Case Study - Page 2

Like many male sex addicts who come into treatment, Jim appeared to be testing me and sexualizing me—basically checking me out to see whether he could manipulate me. I usually take this kind of behavior in stride because I recognize that it's a way to create distance and maintain a sense of power and control. During our first session, he said he'd begun masturbating to pornography when he was 12 and had never stopped. With the advent of the Internet, his behavior escalated to a daily occurrence, usually for many hours. Sometimes he stayed on the computer all night, going to work "hung over" the next morning, and had at times masturbated to the point that his penis was raw and even bleeding. After 17 years of heavy daily drinking—often while watching porn—he'd joined AA several months earlier and was now sober. But now, he told me, he'd begun to skip AA meetings, claiming that he "didn't need to go anymore." When I confronted him about this, telling him he was still at risk of relapse, he left in a huff. I was sure that he'd never come back.

A few days later, he called, still angry, to complain about my "hurtful style," saying that he thought I was attacking him. I said I was sorry he felt upset and asked him if he wanted to talk about it. Still smarting from his wife's ultimatum and knowing he needed help, he agreed to come in for another session.

Assessing Underlying Attachment Issues

Jim's childhood attachment experiences had been anything but stable, loving, and secure. His mother was a severe alcoholic. She beat her four young sons when drunk and enraged—which was quite often. Once, after hitting Jim, who was 10 years old at the time, she locked him in the basement for several hours. Meanwhile, Jim's father stood by passively, or simply retreated to
his study.

Not surprisingly, Jim had developed an ambivalent attachment style: he flipped back and forth from direly needing the attention of others to completely avoiding any contact at all. Ambivalently attached children often turn into narcissistic adults who persistently crave attention and feel deep shame when they don't get it. This combination—excessive neediness, the feeling of not being entitled to have one's needs met, and unbearable shame—doesn't make for an appealing personality style.

Jim tended to be passive-aggressive in getting his needs met—never directly asking for what he wanted, but indirectly taking it. Unable to connect in any other way with his coworkers, for example, he constantly picked fights with them and then felt victimized by their annoyance or disagreement. This would lead to anger and the desire to retaliate. Not surprisingly, he had few friends. All of his adult life, he'd used both alcohol and compulsive masturbation to pornography to make his intense feelings of need and shame go away.

Jim's inability to be assertive and his passive-aggressive response to others—a hallmark of sexual addicts—created problems with his wife. He could never stand up for himself, so he was always going behind her back to get what he wanted. This was a recreation of his relationship with his mother, in that his wife was always angry with him, repositioning him as a perpetual victim. As his therapist, I, too, experienced the impact of his shaky capacity for attachment. Early in therapy, he did what he could to recreate with me his relationships with his mother and wife, thus maintaining his status as a chronic victim.

I ask all my clients starting therapy to complete a Sexual Dependency Inventory (SDI)—a-200 item questionnaire with several other checklists and essay questions—that details their sexual history. Jim's SDI clearly indicated that he was a cybersex addict. It also showed me that he compulsively used pornography and masturbation as an analgesic—to numb his pain.

Next I helped Jim design his Sexual Sobriety Plan, which simply stipulated no viewing of pornography in any form and no masturbation. He agreed that, once he'd achieved six months of sexual sobriety, we'd revisit the topic of masturbation to determine whether it could be reinstated in his life. His most addictive behavior—viewing Internet pornography, or cybersex—fit perfectly with his personality: disconnected from others and dismissive of his own feelings. At this point, the only feeling Jim seemed to recognize in himself was shame. He could say, "I think I feel sad," but couldn't yet experience sadness as a body-based feeling. If any affect appeared to be arising, his jaw would visibly tighten and he'd swallow the feeling.

Impatient to move the process along, Jim expected he'd join my therapy group right away and so was unpleasantly surprised to hear that he had to "earn" entry into it. Before he could join, I said, he had to follow his Sexual Sobriety Plan for 30 days, come to individual therapy each week, check in by phone between sessions, complete homework assignments like his SDI, and further define his Sobriety Plan. This ultimately needed to encompass the destructive sexual behaviors he wanted to abstain from, a boundaries list of the behaviors that might lead to his acting out (like an argument with his wife), and a healthy list of behaviors that would support his sexual sobriety, such as attending Sex Addicts Anonymous (SAA) meetings weekly. Even when he successfully completed his month, I was worried about his joining my group. Although I knew that group therapy is crucial for SA treatment, I feared that, because of his social rigidity, it would be a struggle for him to fit in with the other males—two gay men, a film director, a Latino artist, an architecture student, and a criminal defense attorney.

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