty, because if one partner is seeking sexual variety but the other is desiring exclusivity, we have both shared values and honesty problems. What we are faced with here is a conflict between existential values (honesty, nonmonogamy) vs attachment (fear of losing one's partner). DBH and Vigorito describe this as "existential pain." Indeed, not every problem can be resolved with a happy ending. Finally, we have #6, mutual pleasure: Are both individuals in the relationship getting what they want out of it?
I'm trying to cram a lot of high-level information here in a short post, but the main point is that sexuality is very, very complex. Very. And the sex addiction label is very, very simple. Clients deserve better. The crux of the model also comes down to something called the Dual Control Model of Sexuality. I've written about this before, but in summation, imagine that our sexuality is represented by a magnet with two poles, positive and negative. The negative pole is represented by sexual inhibition and the positive by sexual excitation. For many compulsive folks, what they are really struggling with is an internal conflict between their own sexual desires and the shame and fear caused by those desires. As I counsel my clients, there is a big gap between thoughts, feelings, and behaviors. At any rate, a large part of the work in this approach is in resolving the discrepancy between values (which often leads to inhibition) and mutual pleasure (which is the positive axis of the dual model). It is complex, nuanced, and sophisticated work, but that is also why it calls for so much self-awareness on the part of the therapist.
In the end, DBH and Vigorito present a rival, much more nuanced and sex-positive approach than that of the sex addiction model. In many ways, their work resonates so highly with me because it already encompasses much of the work that I've already been doing. I'll leave you with a few choice quotes that illustrate their approach. "The addict label rescues from deeper exploration." Yes, precisely true, it is so easy to hide behind a label without truly understanding one's own sexuality. And it also protects the therapist from having to examine his or her own sexuality as well. Which leads to their most important and beautiful quote of all: "As therapists, we need to protect the clients from us." Bravo!