Monthly Archives: November 2021

An analytic treatment of addiction: a follow-up argument

So, if treatment for an addiction, whether that is newly discovered or a relapsed condition, is to be longer-term, as in longer than a month or ninety days in a rehab, and intensive (meaning, multiple sessions per week), then that in part addresses one area of contention in the field: what should be the scope and duration of treatment. Linked to the scope of treatment is an area of treatment for addiction–and next I will specify sex addiction treatment–that is aimed at partners of sex addicts. This is an important if problematic area of treatment whose most prominent models espouse perpetrator/victim labeling that inclines participants towards splitting defenses which thwart in-depth or nuanced thinking, instead privileging fixed idea responses. This is further problematic if one considers that the assessment of sex addiction is yet to be codified across the medical or psychiatric establishment, which means that associated conditions or assumptions predicated on such assessments are in turn questionable. I’ll address that issue more fully in a later blog about betrayal trauma, but for now pose a question that lies within but also beyond medicine or psychiatry into the realms of culture and philosophy: what is addiction?

As suggested in previous entries, and of course in mine and Joe Farley’s forthcoming book, Getting Real About Sex Addiction, the matter can be addressed with metapsychological assumptions: epistemological (seeking to understand, or know), ontological (helping the patient emerge a state of being—who they are), or medical/scientific “problem-solving”, means-end analysis (as in achieving sobriety by any…), or utilitarian assumptions (going for the “greatest happiness”), which might mean privileging what is deemed most important by an arbitrary authority, or the needs of the victimized, which makes treatment about justice for the impacted. Notwithstanding the importance of those assumptions and hypothesized priorities, there are several psychoanalytic ideas, or “assumptions” if you prefer, that we explore in our book.

Firstly, because addiction is a cultural term and not in itself a scientific construct denoting a physiological phenomenon, we consider that addictive behaviors plus “addictive thinking” or “addictive personality” contain the following intrapsychic purpose: avoidance of conflict. Like the neurotic, the addict represses, displaces, sublimates (goes to work, or “keeps busy”), or exhibits reaction formations (shame/guilt self-loathing: “I’m such a piece of — for doing…”), but paradoxically continues the problem behavior, usually in secret. Reaction formation is a less popular artifact of psychoanalytic thought. By and large we don’t like the imputing of a reversed motivation beneath a virtuous surface. There are too many “nice” people who needn’t be troubled by assignments of concealed lechery, corrupt and self-serving motives relating to money; unconscious bias, racial and gender isms. The problem in another sense is one of thinking, of not thinking integrally. By that, I mean the difficulty of weighing matters, considering pros and cons, conflictual emotional states, or seemingly irreconcilable contingencies. Self-identified addicts tend to decry thinking, calling it analysis-paralysis, and usually confuse thinking with obsession. They fear their own minds, say things like, “I need to get out of my own head”, or “my head is a dangerous place to be”. There’s a deceptive humility in these expressions, as if the extinguishing of thought were a submissive act.

My wife doesn’t want me anymore, the sex addict laments. Or she does, but there are conditions that complicate sexuality, render it difficult. Well, addiction simplifies. Porn actresses, prostitutes, or “sex workers” want; they are accommodating, un-demanding; they appear to enjoy you, appreciate you. Depending upon how often you lease their services, they may even depend on you. And they’ll never criticize you for wanting too much, or wanting “it” too often, for their bodies are there for your use, and yet the maintenance of those bodies isn’t even your concern. This kind of person is irresistible psychologically, no matter how “hot” she might be. As a result, she may graduate to the level of affair partner, 21st century style. Actually, I don’t know how old the next phenom is: a man enjoys his regular sex worker for a spell; then she starts calling him “boyfriend”, which he starts to take seriously—he starts tipping her a bit more, maybe adding even more $ when she starts talking about her life, especially the aspects she wants to escape from. Soon, an enmeshment emerges, one that blends her desire to use you, plus your desire to be used…as a hero. This is power of a fragile kind, one that can easily be exploited, paradoxically, by those in underprivileged positions. How often does this happen? I don’t know. I’ve just met a lot of couples who began life as affair partners—that’s all—oh, except that many of the women were sex workers at the time of meeting.

So, you may be thinking this is all very phallocentric so far; that my assumptions are cisgendered, heteronormative, and privileging of heterosexual—wait, would it really privilege heterosexual men if a stereotyped image of their sex addiction elicited wide contempt, leading to pigeon-holing theories of intervention? Because that’s what has happened. The sex addiction treatment sub-field, contrary to the beliefs of some, is not exactly peopled with apologists who think that sex addiction is to be indulged. This is not 1959. Three quarters of our mental health proletariat is female, and the remainder of men are more or less compelled to patronize concepts like “toxic masculinity”, which is aimed at sex addicts, not just rapists or coarse men who loudly say things like, “yo, bro, what’s your problem?” in public places when someone is calling them out.

Share the average sex addict profile with the average observer, professional or not, and observe the rising judgement. Such figures are exploitative, sexually lazy, or guilty of relational cowardice, most will opine. Meanwhile, narrowing traditionalist circles, pockets of locker room talk, may continue to sanction the seemingly masculine habit of attaching to things versus people, or people-as-things; the practice of outsourcing frustrated sexuality to sex workers and such. But the above-ground world of progressive orthodoxy is having none of this. Theoretically, most clinicians are aware of the concept of splitting—the Freud/Kleinian idea that a mind keeps separate good and bad—and thus creates what today we call “compartmentalized” worlds in which the civilized ego is protected from the timeless desires of the id; a traumatized mind undisturbed by complexity. As a patient of mine who wrestles with his dilemmas has put it: “If I act out (sexually), I’ll kill off the intimacy between me and her, my best friend. But if I don’t act out, I’ll just grow to resent her”. Note the impossibility of resolving conflict, or even living with a problem, without the valve of release. The “solution” is in the escape, this person believes. The “problem” is in the escape, this person believes.

I believe that most of my colleagues in this field, even the angry and strident ones, are reasonably nice and compassionate with the sex addicts who stir their countertransference (psychoanalytic-speak for hate). They are professional, empathetic; sometimes patronizing; they use terms like “insecure” to denote an underlying neurosis to addiction—that reservoir of soft feeling that many just have not learned to share in our modern world. Putting aside the strained expressions of concern, the activist among us reserve their hard comments for the consulting office, or for networking, coffee-talk circles: rigorous, pamphlet-wielding exercises, no doubt. Within this field there are assumptions and politics—sorry, the intersecting social context and treatment strategies—that either inform or contaminate approaches depending on your point of view. Don’t split on that thought, however. 

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An analytic treatment of sex addiction: a basic argument

“Analyses which lead to a favorable conclusion in a short time are of value in ministering to the therapist’s self-esteem and substantiate the medical importance of psychoanalysis; but they remain for the most part insignificant as regards the advancement of scientific knowledge. Nothing new is learnt from them. In fact they only succeed so quickly because everything that was necessary for their accomplishment was already known. Something new can only be gained from analyses that present special difficulties, and to the overcoming of these a great deal of time has to be devoted”

— Sigmund Freud

One of the basic criticisms of psychodynamic or analytic treatments, particularly as they pertain to addictions, is that they don’t do enough, aren’t urgently focused enough, to arrest the escalation of problems associated with addiction. The epistemological approach (knowing, understanding) isn’t sufficiently pragmatic to halt unnecessary suffering for those directly afflicted, or their impacted others. Or, a more ontological approach, wherein emphasis lies in exploring a person’s being—discovering who they are as an emerging self—misses the severity of problems that addicted patients present.

I understand. As a patient in analysis, a past and present practitioner of analytic psychotherapy, and as a current candidate in full analytic training, I get that changes (or progress) in analytic treatment can seem “glacial”, as some put it. So, what would be the rationale for an analytic treatment of an addictive pattern, which is the matter of concern as addressed in mine and Joe Farley’s book, Getting Real About Sex Addiction. Well, sidestepping for now the questions of whether sex addiction is a legitimate diagnosis, or the linking question as to whether it merits an urgent, detoxifying focus comparable to say, chemical dependency, I’d like to offer more of a perspective than a rationale.

I’ve worked in the field of addiction, either directly in hospital-based programs, or peripherally in my private practice, for roughly twenty five years. In that time, I have, like many other psychiatric or mental health professionals, known countless individuals to go in and out of treatment multiple times, whether in rehab or therapy, upon slipping and/or relapsing, reflecting a chronic, repetitive problem. This observation is nothing new. Anyone who has ever attended a 12-step meeting will attest to hearing rhetoric asserting that addiction is a progressive, relapsing, even “incurable” disease, etc. Yet the crossover fields of addiction and chemical dependency treatment continue to offer as its dominant paradigm a short-term approach that ever treats the incoming patient as a so-called “newcomer”. Though acknowledgement of a relapsing pattern may be given by interventionists in such programs, their approaches tend to operate as if the patient is ever starting over.

I say the following: particularly when someone presents for therapy observing that their so-called addiction has lasted for years, with only sporadic interruptions due to painful consequences, followed by decisive interventions, why not suggest the following plainspoken yet analytic prescription: “Let’s explore the root of the problem. Let’s go deeper this time”. Does this proscribe some of the following tasks that are offered with virtue-signaling language: boundary-setting, relapse prevention plans, 12-step meeting attendance, medication consultation and regimens; the “inclusion” of an impacted partner in treatment? Of course not, though that last one is particularly tricky, as undue disclosures, explanations of pathology, achieved collaterally or directly, may thwart confidentiality and contaminate transference (development of a patient-therapist relationship). *Incidentally, disclosure exercises may also conflict with 12-step principles, an implicitly individualized model in which participants are typically urged to consider partners’ needs “none of your business”. Next, I hear some who suggest that a separation from the “triggering” environment is necessary for acting out persons, hence referrals to intensive outpatient programs or residential facilities. Okay, but with respect to sex addiction especially, such options are expensive and are thus available only to the wealthy. What’s that? I hear you scoff. Isn’t psychoanalysis expensive, especially if it lasts for years?

Not necessarily. Many analysts or analytically-oriented clinicians are quite flexible with those with low-fee needs, especially if they commit to multiple-sessions per week treatment. I’d be willing to bet that many such clinicians are more affordable than an average, one meeting per week, certified sex addiction specialist, and certainly more affordable than an out-of-state residential or short-term intensive program. Besides, what would you rather spend your money on? Thousands of dollars for an episode of treatment that will be over in a month, or the same amount (roughly) for something that may proceed more practically, more steadily, with more room for thought versus shoot-from-the-hip judgement, for over a year? I know. Get it over with quickly, some would counter—professional and lay-persons alike. But does anyone think it ironic that a condition epitomized by a mindset of immediate gratification would be treated with an approach that mirrors that thinking? Also, again with respect to sex addiction (versus chemical dependency), urgent, intensive interventions designed to arrest behavior ASAP are more about placating the anxiety of impacted others—not a requisite detox from a life-threatening withdrawal syndrome, or the imagined dangers of a sexual overdose.

Chill, one might say, crudely. Time to slow down, just a little at least, and think, and allow time to pass, which means space for a person’s motivation for care to intertwine with what is truly there within them: a pattern of defense that manifests habitually, often unconsciously, and sometimes dangerously. This pattern of defense is a character trait in all likelihood, not just a feature of “addiction”, and it reveals itself over time if someone is there to notice it regularly. Time. And Transference, actually. This is also why I place less stock in psychological testing, whether a comprehensive, “battery” of questions that may capture contradictions, indicating conflict, or a simple effort to elicit memory and conscious reflection, such as the HB-19 (regarding hypersexual behavior) inventory. Though I don’t have specialized training in psyche testing anyway, my basic objection is that such testing explores a patient’s mind outside of context—that is, outside of the flow of therapeutic relationship (known as Transference), and is therefore artificial. Simply put, patience and conscious witnessing are the two ingredients that counter the addict’s propensity to hide, facilitating change with lasting effect.

Consider two psychic defense concepts, one of which is decidedly psychoanalytic (displacement), while the other has a psychoanalytic pedigree but has been co-opted by other models: the aforementioned “acting out”. In sex addiction treatment, the term “acting out” denotes a sexual act, or a pattern of sexual activity, that is deemed inappropriate, exploitative, adulterous, etcetera. In psychoanalytic terms, it means replacing thoughts and feelings with action. Now consider two popular phrases whose ethos contradict each other: “actions speak louder than words” (positive connotation assigned to “action”), and “think before you act” (negative connotation assigned to “action”).

Thinking.

Analytic treatments privilege thinking, not to be confused with intellectualism, observing that addicts, in particular, act rather than think or feel, largely to their detriment. Still, they (would-be addicts) tend to enter treatment extolling the values of action in general, thinking it’s best to keep busy, don’t let idle hands…you know the rest.

Thinking

They’ve been there before. Those who have rinsed and repeated, done this cycle of keeping busy, overworking, then feeling entitled to binge on pleasure and seek inappropriate rewards may take notice. Back to that notion of “chill”, which doesn’t mean lounging on a non-analytic couch smoking something that used to be illegal. It means not acting, not acting out that is, which doesn’t just mean not looking at porn, not finding a massage parlor, or not checking out the profiles on Tinder. What next? Well, imagine you, the would-be analytic patient, are laying on an analytic couch, or (okay, let’s defer to Covid for now), speaking on the phone with an analytic practitioner, someone trained to observe the mind as it is working moment to moment, feeling it’s anxiety and restlessness, poised to act out a state of unease…about anything. You start speaking of something that, by implication, causes anxiety. But you took care of it! You paid that bill, you made that call, sent that e-mail, or said that peace to someone who was giving you grief. Next, you moved on to the next subject. Have you? Have your thoughts and feelings really moved on? And did you notice something else? The thing you were anxious about pertained to the person you were talking to, only you didn’t really go into that–that relationship with that professional who is really in your head, which is…what you asked for? You vented about someone or thing else, which is called a displacement. That means a way to avoid the conflict you are feeling, which leads to a climactic theory: addiction has two names, two categories of motive. One we know easily: pleasure seeking. The other is conflict avoidance, the escape from unpleasure, as Freud will have put it. And you know the rest.

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