The Making of a Sex Addict Prior to the 19th century the word “” …from the Latin deditus, meaning given up, surrendered; given to, (Roman law) a formal award by a court sentence of a thing or person to another (as of a debtor to his creditor), was used in a broad traditional sense of addiction being viewed as the lifestyle of a person who has given himself or herself over to any pursuit whatsoever and not meant to describe minor habits, but involvements that overwhelm and harm a person’s life. Bruce Alexander “In my beginning is my end.” T.S.Elliot, “Four Quartets”

“…The usual concept of addiction essentially states that the compulsive use of addictive substances, (behaviors) is in some way caused by properties intrinsic to their molecular structure. This view confuses mechanism with cause. Because any accepted explanation of addiction has social, medical, therapeutic, and legal implications, the way one understands addiction is important. Confusing mechanism with basic cause quickly leads one down a path that is misleading….” Felitti. 2004. • “In our detailed study of over 17,000 middle class American adults of diverse ethnicity, we found that the compulsive use of drugs increases proportionally in a strong, graded, dose- response manner that closely parallels the intensity of adverse life experiences during childhood…Our findings are disturbing to some because they imply that the basic causes of addiction lie within us and the way we treat each other, not in drug dealers or dangerous chemicals. They suggest that billions of dollars have been spent everywhere except where the answer is to be found ACE Study Design

Mortality National Death Index Morbidity Hospital Discharge 17,421 Follow-up Outpatient Visits Respondents Pharmacy Utilization (1995-1997) Through 2005 Emergency room visits All medical evaluations abstracted Adverse Childhood Experiences Are Common

Household dysfunction: 27% Parental sep/divorce 23% Mental illness 17% Battered mother 13% Criminal behavior 6%

Abuse

Psychological 11% Physical 28% Sexual 21% Neglect:

Emotional 15% Physical 10% Death

Early Death

Disease, Disability and Social Problems Scientific gaps Adoption of Health-risk Behaviors

Social, Emotional, & Cognitive Impairment

Adverse Childhood Experiences

Conception “What is the function of an addiction? What does addiction mean? First of all addiction is a way of life. A way of dealing with difficulty; of soothing . It’s a means of living , as well as a means of escape. The escape may be from tension, , inadequacy, or the grinding of poverty and oppression. It’s a means of normal and acceptable, even if only temporarily. It’s a false mechanism of fulfillment.” Donald Ottenberg, M.D. Sex Addiction “Sex addiction refers to the thinking and behavior patterns of a person who uses sex to cope with life and to defend against low self-worth and a shameful identity. For the addict sex is not a fulfilling experience that enhances a primary relationship, but a compulsive , often highly ritualized activity that ultimately adds to the pain and the addict is already battling.” Hunter. 1989 • Sexual Addiction is defined as a “pathological relationship” with a mood altering experience. For sex Addicts, sex has become their primary relationship. “Their…behavior becomes part of a cycle of thinking, feeling, and acting which they cannot control”. Sex is seen as a means of comfort in times of pain, a way to relieve , and a source of ever present and always dependable nurturance (Carnes, 1989). Sexual Addiction is a manifestation of altered neurochemistry brought about by behavioral excess. Neurochemical changes in the brain’s reward center that accompany drug abuse are comparable to those endured by the sexual Addicts. Addicts choose drugs that are commensurate with their characteristic style of dealing with stress. Milkman & Sunderworth (1982, 1983) explored the relationship between preferred styles of experience and self-induced changes in brain chemistry. For example an prone individual chooses stimulants, while the -prone individuals chooses opiates, and the fantasy-driven individual prefers hallucinogens…What makes Sexual Addiction so complex and so compelling is that it appears to encompass all three modes of compulsion- fantasy, arousal, and relaxation.” “… “…complicating the phenomenon of sexual addiction is the wide variety of behaviors- from to sadism, from visiting prostitutes to fetishism, from to serial raping….Sexual addiction can be simply a continuation of the normal human sex drive carried to extremes. The behavior becomes an addiction when it fulfills the addiction model, which is best described in the classic addiction mantra: Compulsion,

loss of control,

and continuation in of harmful consequences. “addiction occurs in the brain. Any behavior that produces will temporarily alter the brain chemistry and may result in a compulsion to repeat the behavior to attain more pleasure. Anyone ingesting an exogenous drug such as will activate one of the reward systems and feel pleasure, as will anyone experiencing sexual . It is the intense feeling that is so seductive. Our own natural tendency to seek pleasure leads us down the path to sexual and other .” Sunderwirth, Milkman &Jenks, 1996.“ “We believe that sexual addiction is accompanied by alterations in brain chemistry brought about by episodes of an increasingly aroused nature. Some individuals may have a propensity for addiction due to inherited or early environmentally induced abnormal neuronal connections. However, the altered brain chemistry accompanying addictions is, we believe, the result of escalating activity itself. According to our model, sexual addiction is the result of the brain’s attempt to restore synaptic homeostasis following each or arousal. To achieve the same level of in the reward centers, the ADDICTS must engage in escalating and more frequent sexual activities….the neurochemical model….is more consistent with true addiction than with obsessive-. For this reason, it would appear the 12-step method of recovery would be an appropriate treatment.” Sunderwirth, Milkman &Jenks, 1996. Etiology of Core Beliefs

Catalytic Addictive Events System Self- Family Cohesion Perception Family Adaptability Transform Addictive Early Sexual Experiences Self-Conclusions Core Beliefs Cultural Beliefs

Catalytic Environments Co-Addictive Support System Carnes & Rening 1994 .

Making of a Sex ADDICTS Family

Impaired: ADDICTS in Family 87%

Sexuality Rigid Family Disengaged Family Work System 77% System 87% Physical Body Life Style Rigid Disengaged Family /Bond System 68%

Addictive System-Multiple addictions Abuse/Early Trauma

Chemical Dependency 42% Eating Disorders 38% Emotional 97% Compulsive Working 28% Sexual 81% Compulsive Spending 26% Physical 72% Compulsive Gambling 5% Dysfunctional System Functional System

1. Rigid, Closed 1. Open, Flexible

2. System Controls 2. are OK to Feelings Express 3.Mistakes are punished, 3. Mistakes are shamed, judged disciplined, forgiven, become learning experiences

4. Awareness is denied 4. Awareness is validated Dysfunctional System Functional System

5. Individual serves 5. System supports system but no support individual

6. Lack of individual 6. Individual boundaries boundaries are recognized, supported and OK 7. Intergenerational 7. Each generation legacies of repeat of the redefines, evaluates its above needs 8. Roles all assigned 8. Roles are chosen BASED PERSONALITY CHARACTERISTICS Low Self-Esteem Human doing vs. human being Responsibility for everything Conflict Avoidance Self- about Effort Perfectionism Failure Prone Over Achieving Desperation for Approval Self-Worth contingent on other’s opinion SHAMED-BASED PERSONALITY Self-critical, self-hating Fear of Discovery of being caught No effort is good enough Categorical Black/White Thinking Heightened Sense of Unworthiness Unaware of feelings Tolerance of Pain Fear of abandonment Conflicted Needs Permeable Boundaries ADDICTSS • WILL NOT LIKE LIMITS • WILL NOT WANT TO SEE THEMSELVES AS HUMANS • WILL HIDE HOW OUT OF CONTROL THEY ARE • WILL BLAME OTHERS OR SELF FOR PROBLEMS • WILL DENY NEGATIVE OR VULNERABLE FEELINGS • WILL BE INCONSISTENT AND UNRELIABLE IN RELATIONSHIPS (INCLUDING THERAPEUTIC) • WILL LEAVE TRANSACTIONS INCOMPLETE • WILL NOT TALK ABOUT ANYONE S ABUSIVE, SHAMEFUL, OR COMPULSIVE BEHAVIOR • WILL SEE THE IDEAL LIFE AS DOUBLE LIFE • WILL CONNECT SEX WITH SURVIVAL • WILL SEE VICTIMIZATION IN TERMS OF PERSONAL NEEDS • WILL SEXUALIZE ATTEMPTS TO HELP AND SUPPORT TRAPS

• ADDICTS WILL SEDUCE, EXPLAIN, OR CHARM WAY OUT OF CONFRONTATION. • ADDICTS WILL ATTEMPT TO DETERMINE WHAT IS BEST. • ADDICTS WILL SEXUALIZE INTERACTION WITH HELPERS.

• ADDICTS WILL ATTEMPT TO INVOLVE YOU IN SOMETHING SOCIALLY OR PROFESSIONALLY OUT OF THE OFFICE. • ADDICTS WILL ESCALATE CONFRONTATIONS AND BLAME OTHERS FOR SITUATION.

• ADDICTS WILL BE STUCK AND SEE IT AS A PROBLEM FOR OTHERS TO SOLVE. • ADDICTS WILL BE “EXHIBITIONISTIC” IN TALKING ABOUT SEXUAL EXPERIENCE. COPYRIGHT: PATRICK j. CARNES. PhD.. C.A.S.. 1990 Etiology of Core Beliefs

Catalytic Addictive Events System

Family Cohesion Self- Family Adaptability Perception Transform Addictive Early Sexual Experiences Self-Conclusions Cultural Beliefs Core Beliefs Sexual Abuse

Catalytic Co-Addictive Environments Support System • “…the growth of the addictive system is a pathology, the significant relationship of the family of origin and the co-addictive system s to the addictive system’s evolution, and the powerful role of the core beliefs as they represent the addict’s shame, the resulting faulty logic, and ultimately compulsive behavior.” • Carnes. 1989 • “..the addict starts with self-perceptions that reflect family extremes including both dependency and intimacy issues. In addition sexual experience, including child abuse and sexual and cultural messages, combine to create negative conclusions about self. Catalytic events and environments in the initiation phase of the addictive system transform those self- perceptions into the core beliefs which drive the addictive system. These core beliefs are sustained by co-addictive systems, which most commonly echo the lessons of childhood…Carnes Shame

• The unconscious, irrational threat implied in shame is abandonment and not mutilation as in …Indeed it is not the malevolently destructive eye, but the all- seeing eye which is feared in the condition of shame, God’s eye which reveals the shortcomings of humankind. • Piers. 1953 Multi-System Support For Addiction

Biological Systems

Work Systems Relationship Network

Addictive Systems

Environment Systems Family Systems

Concurrent Addictions Friberg & Lasser

Condition in the Offender

OM Conditions in the Environment Conditions in the Potential Victims

OM= “Offending Moment The Addictive System

Belief System

Unmanageability Impaired Thinking

Addiction Cycle

Preoccupation ShameShame Ritualization S Despair Guilt Guilt Compulsivity DIAGNOSTIC PROCESS CLIENT CHARACTERISTICS DIAGNOSTIC CRITERIA Excessive Sexual Humor Presence of Five of More of The Following: Seductivity/Charm 1. Sexual obsession and fantasy is a primary coping strategy. Inappropriate Dress 2. Sexual behavior is central organizing principle of daily life. Patterns of Short-term Relationships 3. Inordinate amounts of time spent in obtaining sex, being Not Accountable for Money or Time sexual, or recovering sexual experience Moralizing/Religiosity 4. Amount extent, or duration of sexual behavior often exceeds Living in the Extremes person intended (On the Edge/Avoidance) 5. Severe mood shifts around sexual acting out Emotionally Unavailable 6. Escalating pattern of increasing amounts of sexual experience Super Achiever/Underachiever because current activity is no longer sufficient (exemplified by Compulsive Busy-ness more of current sexual behavior, addiction of new sexual Physical Problems around Sex behavior, or initiation of new high risk, illicit, or behavior Self Abuse Especially Around Sex considered to be immoral) 7. Persistent pursuit of self-destructive or high-risk sexual behavior THERAPY ISSUES Shame Based 8. Persistent or efforts to limit sexual behavior Trouble Around Sex (Affairs, 9. Inability to stop behavior despite adverse consequences Conflicts, Arrests) 10. Pattern of out of control (compulsive) sexual behavior for 2 years Inconsistency Between Values and Behavior 11. Pattern of alternating excessive control & out of control behavior Delusion Around Sexual Behavior over 5 years Secrets About Sex 12. Severe consequence due to sexual behavior Exhibited (Either Partner) 13. Presence of clear hierarchy of sexual acting out behaviors Spouse (Or Someone Else) is a Victim or 14. Important social, occupational, or recreational activities sacrificed feels Victimized or reduced because of sexual behavior Control/Release Cycle of Shame 15. Presence of and three of the following associated conditions

- extreme sexual shame --other addictions -secret or “double life” due to sexual behavior-has been or is currently victim if sexual abuse-has been or is victim of emotional or physical abuse-sexualizing of nurturing -few or no non-sexual relationships-suicidal ideation or attempt -presence of sex-negative behavior-presence of co-dependent

33 “ We look for that ideal family- the one we all want and nobody has: that happy group of people who are successful in their endeavors, who share common goals and values, who have each other’s best interests at heart and who all get along. Outwardly, a number of groups seem to qualify. But appearances deceive, and what most of us settle for is the fake family – the one we pretend we have in order to fool ourselves and others.” ~The Mythic Family , Judith Guest • “Some argue that addiction is a social problem (Alexander), that private troubles are public issues, that is, an individual’s addiction transcends any individual in that its roots reside in the broader social and cultural conditions that prevail in society, and might even be said to be an expression of adaptation to prevailing social conditions….Addictions are powerful precisely because they provide at least temporarily, effective avenues to personal meaning in societies in which the search for personal meaning has become increasingly relegated to an individual project.” • “…Addiction and dependency becomes ways of coping with the personal fragmentation experienced in social life. Thus the dislocation experienced in modern society contributes to addiction, addiction becomes a potent source of meaning in advanced society. Addiction becomes a cultural problem… in a world that has become increasingly commodified. Is it really any that there are addictions to all sorts of things when people are sold a bill of goods that promises that they will experience greater satisfaction in life if they use product A or product B?” • “Individuals in advanced societies more and more measure themselves by their possessions, power, and prestige. … “Many social critics have described a kind of cultural devolution that has taken place in advanced capitalist societies. characterized by the collapse of established patterns of social and institutional life. As a result, post- modern societies have seemingly lost their core as more and more people feel their world is spinning out of control”. • “ A sense of social and loss of community characterize this pervasive crises of meaning. For many, the social institutions of family, work, religion, and education no longer provide the comfort, support, and continuity that are necessary to foster meaning and satisfaction. Dramatic population shifts, raging culture wars, unpredictable upward and downward mobility, major technological change, and the globalization of markets have produced increased levels of fear and vulnerability within society that have left people feeling increasingly dislocated and disconnected.” Trans-generational Solidarity

• “Inevitably, the quality of individual satisfaction depends on responsibility for relational consequences, ultimately for the offspring. Denial of consequences weakens prospects for coping with relational reality.” (Boszormenyi-Nagy, 1987) Transgenerational Solidarity • “Exactly because the quality of our relationships has consequences for the survival of the future, relational ethics is not some collection of abstract moral values but the realistic criterion and the main mechanism of survival. Both destructive and constructive inputs can have lasting transgenerational consequences. They the offspring’s capacity for . Once the trust of a child has been badly damaged, chances are that his or her children will grow even more mistrustful.” Transgenerational Solidarity

• “Having received from the past and owing to give it back to the successors, each person is cast into an unspoken ethical contract with the justice of transgenerational solidarity. If one generation returns less than it received, this justice is bound to be violated. Thus, I propose that the most crucial generational consequences… essentially feed forward.” Transgenerational Solidarity

• “The ledger of giving and receiving between generations impinges on the offspring’s chances, his good or bad luck. Yet not every injustice originates from personal malice or neglect. Destiny itself brings with it the prospect of the offspring’s unfair victimization… Transgenerational Solidarity

• “If loss of reassuring, concerned relationships engenders serious misfortune, recent history pictures an ominous course of each successive offspring’s progressive bereavement of for security. The loss of stabilizing supportive , if burdensome, ongoing family relationships places each subsequent generation into a more exposed, vulnerable condition.” Transgenerational Solidarity

• “ I propose the relational predicament of our age results primarily from a relational fragmentation and disintegration of earned trustability…Disintegrative forces bombard children’s brains through television and the “values” of desperate peer groups. More importantly many bitterly disillusioned adults are unable to infuse their children with trust. Instead, they drain the trust offerings of their children. Through our inaction we contribute to the implicit exploitation of posterity.” Transgenerational Solidarity

• “Returning to the realm of close relationships, a regard for the quality of any and every individual human life requires that future accumulation of destructive entitlement be kept at the lowest possible level. The induction of destructive entitlement undermines transgenerational solidarity.” Alone Together: Why We Expect More From Technology and Less From Each Other • Facebook, Twitter, Second Life. “Smart Phones. Robot pets. Robot lovers. Thirty years ago we asked what we would use computers for. Now the question is what don’t we use them for. Now, through technology, we create, navigate and carry out our emotional lives. (Sherry Turkle, 2011) The Medium is the Massage

“All media work us over completely. They are so pervasive. They are so pervasive in their personal, political, economic, aesthetic, psychological, moral, ethical, and social consequences that they leave no part of us untouched, unaffected, unaltered. The medium is the massage. Any understanding of social and cultural change is impossible without a knowledge of the way media work as environments.”

Marshall McLuhan Top Five Uses of the Internet

1. Communication 2. Information Accessibility 3. E-Commerce 4. Social Networking 5. Entertainment

48 Source: Pew Internet Research, 2011

50

• “Technology promises to let us do anything from anywhere with anyone. But it also drains us as we try to do everything everywhere. We begin to feel overwhelmed and depleted by the lives technology makes possible. We may be free to work from anywhere, but we are also prone to be lonely everywhere. In a surprising twist, relentless connection leads to a new . We turn to a new technology to fill the void, but as technology ramps up, our emotional lives ramp down. (Turkle, 2011) Slide #10 • “An interpersonal neurobiology view of well-being holds that the complex, non-linear system of the mind achieves states of self-organization by balancing the two opposing processes of differentiation and linkage. When separated areas of the brain are allowed to specialize in their function and then become linked together, the system is integrated. Integration brings a special state of functioning of the whole…flexible, adaptive, coherent, energized, and stable. This coherent is bounded on one side by chaos and the other by rigidity. In this manner we can envision a flow or river of well-being…This flow can be seen…to reveal the correlations among an empathic relationship, a coherent mind, and an integrated brain…(Siegal, 2006) Empathic Relationships

Coherent Mind Integrated Brain

Daniel Siegal. 2006 • “In the attachment research world, coherent narratives are the most robust predictor of how children will attach. This finding suggests that parents who have made sense of their lives…will be those that offer their children patterns of communication that promote well- being….it is the parent’s neural integration that helps them create a coherent narrative and helps them be receptive to their child’s own mind and communicate signals. Such a pattern may reflect the central role of interpersonal mental attunement in the development of well-being.” (Daniel Siegel, 2006) Nine Middle Prefrontal Processes 1. Body Regulation: balance of the sympathetic (accelerator) and parasympathetic (brake) branches of the autonomic nervous system. 2. Attuned communication: Enables us to tune into other’s states and link minds. 3. Emotional Balance: Permits the lower limbic regions to become aroused enough so life has meaning, but not too aroused that we become flooded. 4. Response flexibility: The opposite of a “knee-jerk” reaction, this capacity enables us to pause before acting and inhibit impulses, giving us enough time to reflect on our various options for response. Ad 5. : Considering the mental perspective of another person. 6. Insight: Self-knowing awareness, the gateway to our autobiographical narratives and self-understanding. 7. Fear Extinction: GABA (an inhibitory neurotransmitter) fibers project down to the amygdala and enable fearful responses to be calmed. 8. Intuition: Being aware of the input of our body, especially information from the neural networks surrounding intestines (“a gut feeling”) and our heart (“heartfelt feelings”) enables us to be open to the wisdom of our non-conceptual selves. 9. Morality: The capacity to think of the larger good, and to act on these pro-social ideas, even when alone, appears to depend on the intact middle prefrontal region. (Siegel. 2006) CATEGORIES OF RECOVERY OVER TIME

Worse Better Better 2nd 6 month 2nd/3rd Year 3 Years Plus

SA Financial Situations* Healthy Sexuality Health Status Coping With Stress Primary Relationship Spirituality Life Satisfaction Self Image Relationship with Family Career Status of Origin Friendships* Relationship with Children

*Continues to improve 3 year plus

Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 DEVELOPING

TASK ONE--- To Break through Denial

TASK TWO--- To Understand Nature of Illness

Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 CRISIS DECISION

TASK THREE---To Surrender to Process

TASK FOUR--- To Limit Damage

Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 SHOCK

TASK FIVE---To establish sobriety for both addicts and co-dependents TASK SIX---To assure physical integrity TASK SEVEN---To participate in a culture of support TASK EIGHT---To reduce shame

Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990

TASK NINE---To Grieve Losses

TASK TEN---To acknowledge cycles of abuse

TASK ELEVEN---To bring closure and resolution to addictive shame Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 REPAIR

TASK TWELVE---To restore financial viability TASK THIRTEEN---To restore meaningful work TASK FOURTEEN---To create lifestyle balance TASK FIFTEEN---To build supportive personal relationship TASK SIXTEEN---To establish regular exercise patterns TASK SEVENTEEN---To structure relationship with self Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 GROWTH

TASK EIGHTEEN---To resolve original conflicts/wounds

TASK NINTEEN---To restore healthy sexuality

TASK TWENTY---To alter dysfunctional family relationships

TASK TWENTY-ONE---To succeed in primary intimacy

Copyright Patrick J. Carnes, Ph.D, C.A.S., 1990 FAMILY

TASK TWENTY-TWO---To commit to recovery for each family member

TASK TWENTY-THREE---To resolve issues with children

TASK TWENTY-FOUR---To resolve issues with extended family

TASK TWENTY-FIVE---To work through differentiation

TASK TWENTY-SIX---To recommit/commit to primary relationship

TASK TWENTY-SEVEN---To commit to couple ship recovery Symptom Healing Through Dialogue

• The Contextual Approach in Addressing Trauma Resolution for Couples engaged in Family Therapy in a Residential Setting. Who Needs to Be Present?

• The major mechanism for healing is the dialogue between significant others who present with the capacity and residual resources for trust-based dialogue. Healing, in whatever outcome may result, entails “meeting” with those we are most connected. The Four Dimensions of Relational Reality

1. Objectifiable Fact Pre-existing Factors Unavoidable Conflicts Consequences The Four Dimensions of Relational Reality

2. Individual Psychology Each person’s Life Goals and Motivation Individual Needs & Developmental Growth Identity Oneness and Separateness The Four Dimensions of Relational Reality

3. Systems of How People Interact Behaviors Communication (Verbal & Nonverbal) Cause and Effect The Four Dimensions of Relational Reality

4. Trust Based Relationships The Balance of Give and Take The Ledger Sheet Due Credit Entitlement Merited Trust The Revolving Slate/Breaking the Cycle Family Therapy at Keystone.

• Contact With Spouses and Other Family Members • Involvement Through: – Solicitation of “Cost Letters – Family History Taking – Family therapy Family Therapy

• Meeting • Disclosure • Response • Development of the Genogram • Intergenerational Aspects of Both Sides • Attention to Welfare of All Family Members • Crediting Positive Contributions • Acknowledging Injury and Unfairness • Education Regarding Addiction and trauma • Boundaries Sexual Energy

• “Sexual energy is a benign, natural force that can be channeled in either a positive or negative directions. The positive qualities increase and intensify as one travels upwards and the negative qualities increase and intensify as one travels downwards.”

Wendy Maltz Positive and Negative POSITIVE DIRECTION Directions in the Maltz Hierarchy of life-affirming celebration Sexual Interaction healthy bonding connectedness creative expression enhanced self-esteem open communication mutual respect trust sense of equality consent safety caring GROUND ZERO: Influx of drives, hormones, and sexual energy Level ±1 ROLE FULFILLMENT

• social customs, religious or cultural duty • goal of procreation, physical release • fixed role behaviors • limited sexual repertoire • sex for drive reduction • willing of inequality Level +2 Behaviors

• Making Love performance/pleasure focus • skills and experimentation • behavioral goal-oriented • mutuality, equality • goal of orgasm • consensual with expectation Level +3 AUTHENTIC SEXUAL INTIMACY

• spiritual connection • honors the inner experience • goal of heart connection, emotional intimacy • sense of and communion • consensual, being in the moment • towards the body Positive and Negative Directions in the Maltz Hierarchy of Sexual Interaction

GROUND ZERO: Influx of drives, hormones, and sexual energy emotional isolation risk and danger dishonesty and shame impulsive, compulsive betrayal of trust imbalance of power coercion and fear dislike of partner silencing of inner reality pain and injury limited options disintegration of relationship destruction of body and soul

NEGATIVE DIRECTION IMPERSONAL INTERACTION

• Other as sex object • Self-denying or self-centered • Generates shame • Sex as uncontrollable, impulsive • Sex under the influence • Disregard for possible effects and consequences ABUSIVE INTERACTION

• Sense of entitlement • Sex as a , exploitation • Manipulation and non-violent coercion • Dominance/Submission roles • Sex on demand • Sex for power and control VIOLENT INTERACTION

• Overt physical coercion • Sadistic, ritualized behaviors • Torture, pain, physical harm • Other as object of sexualized and • Goal is absolute dominance, destruction Continuing Care and Recovery

• Therapeutic Contract Including: • Boundaries • Family and Couple’s therapy • Attendance at 12 Step Meetings • Recommendations from Spouse • Recommendations for Spouse • Clarification of “Expectations” and Prognosis?