14 RESEARCH HEALTHCARE Counselling and Psychotherapy Jour.docx

14 RESEARCH HEALTHCARE Counselling and
Psychotherapy Journal October 2018
SEX ADDICTION:
THE SEARCH FOR
A SECURE BASE
JOANNA BENFIELD PROPOSES AN
ATTACHMENT-BASED APPROACH
TO WORKING WITH
SEXUAL COMPULSIVITY
UNDERSTANDING SEX ADDICTION
For many therapists with no specialised
training in psychosexual therapy or
addiction treatment, a client’s
pronouncement that they are a sex addict
might cause alarm bells to ring. A number
of questions are likely to spring to mind:
does such a diagnosis actually exist? If it
does exist, how do we recognise it? And,
what is the most effective way of treating it?
The jury is still out on whether sex
addiction can be seen as a true addiction
or even mental disorder. The World
Health Organisation recently included
‘compulsive sexual behaviour disorder’
as an impulse-control disorder in the
International Classification of Diseases
(ICD-11),1 but the American Psychiatric
Association failed to recognise sex

addiction in the latest version of the
Diagnostic and Statistical Manual of
Mental Disorders (DSM-5).2 There was
disappointment among many sex addiction
therapists at this omission from the DSM-5
as, on a daily basis, they come face to face
with individuals who suffer greatly as
a result of their out-of-control sexual
behaviour. For some clients, this might take
the form of prolific pornography use, while
for others, it might be weekly visits to
escorts or a never-ending stream of
one-night stands. It is not the behaviour
per se that is the marker of sex addiction,
but rather the negative impact that it has
on the individual’s life. For these clients,
rather than being a pleasurable experience,
sex is used compulsively to relieve
negative emotional states and, as a result,
often causes significant distress.3 Despite
this distress, they feel unable to stop the
behaviour. Clients usually only walk into
the therapist’s consulting room once the
addiction has become completely
unmanageable, for example because it
has resulted in loss of employment due
to pornography use on work computers,
financial ruin due to numerous escort
visits or marriage breakdown due to
multiple affairs.
Whether or not we wish to use the term
‘sex addiction’, or prefer to refer to this
as out-of-control sexual behaviour,
hypersexuality or sexual compulsivity,
what is clear is that it poses a significant

problem for an ever-growing number
of people. The availability of free online
pornography and ‘hook-up’ apps has
done nothing to alleviate the problem.
We are likely, therefore, to see an
increasing number of clients walking
through our doors for whom out-of-control
sexual behaviour causes mental and
emotional distress.
Most sex addiction treatment strategies
are based on a cognitive-behavioural
approach.4 Sex addiction therapists will
typically work with clients to help them
to identify their addiction cycle, recognise
the triggers for acting out, understand the
harmful consequences for them and those
around them, uncover the core beliefs that
fuel the behaviours, and put in place a plan
for sobriety, eventually resulting in the
development of a healthy relationship
with sex. This approach has proven very
effective. However, it may be that it
overlooks a particularly important aspect
of sex addition.
THE RELATIONSHIP BETWEEN SEX
ADDICTION AND ATTACHMENT
Increasingly, addictions are being
recognised as attachment disorders.5
Studies across a range of different substance
and behavioural addictions have shown
addicts to be more likely to have an insecure
attachment style than non-addicts.5 A small
number of studies have focused specifically
on the relationship between insecure
attachment and sex addiction.6–8 In these

studies, over 90 per cent of sex addicts
15 RESEARCH
My study, which has been published in full
in the Journal of Sexual Addiction and
Compulsivity,15 identified three common
overarching attachment themes in the
therapists’ work: (i) regulating closeness
and distance in the therapy room; (ii) affect
regulation; (iii) risking connection in the
outside world. The remainder of this article
explores how each of these themes might be
addressed when working with sexually
addicted clients. I also provide a clinical
vignette to demonstrate how I have
integrated these findings into my own work.
REGULATING CLOSENESS AND
DISTANCE IN THE THERAPY ROOM
As a result of their insecure attachment
style, sex addicts generally lack the ability to
enter into close, intimate relationships with
other people. Due to their attachment
history, such relationships seem fraught
with danger and the addict therefore
keeps people at arm’s length. While these
individuals may seem to have close family
and friends, their addiction prevents true
intimacy, as it is kept hidden through
continual lies and deception. At the same
time, these clients may engage in intense
sexual relationships with people with whom
they have no real attachment, allowing them

a brief semblance of connection without the
attendant danger of real intimacy.
Bearing this in mind, the idea of entering
into an intimate therapeutic relationship
can seem overwhelming and dangerous for
the sex addict. They may well have come to
therapy as a result of an ultimatum from a
distraught partner who has discovered the
addiction. It may, therefore, prove very
difficult to create a therapeutic alliance with
them. These clients are likely to shrink away
from all attempts at truly getting to know
them; they may end therapy prematurely
or miss sessions without warning. It is
important to remember that they are often
caught in a paradox: they are longing to get
close, in order to have their pain soothed
by another, and yet closeness feels so
dangerous that they dare not approach.
The therapist, in turn, is faced with a
conundrum; they need to be able to draw
close to their client in order for the real work
to begin, and yet in doing so, they may scare
the client away.
The therapist must therefore attempt to
meet the client where they are, rather than
where the therapist may want them to be.
In order to do this, they will need to work
sensitively in the here and now of the
therapeutic relationship, looking out for
any openings for connection, however
miniscule these may be. This may be slow,
painstaking work.
AFFECT REGULATION
One of the most important advances in

attachment theory over the past few
decades has been the understanding that it
is a theory not only about relationships but
also about affect regulation.16 We develop
our models for affect regulation at a very
early age, with infants programmed to seek
out attachment to their primary caregivers.
The caregiver’s role is to soothe the infant’s
emotions and help them to self-soothe. If
they fail in this task, the individual does
not learn how to adequately regulate their
own emotions and also cannot turn to
others for emotional regulation. Instead,
they look outside themselves to control
their emotional state, and drugs, alcohol,
food, gambling and sex can all step in to
fill this void.
The role of the therapist is, therefore, to
help the client to understand that they are
capable of experiencing and regulating their
emotions, rather than acting out in order
to escape them. The first challenge for the
therapist in this process is that sex addicts
often suffer from alexithymia and are
unable to identify their emotions, having
cut themselves off from them at an early
age. Somatic awareness is a key route to
reconnecting the client with their emotional
state, helping them to focus on what they
feel in their body. The therapist will need to
pay close attention to the client’s somatic
cues and draw attention to them, helping
them to move firstly towards self-awareness
and then to self-regulation, for example
through breathing and relaxation exercises.
Affect regulation has two complementary

parts: self-regulation and co-regulation.
In order to help the client experience
co-regulation, the therapist will need to be
attuned to their own thoughts, feelings and
bodily sensations, using them as a compass
for how the client might be feeling. For
example, if the client is in an anxious state,
breathing shallowly, the therapist can adjust
‘The jury is still out on whether sex
addiction can be seen as a true
addiction or even mental disorder’
displayed an insecure attachment style.7,8
This is in marked contrast to the population
at large, where under 45 per cent of
individuals are insecurely attached.9,10
If addiction is viewed as an attachment
disorder, then perhaps there is some merit
in considering the place of attachment in the
treatment of addiction. Some researchers
have certainly recognised the value of such
an approach, arguing for attachment-based
treatment approaches to substance abuse,11
alcohol abuse12 and gambling disorder.13
However, to date, very little work has been
done on the relevance of an attachment-
based approach to the treatment of sex
addiction (with the exception of an excellent
book by Alexandra Katehakis).14 In order to
discover more about how such an approach
might work, I decided to interview six sex
addiction therapists in the UK, the US and
Australia who include a focus on attachment
dynamics in their work with clients
suffering from sexual compulsivity. I

analysed the interview data to explore
whether there were any common themes
or approaches in the therapists’ work
that might form the basis of a tentative
attachment-based approach to treating
sexual compulsivity.
16 BEST PRACTICE HEALTHCARE Counselling and
Psychotherapy Journal October 2018
their own breathing and help to ground
the client. As the client learns how to
experience both co-regulation and
self-regulation, their need for addictive
behaviours lessens.
RISKING CONNECTION IN THE
OUTSIDE WORLD
Achieving a connection with the client
in the therapy room is only the first step
towards secure attachment. For change to
really occur, this new way of relating then
has to be transferred to the outside world.
The addict has used their addiction as a
replacement for close relationships; if
they are to truly recover, they will need to
begin to forge relationships, trust others
and maintain an emotional connection
with them.
Groupwork plays a key role in helping
recovering sex addicts to risk connection
in the outside world. In group, whether it
be a 12-step group such as Sex Addicts
Anonymous (SAA) or a therapeutic
community for recovering sex addicts,

the addict learns to reveal who they are
underneath the false exterior. Being in
the presence of others in similar positions,
they learn that they can disclose the more
shameful parts of themselves without
humiliation. They receive understanding
from other group members, who can share
their experiences. Secure attachments
begin to form between group members,
many of which may become enduring
bonds that last a lifetime.
The couple relationship often comes into
crisis as a result of sex addiction being
uncovered. The partner may experience
trauma as a result of discovering that their
life with their spouse is based upon lies and
deception. They may feel that they don’t
know their partner at all. They may need
individual therapy, and the couple, if they
decide to try to mend the relationship, will
also need to engage in couples’ therapy.
If sex addiction is found to be predicated
upon attachment ruptures in early
childhood, part of the therapeutic work
may need to focus on healing these
traumatic attachments in the present.
Attachment traumas might include
rejection, abuse, abandonment and
neglect. It is vital to obtain a comprehensive
history of the client’s attachment patterns,
both as a child and adult, as well as
exploring any attachment trauma within
the wider family. The therapist will need
to help the client work with attachment

traumas in order to grieve loss, as well as
to repair relationships, where this is
relevant. This can allow the client to
revise their internal working models,
both of themselves and of others, enabling
them to risk intimacy and move towards
developing more securely attached
relationships.
CASE STUDY: JAKE
When Jake entered my therapy room,
he appeared stiff and formal. He sat up
straight in his chair and refused to make
eye contact. He told me that his wife, Sarah,
had insisted that he come for therapy. As
I tried to probe gently into what he might
want from our work together, he appeared
at times defiant, professing that he did
not need help, while at others defeated,
muttering that he was beyond help. In our
early sessions, I sometime doubted that we
would ever be able to form a therapeutic
alliance, but I sat listening to him quietly
and non-judgmentally and, little by little,
he began to let me see him. I was careful
to go at his speed and not try to get too
close too quickly.
It took a few sessions for Jake’s story of
addiction to unfold. He explained to me that
Sarah had opened a letter from the bank
and discovered that they had defaulted on
their mortgage repayments. The bank was
on the verge of repossessing the house.
When Sarah confronted Jake, he pleaded
ignorance, but as Sarah uncovered more

evidence of their financial situation and his
exorbitant spending, he eventually broke
down and admitted to her that the money
had been spent on strip clubs, prostitutes
and gambling. Sarah had gone into deep
shock and depression. As Jake gradually
revealed all this to me, I listened to him
without judgment, showing him that I could
bear the weight of his admissions without
also being shocked. This was the beginning
of modelling a new attachment experience
for him.
I began the work with Jake with the
traditional CBT tools, helping him to
put into place a plan for managing his
addictive behaviours, identifying triggers,
challenging unhealthy thought processes,
and replacing the acting out with new
healthy behaviours. As we worked together
in this very practical way, I sensed his trust
in me growing. I was able to recommend
local Sex Addicts Anonymous (SAA) and
Gamblers’ Anonymous (GA) groups, which
Jake soon began to attend on a weekly basis.
Although the recovery went well in the first
few months, Jake would come to some
sessions on the verge of acting out. We
would try together to identify the emotional
triggers. In one session, I noticed a hollow
feeling in my stomach, which did not seem
to relate to my own emotional state. I told
Jake what I was sensing and wondered
whether it seemed pertinent to our work.
He was quickly able to identify a similar

sensation in his own body and together
we were able to name it as loneliness.
Recognising and naming his emotions
was a new process
for Jake, and one
which he found
very uncomfortable.
I taught him some
mindfulness
techniques which
helped him to
acknowledge and
accept his emotions
without acting out.
We also discussed
how connecting with
some of the people he
had met in SAA might
help to alleviate the feeling. Jake also had
to learn how, when he was experiencing
difficult emotions in the relationship, he
could allow himself to be vulnerable and
discuss them with Sarah, rather than
running away and seeking solace in sex
and gambling.
‘The addict has used their addiction as a
replacement for close relationships; if they are
to truly recover, they will need to begin to forge
relationships, trust others and maintain an
emotional connection with them’

17BEST PRACTICE
As our relationship strengthened, I was
able to take a full attachment history,
with a view to identifying and working
on attachment trauma. Jake’s father had
suddenly disappeared when he was three.
His mother sank into depression and so
neither parent was available to help soothe
his distress. His older brother had a stash
of porn magazines, which Jake discovered
when he was 13. Soon, he found that looking
at the magazines and masturbating
helped to ease his sense of loneliness and
insecurity. As Jake grew up and went to
work in the City of London, visits to strip
clubs and escorts seemed the norm among
his colleagues, who also drank heavily.
Jake soon found that any difficulty in
his professional and private life could be
effectively obliterated with a potent mix
of sex, alcohol and gambling. When he met
Sarah, he vowed to himself that he would
stop. He was successful until they had
their first argument, at which point he
immediately turned back to his old habits in
order to soothe himself. This then became
his normal way of dealing with any problem
in their relationship, particularly after their
son, Sam, was born and Sarah no longer
seemed to have any time or energy for Jake.
As a result of his attachment history, Jake
had developed an internal working model
that he was not good enough (after all, his
father left him) and others were unreliable
(neither his mother nor his father were

there to ease his pain). After many months
of work, Jake decided that, as part of his
recovery process, he wanted to make
amends with his mum, from whom he was
estranged, understanding that she had
done her best under difficult circumstances.
Much of Jake’s concern within therapy
was the restoration of his relationship with
Sarah. She had entered individual therapy
and, six months into their work, both of
them decided that they were ready for
couples’ therapy. I referred them to a
couples’ therapist who specialised in
treating sex addiction. Even though Sarah
had been unaware of the addiction, it had
pervaded their relationship from the start.
Both of them had to relearn how to be in
relationship with each other without the
addiction present, to form a secure
attachment. The couple work centred on
rebuilding trust, re-establishing sexual
intimacy and emotional co-regulation.
Eighteen months later, Jake and I still see
each other on a weekly basis, and he still
attends weekly SAA and GA meetings. He
and Sarah have repaired and strengthened
their relationship, and Jake is no longer
acting out. Sarah is now pregnant with their
second child, and Jake and I are exploring
how this shift in the family may once again
trigger difficult emotions. This time, Jake is
armed with the emotional resilience and
communication tools that will hopefully
allow him to manage the transition without
seeking solace in sex and gambling. For

Jake, the addictions had indeed been a
misguided search for a secure base.
CONCLUSION
An attachment-based approach to sex
addiction treatment provides the client
with a new attachment experience within
the therapy room, which they can use
as a model for forging new types of
relationships in the outside world. It is a
two-person, immersive process that occurs
at a physical and emotional level. This
approach requires a complex array of
individual therapy, couples therapy (if the
client has a partner) and group therapy. It
is long-term work and this can be one of the
greatest challenges for the addict. These
clients are used to seeking an immediate
response to difficult emotions, a response
that prevents them from ever having to
feel their emotions too deeply. Therapy
is difficult for them because it is a slow,
painful process, in which they are brought
face-to-face with their emotions in order
that they learn that they can face them
and feel them without the need to act out.
This article first appeared in the September
2018 issue of Private Practice, a quarterly
journal published by BACP. ©
Joanna Benfield is a psychosexual and
couples’ therapist in private practice in
Kingston upon Thames. She has an MA
in counselling and psychotherapy and a
postgraduate diploma in psychosexual
and relationship therapy. Joanna is
author of Three in a Bed: Conversations

with a Sex Therapist and co-editor of the
Routledge International Handbook of
Sexual Addiction. She is a registered
member of BACP and an accredited
member of the College of Sexual and
Relationship Therapists (COSRT).
Joanna is also editor of this journal.
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14 Katehakis A. Sex addiction as affect dysregulation.
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addiction? A thematic analysis of therapists’
experiences of utilizing attachment-informed
treatment strategies to address sexual compulsivity.
Sexual Addiction and Compulsivity 2018; doi
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16 Schore JR, Schore AN. Modern attachment
theory: the central role of affect regulation
in development and treatment. Clinical
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READER RESPONSE
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9. Rosenthal R. J., Lesieur H. R. Self-reported withdrawal
symptoms and pathological gambling. Am J Addict
1992; 1: 150–4.
SEARCHING FOR CLARITY IN MUDDY

WATER: FUTURE CONSIDERATIONS FOR
CLASSIFYING COMPULSIVE SEXUAL
BEHAVIOR AS AN ADDICTION
The debate about whether to classify compulsive sexual
behavior as an addiction continues to evolve. Additional
research is needed to clarify the terminology and diagnostic
criteria used for classification purposes. Data assessing
prevalence and other comorbidities are needed to further
policy, prevention, diagnosis, and treatment efforts.
We recently considered evidence for classifying compulsive
sexual behavior (CSB) as a non-substance (behavioral)
addiction [1]. Our review found that CSB shared clinical,
neurobiological and phenomenological parallels with
substance-use disorders; however, we concluded that more
research is needed in order to address current shortcomings.
The responding commentaries highlight important
issues regarding classification efforts including the lack of
a consensus definition for CSB and disagreement about
proposed criteria central to defining CSB [2]. More research
should examine which proposed criteria – whether those
relatingmore closely to sexual addiction [3] or hypersexual
disorder [4] – accurately reflect CSB in clinical contexts.
Although the two diagnostic categories may conceptually
differentiate between addiction and excessive drive, the
criteria overlap and stress and negative emotionality as
triggers apply to both [5]. More research is needed to better
understand in CSB how central features of addiction (e.g.
tolerance, withdrawal) relate to CSB and its treatment.
Additional concerns included improving research method-
ologies and minimizing possible confounds that may limit
generalizability of studies [2]. Although data suggest that
other behavioral addictions are comorbid with other
psychiatric disorders [6,7], additional research is needed

to determine the prevalence of co-occurring disorders with
CSB [8]. Co-occurring behavioral addictions with CSB
should be considered, particularly if the behaviors are
intertwined (e.g. traveling to resort casinos to engage in
sex and gamble). Further, additional research is needed to
better understand the prevalence of CSB among the
general population.
Additional points were raised regarding the language
used to describe CSB, with ‘risky’ or ‘excessive’ terminology
being potentially misleading. ‘Excessive’ sex may not be
problematic [8]. Instead, sexual behavior leading to
significant functional impairment or psychological distress
maymore likely reflect important clinical hallmarks of CSB.
Applying a more objective approach to developing a
diagnostic framework for CSB may promote advancement.
Objective indicators of distress (e.g. repeated attempts to
quit, craving, etc.) rather than frequency of sexual behav-
iors should be a focus [9], particularly as frequency of
sexual behaviors may not be a strong predictor of CSB [10].
The pathologizing of sexual behaviors falling outside
normative standards or ranges and the evolution of sexual
practices and societal values over time were also discussed
[11]. Notably, changes in usage of digital technologies have
altered sexual behaviors, particularly amongst youth and
young adults. Internet pornography is thriving, casual
sex (‘hook-up’) websites are widely popular, and social me-
diamay act as a sexual conduit formany individuals. These
developments are accompanied by many unanswered
questions [12]. Future longitudinal research is needed to
examine how digital technologies are related to the devel-
opment and maintenance of CSB over the lifespan.
Although the American Psychiatric Association

rejected hypersexual disorder [4] from DSM-5, a diagnosis
of CSB (excessive sex drive) can be made using ICD-10
[13]. CSB is also being considered by ICD-11 [14], al-
though its ultimate inclusion is not certain. Future re-
search should continue to build knowledge and
strengthen a framework for better understanding CSB
and translating this information into improved policy, pre-
vention, diagnosis, and treatment efforts to minimize the
negative impacts of CSB.
Funding sources
This study was funded by support from the Department of
Veterans Affairs, VISN1Mental Illness Research Education
and Clinical Center, the National Center for Responsible
Gaming, and the National Center on Addiction and
Substance Abuse. SWK is a full-time employee of the
Department of Veterans Affairs. The content of this
manuscript does not necessarily reflect the views of the
funding agencies and reflects the views of the authors.
Declaration of interests
The authors report no conflicts of interest with respect to
the content of this manuscript. Dr. Potenza has consulted
for and advised Ironwood, Lundbeck, INSYS, Shire,
RiverMend Health and Opiant/Lakelight Therapuetics;
has received research support from Mohegan Sun Casino,
the National Center for Responsible Gaming, and Pfizer;
has participated in surveys, mailings or telephone consul-
tations related to drug addiction, impulse-control disorders
or other health topics; has consulted for gambling and legal
entities on issues related to impulse-control and addictive
disorders; provides clinical care in the Connecticut
Department of Mental Health and Addiction Services

Commentaries 2113
© 2016 Society for the Study of Addiction Addiction, 111,
2107–2114
Problem Gambling Services Program; has performed grant
reviews for the National Institutes of Health and other
agencies; has edited journals or journal sections; has given
academic lectures in grand rounds, CME events and other
clinical or scientific venues; and has generated books or
book chapters for publishers of mental health texts
SHANE W. KRAUS1, VALERIE VOON2, ARIEL KOR3 &
MARC N. POTENZA4,5
VISN 1 New England MIRECC, Edith Nourse Rogers Memorial
Veterans Hospital, Massachusetts, USA,1 Department of
Psychiatry,
University of Cambridge, Cambridge, UK,2 Department of
Psychology,
Teachers College, Columbia University, New York, USA,3
Department
of Psychiatry, Yale University School of Medicine, New Haven,
Connecticut, USA4 and Department of Neurobiology, Child
Study
Center, the National Center on Addiction and Substance Abuse
and

Connecticut Mental Health Center, Yale University School of
Medicine,
New Haven, Connecticut, USA5
E-mail: [email protected]
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2114 Commentaries
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accuracy of the copy. Users should refer to the original
published version of the material.

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