It was a great honor and pleasure to present to professionals at the ANZ addictions conference of 2019. Here are some clips from my speech on Alcohol & Stimulant Sexual Addiction.
My name is John Arber and i’ve got an office out in Melbourne, in the past I’ve worked with youths and adults in detox, i’ve worked outreach within the intervies drug use using people, i was counselling service manager and i used to write programs and run 2 drug and alcohol rehabs and i’ve taught AOD to Swinburne University undergraduate psychology students as well as teaching undergraduate and post graduate students at the Australian College of Applied Psychology.
When i make reference to clients today it’s all been de-identified and i’ve changed and amalgamated the cases.
This presentation is about the male cohort with ASISA and it is usual for an ASISA client to present to the therapist often with a binge drinking or alcohol related issue so of course it’s not often disclosed straight away and of course the partner may also be involved in some of the alcohol or stimulant uses and when i talk about the stimulant uses i am talking about cocaine and methamphetamine and the parter is often un aware of the sex addiction. The ASISA clients cross over no socio-economic or ethnic boundaries and affects the gay and heterosexual males and i’ve seen clients from 18 to 82 years old and there was a study in 2006 theres not much on this field but phong identified men with sexual addiction if they have been diagnosed with a lot of co morbid disorders and Phone found that 86% of them had an anxiety disorder. 71% had a mood disorder such as depression, 71% had a substance abuse disorder, 46% had a personality disorder, 38% an impulse control disorder, 83% of self identifying people with sex addiction are all agreed that they were dependant on alcohol and drugs, they identified themselves workaholics and compulsive gamblers and 14% had obsessive compulsive disorder and a lot of these are very combatant to the presentations in my own practice.
Let’s identify in ASISA there’s counselling 101 type counselling to build rapport which encompasses normalising and we start off with our clients with alcohol and you’d never ever ask your client what they drink or quantity because they are going to feel shame and minimize so if you want to get an accurate picture you might say something like this “hey some of my clients might drink 2 bottles of wine, some might drink a slab a day while some of them when having a binge might go over 15 standard drinks and i’m wondering how that is for you and of course we need to probe further because we are looking for SAISA so then i might from there say something that “it’s quite common for clients to score coke or ICE when they’re drinking and i’m wondering if you sometimes score?”.
This is the hard part and you’ve got to learn this as therapist you’ve got to get out of your comfort zone. Some therapists won’t scratch where it doesn’t itch but if you’re working with ASISA clients you must scratch, you need to ask the question and you need to explore and you need to ask them and say “hey you’re going out, you’re clubbing you’re doing lines of coke or ICE so it’s really common for a lot of people to watch hours of pornography after that, visit happy ending massage shops, visit strip clubs, brothels, getting online chat forums, exchanging images etc. So you’ve got to ask your client if this resinates with them and then it would be expected that you explore any drug induced psychosis because many of my clients report paranoia after using, when coming down and this is often a really good motivator to stop so those that are familiar with the cycle of change you will recognise this as the contemplation stage. A typical example is some clients report to go to a club or hotel and they drink and reach the stuff it button, they score cocaine or ICE and a lot of them book into a hotel, they go on a bender and they watch hours of pornography, chat lines or even calling some escorts and believe it or not this can go on for 2 days. They sometimes feel so paranoid that they can’t even leave the room until they straighten up.
People as me, what comes first the chicken or the egg and its really hard to get this right so we have to consider the following things, we have to ask, does our client have a history or sexual or pornography addiction and when sober does your client experience any sexual anxiety, including but not limited to erectile disfunction, premature ejaculation as well as any of the underlying disorders as identified in Phongs study. Also you’ve got to consider is your client experiencing cognitive dissonance are they grappling with their sexual identity and are they using alcohol and stimulants to fulfil their true sexual desires.
You’ve also got to distinguish if it’s only when your client goes past that stuff it button, acts impulsively and doing lines of coke and stimulant the acting out sexually.
Some of them come because their partners are concerned about their binge drinking or perhaps stimulant use and often it’s that failure to come home.
Sometimes the client will present with their partner in crisis following being caught, and the partner usually discovers these things by looking on their devices, looking at emails, bank statements, phone bills and some of them even put gps tracking devices on their partners phone.
I’m going to give you a case example here is Sam, and sam is a married 49 year old tradie and he goes out for drinks on a Friday night and one Friday night he usually uses lines of coke and he drinks heavily, and while he was out that night he scored cocaine and he arrived home Sunday, substance affected and of course he kept drinking because he was coming down off the stimulant so he was using a depressant. He was lying on the lounge watching graphics of porn and eventually he passed out on the couch and soon after that his 14 year old daughter discovered he was asleep and saw the images still visible on his phone and of course the parents presented together in couples counselling in crisis.
There’s a lot of impacts on the relationship and quite often the partner feels an emotional and sexual disconnection and they suspect something is wrong and they often say look i knew something was not right. The person addicted is going to experience erectile dysfunction for the following reasons, ones a bit obvious because they are used to doing these activities while on stimulants, they’ve maxed out their sexual credit card, masturbating, watching porn and getting on chat lines, perhaps they’ve been exchanging images and they’re having external sexual encounters and what happens is they need so much dopamine that they’re actually now in the virtual world and their sexual expectations become unrealistic and sex with their partner just does not do it for them anymore and they avoid initiating sex because of lack of libido, they reject their partners advances, and the partner feels they are no longer sexually attractive to them and the partner begins to question their own attractiveness and the partner often presents with low self efficacy and perceives they have a negative body image. An example of this a i’m in a session and a female partner looked at her fiance’ and said “i don’t understand this, i caught you in the bathroom masterbating watching porn during one of your benders and i wanted to do xxx to you but you never come near me and what really really peeves me off is the images you were viewing the images of the girls were a lot slimmer than me”
So let’s just have a look at a bit of some of the treatment now. It’s useful to consider alderian paradigm in the treatment of ASIAS and Alfred Adler said that our thoughts determine our feelings and this is fuel for our behaviour so think of this for any addiction we have a thought and we could call that the trigger, then we have a feeling so we become anxious and then we have a craving and of course then we behave accordingly and we act out on our addiction.
So now let’s have a look at the maintenance stage in the cycle of change how we have to look at that. you have clients presenting the mid brain and what i call the dopamine this is the pleasure centre of the brain, then we have the frontal lope the logical part of the brain and people come for addictions and ASIAS because the dopamine central overrides the frontal and logical part of the brain with that self dialogue using rationalisation and giving permission and clients are then taught how to recognise this self dialogue because usually this self dialogue happens pretty early in the cravings part of the cycle. So what we’ve got to do there we develop a plan but we’ve also got to keep in mind that chicken and the egg situation i talked about earlier and this is pretty complex, it’s not just a matter of let’s develop a plan because we have to look at underlying issues, we have to look at sexual anxiety, we have to look at unsureness around the persons sexuality, we have to look at any co existing disorders as identified and these must be addressed in the counselling aspect or if it’s out of our expertise we might have to refer on, sometimes i’ve referred to a psychiatrist.
It’s really essential to go into the history of the client, sometimes there are attachment issues you should all be familiar with John Bowlby. Look at the couples emotional and sexual intimacy and look at if they’ve gone down that spiral.
A plan can range from total abstinence of alcohol, stimulants and sexual acting out. We can then look at moderation of alcohol provided that there is no dependancy there and sustain of stimulants, porn and acting out. The important thing is here to realise is when a person ceases to watch porn and act on they sexual addiction their dopamine experience slowly returns to their pre addiction. So their stimulation returns to their biological libido patterns and there out of their fantasy world they don’t need that anymore.
Post addiction many couples report the regaining of their sexual intimacy and often the parter attends and they include the partner in the plan because if the partner is struggling the partner is able to provide support and what this does is foster the shared feelings that perhaps haven’t been shared before and thats really putting the seeds of trust back into that relationship, i know what he’s thinking.
When partners ask about how long life will take for their world to get back to normal i’ve adopted Strobe and Shut grief dual process model because we have to recognise that giving up an addiction is a loss issue so i think that it’s logical that i encompass some of griefs theory. So in early stages of recovery a person then is going to isolate between intense thoughts and cravings and then they’ll be distracted from it, something will distract them from it and they’ll move away from that and as time marches on they’re going to have less intense thoughts and cravings and they’ll move more into the distraction mode as the addiction experience fades.
When you look at the prevention and relapse prevention i use this metaphor. I call it the wheat field metaphor. Imagine if you’re a wheat farmer and you’re all working in the wheat field and theres a farm house there and theres a long winding track going to it and you have a look that you find that theres a shorter way so what you’re going to do is decide you’re going to treck down this much shorter path and you’re doing well and you’re getting there and things are going fantastic and one day it rains and it hails and the tractor won’t start and the farm hand takes a day off and you’re tired and you’re stressed and you feel today is too hard to tread down that track so you take the default, you take the familiar path. This explains and normalises a little bit of a lapse and if we learn from our experience we can then use new tools for the next time we’re tempted to go into that default. This is why the alarm bells raise when people say they are fine and they are fine when they come out of therapy but then they’ll prop back into therapy because clients always need to be aware of identifying times when they are at risk. They continually need to refer to their plan and i’ve had clients, one guy that was . financial analysis who did about a 40 page spreadsheet on his plan but he said that if he doesn’t look at his plan he lapses. So they have to refer to their plan because cravings can come from the left field often when the client is doing really well.
Finally we’ve got to look at the limitations of the treatment plans and everything, but the important thing everyone should know, it’s with all addictions the client is usually the last to see they have an addiction and if the client doesn’t see that and if they’re coerced into coming to therapy theres nothing we can do but harm minimisation and this often occurs as i said when they are coerced.
Video Transcript: What is the typical client cycle of ASISA
To get that rush they start to go through the whole cycle of pornography, it’s almost similar to alcohol abuse or dependance so they need to watch more to get that same effect.
So what happens is commences normally with less graphic images, they might start with watching instagram images, they might look at google images they might look at social media images but then it progresses to more graphic pornography, increasing need to watch more extremes and it often moves on to needing to participate in online chat rooms and they exchange images and masterbate and eventually they move so far out of this world into meetups, brotherls, massage shops, interestingly some of the clients report they heighten their dopamine rush by having unprotected sex. It’s not surprising of what i’ve noticed and there has been a little bit written on it that heterosexual males over the age of 55 are often drawn to exploring transgender or gay porn and participating in those experiences and the reasons being is that these guys have experienced a lot of things sexually and they’re looking for a new high and new dopamine rush
Watch Video 3