This document discusses a study examining the relationship between insecure attachment and out of control sexual behavior in men. It provides background on attachment theory, summarizing the work of Bowlby, Ainsworth, Main, and Bartholomew. It then reviews theories of out of control sexual behavior and how recent research has linked it to issues with attachment and affect regulation. The study measured participants' attachment styles and level of hypersexual behavior to examine the relationship between the two. It hypothesized that out of control sexual behavior may be related to early attachment issues and difficulties with emotion regulation, especially for men.

1. Looking for Attachment Solutions in all
the Wrong Places:
Sexual Addiction as a Symptom of
Insecure Attachment in Men
Michael M. Crocker, DSW, LCSW, MA
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2. Learning Objectives
To increase understanding of various theories of
etiology of out of control sexual behavior.
To increase understanding of the developments
in attachment theory.
To increase awareness of advancements in the
understanding of out of control sexual behavior
as it relates to attachment theory.
To increase understanding of treatment
modalities that address the attachment related
issues pertaining to out of control sexual
symptoms.Michael Crocker, DSW, LCSW SAT Project Materials

3. Presentational Model
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4. WORKSHOP OUTLINE
10:00AM Introduction and Overview of Program
10:15AM Sexual Addiction – History, Controversy &
Current Thinking
11:00am Attachment Theory – History and
current thinking
11:30am Men, Attachment Issues, Out of
Control Sexual Behavior
12:00pm Lunch
1:00pm: Study Design and Results
1:30pm: Case Vignette and Group Supervision
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5. A Diverse Audience
 Some of you know Sex Addiction Theory and Intervention
– C.S.A.T. Folks
 Some of you know Attachment theory – theory and
application - EFT folks, AEDP folks, etc.
 Some of you are psychoanalytic students
 Some of you are seasoned psychodynamic
psychotherapists and psychoanalysts
 This workshop will integrate these knowledge bases and
hopefully leave you with something new and as they say
“you can take what works and leave the rest behind.”
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6. Out of Control Sexual Behavior
IT’S EVERYWHERE
THESE DAYS!!
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7. Out of Control Sexual
Behavior? Clinton
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8. Out of Control Sexual
Behavior? Tiger Woods
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9. Out of Control Sexual
Behavior? – Eliot Spitzer
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10. Out of Control Sexual
Behavior? Anthony Weiner
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11. Out of Control Sexual
Behavior? – David Duchovny
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12. Out of Control Sexual
Behavior? Bill Cosby
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13. Out of Control Sexual Behavior
Constantly Front Page News and so we have
the….
Development of…..
Sexual Addiction Treatment Centers
Sexual Addiction Rehabilitation Programs
Certification as a Sexual Addiction Therapist
Considered for the DSMV
Rejected
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14. Out of Control
Sexual Behavior:
It’s everywhere
these days….
THE IMPACT OF
TECHNOLOGY
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15. Multiple
Selves/Compartmentalization
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16. Impulsivity
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17. 463 Feet Away
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18. Anonymity
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19. Out of Control Sexual Behavior
Data on prevalence is scarce
3-6% of the population may suffer with OCSB
No information as to how these authors
obtained that estimate
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20. Historically Controversial
Is it an Addiction?
Is it a Compulsion?
Is it an Impulse Control Disorder?
Is it a Psychobiological Disorder?
Driven Spectrum Disorder?
Hypersexual Disorder?
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21. The DSM V Proposal
Marty Kafka’s proposal
Hypersexual Disorder
 Frequency
 Distress levels
 Consequences of sexual behavior
Rejected
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22. The History of understanding OCSB
Behavior
Prior to 1980s OCSB was Subsumed under
“Perversions”
Patrick Carnes writes Out of the Shadows, 1981
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23. Carnes’ Model
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24. Etiology
Trauma based issue - In a
survey of 233 men and 57
women in recovery for
sexual addiction:
•81% Sexual Abuse
•97% Emotional Abuse
•72% Physical Abuse
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25. Aviel Goodman
It’s a compulsion AND it’s an addiction
Warding off Affect and Getting people high…..so
how about “Driven Spectrum Disorder?
No, thanks.
Never took.
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26. GOODMAN’S THEORY
PARAPHILIC VS NON-PARAPHILIC
(AVIAL GOODMAN, 1998)
Non-paraphilic:
 Out of control sexual behaviors
 Multiple behaviors – pornography, multiple
partners, anonymous sex, etc.
Paraphilic
 Perversions – now called paraphilias
 Specific rituals/objects
 Specific fantasies
 Fixity
 It is NECESSITY FOR AROUSAL
 The arousal is INTENSE
 Often time need psychopharmacological assistance
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27. Goodman Identified Core Psychodynamic Issues that included…..
Ego Weakness from a breakdown in the
separation-individuation process that resulted
in…
 An impaired ability to regulate affect
 An affect tension that feels like a threat to
survival
 And the use of primitive defenses
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28. GOODMAN’S INTEGRATED THEORY…
Looks at core psychodynamic issues
Addresses underlying issues in addiction
Implies character pathology issues that need to be
understood and treated
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29. GOODMAN IDENTIFIED SUPEREGO PATHOLOGY
MANIFESTED AS….
Structural defects or lacunae that…
 Produces guilt BUT NOT controls
 And impairs the approving, caring, self-esteem regulating and
protective aspects of the superego
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30. GOODMAN THOUGHT OF
HYPERSEXUAL BEHAVIOR AS...
A reliance on some sort of external pleasure
producing behavior as an attempt to –
 Regulate emotions/affects
 Repair self-esteem
 Repair narcissistic balance
 Manage aggression
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31. Goodman Identified Deficits in:
Self Care
Self Regulation
Self Governance
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32. Goodman’s Theory
Is Comprehensive
Goes beyond the Cognitive-Behavioral
Model of Carnes
Provides Treatment Suggestions
Did not include any Attachment Theory
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33. Advances in Understanding Out of
Control Sexual Behavior
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34. Out of Control Sexual Behavior as a
Attachment and Regulation Problem
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35. Out of Control Sexual Behavior as an
Attachment Disorder
 Chronic misattunement
 Sympathetic system goes into fight/flight response
 Parasympathetic system is activated to protect the child
from heightened affective state (fight/flight)
 The child looks calmed; however he is actually dissociated
 The repetition of this system impairs regulatory abilities
 OCSB as a strategy of self-regulation
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36. ATTACHMENT THEORY
THERE IS A FINE LINE
BETWEEN THE THEORY
AND THE THEORIST
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37. Bowlby
British Child Psychiatrist
Mother is said to have only attended to him for one hour
per day to prevent him from being spoiled.
Nanny attended to him more consistently, but she moved
on when he was age four.
He later described this as a “tragic loss of a mother”
He was placed in boarding school at age seven
Performed volunteer work with maladjusted children in
his early career
Forty-Four Juvenile Thieves
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38. Ainsworth
Mary D Salter Ainsworth: 1913-1999
Developmental Psychologist
Student of John Bowlby
Conducted research focused on supporting Bowlby’s
attachment theory.
Published works include the “Strange Situation”
experiment, which yielded formulation of the three
attachment styles.
The Uganda Project
The Baltimore Project
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39. Three Attachment Styles
A Style or Pattern NOT a Diagnosis
Secure
Insecure-avoidant
Insecure-ambivalent
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40. Mary Main
Researcher with linguistic background
Identified the fourth attachment style – Disorganized
Develop the Adult Attachment Inventory (AAI)
Translated Ainsworth’s child attachment style to
adult attachment styles
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41. INSECURE ATTACHMENTS
They Are an Exquisite Adaptation…
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42. Adult Attachment Interview
Questions about their early relations with their
parents
Questions to “surprise the unconscious”
Listening for inconsistencies in the narrative
Listening for a coherent narrative
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43. The Berkley Longitudinal Study
Infant-Parent Pairs:
 1978 – Infants in Strange Situation Studies
 1983 – Infants Restudied in Strange Situation
 1983 – Parents Studied through AAI
 1996 – Restudied the original infants through the AAI
 Intergenerational concordance of attachment styles was
at 80%
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44. Adult Attachment Interview
“What was important was not whether the parent has been
deprived or nurtured as a child, but the degree of coherence
versus incoherence in the parent’s subsequent memory of
her childhood”
(Mitchell, 2000, p. 85).
The organization of a mother’s narrative and how it has
been processed over the years was found to be the most
crucial predictor of attachment style, rather than actual
lived experiences and behaviors.
(e.g., Main, 1995; Main & Solomon, 1986; Mitchell, 2000; Siegel &
Hartzell, 2003).
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45. Bartholomew
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46. Attachment Patterns in Adulthood: Not Types,
But Regions in a Two-Dimensional Space
HIGH ANXIETY
HIGH AVOIDANCE
SECURE PREOCCUPIED
FEARFUL-
AVOIDANT
DISMISSING-
AVOIDANT
LOW ANXIETY
LOW AVOIDANCE
Adapted from Fraley & Shaver (RGP, 2000)Michael Crocker, DSW, LCSW SAT Project Materials

47. WHAT IS YOUR
ATTACHMENT STYLE?
http://www.web-research-design.net/cgi-bin/crq/crq.pl
ECR-R QUESTIONNAIRE, FRALEY, BRENNAN, AND WALLER (2000)
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48. Use of Attachment Theory
 Attachment patterns can help to understand the risk of
psychological dysfunction and may help to direct
intervention strategies (Siegel, 1999)
 Insecure Attachment patterns have been associated with
mood disorders, anxiety disorders, eating disorders and
personality disorders
 So how about Out of Control Sexual Behavior?......
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49. The connection between Attachment,
Affect Regulation and Out of Control
Sexual Behavior
 Studies exist that have connected insecure attachment with varied sexual
behavior
 Insecurely Attached Students had tendency towards multiple relationships
(Feeny and Noller, 1990)
 Insecurely Attached Students had tendency towards rapid sexual involvement
(Feeny and Noller, 1990)
 Insecurely attached individuals tended to use sex for manipulative, self
serving purposes, so is true for individuals with out of control sexual
behavior (Davis, Shaver and Vernon, 2004; Schacner and Shaver, 2004,
Carnes, 1983, 1991, Goodman, 1997)
 Insecurely attached individuals are known to lack a sense of play, so is true
for individuals with Out of Control Sexual Behavior. (Bowlby, 1969,
Ainsworth, 1991, Weiss, 1998).
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50. Men, Hypersexual Behavior
and Attachment
OCSB related to Alexithymia (Goodman,1998)
Alexithymia: The inability to identify, label and
express emotions
Gender Studies have indicated the possibility of a
“Normative Male Alexithymia” (Levant, 1990)
Normative male alexithymia mirrors aspects of
insecure-avoidant individuals (i.e. being deactivated,
defended and unaware of emotional reactions)
Male issues related to attachment and alexithymia
may explain why they corner the market on OCSB
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51. So we start here…………
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52. And end up here..........
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53. And here……………….
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54. Michael Crocker, DSW, LCSW SAT Project Materials

55. AUTO-REGULATION IN MEN –
NORMATIVE MALE ALEXITHYMIA
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56. Our Thesis
Out of Control Sexual Behavior is a set of
symptoms related to:
 Early Attachment Related Issues
 Alexithymic Issues – Whether Trauma Based
and/or Normative
 Affect Regulation Problem
 And Can Have Compulsive and Addictive Qualities
Depending on Intensity, Frequency, and Duration
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57. The Measures
 The Emotions in Close Relationships Revised (ECR-S):
 Wei, (2007)
 12 items
 High anxiety rating = insecure-ambivalent
 High avoidance rating = insecure-avoidant
 Low anxiety and low avoidance = a secure attachment
pattern
 Hypersexual Behavior Inventory (HBI):
 Reid, (2010)
 Reflects the DSM V diagnostic criteria
 19 items
 Measures frequency, distress levels and consequences of
sexual behavior
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58. Emotions in Close Relationships
AMIVALENT/ANXIETY
a. I need a lot of reassurance that I am loved by my partner.
b. I find that my partner(s) don't want to get as close as I would like.
c. My desire to be very close sometimes scares people away.
d. I do not often worry about being abandoned. (R)
e. I get frustrated if romantic partners are not available when I need
them.
f. I worry that romantic partners won't care about me as much as I
care about them.
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59. Emotions in Close Relationships
AVOIDANCE
a. It helps to turn to my romantic partner in times of need. (R)
b. I want to get close to my partner, but I keep pulling back.
c. I turn to my partner for many things, including comfort and
reassurance. (R)
d. I try to avoid getting too close to my partner.
e. I usually discuss my problems and concerns with my partner.
(R)
f. I am nervous when partners get too close to me.
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60. 3 or more of the following over a period of at least six
months as related to sexual behaviors, fantasies and urges:
Interference with other important, non-sexual
goals, activities and obligations
In response to dysphoric mood states
In response to stressful life events
Repetitive but unsuccessfully attempted to be
controlled or reduced
Disregard for the risk of physical or emotional
harm to self and others
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61. Hypersexual Disorder
Clinically significant personal distress or
impairment in social, occupational, or other
important areas of functioning
Not due to the direct physiological effect of an
exogenous substance
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62. Recruitment Outcome
Initially had 81 Participants
Four Subjects Disqualified for not completing
the Measures
77 Male Subjects
45 Cases
32 Non-Cases
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63. ECR Scores
 ECR Total = Attachment Anxiety and
Attachment Avoidance overall
Scores
 ECR Anxiety: Attachment Behaviors
Specific to Anxiety (e.g.,
worry, fears, insecurities)
 ECR Avoidance: Attachment Behaviors
Specific to Avoidance (e.g.,
self reliance, pulling back, pushing
away)
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64. Study Findings
 Higher ECR-Total had higher HBI score
 ECR-Avoidance rather than ECR-Anxiety is much more important
factor that affects HBI score.
 Individuals with high ECR-Total had a higher probability of being
in the case group (Hypersexual Disorder - HD).
 Especially, ECR-Avoidance rather than ECR-Anxiety is a much
more important factor that affects the likelihood of being in the
case group (HD).
 The avoidance score alone is a better predictor than the total
score and is much more strongly correlated to out of control
sexual behavior than attachment anxiety scores.
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65. Implications
Attachment Avoidance as Key Factor in OCSB
Attachment Avoidance was the Key Factor in
both Self-Report and in Clinical Diagnosis
Emotionally Shut Down
Excessive Self-Reliance
Defense against Fears of Intimacy
Depressed, Anxious and Lonely But Defended
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66. AVOIDANTLY ATTACHED
MEN…….
Act unreactive but their hearts would give
them away
Create distance
Sexualize/eroticize their needs
Act out their needs
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67. Clinical Issues To Address
in Process Addictions
Addictions have some key clinical issues to
address
These key issues relate to both the
vulnerability and etiology of addiction as
well as the continued consequences
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68. Compartmentalization
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69. Feeling are Not Easily
Identified
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70. Feelings and Needs Are
Shameful
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71. Toxic Self Sufficiency and
Defensive Autonomy
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72. Difficulties with Object
Constancy
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73. Focused Interventions
Fears
Defenses
Relational skills
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74. Addressing Avoidant
Attachment
• Note character organization related to the attachment
style
• Those with avoidant attachment styles often present as
either narcissistic or schizoid
• Necessity for specific treatment approaches depending on
characterological differences….i.e. Schizoid vs Narcissistic
• One size does not fit all!
(SLADE, 200, MASTERSON & KLEIN, 1995)
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75. Masterson and Klein
 Dismissive avoidant behaviors must be addressed as
defense against narcissistic vulnerability
 Must mirror the narcissistic vulnerability and
 The defense used to ward against the vulnerability
 Transferences and off-target transferences
 Fearful avoidant behaviors must be addressed by noting
the schizoid dilemma – the desire for connection, yet the
fear.
 Closeness brings risk of aggression, smothering, and/or
appropriation
 Distance brings risk of desolation and/or disconnection
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76. Hypersexual Behavior, Attachment
and Characterological Organization
Hypersexual
Behavior
Characterological
Organization
Attachment Adult
Attachment
Compulsive
Internet
Schizoid Avoidant Fearful
Multiple affairs
Prostitutes
Narcissism Avoidant Dismissive
Romantic
Obsession
Borderline Anxious/Ambival
ent
Preoccupied
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77. Out of Control Sexual Behavior as an
Enactment of Insecure Attachment
Siegel’s Rupture and Repair
Repetitious and expectable patterns of
relational connection
Avoidant dyads - the repair is non-existent
Ambivalent/anxious dyads - the repairs are
inconsistent
Disorganized dyads - the relationship is the
source of distress
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78. Rupture and Repair
In adults this ability comes from and
enhances secure attachments
It is connected to co-regulation of affect
Without it you are left in a state of insecure
attachment and are left to use auto and self
regulating strategies
With it you can “Earn Security”
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79. The Power of Combined
Treatment
Individual Treatment
Group Treatment
Self-Help Groups
Focus on the Underlying Alanonic,
Relational Issues to include
Caretaking
Resentment
Self-reliance
Negotiation and Compromise
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80. Conclusions
 Treatment must be tailored to the specific client and not
operate out of a one size fits all model
 Attachment theory is integrally connected to affect
regulation theory
 Hypersexual is an attempt at solving the original
attachment, affect regulation problem
 Psychotherapy can offer the opportunity to help our
clients find their way to better attachment, affect
regulating solutions…..It can help them move from
insecure attachment to “earned security”
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