Sex Addiction as
Affect Dysregulation
A Neurobiologically Informed
Holistic Treatment
Alexandra Katehakis
Foreword by Allan N. Schore
W. W. Norton & Company
Independent Publishers Since 1923
New York London
A Norton Professsional Book
The Norton Series on Interpersonal Neurobiology
Louis Cozolino, PhD, Series Editor
Allan N. Schore, PhD, Series Editor, 20072014
Daniel J. Siegel, MD, Founding Editor
The field of mental health is in a tremendously exciting period of growth and conceptual reorganization. Independent findings from a variety of scientific endeavors are converging in an interdisciplinary view of the mind and mental well-being. An interpersonal neurobiology of human development enables us to understand that the structure and function of the mind and brain are shaped by experiences, especially those involving emotional relationships.
The Norton Series on Interpersonal Neurobiology provides cutting-edge, multidisciplinary views that further our understanding of the complex neurobiology of the human mind. By drawing on a wide range of traditionally independent fields of researchsuch as neurobiology, genetics, memory, attachment, complex systems, anthropology, and evolutionary psychologythese texts offer mental health professionals a review and synthesis of scientific findings often inaccessible to clinicians. The books advance our understanding of human experience by finding the unity of knowledge, or consilience, that emerges with the translation of findings from numerous domains of study into a common language and conceptual framework. The series integrates the best of modern science with the healing art of psychotherapy.
To Douglas
For believing in miracles
like I believe.
Contents
PART ONE
Understanding SA:
Terms, Etiology, Mechanisms, and Effects
PART TWO
Assessing and Treating SA
Chapter 5 Presentation and Initial Assessment of
Sex Addiction
Chapter 7 First Steps: Extinguishing Addictive Behaviors
Using PASAT
by Allan N. Schore
THE CLINICAL PROBLEM of understanding the mental and physical symptomatologies of addiction has a long history of controversy, and for some time working with such patients has presented a considerable challenge to the mental health field. In part this is due to the fact that such disorders represent a dysfunction of both the psychological and biological realms, and until recently these mental and bodily-based dimensions of human functioning were seen as mutually exclusive Cartesian dualities that demanded very different treatment approaches. In terms of the more recent construct of sexual addiction, the topic of this book, for most of the last century the study of human sexuality was also dichotomized into either psychological or biological conceptual frameworks. That said, as the reader will soon learn, by the 1980s a number of therapists began to offer clinical models for working specifically with sexual addictions. Indeed, these patients, like those with drug and alcohol addictions, were generally seen as extremely difficult to treat and refractory to the talking cure. To improve the efficacy of treatment models clinicians were increasingly attempting to confront and resolve a number of previously unsolved etiological and diagnostic problems. In other words, what was needed was a clinical theory of addiction--an overarching integrated conceptual model that could more precisely define and describe deficits in both mind and body seen in these patients.
As a result, a more complex biopsychosocial theory that could support more effective clinical approaches to SA slowly evolved over the last few decades, along with a number of more encompassing paradigm shifts in psychology and psychiatry. From the 1960s through the 1980s, behavioral psychology and the psychotherapy of addiction and sexual disorders focused exclusively on changing behaviors had dominated. In the following decades, cognitive psychology and cognitive-behavioral psychotherapy (CBT) targeting alterations in the patients sexual thoughts and fantasies rose to the clinical fore. But in both, there was little attention paid to the SA patients body, the source of the strong sexualized sensations and feelings, or to the intense physiological expressions of both craving and withdrawal. In recent years, the ongoing paradigm shift into a bodily-based emotional psychotherapy that integrates psychology and biology underscored how urgently the underlying psychobiological and social-emotional problems of sexual addiction required an integrative, holistic conceptual model.
Indeed, by the 1990s emotion per se had become a legitimate focus of research science, finally bridging the Cartesian divide. And the addition of data from neurobiology and affective development studies into the understanding of SA achieved significant advances in resolving the previously unsolvable dualities and paradoxes of addiction. The explosion of neuroscience data began to be incorporated into the core of biological schemas of addiction, mostly focused on drug and alcohol addiction. Of special importance to more complex etiological models were contributions from affective neuroscience and developmental neuroscience, especially on the early-developing emotion-processing right brain. With an intensified interest in emotions, researchers and clinicians became aware of the primacy of affect regulation for adaptive functioning, and of affect dysregulation as a central psychobiological feature of all psychiatric disorders, including SA. As the decade progressed the addiction field became very attentive to the nascent discipline of interpersonal neurobiology and its explication of how early attachment experiences shape, or misshape, the growing brain, especially concentrating on attachment disorders commonly associated with the etiology of SA. Related to this was the incorporation of modern developmental trauma theory. Echoing the new concern with early social and emotional development, psychological explanations of change shifted from behavior to bodily-based subjectivity, and from a one-person to a two-person psychology, and thereby initiated relational trends in psychotherapies with all patients, including those exhibiting SA.
Among my own contributions during that decade of the brain, Affect Regulation and the Origin of the Self (1994) presented extant studies which strongly suggested that addictions fundamentally represent psychobiological deficits in affect regulation. Synthesizing new data from a small but growing body of studies across disciplines, I proposed that addictions evolve in early traumatic attachment misattunements associated with enduring high levels of negative affect; that developmental deficiencies in mesolimbic dopaminergic circuits and the hypothalamic-pituitary-adrenal axis are imprinted in an early critical period of right brain development as an inefficient affect- and stress-regulating system in the orbitofrontal cortex; that shame sensitivity, relational deficits, and impairment of the self-regulatory capacity lie at their emotional core; and that the addict uses external auxiliary regulators in an attempt to restore homoeostatic regulation. I also distinguished two different forms of self-regulation generated in the right brain attachment relationship--interactive regulation in interconnected contexts, and autoregulation in autonomous contexts--with a flexible balance being necessary for secure attachment. The latter, of course, dominates rigidly in addictive disorders that preclude intimate contact.
