Literature Review of Treatment of Compulsive Pornography Use by Adults & in Married Relationships
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Pornography Intervention - A Training Resource
By Jim Messina, Ph.D., CCMHC, NCC, DCMHS-T
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One Size Treatment Does Not Fit All – Given No Agreed Upon Diagnosis of the Condition
The use of the term “addiction” when dealing with compulsive use of pornography might be an over stated diagnosis given the DSM-5 does not even include such a diagnosis at the current time. But the fact is that compulsive pornography and cybersex utilization is a problem and needs treatment (Levine, 2010). It is important to address the underlying psychological issues and explore the societal context within which clients have developed their meaning of their problem with pornography/sex and this requires taking steps to review their biopsychosocial development (Hall, 2011; Hall, 2014). Given the recent emergence of sexual pornography compulsivity and cybersex pornography addiction there is a need for standardized dagnostic criteria, evaluation protocols, comorbid disorders, neuroscience, and treatment strategies (Rosenberg, Carnes & O’Connor, 2014). Evidence points to overlaps between behavioral (including pornography/cybersex addiction) and substance-related addictions in phenomenology, epidemiology, comorbidity, neurobiological mechanisms, genetic contributions, responses to treatments, and prevention efforts (Yau & Potenza, 2015). More response to the absence of compulsive pornography/sex addiction not being in the DSM-5 more evidence was presented of its being: a primary, chronic disease of brain reward, motivation, memory, and related circuitry, with manifestations along biological, psychological, social, and spiritual domains (Phillips, Hajela & Hilton, 2015).
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Compulsive Sexual Behavior (CSB) is a common disorder featuring repetitive, intrusive and distressing sexual thoughts, urges and behaviors that negatively affect many aspects of an individual’s life but it continues to defy easy categorization within mental health community (Derbyshire & Grant, 2015) but popular media and academic research are not on the same page in terms of definition of the condition and its impact (Montgomery-Graham, Kohut, Fisher & Campbell, 2015). It is well known that men and women turn to drugs and other addicting behaviors in gender-specific ways and for gender-specific reasons and that in planning treatment one must recognize that what works with men might not work with women (Hasletine, 2000). Increased levels of boredom, diminished social connections, and dissociative symptoms while engaged in excessive online sexual activities are conceptualized as components that facilitate and maintain Internet sexual addiction and in treatment these issues need to be addressed (Chaney & Chang, 2005).
In a comparison study of three groups: child pornography offenders, non-contact sex offenders and contact child molesters, the results indicated that the three groups were more similar than different; however, child pornography offenders were distinguished by greater academic and vocational achievement, fewer childhood behavior problems and by select relational variables (Jung et al., 2013). This brings into focus the reality that use of online pornography of children has increased by people who do not fit the profile of sex offenders and child molesters.
Another study found that in treating compulsive sexual behavior reduced the risk for sexual boundary violation (Menassa, Holden & Bevly, 2015) which supports the need to intervene in compulsive pornography behaviors as soon as they are identified to prevent them from maturing into more antisocial implications. This study was supported when another one found that sexually aggressive women reported significantly higher levels of sociosexuality, sexual fantasies of dominance and submission, sexual compulsivity, sexual excitation, and sexual inhibition due to the threat of sexual performance failure based on their use of internet sex sites (Carvalho & Nobre, 2016).
As online pornography/sex materials expanded, a study in 2016 found links between Internet addiction, engagement in online erotica (including pornography usage and usage of sex-based Internet chat sites), and engagement in risky online sexual behaviors (sending sexually-explicit pictures to those known only online; sexting) and expecting to engage in offline sex with those known only online which has been exacerbated by the onslaught of Internet sex chat sites (Drouin & Miller, 2016). Research demonstrates that Adolescents aged 15-16 years, especially male adolescents, are the most prone to the development of Internet addiction, whereas adolescents aged 11-12 years show the lowest level of Internet addiction (Karacic & Oreskovic, 2017).
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Backgrounds common to Compulsive Pornography Users
Years of data have shown that they are typically: 1. victims of abuse (sexual, physical, emotional). 2. come from rigidly disengaged families. 3. to see themselves as shameful, bad, unworthy persons. 4. are codependent and believe no one will love them as they are. 5. see sexual activity as the most important way of taking care of their emotional needs. 6. engage in a variety of sexual behaviors (Levert. 2007). Even though high sexual compulsivity was associated with sexual risk taking, (mainly among women) decreased levels of relationship intimacy and lesser sexual contentment there was no significant association between early exposure to pornography and high sexual compulsivity either among men or women (Stulhofer, Jlovica & Ruzic, 2008). Cognitive-behavioral, task oriented treatment with attention to the neurobiological causes, and costs, of sexual addiction create a recovery protocol that helps clients progress beyond sexual sobriety to achieve previously unattainable interpersonal connection, self-reflection, and internally regulated affective states (Katehakis, 2009).
Since the onset of high speed internet in 2006, there has been the emergence of a “contemporary” sexual addiction with “rapid-onset.” Its characteristics are: 1. Etiology stemming from chronic exposure to sexually graphic online content, the uniqueness and intensity of which are theorized to facilitate rapid-onset addiction and to disrupt normal neurochemical, sexual, emotional, and social development particularly when occurring early in the. developmental process; 2. Chronicity and content interact; 3. Rapidly changing cultural sexual norms trending toward virtual and nonrelational sex (Riemersma & Sytsma, 2013). It has been shown that gender, sexual orientation, childhood emotional abuse, childhood exposure to pornography, and parental sex addiction were associated with sexual compulsivity in adulthood (McPherson, Clayton, Wood, Hiskey & Andrews, 2013; McKeague, 2014). Further, craving, sexual arousal rating of pictures, sensitivity to sexual excitation, problematic sexual behavior, and severity of psychological symptoms predicted tendencies toward cybersex addiction of women who were users of internet pornography (Laier, Pekal & Brand, 2014; Laier, Pekal & Brand, 2015).
Adult interest in sex and the likelihood of engaging in risky sexual behaviors tended to be increased if participant’s first experiences with masturbation and partner sex had occurred early in life. Conversely, adult interest in sex tended to be lowest when neither masturbation nor sex with a partner had occurred prior to 18 years of age (Griffee, et al., 2014). Psychological well-being factors and sexual interests/behaviors are involved in the development of compulsive use of sexually explicit Internet material among adolescent boys given that higher levels of depressive feelings and excessive sexual interest predicted relative increases in compulsive use of cybersexual materials (Doornwaard, van den Eijnden, Baams, Vanwesenbeeck & ter Bogt, 2016).
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Religion Based Issues to Address in Treatment of Compulsive Pornography Users
Ground breaking research into the relationship between religiosity and compulsive cybersex/pornography found that: at a rate of 74 min per week. Internet pornography use interfered with individuals’ relationship with God and spirituality. Religious individuals were less likely to view internet pornography. Lack of intrinsic and extrinsic religiosity and alignment of spiritual values were associated with excessive use (Short, Kasper & Wetterneck, 2015).
“Shame-based” is self-message most often experienced by adults with sexual related addiction. Efforts in treatment to reduce this shame is a goal and one approach is to use creative arts to get out the shame in a non-threatening manner (Wilson, 2000). Not only for treatment to be successful should the goal be to reduce shame, but also to help the client regulate one’s own affect, and create healthy sexual boundaries with others (Adams & Robinson, 2001). When working in faith communities, one must zero in on shame reduction strategies, given shame is an issue in treating any sex related problems because they are termed “sexual sins” and are perceived as the worst transgressions thus magnifying the shame since it is perceived as a moral failure (Ferree, 2002). Pastoral Counselors have been encouraged to focus primarily on preventing Internet addiction, with women and men who already suffer from depression, bipolar disorder, anxiety, low self-esteem, or the struggles with recovery from a prior addiction (Waters, 2005).
In working with Clergy who have sexual addiction it is important to: Provide them professional education and openness; an integration of the whole person with the role as pastor; breaking isolation with accountability; proactive denominational care for clergy; and a proactive response for the clergy sex addicts (Davies, 2003). In treating clergy for cybersex addiction, it is important to recognize the nature of their role increases vulnerability to addiction and adds unique challenges to treatment. Also is is important that treatment for clergy be sensitive to these challenges particularly in assessing ability to remain in or return to the practice of ministry. Finally, an ongoing accountability plan needs to be spelled out that allows church authorities to feel confident about the ministerial practice of those who suffer from Internet addiction (Laaser & Gregoire, 2003). It has been pointed out that for pastors, loneliness, anger and boredom often play a role in the development of sexual addiction (Frykholm, 2007).
Most committed relationships begin as an expression of spiritual belief. Jewish, Christian, and Islamic traditions view this as a sacred covenant between the couple and God. Jewish scripture, which is the foundation of all three traditions, describes marriage in the second chapter of the book of Genesis as a “one flesh” union (Laaser, 2006). This is a concept that strikes fear in the hearts of some of those who fear codependency and enmeshment and it is important to help the couples who are dealing with pornography addiction to accept their Spiritual Foundations if they are to heal, grow and move on in their mutual recovery (Laaser, 2006).
A 2014 study found that among college students, lower levels of Purpose/Meaning (i.e., spirituality) and higher levels of Negative Religious Coping significantly predicted hypersexual behavior, specifically, religious coping and spirituality accounted for the variance in collegiate hypersexuality (Giordano & Cecil, 2014). The role of shame and negative spirituality fosters and exacerbates pornography addiction in individuals (Chisholm & Call, 2015; Iwen, 2015; Patrician, Burris & Moscovitch, 2015).
A 2017 report demonstrated that both insecure attachment styles and shame based or punishment-based religious beliefs were related to college students’ addictive sexual behaviors (Giordano, Cashwell, Lankford, King & Henson, 2017).
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Treating the Comorbid Disorders along with Pornography/Sexual Addiction
PTSD is a major comorbid disorder connected with Pornography/Sexual addiction for veterans of the Irag and Afghanistan wars. Plagued by nightmares, flashbacks, and a host of family and work–related problems, these individuals often turn to mood-altering substances and behaviors as an escape from their memories (Howard, 2007; Cox & Howard, 2007. Smith, et al., 2014). It is important to treat both conditions simultaneously so as to reduce the impact of one on the other.
Recognizing the comorbidity issues, it is important to identify the competencies needed by counselors with dealing with pornography/sex addiction who are capable dealing with all rather than “either or” diagnosis (Hagedorn, 2009). A study reported in 2015 treated internet pornography addiction long with Obsessive Compulsive Disorder with success in lessening the internet addiction after a year or more (Bipeta, Yerramilli, Karredia, & Gopinath, 2015). Concurrent treatment for Panic disorder (PD) and generalized anxiety disorder (GAD) and internet pornography addiction using pharmacotherapy and cognitive behavioral therapy have been reported as successful (Santos, et al., 2016).
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Treatment Modalities with Clients with Compulsive Pornography Use
There is a diverse number of modalities and theoretical approaches used with clients who suffer from Compulsive Pornography Use. The sex addiction literature lacks examples of explicit applications of EBP/EBT models in the development and assessment of clinical interventions (Delboy, 2015).
The modalities identified in working with compulsive pornography/sex behaviors include:
- Brief Multimodal Experiential Therapy (Klontz, Garos & Klontz, 2005);
- Group Hypnotherapy (Millet, 2005);
- Motivational Interviewing (Del Guidice & Kutinsky, 2007; Reed. 2007);
- Sandtray Therapy (Spooner & Lyddon, 2007);
- EMDR (Cox & Howard, 2007);
- The ARISE model of invitational intervention (Landau, Garrett & Webb, 2008); Relational Power for Self-Correction (Reith, 2008);
- Transactional Analysis (Schaeffer, 2009);
- Bio-psychosocial Model (Hall, 2011);
- Psychoanalytic (Wood, 2011);
- Opportunity, Attachment, and Trauma (OAT) Model (2013);
- Family Systems Theory Model (Hentsch-Cowles & Brock, 2013);
- Group Analytic Therapy (Woods, 2013);
- Cognitive-behavioral, Task Oriented Treatment (Katehakis, 2009);
- Cognitive Behavioral addressing factors of vulnerability, the role of cognitions, and the role of positive and negative reinforcement (Laier & Brand, 2014);
- Mindfulness to control emotional dysregulation, impulsivity and stress proneness (Reid, Bramen, Anderson & Cohen, 2014);
- Psychoeducation and Self-Leadership Development (Georgianna, 2015);
- Adlerian Individual Psychology (Fall & Howard, 2015);
- Use of the Evidence Based Practice (EBP) model: Step 1. Client Background and Case Conceptualization; Step 2. Literature and Research Review; Step 3. Appraisal of Existing Literature; Step 4. Treatment Plan Development; and Step 5. Implementation Considerations (Delboy, 2015);
- Self-Forgiveness (Hook, et al., 2015);
- Spirituality Integrated Therapy (Chishol & Call, 2015);
- Humanistic: Experiential personal construct psychology (Thomas, 2015);
- Inhibitory repetitive transcranial magnetic stimulation (Tripathi, Singh, Singh & Kar, 2016) and
- Anti-anxiety Medications and Modified CBT (Santos, et al., 2016).
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Neuroscience & Psychopharmacology Treatment for Compulsive Pornography Use
Rewards are both “liked” and “wanted,” and those 2 words seem almost interchangeable. However, the brain circuitry that mediates the psychological process of “wanting” a particular reward is dissociable from circuitry that mediates the degree to which it is “liked.” Incentive salience or “wanting,” is a form of motivation, is generated by large and robust neural systems that include mesolimbic dopamine. By comparison, “liking,” or the actual pleasurable impact of reward consumption, is mediated by smaller and fragile neural systems, and is not dependent on dopamine (Berridge & Robinson, 2016).
The incentive-sensitization theory posits the essence of drug addiction to be excessive amplification specifically of psychological “wanting,” especially triggered by cues, without necessarily an amplification of “liking.” This is because of long-lasting changes in dopamine-related motivation systems of susceptible individuals, called “neural sensitization.” A quarter-century after its proposal, evidence has continued to grow in support of the incentive-sensitization theory its scope is now expanding to include diverse behavioral addictions and other psychopathologies (Berridge & Robinson, 2016).
Support for use of psychopharmacology use in treating pornography/sex addiction comes from the fact that these addictions manifest in symptoms including craving, impaired control over the behavior, tolerance, withdrawal, and high rates of relapse. These alterations in behavior suggest that plasticity may be occurring in brain regions associated with drug addiction and that use of medications might be warrented (Olsen, 2011).
There are no US Food and Drug Administration (FDA)-approved medications for compulsive sexual behaviors (Fong, 2006). However, the following medications have been used: SSRI’s; Naltrexone-opiate-antagonist; Moods stabilizers including clomipramine, valproic acid and lithium and anti-androgens to alter sexual hormone functioning (Fong, 2006; Gulsun, Gulcat & Aydin, 2007). However, drugs that may influence mesolimbic dopamine function indirectly, such as opioid receptor antagonists like naltrexone and nalmefene and glutamatergic compounds like N-acetyl cysteine, have shown more consistent findings in both substance and nonsubstance addictions like pathological gambling (Potenza, 2013).
Other molecular targets that may influence mesolimbic dopamine function, like the serotonin 1B receptor, show similarities in substance and non-substance addictions and these entities may represent better targets for treatment development than do less specific serotonergic proteins like the serotonin transporter targeted by serotonin reuptake inhibitors, a class of compounds which has shown only modest effects in treating addictions (Potenza, 2013). The role of the neuronal receptor in addiction-related neuroplasticity, supported by the historical behavioral perspective may be amplified by the accelerated novelty and the ‘supranormal stimulus’ (Hilton, 2013).
Findings of shared neurobiology between aggression and Internet addiction disorder have major implications for future research for psychopharmacological agents to treat these two psychological disorders (Hahn & Kim, 2014). Selective Serotonin Reuptake Inhibitors and anti-androgens when used with patients with hypersexuality, sexual preoccupation and sexual compulsivity were found to result in positive outcomes (Winder, et al., 2014) especially Paroxetine (Paxil) (Gola & Potenza, 2016).
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Strategies in Working with Couples dealing with Compulsive Pornography Use
When working with couples, the therapists need to screen each of the members for Problematic Internet Use (PIU) which has been reported in children as young as six years of age. It is important to screen since individuals with PIU behaviors may lead to decreased offline social activities and increased depression and loneliness over the course of several years. (Brezing, Derevensky & Potenza, 2010).
Understanding and treating compulsive sexual activity in marital therapy is a stepwise process:1. careful history taking and diagnostics of both partners; 2. identification of the mutually reinforcing relationship dynamics keeping destructive behaviors in play; 3. processing of underlying psychological and developmental roots of such behaviors; 4. cultivation of empathy and trust, and 5. revitalizing of the couple’s sexual relationship (Cohn, 2014). In assessing status of the relationship, it is important to ask the couples to come clean about their use of social media since there could be covert relationships being built on these platforms (Cravens & Whiting, 2014).
In working with couples, it is important to recognize that they may not often realize that pornography/sex addiction lies at the foundation of their problems. For this reason, counselors must be ready to help them uncover the presence of such addiction in their lives (Turner, 2009). Often in the past, therapist would use erotica to assist in dealing with sexual dysfunction in the couple relationship, but with the increase of internet pornography there is plenty of rationale for leaving erotica in the past when two people vow to forsake all others—even computer-generated ones (Puterbaugh, 2013).
The intimate partners of sex addicts, also known as coaddicts, are often the unrecognized “difficult” persons in the spectrum of sex addiction recovery (Tripodi, 2006). So it is important when working with the partners of Pornography/Sex addicts to have the following goals: 1. Accept that their partners’ problem are not their problems they accept it is not about them but their partners; 2. Accept their partners as descent individuals who are in a pathological state; 3. Develop a set of healthy goals that: carefully defining their own personal limits regarding what they can and cannot live with, communicating these to their partners in a spirit, not of ultimatum or of bending their will, but of preserving their own dignity and integrity, and taking actions up to and including separation to back up such statements (Bergmer & Brodges. 2002).
Conjoint marital therapy is recommended as a useful component in treating compulsive pornography consumption because it: builds marital trust and confidence in the future, with mutual softening, increased ability to discern key points of intervention sponsoring and supporting recovery, and the couple clients-perceived marital enhancement (Zitzman & Butler, 2005). It is critical to recognize that healing the individual works at the same time as the healing of the partnership the client has with the innocent coaddict (Butler & Seedall, 2006) utilizing attachment-anchored, enactment based interventions (Seedall & Butler, 2008). Repairing the ruptures in couples caused by pornography addiction can be a delicate and challenging to restore trust and forgiveness in their relationships and Emotionally Focused Therapy has been described as an intervention to facilitate this reparative process (Reid & Woolley, 2006). Couples need creative interventions for relational transformation in order to move from a state of disconnection towards mutuality, growth, and connection (Vogel, 2006/2007). Relapse is a common experience among sex addicts, and the disclosure of relapse has a range of consequences for addicts and their relationships, however, voluntary disclosure of relapse (rather than the partner discovering relapses independently) has been found to be associated with positive relational outcomes (Corley, Pollard, Hook & Schneider, 2013).
Internet pornography’s unique properties (limitless novelty, potential for easy escalation to more extreme material, video format, etc.) may be potent enough to condition sexual arousal to aspects of Internet pornography use that do not readily transition to real-life partners, such that sex with desired partners may not register as meeting expectations and arousal declines which clearly points out the need to work along with partners of those experiencing this compulsive condition (Park, et al., 2016).
Recovering Pornography Addicted Parents’ Role with their Children
Recovering parents have an excellent opportunity to rebuild trust and improve their own relationship by learning to be better parents and by talking to their children about the use and misuse of sexuality. As with all parents, they are responsible for providing structure, guidance, protection, and nurturance for their children. When couples prepare to discuss any valued-based information, theyneed to agree about what to say and both should take responsibility for talking and responding to teachable moments. The couple must take the time to clarify their values about general topics as well as difficult topics like masturbation, use of pornography, what needs to be private about their own lives and history, pre-marital sex and fidelity. Once values are clarified, the couple is able to easily determine the goal and create any planned message they want to send when talking about sexuality, or any other value-based topic. With practice, the message becomes easier and family values emerge as a strength for families in recovery (Corely, 2005).
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12 Step Programs for Pornography/Sex Addicts
Various types of psychosocial treatments are available for individuals suffering from compulsive sexual behaviors. The most widely available and accessible are Sexual Addicts Anonymous, Sex and Love Addicts Anonymous, and Sexaholics Anonymous (Fong, 2006). All three are modeled after 12-step theory and practice, and are available throughout the US. There is almost no data evaluating their efficacy or effectiveness. Nevertheless, participation in these groups is usually recommended because they provide a place for fellowship, support, structure, and accountability, and they are free of charge (Fong, 2006). Supportive communication received through 12-step processes may enable addicts to change their behavior or motivated addicts who change their behavior diligently attend to12-step processes, either way such programs appear to be highly productive (Wright, 2010).
Modes of Treatment Delivery
Behavioral Telehealth, is a comfortable venue for online addicts which conducts psychotherapy using communications technology with which the addicts are quite comfortable with and thus perhaps less resistant to (Putnam & Maheu, 2000).
Greater use of pornography on the Internet may reflect a general vulnerability to compulsive problems related to basic disposition, and that problems associated with this behavior can be managed with generic clinical approaches to obsessional and compulsive disorders with no need to develop unique treatment approaches (Egan & Parmar, 2013).
Whatever modes of treatment used with clients it is important that counselors listen to their clients, create safe space, encourage movement—physical, emotional, mental, and spiritual, and trust their clients to do their own work so that the counselors are not working harder in their therapy than they are (Ogden, 2014).
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