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Your Sexually Addicted Spouse: a review


A subdivision of sex addiction treatment is a therapeutic effort–a worthy effort–directed at partners of so-called sex addicts. Within the model more or less introduced by Patrick Carnes, and promulgated by his (followers?), a Co-Addict model emerged over the last three decades, which has been written about by the likes of Stephanie Carnes (his daughter) and Claudia Black, author of Deceived. Then, as the Co-Addict model  was being criticized as either ill-conceived or derivative, another model of partner treatment emerged called the Relational Trauma Model, which is somewhat preciously described as “a paradigm shift” by its adherents. One of its notable guidebooks is the Barbara Steffens/Marsha Means penned work, Your Sexually Addicted Spouse. Check out the reviews on Amazon and you’ll find, for the most part, gushing statements of gratitude from its targeted readership: “This book really helped me”, or “Finally, a book that addresses trauma” (actually, innumerable books related to SA address trauma). There are some dissenters, women who bristle at the victim-identification focus; the vague suggestions as to solutions–what to do. I’m a dissenter also, for the following reasons.

Several problems with this book: firstly, it aspires to a gender neutral position, using terms like spouse instead of wives or husbands, but of its two dozen or so testimonials from betrayed partners, not a single account is from a male partner of a woman (or even male) sex addict–a glaring problem in the development of this field, especially if the POV of the gay community is to be known. Secondly, the book goes to great lengths to disparage the so-called ‘Co-Addict’ model of care, hitherto directed at partners of sex addicts. The term Co-Addict, previously espoused by apparently like-minded colleagues such as Claudia Black and Stephanie Carnes, is now “invalidating”, a residue of a pathologizing bias. However, if one reads the recommendations and characterizations in Carnes’ and Black’s work, the reader would find remarkable similarities between their opinions and those of Steffens and Means. The same reactive, as in controlling behaviors of partners are identified (and discouraged) by these supposedly disagreeing authors, and while the ‘Co-Addict’ reactions are deemed ‘normal’ in Steffens’ and Means’ model, the characterization of betrayed response is dubbed ‘natural’ in Carnes’ and Black’s literature.

Hmm? Not exactly a gulf in empathetic reaction. Anyway, trauma is the new word: the more palatable, “evidence-based”, client-friendly word. Trauma is popular amongst readers of self-help literature, more so than ‘Co-Addict’, or ‘personality disorder’, perhaps because trauma connotes victimhood. The intent of RT practitioners is reasonable enough: when they use the word trauma, the accent of approach is upon empathy for suffering, the prospect of survival versus ‘victimhood’; less so upon implied criticism of behaviors (which again is there, but in muted form), or the inference of an underlying disorder with a backstory. However, not only is this position facile, it presents the issue of so-called relational trauma in a confusing way. For example, a passage in Your Sexually Addicted Spouse presents PTSD as a lifelong condition, entailing “coping mechanisms that become ingrained in personality”. Doesn’t that sound like a personality disorder? One gets the sense in books like this that marketing trumps clinical accuracy, and that concepts get conflated, like personality disorder and trauma. But personality disorder is not a nice term. Nor is Co-Addict. Nor is addict, for that matter, but Steffens and Means would have the reader reserve pathology for the people we’re meant to be angry at: the addicts. The men.

What do men think, other than me?

We don’t know. They don’t read books like this, so as far as promoting books like Your Sexually Addicted Spouse is concerned, it doesn’t matter.

Graeme Daniels, MFT



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Sex addiction stigma debate (part two)


She spoke haughtily, which has a peculiar effect on me: I start questioning my right to think. “You’re speaking of men who acted out with their sexuality, and society is pushing back against that kind of privilege.”

“Acting out? Wait, are we now talking about something different than when you spoke of female sex addiction?”

“The men you indicated are compulsive philanderers, porn addicts, acting upon an exaggerated sense of entitlement. Women are no longer willing to tolerate that.”

“Whereas female sex addiction is…different?”

“Women are stigmatized for simply having sex before marriage. Men aren’t!”

“Okay, but women are not being assessed as sex addicts for simply having sex before marriage.”

She waved her hand in an expansive fashion. “No, but that’s part of the context, that generally lesser tolerance for their sexual freedom. It just makes it harder for women who do have problems to come forward and get help.”

I tilted my head, affecting skepticism.

“I can see you’re having a hard time accepting this.”

“You say ‘accepting this’ like you’ve already landed a truism, and I’m like a holocaust denier or something.”

“Seriously, you don’t think society has traditionally been harsher, more devaluing of women’s sexual behavior than men’s.”

“Traditionally is a key word there. Time’s change. Not sure I accept the conclusion based upon your premise.”

She shook her head. “You lost me,” she said.

“So let’s go back to the earlier point. You say that women feel a greater stigma around their sexuality than men, right? And this stigma, which is a societal phenomenon, is internalized by women, causing extra layers of shame?”

“Correct,” my colleague said cautiously.

“Well, consciousness leads to change. That’s the basic promise of our profession, after all. Now again, we’ve had at least two generations since the so-called sexual revolution, which sought to liberate men and women from sexually repressive values. I think many women now externalize the problem of that stigma you reference. They resent society’s traditionalist constraint of their sexuality, and therefore push back against institutions, including schools of thought like sex addiction treatment models, that would pathologize that newfound sexual freedom. It’s like when political outcasts used to get diagnosed with schizophrenia and other mental illness labels: I think some people think the term sex addiction is a sex police invention, and I think it at least one alternative reason why women especially, as well as the gay community, might reject sex addiction treatment.”

My colleague offered a soft utterance, one aimed at neither agreement nor concession, but merely diffused conflict. I think she wasn’t sure if we were saying different things.

“Interesting,” she said neutrally. “Still, I think the women that I see and talk to retain that traditional internalization, and they hold other women to the standard they believe in.”

“With respect, most of the women you speak to are over fifty, and their husbands are John Wayne-types.”

“Maybe. But I just don’t think men judge each other about sexual misbehavior as women judge other women who act out.”

I sort of rolled my neck, like I was straining to take this in.

“You don’t agree? You don’t think men encourage other men, even boys, implicitly or not, to be sexually active, to have as many partners as possible?”

“I’m not sure that matters with respect to the issue at hand. If women, traditionally or presently, stigmatize men for their sexual misbehavior, and you aren’t disputing that—merely justifying it, sort of—then men will have problems in relationships. Period. It doesn’t matter what the ‘patriarchy’ thinks today. If I cheat on my wife, for example, it’s not like I can say, ‘but my buddy Jay says it’s cool’ and expect everything to be all good with her. And that’s what matters to the men who seek treatment, who are mandated into treatment: they want to fix things with their partners.”

She shrugged coolly, apparently more at home debating this issue amid tangents.

“Seems to me it’s the same for women, only I think history and tradition lingers more than you believe it does. But if, as you suggest, it doesn’t matter so much—this matter of stigma, whether it’s directed by the same sex or not—then what’s this discussion about?” She shrugged again, this time presaging finality. Suddenly, she sounded weary, not so much curious, only I wasn’t done.

“Because it seems important, this question of why people go into treatment and why they don’t—why women don’t seek treatment, which is what you said today, only your bias suggests that women are being under-served, which implies women would choose sex addiction treatment if they were offered it. Like I said, it’s 2016. I think many, perhaps most women are shedding terms like ‘slut’ and ‘whore’, or trying to, anyway—and that places the problem in society, not in individuals. Meanwhile, I think men are internalizing what’s happening to some of their fellow alpha males. That lesser judgement, or entitlement, that you perceive? It has a flip side, one that’s center-stage now. Justly or not, the men I talk to take on board labels like ‘horndog’, accepting their comparison to animals, their compliant exile to the ‘doghouses’ when they’ve ‘strayed’. Then they sit with me, feeling incompetent and saying, ‘I was never raised to share my feelings’, having internalized that feminine critique also.

Joanne averted her eyes, like she wanted out of this conversation; it’s ambiguous agenda and questioning of trends. What would she do with this, I could hear her thinking. She finished her coffee, asked a passing waitress where the bathroom was. The epicene worker whom she stopped had an untroubled, these-matters-are-not-on-my-radar look about her. She (I think) wordlessly pointed to a door just beyond our table, concealed by a disorganized gathering. It was a tiny room, this bathroom—not big enough for the café’s throngs, and amongst customers, unbeknownst to café owners, it was controversially unisex.

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Sex addiction stigma debate (part one)


During a local talk on sex addiction to an earnest group of Saturday morning listeners, my two female colleagues, Joanne and Gina, and I gave a modest introduction to the demographics of our business. As we sat listening to one another, we gave supportive nods, affirming all of our thoughts, though in truth, a couple of my one colleague’s ideas had me bristling. One of her chestnuts concerns the under-researched area of female sex addiction: “as shameful as this condition is for the men, it is especially stigmatizing for the women.” She also said something about men being raised with a ‘John Wayne’ model of emotional expression, and were thus constricted, suffering from intimacy disorders, which in turn impacts their partners. Everyone nodded, including me, only more faintly. I didn’t say anything contrary, partly because of time constraints, partly because of the agreeable ambience in the room, and also, frankly…I’m not sure how important this issue is.

It seems worth writing about, anyway. And arguing about, I guess. As Joanne made one or two other similarly-themed remarks, I recalled the comments of her junior colleague, Gina, from a day earlier, during a staff meeting at our shared agency. At that time the context was our much maligned room schedule board, admittedly outdated, but still in use because no one wants to take time to devise a new system, or tear down our old but beloved white board, streaked as it is with cheesy black demarcation strips and years’ worth of dry erase pen smudges. An online calendar would be best, chirped our newest colleague, proclaiming it is 2016, after all, not 1972.

Not 1972. My mind turned back to the present context and Joanne’s assertions. Frozen in time, I think. Afterwards, over coffee, I told her that I thought some of her pronouncements tired and superannuated, though I didn’t quite put it like that. How so? She queried, comfortably unoffended.

“Well, let’s take the one about women and sexual stigma. You say that women feel an extra layer of stigma in society about sex addiction, and therefore shy away from treatment or recovery, which is why we have less research about them.”

“That’s right.”

“Okay, but the point seems moot, because men aren’t seeking treatment either.” Her head sort of went crooked at this point, indicating surprise and perhaps something else; a playful rebuke, maybe. I was nit-picking, or something. Anyway, I continued. “You said later in the talk that many if not most of the men in our program are mandated: there because of a court order, or a demand from a disgruntled partner. So in my opinion the more pertinent question is this: if there are scores of untreated female sex addicts out there, why aren’t their disgruntled partners mandating treatment?”

She was unperturbed by this challenge, but still waffled with unconvincing polemics. Husbands and boyfriends are less forgiving, she opined, and also—many of those women’s partners are also sex addicts; that women are more judgmental of each other’s sexuality than men are. She spoke with authority on these points, as if she had volumes of data at her disposal. We don’t know these things, I contested, though I sort of agreed with the middle assertion, while thinking the first and the third contradicted each other. We danced around items of research for a bit, eventually dissolving the ‘evidence-based’ part of the discussion and finally dropping into what’s left: what people actually think, which is what matters. I countered her first idea: “While there may be something to your first point—the humiliated male being an especially unforgiving figure—I’m not sure that history or tradition shows that the cuckolded man is a fiercer image than the ‘hell hath no fury’ woman. But regardless, as Gina would say, this is not 1272, or 1972, and by the way, millennials don’t even know who John Wayne was.”

“What’s your point?”

“My point is this: over the last generation, possibly two, most of the scarlet-lettering that happens in society—at least that which gets media attention—has been aimed at men. Or maybe you can tell me: who would be the female equivalents of Tiger Woods, Anthony Wiener, Elliot Spitzer…Bill Clinton?”

“That’s different,” she said, a bit sharply. It was on.


Graeme Daniels, MFT

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The problem of listening


“Thanks,” said the man in the bad shirt to his group. He kept a peripheral eye upon me, picking up my distaste in the air, my discrepant air. The process moved on, with my journeyman skills keeping things in order, neutral—not taking sides, not standing up for anything yet; not saying much of anything, even though talking’s easier than listening. Talking’s way easier, believe me. Storytelling: now that’s a cinch. Neutral is how I am, professionally and, now that I’m alone, also personally. Wanna know what listening looks like? It’s a stifled yawn pinching oxygen; a blank stare held together with tautened facial muscles, and a soft, metronomic nod providing faint reinforcement, possibly a tease, because maybe it’s a nothing, this service I give. Some really want it, and I’ve been like this for years: a cipher into which people deposit their brokenness, and then leave. Not much of a story here, you might think. If you’re a film producer, you’d say, “I’m not touching this, it can’t be done”, thinking this dull: unwatchable, or unreadable. Pornified eyes wouldn’t like it. But in the unlikely event that it hits big, is binge-read and wins awards I’ll gladly take the stage, drunk, saying “For twenty years people tried to write this script but everyone said it couldn’t be done. So and so tried it and failed. So did whatsisname, that other really famous guy.” That’s when I’d punch stuffy air; thank doting mom and rival dad, the wife and kid for their support, God for doing whatever he does, and say goodnight.

In group I became restless, started saying some things I shouldn’t have said, slipping from the listening stance: fighting with men as well as women. It’s what happens when people stop listening.

— a passage from Venus Looks Down On A Prairie Vole

Part of a polemic that runs through the novel: I set up a binary between notions of listening versus doing. Therapists don’t do anything. That’s the sometimes comic refrain that Daniel Pierce expresses, at times to punctuate a dramatic event. It’s not a popular image, this one of therapist neutrality, this sense that we sit back in our cozy offices, smugly observing pathology, remarking on it but not acting as agents of change. Not really. See, the task is to render it invisible…the change…so you won’t notice.

Not good enough, of course. For the general public, I mean: this traditional stance of not doing is not good enough.”I’M A DOER”. Isn’t someone scoring political points with this currently? When parents bring oppositional teens into therapy (as in Working Through Rehab), when wives call up and make appointments for their depressed husbands, when a couple presents for therapy needing help with a ‘crisis of communication’, and when people get out of line with respect to drugs, violence, and especially sex, people from officialdom call, asking for therapists to do something.

And so I chat the other day with an amiable lawyer, a good guy looking to represent his client and mine, someone who did something he shouldn’t have done, with a girl who was younger than she should be if doing what she was doing. But it was his fault. No argument there.It’s just that this lawyer wanted to know…what I was going to do. He knows what therapists do. He knows that we listen; that we don’t judge. But could I give him something, anything, live or in a letter, that he could share with a court and sound, ya know, convincing. He even voiced his suppositions, as if he’d hacked my association’s list-serve and scrolled through the typical ways therapists market themselves. Would I offer coping skills, he asked tentatively?  Teach ‘tools’ for affect regulation (actually, he didn’t ask that).

Empathy. Victim empathy.That’s what I offered. That plus the hope that what my client did he would not do again.


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Sexual Narcissism


“I’m in porn.” He’d said it quickly, in a clipped voice, while looking away, like he’d wanted the words off him, shooed away. I gave him a stilled look at which he grinned teasingly, masking unease. “Well, alright. I’m getting into porn, I should say. I’ve been in one clip so far.”

“Uh-huh. What film? What’s its title?” Rick laughed again, and shook his head. I felt like an idiot, stalling with questions to conceal my blushes.

“What film? I don’t know, man. Who cares…what film? Big dicks. It’s called ‘Big dicks’. There. I just gave it a title.”

“I’m sorry. I don’t mean to—”

“Nah, it’s cool. I don’t know why I’m giving attitude, actually. I’ve got a name, if that means anything. Kane—Kane Able. How do you like it?”

“A play on…I suppose.”


“That’s good,” I lied.

So I asked about plot. About the film with no name: I asked if his clip contained any plot, or acting, or even theme. Surprisingly, Rick, or Kane—was pretty sure I’d not make the shift on this one—said there was. Firefighting, he said, not surprisingly. His part, as in his role, was that of a firefighter who has entered a burning building to rescue a trapped woman, who is feebly crying out (I imagined the acting) until the hero arrives, ready to spare her. The room is very hot, about which the performers comment wittily, and then the room gets hotter, and soon they don’t care so much about the fire and…well, you get the picture.

“Any dialogue?” I asked. Rick looked at me as if I were reading from a book of stupid questions.

“I ad-libbed this one line as I came: ‘fire in the hole, baby’, I said.” This time I said nothing. “I know, don’t tell me,” Rick lamented. “Pretty dumb, huh?”

“Did she say anything, have any lines, ad lib or scripted?”

Rick shook his head, uttered a dismissive noise, like I’d asked whether the props spoke on set. I blew air through my teeth, and thought of Lira.

“That’s typical. It goes to show there just aren’t enough good roles for women these days.”

— a passage from Venus Looks Down On A Prairie Vole

An example of parody in my mischief novel: the name Kane Abel is a play on words, of course, common to porn actors. My favorite from the real world of porn? Peter North. Subtle, right? Anyway, Kane is otherwise Rick, a young man whom Daniel Pierce meets while living at a sober living house, wherein he’s in retreat from a fraught personal and professional life. Rick’s day job is in a seafood restaurant, as a chef. There he causes trouble, disturbing his boss and Daniel’s temp boss, Jimbo, by stirring unrest, harassing female staff, flirting with nubile customers, doing very little cooking, it seems, while strutting his sex like a farmyard stud. Rick likely thinks his place in the service industry has layered meaning. He’s the kind of man who feels entitled to promiscuity, who feels offended, let down by another man’s diffidence, thinking that humankind benefits from the indiscriminate sharing of seed. He’ll try to re-ignite something in Daniel, provoke a libidinal return in the grieving, wilted psychologist. That last line, Daniel’s teasing of a feminist complaint, glides over Rick’s head, not so much because of stupidity, but rather self-absorption.

The role of women. What indeed is the role of women?

**image by Philip Lawson



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Have you ever been with…?


She rolled her head slightly, like she was lining me up in her crosshairs. “You are shitting me”, she began hotly. “I know what you’re saying, but it’s not even the same. Man, I’d like to see you walk in a prostitute’s shoes. Only then would you know how lonely and scary it can be. Tell me you know what it’s like to work knowing your life is at risk: that you could be killed, jumped at any time because you carry cash; jumped in your own home if that’s where you do business; that no one will protect you unless you pay them; that no one would even care what happens to you cuz they think you’re nothing. Tell me you know what it’s like to give up your body everyday, to men who barely think of you as human, knowing that you’re giving away that part of yourself, every night.”

I gazed upwards, studiously contemplating sky and stars, life on Venus and Mars, alien yet pure of love and hate. “Well, I don’t know about the getting killed part. But the rest I can compare with, roughly.”

“Uh-huh?” she scoffed. “So you think you relate to prostitutes. How many have you been with?”

“Wait, I never said I’d been with a prostitute. I mean—”

She laughed back. “Yeah, I bet you haven’t.”

“I haven’t,” I replied adamantly. She relented.

“Alright. I’ll believe that, I guess, but it shows you don’t know what you’re talking about.”

“Well I’ve listened to quite a few—had them as patients.”

“Uh-huh.” She sat quietly for another few moments, letting her amusement subside. Then her voice turned somber, almost reverent.

“You ever cheat on your wife?”

“No,” I said flatly. She nodded inertly. “You believe me?” I followed up.

“I guess.” I uttered a noise which she took as a rebuke. “What do you want, a medal?”

I paused upon feeling aggrieved. “Sort of,” I replied.

“What?” she asked laughing.

“I should get a medal, actually. Any man who manages to avoid temptation should get a medal.”

“Any man? How about women?”

“Okay, women too, but it’s not the same for them.”

It got better. Soon I was expounding upon all the disadvantages men feel in the realm of sex.

–a passage from Venus Looks Down On A Prairie Vole

So a character poses a question, “have you ever been with a prostitute?” In doing so, the female antagonist is half-shaming the everymale of my story, and half-challenging his social critic credentials. Because he claims to know something. Daniel Pierce, my jaded psychologist, alcoholic widower, has a few thoughts on the subject of prostitution: like the chestnut leftist argument that all occupations in the western world entail prostitution. Therefore he doesn’t wring his hands on behalf of women, especially not women like Lira, who hardly seem like victims. Objectified? As in treated as, or thought of as an object? Sure, he concedes. But so is everyone to one degree or another, he retorts. Has she been subjectified, as in abused, or discarded. Not really, she admits, though she’s had close calls, and felt a constant risk. But she’s also profited considerably from her illicit business, spared herself the financial uphill that many of her same-age peers, male and female, face in today’s world. Above all, like any natural survivor or leader, this alpha prostitute has been nobody’s waif, but rather a cool, even dominant figure in the quasi intimate transactions of her past. In those dark, clammy pairings who has been more vulnerable, more ashamed, more consistently?

Her? Daniel Pierce writes a different script

** rendering by Philip Lawson






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The Trauma Currency, Part Two

(Continued from part one)

Cermak’s intent was to present codependency as a legitimate focus of clinical attention, applicable to a variety of contexts. And so we have the Co-Addict Model, which draws attention to problematic behavior as a function of an underlying, pervasive disorder. While RT adherents may agree with aspects the co-addict corollary, their clinical focus downplays the pathologizing accent. Coping strategies, such as keeping busy with tasks, are instead normalized, cast as affect regulating under exceptional circumstances. Certain behaviors such as indiscriminate sharing of a sex addict’s behavior with friends or family, including children, are discouraged; however, these behaviors are framed as products of social isolation and episodic trauma brought on by an addict’s behavior, not an underlying or even associated pathology. The notable literature that represents this position includes Your Sexually Addicted Spouse (Steffens, Means, 2009), and Facing Heartbreak: Steps to Recovery for Partners of Sex Addicts (Carnes, et al., 2012): the latter, in keeping with recovery tradition, outlines a healing process in stages: a pre-discovery stage, followed by phases of crisis/decision, and repair. In the crisis/decision stage the partner asks, “how did I get here?”, and comes to realizations like, “nothing in this marriage has been real”. Note the emphasis upon present or recent past events, not family of origin, early developmental or even adult developmental material.

The framework of RT appears to contraindicate a neutral therapeutic stance, becoming partner-centric, especially upon discovery of sexual betrayals, because the proposed de-pathologizing shift only applies to partners. There’s nothing in the RT paradigm that contests the assessment of sexual addiction. Indeed, the scope of questions for the revised version of the Sex Addiction Screening Test (or SAST) has widened in recent years, to address not only changes in technology—the broader means of acting out available to sex addicts—but also the impact upon partners of sexual betrayals. Notice, for example, a question on the 1989 version of SAST, “Does your spouse ever worry or complain about your sexual behavior?” (Carnes, 1989), versus a question on the revised 2008 version: “Has your sexual behavior ever created problems for you and your family?” Notice the slant has shifted to query problems identified by the would-be addict, instead of that which is externally identified by a partner whose perspective might be denied by the would-be sex addict, or distorted by a co-addict disorder.

The RT model calls for sex addicts or acting out partners to be identified as perpetrators of trauma, and this term—“perpetrator”—seems close enough to the connotations of “offender” that observers may be surprised that APSATS hasn’t called for the inclusion of more sex addicts on public sex offender registries. In the RT model, partners are validated as victims of a relationship-specific betrayal, and thereafter supported to integrate this experience in a way facilitates a healthy re-emergence in life, comprised of self-care, fellowship with a strong support system, realistic observation of sex addict behavior, but also renewed trust in humankind. The approach suggests that observation of predisposing pathology and validation of traumatic experience are mutually exclusive goals, which may lead to facile, short-term interventions, tailor made for practitioners presenting brief, intensive programs of care. While this may be an appropriate shift in the paradigm with respect to many partners or with all partners of sex addicts in the immediate aftermath of discovery, I wonder about the pathology that will be overlooked in the service of trauma validation, especially amid follow-up treatment episodes wherein identified-patient premises collapse over time.

In cases of sexual betrayal, a therapist working with acting out and non-acting out partners functions as a container for memories and emotions that cry out for expression, or disavowal in the case of those struggling to cope with the past. This Winnicottian task dovetails with reparation efforts—a Kleinian concept before a sex addiction treatment strategy—which hinges upon individuals’ capacity for mourning. Klein (1975) wrote that grievances we harbor towards parents for the wrongs they have committed, and for having denied those wrongs, elicit feelings of hate and desire for revenge. Durham (2000) has argued that the capacity for making reparations in the internal world is the basis on which empathy for others is established. When individuals defensively split, they attach to a narrowly defined narrative: therefore (borrowing the RT Model identifiers) a victim’s anger and hatred is rigidified in the face of a perpetrator’s denial, which represents an evil system built upon a primitive intrapsychic structure. A working through of splitting, into mourning, requires the perpetrator to own his destructiveness so as to experience mourning; then, if the victim is sufficiently open to an awareness of “good enough” qualities in the perpetrator, a re-internalization of that individual as a good object might occur, which in turn enables the victim’s own work of mourning.

Whether or not labels of victim, perpetrator, addict, or codependent are necessary, harmful, or inhibitive of this process seems ambiguous. Assessment and diagnostic nomenclature informs psychiatric intervention; enables the placement of individuals in appropriate levels of care, including hospitals when necessary; generates short and long-term treatment planning goals. Informing patients of their diagnoses gives informed consent to treatment based upon an understanding of conditions that are the focus of clinical attention. At the same time therapists know the stigmatizing risk associated with assessment and diagnostic labels, particularly those whose prescriptive measures are not clearly defined, or subject to a range of treatment alternatives, despite the attempts of some who promote protocols in response to diagnoses. The advisability of informing a patient or client that he or she has a substance dependence, for example, seems predicated on particular factors well understood across professional disciplines, and by the general public: that the problem can be accurately assessed in a short time frame; that prescriptive measures can be readily understood by those potentially receiving services (such as recommendations of abstinence, or attendance at 12-step meetings); that a person may be at grave risk of illness, injury, or even death if immediate intervention does not occur.

Are these factors true with respect to sex addiction, or codependency, or personality disorders? Maybe in some cases, but of the forty five questions on the revised SAST, for example, only one pertains to behaviors that place afflicted individuals in dangerous situations. In my training I learned to refrain from using diagnostic or assessment labels when addressing clients about their problems, unless the applicable term or terms seem critical for intervention, or unless prescriptive measures based upon the nomenclature can be articulated succinctly and concretely. Otherwise, confusion and/or resistance typically follows, with clients left thinly understanding conditions, floundering to make sense of new identities imposed by expert opinion. I often experience this when clients meet with me for the first time, having been diagnosed by a previous practitioner with, say, Narcissist Personality Disorder. They’ve been given an article to read, or a DSM criteria sheet to examine. Afterwards, they exhibit disorientation, manifest with awkward attempts to describe their freshly assigned disorder. When devising a plan, they offer that they need to learn to empathize with others more. Woodenly, they report feeling instructed, and branded, but not understood.

This is often true with individuals who are told they have a sex addiction, or a codependency problem, and while many can wrap their minds around the concept of sex addiction, the assessment still bears much explanation and holding of emotion. As for codependency: from an object relations point of view, that umbrella term represents a whole multitude of dynamic relational configurations, replete with intersecting projections and introjections. So no wonder partners of sex addicts are flummoxed and invalidated by the term, regardless of what betrayals they have felt. Aren’t many or even most shocked to hear that they may have enabled another’s addiction? Won’t many be confused to hear they may have contributed to another’s disorder by an overly close, or conversely, a distant involvement? Doesn’t it jolt the senses, the unconscious, one’s entire being, to hear that one might have a sex addiction, and that an important aspect of that concept is its impact upon intimate partners? Ultimately, what seems important is to hold the idea of a complex problem, brought to light by acting out behaviors, but not reducible to those habits, necessarily. Might it not render the divide between rival models of treatment moot to consider that our clients deserve to not be hamstrung by labels, or denied what is useful in our nomenclature? Rather, they should feel held by our open minds and fuller understanding.



 American Psychiatric Association (2013). Diagnostic and statistical manual of mental disorders (5th ed.). Arlington, VA. American Psychiatric Publishing.

 Bergner, R. & Bridges, A. (2002). The significance of heavy pornography involvement for romantic partners: research and clinical implications. Journal of Sex & Marital Therapy, 28, 193-206.

Black, Claudia (2009). Deceived. Hazelden. Center City, Minnesota.

Carnes, P. (1989) Contrary to Love. Hazelden.

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