Out-of-control sexual behaviour was documented as early as the 3rd century by St Augustine and later from the mid-18th century by medical pioneers such as Benjamin Rush (1745–1813) and sexologist Richard von Krafft-Ebing (1840–1902). Krafft-Ebing observed one patient suffering:
To such an extent that permeates all his thoughts and feelings, allowing no other aims in life, tumultuously, and in a rut-like fashion demanding gratification and resolving itself into an impulsive, insatiable succession of sexual enjoyments. This pathological sexuality is a dreadful scourge for its victim, for he is in constant danger of violating the laws of the state and of morality, of losing his honor, his freedom, and even his life. (Krafft-Ebing, 1886) (in McKinney, 2014)
Definition of Compulsive Sexual Behaviour Disorder (ICD-11)
Compulsive sexual behaviour disorder (CSBD) is characterised in the ICD-11 (International Classification of Diseases, 11th Revision, World Health Organization, 2018) as,
“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.”
The classification of Compulsive sexual behaviour disorder as an impulse control disorder is being debated. Some in the DSM camp, that has not classified this disorder, argue that hypersexuality is more related to addiction than compulsion. We can consider both arguments to be true.
Diagnostic requirements (ICD 11) are as follows:
- A persistent pattern of failure to control intense, repetitive sexual impulses or urges resulting in repetitive sexual behaviour, manifested in one or more of the following:
- Engaging in repetitive sexual behaviour has become a central focus of the individual’s life to the point of neglecting health and personal care or other interests, activities and responsibilities.
- The individual has made numerous unsuccessful efforts to control or significantly reduce repetitive sexual behaviour.
- The individual continues to engage in repetitive sexual behaviour despite adverse consequences (e.g., marital conflict due to sexual behaviour, financial or legal consequences, negative impact on health).
- The person continues to engage in repetitive sexual behaviour even when the individual derives little or no satisfaction from it.
- The pattern of failure to control intense, repetitive sexual impulses or urges and resulting repetitive sexual behaviour is manifested over an extended period of time (e.g., 6 months or more).
The patient is not considered to be diagnosed with CSBD if:
- There is another mental disorder that can better explain the behaviour, e.g. mania, or if the patient’s behaviour is due to drug use or medications.
- The personal and relational distress experienced is due to moral judgement and societal disapprovements.
Variations of Compulsive Sexual Behaviours and Sex Addiction
There are controversies surrounding labelling behaviours as CSBD and debate over whether the behaviour should be considered a disorder or a moral judgment. Sexual habits become disordered when the relationship to the behaviour becomes a problem to the individual’s life. Compulsive sexual behaviours include dysfunctional pornography use, excessive use of sexual services, chem sex, and sexual acts done indiscriminately with consenting or non-consenting others.
Life Consequences caused by CSBD
Patients who arrive to therapy seeking help to overcome CSBD reveal how seriously their compulsive sexual habits affect their personal lives. They seek therapeutic intervention on their own accord or through the advice or demands from loved ones.
- Loss of jobs due to porn use at work
- Legal issues
- Damaged intimate relationships
- Negatively affected social standing
- Diminished libido
- Sexually transmitted diseases
- Sexual dysfunction
- Escort /sex-worker engagement
- Substance abuse
- Physiological issues, e.g. insomnia
- Social isolation, anxiety, depression, self-harming behaviours.
Who are at risk of developing CSBD?
Many individuals with CSBD report having experiences of acting out during pre-adolescence or adolescence, engaging in risky sexual behaviour, masturbation and using explicit material to cope with emotional challenges.
Other factors that have been found to increase the risk of developing CSBD are:
- Early exposure to sexually explicit material.
- Early onset of internet use.
- Childhood sexual abuse.
There are gender differences associated with CSBD:
- Most clients who report having CSBD are men of all sexual orientations.
- Women with CSBD usually label themselves as “love addicts”. They are more likely to report having experienced sexual abuse at an early age.
How Addiction to the Compulsive Sexual Behaviour Starts
Hall (2018) categorized broadly the processes in which sexual addictive behaviours are induced in individuals. We can consider that the individual may be influenced through one or more induction processes.
- Opportunity-induced: with internet pornography accessible with just a mouse click, it becomes the cheapest, lowest-hanging self-soothing treatment choice. Several clients who are addicted to hiring escorts or sex workers report having lived in proximity to brothels and within sex districts as children.
- The Trauma-induced: children and pre-adolescents discover masturbation as a means of self-soothing and coping with anxiety-triggering home environments.
- The Attachment-induced: the child learns to cope with loneliness due to percieved neglect or abandonment by primary care-givers by self-gratifying and living in their sexual fantasies. These children are also more likely targets of grooming by sexually-predatory adults.
The psychotherapeutic approach to CSBD treatment needs to be holistic since the source of addictive sexual behaviour is multi-factorial.
How Addictive Behaviour is Reinforced
Psychotherapy with clients dealing with addictions is primarily about getting roadblocks out of the way. These roadblocks impede the client’s ability to break the cycles of addiction. If the client cannot break the cycle, the addiction is reinforced.
Addictive behaviours oscillate between the individual’s need for control or release, in a flip-flop between extreme states of euphoria and despair, avoidance and surrender, self-punishing (guilt) and exhaustion (shame).
Hall (2018) also introduced the six-phase cycle.
The Compulsive Sexual Behaviour Disorder cycle is repetitive, rendering the patient helpless to stop the habit.
This is the compulsion cycle.
There lies in going through this cycle repeatedly, painful feelings of deep-seated guilt and shame. The individual with CSBD is particularly likely to suffer this intensely and alone, keeping the habit out of the scrutiny of others for fear of persecution or being made to halt the habit.
The way out of this psychological pain is for the psyche to form cognitive distortions, like rationalizing, justifying, minimizing the impact, magnifying the need, blaming others and situations for causing them to be addicted, and feeling entitled/deserving of the pleasure, denying the gravity of the behaviour and its potential dangers.
Comorbidity with other Psychiatric Disorders
A recent study in Spain showed that over 90% of CSBD participants met the criteria for at least one Axis I disorder, compared to 66% of non-CSBD participants. CSBD participants were more likely to report an increased prevalence of alcohol dependence (16.2%), alcohol abuse (44%), major depressive disorder (39.7%), bulimia nervosa (5.9%), adjustment disorders (20.6%), and other substances –mainly cannabis and cocaine– abuse or dependence (22.1%). The prevalence of borderline personality disorder was significantly higher in CSBD participants (5.9%). (Ballester-Arnal et al., 2020).
Neural Correlates of Compulsive Sexual Behaviours
Voon et al. (2014) provide a study of the neurobiology of CSBD in this article.
Through fMRI brain imaging comparison studies of CSBD and healthy subjects, they were able to draw the following confirmation and conclusions:
- That the neural circuits that govern the reward processing in compulsive sexual behaviour and substance dependency overlap.
- That the CSBD group, compared to healthy individuals, had higher “desire” but similar “liking” scores when exposed to explicit sexual material.
- Exposure to sexually explicit cues in CSB compared to non-CSB subjects was associated with activation of the dorsal anterior cingulate, ventral striatum and amygdala.
- Functional connectivity of the dorsal anterior cingulate-ventral striatum-amygdala network was associated with subjective sexual desire (but not liking) to a greater degree in CSB than non-CSB subjects.
In CSBD subjects, there is evidence of a dissociation between desire (or wanting) and liking towards sexually explicit material. This split is a consistent phenomenon associated with drug addictions.
“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 the biological craving in the brain” and is not correlated with high sex drive (Hall, 2018, p. 7). The motivation for such behaviour is to dissociate oneself from reality and the painful feelings that are present in it.
This demonstrates the splitting that exists in subjects with CSBD.
Gestalt Therapy for Treatment of Compulsive Sexual Behaviour Disorder
Considering the conditions and phenomena around CSBD, Gestalt therapy is arguably a model psychotherapeutic method for treating CSBD. Gestalt therapy, more evident than other modalities, directly addresses intra-psychic splitting mentioned in the above section. Therapeutic work revolves around integration. Integrative Gestalt therapists adopt a holistic approach when working with clients.
Gestalt Awareness Continuum approach and Contact Interruption in CSBD
Dissociation points us to realise the impact of trauma, particularly childhood trauma, on clients.
In Gestalt Therapy, we stay in contact with the client by being attentive to the interruptions in the contact cycle. This therapeutic philosophy is more effective than trying to get the client out of or breaking the compulsion cycle. This is the way to therapeutic change, even though the client who is desperate to break the cycle may not appreciate this.
The Therapeutic Contact begins before the Beginning.
This is also known as the pre-contact phase.
Clients approaching us for therapy may or may not pose CSBD as a presenting issue. There are possible reasons for this:
- There are more pressing issues that are at the forefront of their minds,
- The client is in denial that the habit causes dysfunction,
- The shame of revealing the habit.
- Fear of persecution.
As therapists, we can be alert to the possibility of CSBD being presented to us later in therapy, which happens when the client feels secure enough in the therapeutic alliance.
The first meeting is very important even though its significance is often overlooked or overshadowed by intake matters. This is the point when the therapist encounters the field of the client. It is like the moment we touch a bucket of cold water. The moment before our organism adjusts to the differences. In this pre-contact phase, we sense the client’s existence most acutely as foreign to ours. The fertile void lies amidst this differentiation.
The Paradoxical Theory of Change in the Treatment of CSBD
We acknowledge the sense of urgency when clients approach psychotherapy to “fix” their addictions. The therapist often feels drawn to this strife. Our first instinct is to yearn for a solution, knowing that diving to “solve the problem” is not the solution. Beisser’s (1970) Paradoxical Theory of Change, a cornerstone of Gestalt therapy theory, becomes an invaluable resource. Biesser adds, “(b)y rejecting the role of change agent, we make meaningful and orderly change possible.”
This does not mean therapists do not care if the client overcomes the addiction. We do, as that is the working contract. It means that therapists do not position themselves as the “maker of change”.
The client overcomes an addiction, and in this case CSBD, in a therapeutic change process of self-actualization. Self-actualization is the holistic embodied shift a person experiences almost unconsciously, sometimes spontaneously. This phenomenon happens with clients in therapy for a period of time. Perls explains that we cannot make ourselves self-actualize as it is not an active process:
[W]e realize that we cannot deliberately bring about changes in ourselves or in others. This is a very decisive point: Many people dedicate their lives to actualize a concept of what they should be like, rather than to actualize themselves. This difference between self-actualizing and self-image actualizing is very important. Most people only live for their image. Where some people have a self, most people have a void, because they are so busy projecting themselves as this or that. This is again the curse of the ideal. The curse that you should not be what you are. (Perls, 1969 p.39)
As Gestalt therapists, we are aware of this change process. Our work is to support change through working with the client. The client self-actualizes within the field of the therapeutic relationship. Changes in the field actualize the field, bringing about change to the individuals within it.
Psychopathology is a Phenomenological Process in Gestalt Therapy
Psychopathology is a process. It is not the same as using a diagnostic manual and questionnaires to diagnose a patient and then telling the patient what ailment they suffer from.
Psychopathology is process.
Psychopathology relies upon the following:
- Observing while avoiding theoretical explanations, presuppositions and prejudices, confining ourselves to the presenting phenomenon in the therapeutic encounter, and
- The attempt to use empathy as a clinical instrument ‘to recreate in the psychopathologist the subjective experience of a patient to obtain a valid and reliable description of his experience.’ (Stanghellini & Fuchs, 2013, p. xviii)
Psychopathology is conceptualised as a process in psychotherapy of bringing to light and making palpable the essence of the suffering of the client. It is through this “en-lightening” or illumination process that therapeutic change can be effected. This process is integral to therapy. It is the therapeutic contract, exists in the therapeutic alliance, and is responsible for therapeutic change.
Gestalt therapy engagement in the phenomenological field persuades the therapist to focus on the process of psychopathology and to perceive the atmosphere of the co-created field of the therapy situation. Through this process, we uncover pathos and painful emotions from trauma while being present with the clients in the here and now. In working with clients with CSBD, this process is crucial for understanding/validating the underlying triggers and suffering the client avoids through addiction.
Shame, Guilt, Despair and Helplessness in the Co-created field
CSBD suffer the pain of shame due to their condition more than any other addicts. Working through shame is fundamental to therapeutic work and is even more crucial when clients struggle with CSBD.
Working with shame in therapy, there needs (Yontef, 1996),
- Empathic understanding of the patient’s experience with shame
- Assist the client in understanding this experience fully.
- Showing warm understanding, acceptance and respect.
- To heal shame, the therapist must understand shame. The therapist must understand this in the context of the patient.
- The therapist must be committed to dialogue (Buber, 1970/1936).
- Hold the client in unconditional positive regard.
Shame is an emotion that holds together the therapeutic alliance when brought into the open. It becomes part of the co-created field. Despair, on the other hand, threatens to break the alliance. This is especially so in work with addictions. Despair is the feeling of resignation and disappointment, especially when relapses happen. Resignation is the sense that there is no hope of resolving the problem, followed by disappointment in the therapy. Recognizing the possibility of despair early in the therapeutic process is helpful.
Creative Indifference as Central Attitude when working with CSBD
Salomo Friedlaender’s “Creative Indifference,” also known as “Schöpferische Indifferenz,” was published in 1918 and is considered a seminal philosophy of Gestalt therapy. Creative Indifference incorporates philosophical values that serve as the bedrock for humanistic psychotherapy approaches like Gestalt therapy:
- “Creative” = to make something exist out of a void.
- “Indifference” = to be unbiased, to be present without agenda.
- Holism = to perceive wholes as more than the sum of parts.
- Inter-subjectivity = the co-creation of the field.
- Intentionality (including creative will and decision-making), and
- Nondualism (emphasising exemption from isolation).
- The Creative pathos.
- Creative relatedness.
- Authentic self.
Polarities as depicted in Zinker (1977).
These values ground the therapist working with CSBD clients. The nature of the pathos in CSBD is compulsivity, guilt and shame, alternating with bouts of despair and helplessness. These feelings exist within the co-created therapeutic field. The therapist will experience these feelings. It is the work of the therapist to willfully attune to the phenomenon of the field and to grasp the feelings that exist in the atmosphere of the therapeutic situation. Creative indifference acknowledges a fertile middle point between polarities (and differences) where contact exists.
CSBD is a complex psychological and physiological challenge to work with clients through in psychotherapy. Shame is an individual’s predominant experience with the disorder, leading many clients to avoid the subject at the beginning of therapy. A contactful therapeutic alliance built on solid footing initiates the treatment process.
The therapeutic change process is organic and progressive. Focussing the work on the abstinence of behaviour alone does not promise a positive outcome of treatment. Therapeutic change depends on the ability of both client and therapist to stay with the process and have the patience and faith to see through cyclical moments of complicated feelings of shame, guilt, and despair. This involves trauma work as well. Feelings of despair usually cause either party in the alliance to give up on the work. The client may despair upon relapse, and the therapist may feel helpless when confluent with the client.
CSBD is a diagnosis categorized only recently in the ICD-11. Having CSBD defined in diagnostics is crucial to recognising and treating the disorder. Clinical diagnosis alone, however, is useless to the therapist. The therapeutic process involves the unearthing of the pathos /or suffering/ trauma that underlie the symptoms. This is the process of psychopathology, which requires sensitivity to uncover and make graspable these feelings, or pathos. Following which, something shifts in the system.
Gestalt therapy engages the phenomenon of the co-created field. This is an ideal philosophy for treatment as it is in the field that the psychopathology in the field comes to the foreground and is witnessed. This works best in the treatment of CSBD, since the behaviour is a dissociative, self-soothing mechanism, which can be “unlocked” only when the client is able to grasp the mental suffering from which they are soothing themselves with the behaviour.
Case Study of “John”
Case study of “Businessman John” 40, was presented in the talk on 4 Mar 23 to DRM (Derimu) Psychological Education, 德瑞姆无形完形俱乐部, China (https://www.deruimu.com/).
Ballester-Arnal, R., Castro-Calvo, J., Giménez-García, C., Gil-Juliá, B., & Gil-Llario, M. D. (2020). Psychiatric comorbidity in compulsive sexual behavior disorder (CSBD). Addictive behaviors, 107, 106384
Beisser, A. (1970). The paradoxical theory of change. Gestalt therapy now, 1(1), 77-80.
Buber, M. (1936/70). I and Thou. Kindle ed. (W. Kaufman, Trans.) Charles Scribner’s Sons.
Frambach, L. (2015). Philosophie, Mystik, Psychotherapie. Die Bedeutung Salomo
Friedlaenders für die Gestalttherapie. In D. T. L. Frambach (Ed.), Friedlaender /
Mynona und die Gestalttherapie. Das Prinzip “Schöpferische Indifferenz. EHP.
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.
Lee, R. G., & Wheeler, G. (2013). The voice of shame: Silence and connection in psychotherapy. Gestalt Press.
McKinney, F. (2014). A relational model of therapists’ experience of affect regulation in psychological therapy with female sex addiction (Doctoral dissertation, Middlesex University/Metanoia Institute).
Perls, F. (1969/1992). Gestalt Therapy Verbatim. The Gestalt Journal Press. Kindle Edition. (p. 93)
Stanghellini, G., & Fuchs, T. (2013). One century of Karl Jaspers’ general psychopathology. (G. Stanghellini, & T. T. Fuchs, Eds.) Oxford University Press.
Voon, V., Mole, T. B., Banca, P., Porter, L., Morris, L., Mitchell, S., … & Irvine, M. (2014). Neural correlates of sexual cue reactivity in individuals with and without compulsive sexual behaviours. PloS one, 9(7), e102419.
World Health Organization. (2018). International Classification of Diseases, 11th Revision. URL: https://icd.who.int/browse11/l-m/en#/http%3a%2f%2fid.who.int%2ficd%2fentity%2f334423054
Yontef, G. (1996) Shame and guilt in Gestalt Therapy. In R. Lee & G. Wheeler (Eds) The Voice of Shame. San Francisco: 390. pp. 370-371.
Zinker, J. (1977). Creative process in Gestalt therapy. Brunner/Mazel.