Compulsive Sexual Behaviour Disorder in Psychotherapy

Compulsive Sexual Behaviour Disorder (CSBD) is also known as hypersexual disorder, and sexual addiction has been included in the World Health Organization’s International Classification of Diseases (ICD-11) #6C72, which indicates the awareness and perhaps the increased prevalence (current estimate is about 5%, and it could be higher) of this condition in today’s society.

Definition of Compulsive Sexual Behaviour Disorder

Classified as a subset of impulse control disorders, CSBD is described in ICD-11 as: characterised by a persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour. Symptoms may include repetitive sexual activities becoming a central focus of the person’s life to the point of neglecting health and personal care or other interests, activities and responsibilities; numerous unsuccessful efforts to significantly reduce repetitive sexual behaviour; and continued repetitive sexual behaviour despite adverse consequences or deriving little or no satisfaction from it. The pattern of failure to control intense, sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more), and causes marked distress or significant impairment in personal, family, social, educational, occupational, or other important areas of functioning. Distress that is entirely related to moral judgments and disapproval about sexual impulses, urges, or behaviours is not sufficient to meet this requirement.

Behaviours associated with CSBD include repetitive sexual behaviour with others or alone, masturbation, the use of sexual services, pornography and cybersex, telephone sex, chemsex and deviant sexual behaviour like voyeurism and taking upskirt pictures, which often gets the sufferer in trouble with law enforcement. The sexual urges are intense, rendering the sufferer helpless at controlling them. The sexual arousal, sexual fantasies and encounters are addictive, taking control of the lives of the person. It is important to note that the behaviours alone do not constitute a problem or an addiction, but the relationship to these behaviours.

Many sufferers report an early onset of impulsive or risky sexual behaviour, beginning during pre-adolescence or adolescence, with a number reporting having stumbled onto and having used porn from an early age. The behaviour often starts off hedonistic, but later on functions as a self-soothing mechanism against mental pain, negative affect, anxiety and depression. The individuals use the high to anaesthetise themselves from feeling negative emotions and emotional pain. The typical porn addict, for example, spends hours online scanning porn sites in an effort to escape reality while keeping themselves in an aroused mental state.

CSBD has consequences for its sufferers and the people close to them. The ramifications range from financial and career failure, breakdown of relationships, sexually transmitted infection and even incarceration. These consequences add to the emotional toll. The shame of having these urges and the potential toll on intimate relationships lead the person to live a parallel secret life, alienating them and crystallising the addiction to the behaviours.

CSBD happens in men and women. While men may report CSBD, women tend to frame the condition as love addiction, often reporting childhood sexual abuse trauma.

Practitioners need to differentiate CSBD from other patients who have feelings of shame and guilt about sexual activity due to moral or religious conditioning, or those who experience fear of consequences resulting from sexual activity. These individuals may inadvertently label themselves inaccurately. It is important for the practitioner to find out if the self-diagnosis is the result of self-judgement, or if there is an impairment.

Some sexual impulses and behaviours are transient. Life transitions and experiences may trigger sexual urges. CSBD should not be diagnosed in individuals who experience only brief episodes of increased sexual activity. One needs to take into account the context in which the person is living before making such a diagnosis.

Practitioners also need to take cultural and religious differences into account when considering this diagnosis.

Differentiation of Compulsive Sexual Behaviour from Sexual Desires and Libido

Patients who suffer CSBD generally complain about suffering sexual dysfunction. We may be able to explain this by considering the dissociative state in which the individual falls into or is on the edge of during the triggers. “Sex and porn addiction are not driven by the physical essence of libido but by the psychological need to satisfy a deeper subconscious urge, or to satisfy biological craving in the brain.” (Hall, 2018) The clients whom I have seen generally encounter sexual dysfunction and low libido.

Neuroscience of Compulsive Sexual Behaviour Disorder

Impulse control disorders as well as addictions appear in brain fMRI scans. In the brains of a sample of individuals who experience CSBD, there appears to be a greater left amygdala grey matter volume and reduced resting state functional connectivity between the left amygdala see and bilateral dorsolateral prefrontal cortex compared to healthy volunteer samples (Schmidt et al, 2017).

Psychotherapeutic Approach to Compulsive Sexual Behaviour Disorder Diagnosis

My therapeutic approach to treating Compulsive Sexual Behaviour Disorder involves a 3-pronged attitude at viewing psychopathology: 

  1. The mono-personal paradigm of diagnosing follows the dominant paradigm of clinical psychotherapy and psychiatry. It views the client’s suffering in isolation and uses third-person descriptive diagnosis and clinical work. This paradigm relies on the client to change independently. The mono-personal approach involves facilitating emotional and sensory awareness, and trauma therapy.
  2. The bi-personal or relational paradigm sees the relationship co-created by the therapist and client, who jointly produce change through their alliance. The therapeutic alliance provides a safe setting for clients to process feelings of shame and guilt experienced.
  3. The field-based paradigm is unique to Gestalt therapy. This paradigm attunes to the atmosphere, sensing the aesthetics of the therapy situation and looking beyond the individuals. Suffering is perceived, and change is co-created. The field-based paradigm requires the therapist to put attention to the “vibe” of the therapeutic alliance. In the atmosphere of the field, the pathos or suffering is felt and brought to the surface.
Figure 1. the three paradigms of psychotherapy and diagnosis

All three paradigms are relevant to the work. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychotherapeutic work with CSBD involves ongoing psychopathology. Psychopathology is the study of the suffering that is the basis of the client’s symptoms. This process is continuing even though a clinical diagnosis has already been made.

Gestalt Therapy understanding of CSBD

CSBD and most compulsive behaviours can be explained as contact interruption due to dissociation. Below is a schematic diagram of the awareness cycle:

An explanation of this concept of the contact cycle of awareness can be found in this article.

In CSBD, the interruption seems to happen as a deflection from sensing, just as the trigger of stimulus is about to be sensed. The individual who is not able to tolerate sensing the stimulus dissociates and the awareness is interrupted.

The dissociation triggers hyperarousal which is a physiological reaction that leads to intense stress which leads to a need for release, which is the compulsive behaviour.

Whenever dissociation is identified, we become aware of trauma, in particular childhood trauma, which the client would need to be worked through in therapy. The effect of dissociating can be described in Gestalt therapy terms as the loss of ground, or being on shaky ground where figural experiences fail to form.

At the heart of the treatment of CSBD is ultimately trauma therapy. To support the process, the client is supported through experiments in awareness and accessing core beliefs. The premise of the therapeutic process is to guide the client out of dissociation and facilitate their awareness in the continuum.

References

Hall, P. (2018). Understanding and Treating Sex and Pornography Addiction: a comprehensive guide for people who struggle with sex addiction and those who want to help them. Routledge.

Schmidt, C., Morris, L. S., Kvamme, T. L., Hall, P., Birchard, T., & Voon, V. (2017). Compulsive sexual behavior: Prefrontal and limbic volume and interactions. Human brain mapping38(3), 1182-1190.

Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.