Abstract:

The correlation between sexual compulsivity and early childhood trauma has now been well established. Several years have passed since the DSM-IV has expanded its definition of Posttraumatic Stress Disorder by including individuals who have been exposed to varying forms of "persistent low-level threat" at critical stages within the life cycle. PTSD has been categorized under the umbrella of an Anxiety Disorder and its role as a "process addiction" has been distinguished from addiction with respect to substance use. Differential diagnosis has become more sophisticated and the sequelae of features associated with sexual compulsive styles have become clearly identified. Treatment, however, remains complex and challenging for the clinician working with clients presenting these personality and character profiles. This article reviews theory and practice as it pertains to clinical intervention. It attempts to pose questions with the intention of expanding existing models of intervention and offers a multi-disciplinary approach for treatment. It is anticipated that the following discourse may not only be of interest to practitioners working in this area, but may also be informative for the recovery community at large. In addition, in light of the endemic nature of these issues within the Lesbian/Gay/Bisexual/Transgender communities, these individuals may also find this discussion particularly relevant.

Overview:

The personal narratives and scripts characterizing sexually compulsive individuals must be embraced by clinicians with a desire to enter into a spirited journey of considerable complexity and challenge. The journey requires that the practitioner be willing to leave the familiar territory and comfort zone of his/her particular modality and transition toward a multi-layered framework supported by an intricate and nonlinear infrastructure. The veneer of the compulsive individual often does not reveal sexual dysfunction as the presenting problem. The therapist is therefore best served by incorporating an identity which is symbolically inclusive of the varied skills of the architect, investigative detective, and compassionate confessor.

The inner emotional realms of the sexually compulsive individual are indeed "worlds-of-pain" with a landscape subsequently comprised not only of shame and guilt, but also saturated with fear and a pervasive sense of loss. They are adults who have emerged from early childhood backgrounds characterized by "trauma". This "trauma" may have occurred by way of direct physical or verbal violence, sexual abuse and/or repeated exposure to emotional/mental assault. Frequently, these are individuals who have endured betrayal and emotional abandonment for prolonged periods within the context of their childhood homes and families. Oftentimes, their early wounds are insidious in nature and disguised by the faces of young children who grow into adults with a tremendous desire to please others and "be good"! They may be found among the vicissitudes of adult "caretakers" whose self-esteem is predicated upon a strong need for approval manifesting in a keen ability to anticipate and respond to the needs of those around them. In addition, compulsive styles may be masked by unconscious aggressive impulses which may outwardly present themselves in the form of obsessive behaviors or thought process. Symptomatically, they may exhibit poor impulse control, noticeable impatience in response to underlying fears and may become easily "flooded/overwhelmed" by their feelings. Anxiety is their most readily identifiable presenting symptom in the initial consultation along with some evidence of a relational conflict which is causing them considerable discomfort. In light of this descriptive profile, the illusiveness of this "process addiction" becomes even more apparent. The question still remains for the clinician as to how these individuals may be accurately diagnosed and engaged in a comprehensive treatment plan. Certainly, anxiety with the possibility of an underlying depression may describe any number of individuals seeking treatment. How does one determine that which constitutes "compulsive behavior." The answer and the challenge is the focus of this paper and requires an in-depth understanding of differential diagnosis along with acute insight into the range of features associated with compulsive styles.

Before delving further into this discussion it is essential to recognize that sexually compulsive individuals have personal histories which reveal considerable boundary violation. They are adults who frequently were not offered the experience of support from their early caregivers. Their familial world may have been far too difficult for them to integrate and subsequently, their often hostile and unresponsive external environments necessitated that they quickly learn to submerge their feelings. They are thus inclined to position themselves so that their external world becomes their primary focus for survival. The lack of trust and mutuality in their historical environment frequently results in a hyper-vigilance and watchfulness which severely compromises their ability to interact with their inner world in a cohesive manner. They are frequently ravaged with ruminating thoughts which cause them to seemingly plummet downwards in emotional spirals. The interior realms of the compulsive individual are therefore usually chaotic, emotionally isolating, frightening and despairing. Their insufficient development of an internal focus sets the stage for internal disorganization, fragmentation and poor object relationships resulting in a distorted sense of self. They are thus in great need of assistance with respect to understanding and managing their feelings and emotions. A therapeutic alliance predicated upon safety, lack of judgement and acceptance is critical for the establishment of a resonant environment for self-disclosure. An interactive psycho-dynamic model which allows for psycho-education is crucial for the development of such an alliance. The sexually compulsive individual is someone who has responded to his chronic anxiety and depression with coping styles that have been infused with stigma. A space needs to be provided where the stigma and shame are removed and the behaviors are reframed in ways that offer the compulsive self-compassion and understanding. While the client is undergoing this process of re-education, there is the profound task of engaging the compulsive with his feelings so that he may more effectively cope, build and store self-esteem, and begin to utilize his emotions for problem-solving in relationship to himself as well as in his relationships with others. Ultimately, the healing and recovery process for this individual involves a rigorous path toward integration which allows for ownership of that which was inherently lost and/or denied, that being an intrinsic connection to self and others.

Definition of Terms:

It is important to begin this discussion on the subject of terminology with some basic differentiation between "substance" addictions and "process" addictions. Substance addictions, in light of their cultural visibility and challenge, essentially require little elaboration. They involve addiction to substances such as alcohol, cocaine, heroin, and may even pertain to the abuse of pharmacological medications, i.e. prescription drugs, etc. Process addictions, on the other hand, are those addictive patterns/substances that are part of our basic fabric of life, i.e. sex, food, etc. They are more insidious than substance addictions because, for the most part, we need them in order to live. Complete abstinence is not an option and thus, individuals who are struggling in this area are confronted with a journey toward sobriety which involves complexity from the onset! Discrimination and "living in the gray" are necessities for the recovery process which can can be daunting for the compulsive individual whose personality profile is often characterized by what may be referred to as "black & white" or binary thinking. Understanding the dialectical relationship between process and substance addictions is therefore critical for effective treatment.

The incorporation of process addictions into one's arsenal of maladaptive coping responses is usually the result of years of patterning and programming in an effort to regulate moods and feelings. Food and sex are just as much forms of "self-medication" as are alcohol and cocaine. These process addictions, however, are culturally much more readily available and may remain inconspicuous for decades before their hazardous nature becomes apparent to either the user and/or members of his/her support system. In addition, it should be noted that these self-sabotaging responses to stress are particularly prevalent in families whose inner landscapes have been impacted by some form of emotional and/or physical trauma. This trauma may not be outwardly perceivable to the casual eye, but may rather be the result of "persistent exposure to low-level threat." The treacherous impact of this trauma may, in fact, be successfully masked by an individual's array of coping responses. These coping responses thus become the signposts and signals for the clinician. This is largely the primary reason for identifying and referring to sexual compulsivity as an "invisible addiction." The rationale is that these adaptive styles may not be identified as a problem, especially among substance abusers, for long intervals from the time of their entering the recovery process. Denial and insufficient diagnostic techniques have been the two most significant reasons for sexual addiction going untreated for extended periods among persons engaged either in recovery programs and/or individual treatment. The second reason for postulating sexual addiction as an invisible addiction in this paper pertains to the subject of differential diagnosis. This point will be discussed later in this discourse.

The issue of "cross-addiction" is not only relevant and specific to the use of substances (i.e. alcohol & nicotine), but it also plays a significant role in the relationship between process and substance addictions ( i.e. sex/food/cocaine). A dialectical relationship exists between process and substance addictions that may span along a continuum of compulsive styles. As a client is progressing in his/her recovery from a substance addiction, that same individual is at-risk for assuming behaviors which are part of a sequelae of features associated with process addiction (i.e. sexual compulsivity). An analogous situation is that of the alcoholic or recovering cocaine addict who may no longer be using mood altering substances, but finds himself incrementally indulging in caffeine and cigarettes. This same person may increasingly gravitate toward sexually compulsive styles. As he is surrendering the use of addictive substances, he may gradually exhibit higher levels of anxiety fueled by a preoccupation with unwanted thoughts or feelings. Sexual compulsion may be his replacement for previous methods of mitigating discomfort. An individual in recovery is thus faced with the task of finding and incorporating more appropriate ways of handling stress and anxiety. If alternative responses to psychic pain or external conflict are not successfully adopted early in one's recovery, then the risks increase for the assumption of compulsive styles. Sexual compulsivity may also be identified as an individual's primary presenting problem in treatment and may not necessarily correlate with a substance addiction. The need to monitor and rule out this possibility, however, is crucial for the development of a comprehensive treatment plan.

Sexually compulsive behaviors may also develop rather early in the life cycle and are not uncommon in pre-adolescent or adolescent boys who have been exposed to extreme levels of stress. For example, an teenager who is residing in a household with a histrionic father who is prone to having frequent outbursts. This teenager, for instance, may engage in excessive masturbation as a way of soothing and re-organizing his thoughts and feelings. These compulsive behaviors may also be exacerbated by the experience of intense feelings of shame and humiliation. The experience of ridicule, self-fragmentation along with an intrinsic sense of being "damaged goods", are among the many circumstances and predicaments which foster adaptive styles that are inherently compulsive in nature. Sexually compulsive behaviors in these instances become a means of ameliorating severe levels of pain and desperation. These coping styles become the anchors for tormented individuals in a world lacking grounding and safety.

Trauma and Sexual Compulsivity:

Sexual compulsivity is, in fact, a response to early childhood trauma. It is, in essence, a SYMPTOM or an INDICATOR that some form of extraordinary stress was experienced by an adult during his/her childhood which required an extreme means of coping to his/her environment. Fortunately, the 1994 edition of the Diagnostic And Statistical Manual of Mental Disorders (DSM-IV) includes childhood abuse among the events/criteria for consideration in assessing an individual for Posttraumatic Stress Disorder (PTSD). Prior to that time PTSD only extended to survivors of war and rape.

An understanding of PTSD is an essential prerequisite for a comprehensive perspective on sexual compulsivity which is inclusive of etiology, epidemiology, neurobiology and associated clinical profiles. There is an evolving science with regard to PTSD and it is critical to be familiar with its infrastructure in order to be resonant with the vast dimensions of our clients' internal realms. In addition, a thorough understanding of PTSD is a crucial component of psycho-education. PTSD may, indeed, be actively and directly utilized as a "functional diagnosis" with individuals in treatment. Educating clients about this diagnosis and how it relates to their sexually compulsive behaviors is of great value with respect to reducing the shame and stigma which they associate with their "acting-out" behaviors. When their maladaptive responses to intolerable levels of pain are framed in an historical and scientific context, it offers them a means toward self-understanding and affords them self-compassion. Patrick Carnes maintains that Posttraumatic Stress leads to one or more patterns of maladaptive responses to stress, which in turn, set the foundation for addiction. His paradigm postulates that Child Abuse (sexual, physical, and emotional) = Posttraumatic Stress (dissociation, flashbacks, confusion, anxiety, distrust, etc.) = Maladaptive Response to Stress (impaired coping, including addiction). From this perspective Posttraumatic Stress Syndrome is an applicable DSM-IV classification for Adult Survivors of Childhood Trauma. This diagnostic tool allows the clinician to trace the symptoms associated with sexual compulsivity to it origins and develop a treatment course that is attuned to the needs and wellbeing of individuals whose lives have been placed at-risk by these undermining behaviors.

A discussion on the symptoms associated with PTSD needs to considered with the awareness that humans are magnificent creatures endowed with an "innate intelligence" which enables them to be programmed for survival. Our coping styles reflect our resilient efforts to overcome our histories. Many of us learn to "make do" with that which is available to us and through our wisdom we organically find ways of adjusting to our painful predicaments. These responses, however, may place our physical bodies under considerable stress. The impact of this internalization may eventually manifest in a variety of symptoms. These symptoms in the course of an in-depth consultation become the signposts for diagnosis and evaluation. They may reveal that an individual seemingly presenting anxiety, may also be experiencing some combination of any of the following maladies/discomforts: Startle reactions, choking sensations, hypervigilance, dissociation, attention deficit disorder, self-fragmentation, splitting, repetitive dreams/nightmares, intrusive thoughts, obsessive thought process, numbing of arm/legs, among other somatic symptoms, i.e. high/low blood pressure, hypoglycemia, irritable bowel syndrome, headaches, etc. These PTSD features may be "tonic" or "phasic". Tonic PTSD features are constant and persistent, but phasic PTSD symptoms are intermittent and episodic. Compulsive behaviors are usually tonic features in direct response to anxiety and/or underlying depression. Their intensity and frequency may vary, but one's predisposition to these styles are consistent. But headaches, nightmares and choking sensations would fall under the category of phasic symptoms. They are inclined to present themselves cyclically during periods of heightened stress.

The long-standing endurance of conditions associated with "chronic exposure to low-level threat" may result in the development of PTSD. This syndrome may, in turn, lead to severe personality disorganization in adulthood. These adults are often lacking in their ability to experience themselves as whole. A cohesive self, interwoven with an identity predicated upon positive self-regard, had not been supported in the course of their early childhood development. Subsequently, many of these individuals are forced to enter adulthood ill-equipped to cope with the complexity of tasks and relational challenges that are endemic to this phase of life. Their noticeable difficulty in effectively managing daily stressors further undermines their self-esteem, possibly exacerbating more profound levels of ego fragmentation. These coping patterns are further complicated by self-sabotaging behaviors that may involve "unsafe" sexual practices and/or varying forms of sexual acting-out. Adaptive styles, such as these, may be indicative of underlying impulses toward re-victimization or possible self-annihilating expressions of unconscious suicidal ideation. The cognitive, affective, behavioral/relational and somatic dimensions of the sexually compulsive individual's world may be harshly impacted by his maladaptive attempts to regulate his largely unconscious responses to anxiety and depression. In some cases, sexual addiction manifests in patterned behaviors which are seemingly progressive and degenerative in nature. There are instances when a compulsive individual may become increasingly "tolerant" of his behaviors and overtime be prone to acting-out experiences of a more intense nature for mitigating anxiety. The "fixes" that he seeks in these moments may be more charged and his ability to regulate his impulses further compromised. Sexually compulsive styles are often seeded in the emotional climates of families characterized by shame and rigidity. It is not uncommon for the sexually compulsive male to be someone who has emerged from a familial environment involving covert (emotional) incest, most often stemming from boundaries violations centered within the mother-son relationship. These individuals may be found among all socioeconomic levels of our society. Some are inclined toward multiple addictions with observable correlation between the degree of historical abuse and the number of addictions (process & substance) characterizing their behaviors. It is also possible for many of their stress reactions/symptoms not to present themselves for long periods after the actual experience of their trauma. Environmental triggers (i.e. emotional abandonment, isolation), however, are powerful switches for igniting these seemingly uncontrollable impulses. Sexual addiction, as exemplified in the diagnostic framework of PTSD, thus operates as a central coping response, in an intuitive effort to organize an inner psyche that is often chaotic, inherently fearful and disintegrated.

Differential Diagnosis:

The character structures and personality profiles of sexually compulsive individuals require the expanded vision afforded by differential diagnosis. The process of differential diagnosis allows the clinician to understand their clients within the colorful range and vicissitude of their multidimensonality. Differential diagnosis enables the clinician to examine PTSD as it relates to the following family of diagnostic classifications described in the DSM-IV: Generalized Anxiety Disorder, Adjustment Disorders (with depressed mood, with anxiety, with anxiety & depressed mood), Obsessive-compulsive Disorder, Attention-Deficit/Hyperactivity Disorder ( ADD/ADHD), Major Depressive Disorder, Borderline Personality Disorder and Dissociative Identity Disorder (formerly Multiple Personality Disorder/ MPD). The major classifications of disorders possibly considered in a differential diagnosis for PTSD may include: the Anxiety Disorders, Adjustment Disorders, Dissociative Disorders, Mood Disorders (Major Depressive, Dysthymic, or Bipolar), and the Personality Disorders (Borderline, Narcissistic, Avoidant & Obsessive-Compulsive). As one reviews the DSM-IV phenomena correlated with these classifications some central themes become evident with respect to the character of sexually compulsive profiles. Certainly the combination and specificity of traits vary among compulsive individuals and these factors will critically impact upon the interdisciplinary models selected for treatment.

Among the most common features present in sexually addicted individuals are: defensive behaviors (i.e. denial, repetition-compulsion), shame/guilt, dissociation, obsessive thought process, "black & white" (binary) thinking, poor impulse control, "blurry" boundaries, suppressed anger/rage, identity and trust issues, low self-esteem with degrees of compensatory narcissism, and an underlying fear of closeness usually experienced in unison with a masked fear of abandonment. Sometimes there is a tendency to confuse their "splitting" behaviors with individuals suffering from Borderline Personality Disorder. Individuals who may be diagnostically assessed as borderline are certainly not exempt from the possibility of symptomatically exhibiting sexually compulsive styles. The clinician, however, needs to be particularly careful not to confuse borderline features in an sexually compulsive individual with the array of features that would more accurately and appropriately be classified as borderline. Sexually compulsive individuals may episodically display some borderline features, but generally their patterns of attachment and conflict management as enacted in the context of treatment, will differentiate them from persons with a primary diagnosis of Borderline Personality Disorder. A percentage of sexual compulsives may fall within the classification of what Dr. Jerome Kroll defines to as PTSD/Borderlines. Dr. Kroll makes some rather astute observations pertaining to the impact of traumatic events upon character development and postulates how these behaviors may be more properly considered as PTSD rather then Borderline Personality Disorder. Sexually compulsive individuals, who are PTSD/Borderlines, usually respond well to psychodynamically-oriented individual interactive psychotherapy, but some special consideration needs to taken for them with respect to group modalities/interventions. For a more comprehensive understanding of PTSD/Borderlines refer to Dr. Jerome Kroll's book entitled, PTSD/Borderlines In Therapy - Finding The Balance.

There are a number of features of PTSD which occur in varying combinations, degrees and frequency among sexually compulsive persons. They may be identified as follows: (a) dissociation, involving a sense of being disembodied with a possible entrance into a "trance" state; (b) confusion, with the experience of shutting down emotionally (freezing) and becoming overwhelmed (flooded); (c) displaced anxiety, laced with fears of anticipated victimization; (d) irritability, (e) shame, (f) distrust, (g) "high" tolerance for pain (sometimes involving forms of self-abuse); (h) perfectionism, with a strong need to control external circumstances; (i) episodes of insomnia; (j) repression/suppression of dependency needs and (k) arousal patterns rooted in anxiety, with significant correlation and impact upon the neurological and biochemical make-up of the sexual compulsive. This is especially significant in light of his utilizing sex as one of his primary coping responses to his internal and external conflicts. Sex for the compulsive is his central filter/regulator and subsequently his ability to process anxiety and negotiate conflict is considerably handicapped. The lives of sexually compulsive individuals are frequently reflective of encrusted patterning, often exhibiting varying degrees of isolation, fear of intimacy, impaired thinking (ADD/ADHD), rigid posturing, obsessive styles, predatory behaviors, ritualistic tendencies, workaholism & excessive exercising, emotional enmeshment/codependent dynamics, guilt and unmanageability.

Currently, sexual addiction does not have a diagnostic category of its own in the DSM-IV classification. This circumstance is, in fact, the second reason offered in this paper for sexual compulsivity still being considered an invisible addiction. Diagnostic categories evolve through the course of time and assume a visible position for assessment and treatment when their occurrence in the field has achieved a critical mass. Attention Deficit Disorder and Attention Deficit Hyperactivity Disorder are prime examples of this process. Established diagnoses also assume greater depth over time. PTSD with its recognition and incorporation of the varying impact of childhood abuse is a clear example of the vital and organic nature of the DSM-IV as a living instrument. It appears that we may be approaching the moment whereby the treatment of sexual addiction is best served by having its own classification. The DSM-IV has consistently demonstrated itself to be a wonderful apparatus for clinicians to employ for self-education and exploration. A multiaxial assessment in the DSM-IV that would allow for an "official" differential diagnosis inclusive of "Sexual Addiction-Related Disorders as it relates to PTSD and Substance-Related Disorders, may also prove to be an extremely powerful and valuable tool for clinicians in the timely diagnosis and treatment of sexual compulsivity.

Theoretical Frameworks for Treatment:

Sexual addiction is symptomatic of a syndrome that requires a broad and receptive outlook on behalf of the clinician in order to support a therapeutic environment that allows for a profound level of healing and recovery. The primary therapist needs to be cognizant of the possibility that the sexually compulsive individual may not only be carrying a background impacted by trauma, but that these clients may also be engaged in unconscious reenactments of these historical wounds. Theoretical frameworks for these individuals are best served when they are flexible and inclusive of a multi-disciplinary approach that can be woven into a cohesive and integrated whole. The selection of theoretical frameworks is as much an intuitive process for the clinician as it is a cognitive one. How the complementary threads of a comprehensive theoretical perspective form a clinical tapestry for amelioration is part of a process guided largely through inquisitiveness and serendipitous association. The blueprint for the discovery process is provided by the questions posed in the symptomatology presented in treatment. With this awareness, the task at hand is to develop a methodology that customizes the interventions which are available for the sexually compulsive individual. An understanding of the acute and chronic fragmentation observed in the intrapsychic world of the sexually addicted client may be enriched and expanded through the application of Object Relations Theory. This perspective emphasizes the importance of a "holding environment" for these individuals as it relates to conscious/unconscious processes, interpersonal dynamics and the historical experiences that lay the foundation for the development of individual identity. Within this school of thought, the central premise is that relationships are primary. The writings of James F. Masterson, M.D. are especially relevant in light of the insights he puts forth with respect to purporting a theory of the self as it relates to object relations theory. In addition, these perspectives are very well complemented by the theories espoused within the discipline of Self-Psychology. The work of Heinz Kohut was pivotal in this area offering an in-depth understanding of the process and development of structural wholeness and cohesion of the self as compared with self-fragmentation. Within this perspective, the "acting-out" behaviors of the sexual compulsive may be viewed as failed attempts toward achieving cohesion. Sexually acting-out is often motivated by an underlying desire to experience wholeness. In the process, however, the self may be undermined and fractured. The wounding that occurs in these instances, although unintentional, may be rooted in a genuine attempt on behalf of the compulsive individual to intuitively and organically ameliorate his pain. The school of Self-Psychology is based on what it refers to as the self and selfobject system. From this framework one is able to more clearly comprehend how narcissistic injury may drive the behavior of the compulsive individual. Kohut viewed addictive behavior as an unconscious attempt to respond to narcissistic disturbance. Self-psychology emphasizes developmental arrest as compared to Object Relations Theory which stresses unresolved challenges with regard to intrapsychic conflict. An example of how this internal conflict may be enacted in a compulsive indivdual is demonstrated by the presence of negative parental intrajects which cause them considerable emotional discomfort. A theorist who was very ahead of her time and who wrote prolifically on the subject of inner conflict was Karen Horney, M.D. Her work puts forth a profound understanding of the impact that a lack of safety has upon development and its subsequent influence upon an individual's defensive structure. Dr. Horney's dynamic theory focuses upon anxiety and inner conflict as they relate to an individual's ambivalence toward closeness. She perceives basic conflict enacted in emotional responses resulting in compulsive movement toward, away, or against others. These coping strategies are largely predicated upon a varying and fragile sense of one's self-worth. This framework may be applied as a perspective to more deeply understand the interpersonal behaviors and inner struggles of the compulsive individual.

Central to any discussion on theoretical frameworks for sexual addiction are the theories of Trauma Recovery. This model formulates the very core of the matter and is the basis, as postulated earlier, for diagnosis and treatment. Posttraumatic stress theory is at the heart of understanding the issues at hand and offers substantive insight into the role of dissociation and how it serves as a protective mechanism for mitigating fear and anxiety. Essential reading on this subject is Dr. Judith L. Herman's work, Trauma And Recovery. The induction of dissociative states and their correlation with sexually compulsive styles offers the clinician fertile ground for exploration. Related to the paradigm of Trauma Recovery is its familial cousin, the Addiction Model. This framework may incorporate trauma theory along with perspectives on dual diagnosis. In light of the inner disorganization of the compulsive person and the frequent occurrence of obsessive thought process and binary thinking in these individuals, some understanding of cognition is prudent. The application of "schema theory" within the framework of Cognitive Therapy may be prudent in working with a client displaying these obsessive-compulsive features. In addition, Internal Family Systems Theory is another potent instrument in assisting the compulsive with the process of organizing his inner world. And finally in order to complete the circle on theoretical paradigms, a holistic and integrative framework would also be inclusive of an Energy Model. This perspective would not only address the emotional and mental needs of the compulsive individual, but it would also allow for interventions via referrals for "adjunctive therapies". These adjunctive therapies have the capacity to engage the client in the process of "subtle energy healing" (i.e. body therapies) and will be discussed later in this discourse. Close relatives of the Energy Model that may also be incorporated in a truly "holistic" framework, are the schools of Transpersonal and Depth Psychology. In view of the emotional and spiritual wounding among sexual compulsives these perspectives speak to the profound emptiness often articulated by these individuals in recovery. In closing, it is important to note that psychopharmacology falls under the Medical Model and its role, when indicated, is critical in the treatment of PTSD and sex addiction. In light of its complexity it will be reviewed in a section of its own.

Clinical Applications:

The opportunities present in the initial consultation are foremost in the clinician's mind. The prevalence of process and substance addictions among sexual minorities place these individuals at-risk and it is desirable for the clinician to rule-out these risk factors in the first two or three meetings. When the client is engaging in a discussion about coping, ignited either by the therapist's inquiry or through his own initiation, this is a crucial moment for the clinician to be alert for clues. Depending upon the client's degree of openness, the practitioner needs to give himself/herself permission to do some exploration with him. The therapist will serve his/her client well by including ,as part of the initial consultation, questions about his general health, dating patterns, support system, and his history with respect to sexually transmitted diseases (STD's). If it feels comfortable, the therapist may enter into some exploration with regard to the use of recreational drugs as well as ask whether the client is taking any prescribed medications. Although these questions are sensitive, investigative instincts combined with the timely assumption of calculated risks, will ultimately allow the therapist to better serve his/her client in the development of a comprehensive treatment plan.

Individuals that have exhibited coping patterns symptomatic of sexually compulsive styles and PTSD, may also need to grieve their childhood along with their past experiences of deprivation. Safety, consistency, and above all, acceptance are among the essential ingredients for the formation of a sound therapeutic alliance. The clinician therefore needs to de-stigmatize their clients' shame-based behaviors as they are revealed and "normalize" their acting-out behaviors. This may be accomplished by reframing these behaviors as innate attempts to cope, regardless of how ineffective they may have proved to be for the client. Psycho-education begins in the initial consultation and it is a process that is ongoing throughout the course of treatment. This also holds true for the risk factors that the clinician needs to be mindful of for the duration of therapy. Compassion is intrinsic to psycho-education and by affording client understanding by reframing, the therapist is offering him a vehicle toward self-acceptance. The practitioner's effectiveness in educating his/her client about his maladaptive coping styles may, indeed, be the factor that determines whether the opportunity to do further work with him is made available. The therapist needs to remember that in asking the "right" questions in the initial consultation, an evaluation is being made regarding his/her appropriateness for the client. Adults with PTSD are often very sensitive to the slightest hint of judgement and it is essential for effective treatment that the clinician be comfortable with the material being presented in the first interview. The consultation is thereby a mutual assessment offering critical pathways of opportunity and insight.

Treatment interventions for sexually compulsive individuals may involve a variety of models and it is recommended that the clinician, at least in his or her mind, establish the eventual goal of engaging the client in at least a combination of two therapeutic settings. An interactive form of individual psychotherapy is preferred for these clients. They need feedback in order to feel safe. In addition, they are often isolated and are in great need of the modeling which is available in an interactive psychodynamically-oriented situation. Participation in a twelve-step recovery program would be a wonderful duet in combination with individual therapy if this suggestion is greeted without initial resistance. It is not uncommon for this recommendation to require some coaching on behalf of the therapist. Clients sometimes are initially more receptive to programs like Adult Children of Alcoholic and Dysfunctional Families (ACOA) before they are willing consider a setting which they may perceive as stigmatizing and shameful, i.e. Sexual Compulsives Anonymous (SCA). Group therapy must be considered on an individual basis and the orientation of the group process is of critical importance in determining a compulsive individual's readiness for this modality. Groups which are based on a model of psycho-education are usually less stressful for individuals in early treatment for sexual addiction. Compulsive persons usually respond well to the structure and find some margins of safety within it. Psychodynamically-oriented groups are usually more appropriate for clients who are in the more advanced stages of recovery. And yet, even in these instances, the therapist must carefully evaluate the client's readiness for the increased anxiety that is intrinsic to the process of psychodynamcally-oriented groups. The therapist needs to be creative and aware of the resources in the community that may provide appropriate and engaging fellowship for these individuals. Sexually compulsive individuals are confronted in treatment with the daunting task of replacing their acting-out behaviors with other forms of connection. Historically, these behaviors had been their primary means of accomplishing this task. The profiles of these clients frequently present not only anxiety, but depressive features with underlying degrees of suppressed rage and anger. The challenge is for them to learn how to respond to the complex range of these feelings without relying upon sex as their central regulator. Facing these emotional difficulties will require alternate means of coping. While the sexually addicted individual is "in-process" with this challenge, intrinsic to his recovery and sexual healing is the treatment issue pertaining to his inclination to compartmentalize sex. For the practitioner working with these individuals, a central objective to a comprehensive treatment plan is the goal of facilitating intrapsychic levels of integration that allow the compulsive individual to develop a relationship with his sexuality that is integral to an identity that is whole, affirming and complete. Their patterns of sexual compartmentalization may have manifested in response to early experiences of emotional trauma and deprivation with subsequent feelings of shame and guilt. In the course of treatment, these individuals are also at risk for assuming avoidant behaviors which may include forms of sexual anorexia. These avoidant tendencies may arise in response to painful associations with previous forms of sexual expression that were largely dissociative, disintegrated and in some cases, self-annihilating. Healing and recovery for them must therefore involve movement toward an integrated sexuality that facilitates expression that not only allows for connection and association, but for self-affirmation intricately laced with interpersonal and relational integrity.

Adjunctive Therapies:

One of the greatest concerns of the sexually compulsive individual with regard to entering treatment is the fear that recovery may further exacerbate his sense of aloneness and disconnection. They are fearful that their central means of coping may be forever taken away from them. This defense may be supported by underlying feelings of anger and aggression. These impulses, although usually submerged, may be outwardly visible through the presentation of an external posturing which manifests in somatic constriction and rigidity. This is largely unconscious on their behalf and they usually are not aware of the degree of body tension that they have accepted and incorporated as a normative component of how they experience and relate to themselves. These unconscious patterns and the subsequent impact they have upon the compulsive person's physical and emotional make-up, may very well be ameliorated by the incorporation of adjunctive therapies in the treatment plan. Fortunately, there are a rich variety of such therapies that may be of considerable benefit for clients recovering from sexual compulsivity. In light of their struggle with mood regulation, anxiety management, and vulnerability toward either manifest or asymptomatic somatic stress in their nerve systems, body therapies such as acupuncture and chiropractic intervention (i.e. Network Spinal Analysis - NSA), may very well offer a significant reduction in dynamic tension. In addition, such adjunctive therapies may also assist in removing blockages while facilitating subtle energy healing in areas historically characterized by rigidity and constriction.

Pharmacological Considerations:

It is essential that the clinician, as the primary therapist treating individuals characterized by process and/or substance addictions, views him or herself as a member of a mental health team. Pharmacology plays a significant role in treating a segment of this population. It is the responsibility of the clinician to be able to recognize the indicators and signposts which warrant consideration for a referral to a psycho-pharmacologist. This is an area where differential diagnosis is especially useful for the primary therapist. There are instances when individuals in treatment may complain of extreme difficulty with seemingly unmanageable levels of anxiety and/or depression. They may also disclose that they are unable to concentrate and perform simple tasks which require them to focus. They may complain of insomnia, early morning lethargy, and of feeling overwhelmed and flooded for a significant part of their waking hours. A pattern may also be revealed that they are unable to be present during the therapeutic hour and that they experience heightened anxiety for prolonged periods after sessions. In isolation these symptoms may not necessarily indicate an immediate referral, but if a constellation of symptoms arise in patterned sequences, a pharmacological consultation is most likely warranted. A handbook of psychiatric drugs is a requirement for therapists who are committed to working with this constituency and who value the importance of educating themselves about basic psycho-pharmacology. The class of antidepressants referred to as Serotonin Reuptake Blockers (i.e. Prozac, Zoloft, Paxel, and Wellbutrin) often have a good result with sexually addicted individuals presenting varying combinations of anxiety, depression, and/or dissociative features. However, it should be noted that patience is required in the effort to identify the "right" anti-depressant or anti-anxiety agent at the appropriate dosage for them. Clients need to be educated about the pharmacological process and be made aware of the importance of working closely with the psycho-pharmacologist to locate and fine tune their "clinical window" for pharmacological intervention. The pharmacological option also has additional implications for an at-risk population for sero-conversion in light of their possible engagement in sexually compulsive behaviors that may involve unsafe sexual practices. A timely referral resulting in early diagnosis and treatment may avert a regressive episode and/or crisis.

Conclusion:

A multi-disciplinary approach for the treatment of sexual compulsivity is the essence of the matter at hand. Healing ultimately involves interventions which address the underlying complexity of symptoms characterizing the profiles of these individuals. The core of recovery is rooted in the capacity to experience a deep sense of connection to oneself and to others. The challenge and the opportunity for the clinician is to recognize and maintain an acute awareness of the profundity of this simple axiom. The sustained vision, afforded by living in this truth, is the jewel that will guide practitioners in wisdom and vitality as they dynamically practice their craft in the diverse landscapes of their communities.

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