This second example applies the Integrative CBT Case Formulation model to a case example where the main issue is sexual addiction.
Once again, the relevant questions, which follow the 5 Levels of Integrative CBT, are:
How do I best connect with this particular person, and form a therapeutic relationship with them?
What are the immediate problems that need action?
What is the individual psychology/psychopathology of this person? What are their typical cognitive distortions, automatic thoughts, compensatory behaviours, maintaining cycles?
What are the developmental sources of the above difficulties? How does this client see the world, what are their Core Beliefs?
What core human issues are they struggling with?
"Larry" (age 53) came for therapy because his wife had given him an ultimatum. She had found him using Internet pornography yet again, after he had repeatedly promised not to. He was also increasingly neglecting his work as a self-employed architect (there had been less work recently, anyway, so this was also getting him down).
Having been “sent” for therapy because of his “misbehaviour”, Larry was initially mistrustful of therapy and of my role. He was also very ashamed and uncomfortable when it came to talking about the subject of his sexual behaviour. Therefore, the initial therapeutic tasks were to engage with him and form a working alliance, and to project a non-judgmental concern about his situation, normalising it by emphasising its familiarity, while not minimising or justifying. A currently active addiction problem like this may also require a relatively firm and direct stance; the reality of the addictive behaviour and its consequences do need to be discussed openly early on in therapy, as time and options may be running out. For instance, Larry talked about there being other problems in his marriage apart from his pornography use, but we needed to agree to come back to those later.
If negative consequences were reason enough to stop, addiction would not be the problem it is. Ambivalent motivation is central to all addictions (“I wish I wanted to stop, but I actually want to continue to look at porn”), so this would need to be explored with Larry, and some cognizance taken of his current stage on the Wheel of Change (probably somewhere between Pre-contemplation, Contemplation, and Preparation/Determination; see Miller & Rollnick, 2002). The natural negative consequences of continuing the addictive behaviour may need to be revisited here, perhaps in the context of a Cost/Benefit Analysis. With Larry, I would be looking at the threatened loss of his marriage, but also the pain caused to someone he loved, his loss of self-respect, his neglect of his work and other important areas of his life, etc.
As with other disorders, a central reason for the continuation of an addiction, despite the damage it causes, is its Vicious Cycle nature (vicious cycles are central to the Cognitive theory of how psychological disorders are maintained, and will be explored in more detail in a later blog). This insight is at the heart of my own definition of addiction:
A progressively tolerated & progressively damaging
biopsychosocial adaptation to/dependency on
(and therefore preoccupation/obsession with)
the initially intensely mood-altering,
but ultimately only superficially satisfying,
emotional rewards (pleasure and/or pain-relief)
provided by certain artificially-enhanced activities (and their associated rituals),
which require minimal personal investment
(e.g. heroin use, gambling, pornography use, etc)
leading to a self-perpetuating cycle of compulsive behaviours in some of the above areas,
which the addicted person sometimes tries to control, with limited success,
when crisis points are reached
(including the crisis of withdrawal,
but also in response to serious negative consequences
in such areas as health, relationships, finances, employment, legal problems etc),
but which they otherwise resist acknowledging by using
various cognitive-emotional avoidance strategies (distortions/defenses).
A discussion of what it means to be addicted is often essential in this kind of work, and runs through all five levels of Integrative CBT (initial naming of issues, realistic action-planning, cognitive-emotional restructuring, facing underlying issues, understanding addictive human nature). If the addicted client is to make any real progress, their individual rituals, distortions, preoccupations, settings, triggers etc, need to be explored and owned in scrupulous detail. For Larry, some of these would be: being on his own in the house, being stressed and irritable, having the laptop already switched on for other purposes, looking forward to using porn all day, telling himself he deserves it, etc. All of these factors will need to be explored, challenged and changed to some degree in order for Larry to gain freedom from his compulsive behaviour.
It is not always the case that there are underlying dysfunctional core beliefs in cases of sex addiction, but it is certainly common (see Carnes 2001, and my Masters thesis at this link). Typically, we might expect maladaptive schemas in areas such as Abandonment, Shame/Self-hate, Entitlement, Mistrust etc. These are likely to have their roots in such early experiences as family alcoholism, violence or abuse, neglect or bullying. Larry’s story was one of alcoholism in both parents, along with depression in his mother, and bullying from elder siblings. His core beliefs certainly made sense in the light of his early learning experiences.
These areas need to be explored, but may be too delicate to work on until there is some stability in recovery.
Of all the issues that I have worked with, one of the most shameful for many people is Sexual Addiction. This is partly due to its associations with perversion and sexual offending, but also arises from beliefs about the “dirtiness” of sexuality itself (a legacy of many Irish Catholic childhoods).
Understanding and humanising the behaviours, thoughts and feelings involved in sexual addiction is not the same as giving permission for the damaging behaviours. But, unless Larry is helped to understand how his addiction has its roots in the nature of human (male) sexuality, his recovery may remain lacking in self-acceptance and humanity.
Carnes, P. J. (2001) Facing the Shadow: Starting Sexual & Relationship Recovery. Wickenburg, AZ: Gentle Path Press
Miller, W. R. & Rollnick, S. (2002) Motivational Interviewing: Preparing People for Change. New York: Guilford.