Emotionally focused therapy for couples recovering from sexual addiction

Heather A. Love, Rachel M. Moore and Natalie A. Stanish

Couple and Family Therapy Center, Behavioral Sciences Department, Purdue University Calumet, Hammond, IN, USA

ABSTRACT

Sexual addiction is described as a pathological relationship with sexual behaviors. Similar to addictions to substances, sexual addiction is commonly associated with dependency, tolerance, and withdrawal. The treatment of sexual addiction within the romantic couple relationship is significantly absent from existing literature. The presence of sexual addiction in a romantic relationship can result in lack of trust, feelings of shame, anger or betrayal, and ultimately the deterioration of the relationship. Emotionally focused therapy (EFT) is a couples therapy modality in which both partners are validated and helped by the therapist to develop a secure attachment to one another. This theoretical treatment model addresses recovery from a sexual addiction within the couple relationship through the incorporation of empirically validated addictions literature and EFT techniques. Both partners simultaneously participate in the modified steps of EFT treatment to address underlying needs of each partner. The therapist facilitates the couple’s expression of emotions and interaction cycles. The goal of this theoretical model is for the couple to develop a secure attachment to one another and to improve resilient coping within the relationship in order to reduce or eliminate the sexually addictive behaviors.

Sexual addiction

Sexual addiction, a term popularized by Carnes (1983, 2001a), is described as a pathologi- cal relationship with sexual behavior. Sexual addictions can lead to dependency (Zitzman & Butler, 2005), tolerance, and withdrawal (Ford, Durtschi, & Franklin, 2012), all of which are common characteristics associated with other addictions, such as gambling or sub- stance use disorders (Carnes & Wilson, 2002). Sexual arousal releases dopamine into the brain’s neurotransmitter and creates euphoria, which is directly associated with pleasure (Ford et al., 2012; Levine, 2010). Carnes (2001a) connects the similarities of sexual activity with cocaine usage because of the duplicated “high” that they both transmit to the brain. A strong hypothesis in addictions literature suggests that individuals may choose to self-medicate by engaging in sexually addictive behaviors (Carnes & Wilson, 2002) as a form of escape from stressful and/or unwanted thoughts and feelings (Zitzman & Butler, 2005).

Currently, sexual addiction is not included in the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM 5; American Psychiatric Association [APA], 2013); however, other commonly used terms such as hypersexual disorder, sexual com- pulsivity, and sexual impulsivity are also not included (APA, 2013). Hypersexual disorder is conceptualized as a loss of sexual control to intense and repetitive urges related to or in response to adverse life events (Gold & Heffner, 1998; Kafka, 2001, 2010). Sexual compul- sivity is associated with obsessive-compulsive disorders (Black, 1998; Coleman, 1990); the function of compulsive behaviors is to relieve anxiety, but does not provide pleasure (APA, 2013; Goodman, 2001). Sexual impulsivity coincides with impulse control disor- ders (Hollander & Rosen, 2000; Mick & Hollander, 2006); while impulsive behavior is seen to produce gratification, the function is to relieve the tension from arousal or tempta- tion rather than reducing painful affects (APA, 2013; Goodman, 2001). For the purposes of this theoretical treatment modality, the term “sexual addiction” was selected due to the lack of focus on addictive tendencies found within other commonly used terminology.

Criteria for diagnosis

Despite the lack of a universal consensus distinguishing which behaviors meet the criteria for sexual addiction, Carnes (1983) developed 11 general categories of sexual behaviors including fantasy sex, seductive role sex, anonymous sex, paying for sex, trading sex, voy- euristic sex, exhibitionistic sex, intrusive sex, pain exchange, object sex, and sex with chil- dren. Cybersex has also been suggested as its own category of sexual behavior and encompasses all online sexual behavior, including pornography, chatrooms, and any other activity and arousal through internet connections (Turner, 2009). Carnes (1992) defines the signs of sex addiction that may appear in individuals: recurring unmanageable sexual behavior; consequences that are severe in regards to sexual behavior; perpetual desire or effort to limit sexual behavior; inability to relinquish the behavior(s) despite severe conse- quences; repeated pursuit for self-destructive or high-risk behaviors; sexual obsession and fantasy as a leading coping tool; tolerance for amounts and varieties of sexual behavior to accomplish the desired effect; severe mood changes concerning sexual behavior; excessive amounts of time engaged in obtaining sex, being sexual, or recovering from sexual encounters; neglect of important social, occupational, or recreational activities based on sexual behaviors (pp.11-12). For the purposes of this paper, sexual addiction is defined as an individual who presents with one or more of the signs as defined by Carnes (1992) while engaging in one or more of the aforementioned 11 sexual behaviors (Carnes, 1983), with the addition of cybersex (Turner, 2009). These behaviors significantly interfere with interpersonal functioning, specifically in romantic relationships. The focus is not on the sexual behaviors themselves, but rather the addictive signs displayed while carrying out the sexual behaviors.

Sexual addiction and the couple

The partner with the sexual addiction (PSA) might exhibit a multitude of the above-men- tioned adverse behaviors that could potentially lead to neglect of pertinent relationships and decreased intimacy (Ford et al., 2012; Green, Carnes, Carnes, & Weinman, 2012; Manning, 2006; Turner, 2009; Zitzman & Butler, 2005). Prompt and full disclosure of sex- ually addictive behaviors from the PSA has a positive correlation with receiving forgive- ness from the partner (McCullough, Fincham, & Tsang, 2003; Vaughn, 2002); however, full disclosure is often not given (Corley, Pollard, Hook, & Schneider, 2013). When secrets about the sexual addiction are revealed after a period of time, trust is broken and can lead to an attachment injury (Zitzman & Butler, 2005). Post-disclosure, the PSA’s partner may feel a violation of trust, a sense of betrayal, or view the actions as infidelity (Corley et al., 2013; Levine, 2010; Manning, 2006). Hurt feelings may not be disclosed fully to the PSA (Corley et al., 2013) if the partner perceives the sexual addiction as a threat to the relation- ship (Manning, 2006). Lack of full disclosure may lead the PSA to view the relationship in a more positive way than his or her partner. Discrepancies often foster or create further attachment injuries within the relationship.

The satisfaction of sexual intimacy between the partners frequently decreases in the face of sexual addiction. Research shows that when the PSA’s partner is female, she may perceive the PSA as distant; this distance might lead her to feel objectified and that the sex is meaningless (Manning, 2006). In some cases, the PSA uses sex as a means of power in the relationship due to feelings of insecurity; however, the PSA’s partner may be using sex as a way to avoid abandonment from the PSA (Turner, 2009). These sexual patterns are frequently detrimental to the relationship because they contribute to the attachment inju- ries. It is therefore recommended that the partners participate in couples therapy to counter the negative ramifications of the sexual addiction (Rosenberg, Carnes, & O’Connor, 2014).

Treatment

There are numerous similarities between sexual addictions and other defined addictive behaviors. Carnes (2001a) connects the similarities of sexual activity with cocaine usage because of the duplicated “high” that they both transmit to the brain. A strong hypothesis in addictions literature suggests that individuals may choose to self-medicate by engaging in sexually addictive behaviors (Carnes & Wilson, 2002) as a form of escape from stressful and/or unwanted thoughts and feelings (Zitzman & Butler, 2005). Based on these similari- ties, it is assumed that the dependency, tolerance, and withdrawal from sexual behaviors can be just as difficult to overcome as other addictions.

Treatments for substance addictions have frequently been modified to suit the needs of the sexual addiction population. Similar to substance abuse treatment, residential pro- grams have been implemented for sexual addiction (Rosenberg et al., 2014; Wan, Finlayson, & Rowles, 2000). Relapse-prevention techniques, including cognitive restruc- turing, skills training, and trigger identification, have been adapted for sexual addiction (Penix Sbraga & O’Donohue, 2003). Hormone therapy has displayed positive effects in the reduction of compulsive sexual behaviors in men (Safarinejad, 2009) while antidepres- sants have been implemented but with inconsistent results (Wainberg, et al., 2006). Self- help practices from Alcoholics Anonymous (AA) have been adapted for Sexual Addicts Anonymous, Sexaholics Anonymous, Sexual Compulsives Anonymous, and Sex and Love Addicts Anonymous (Garcia & Thibaut, 2010; Kaplan & Krueger, 2010; Parker & Guest, 2002; Schneider & Schneider, 1996). The majority of treatment offered for any addiction (including sexual addiction) is group therapy, in which a group of individuals with a shared problem join under the direction of a facilitator or therapist (Hook, Hook, & Hines, 2008; Swisher, 1995). Group therapy is beneficial for individuals with sexual addictions because it allows the individuals to express shame and guilt in a safe, supportive environment (Adams & Robinson, 2001). Group therapy that utilizes cognitive-behavioral therapy has proven effective in multiple instances (Quadland, 1985; Schwart & Bratsed, 1985). Turner (2009) suggested separate therapy groups for the person with the sexual addiction as well as the partner so that each member of the couple can develop empathy, acceptance, and self-love. A 12-step model involving treatment for couples experiencing sexual addiction has been designed and suggested, but has not yet been empirically vali- dated (Laaser, 1996).

In Schneider and Schneider’s (1996) study on married couples receiving treatment for sexual addiction, the relationship problems most listed were rebuilding trust, lack of inti- macy, and the need to set limits/boundaries, all of which are difficult to resolve solely in individual treatment. When partners are involved in treatment, they learn about the addiction, are able to address their own traits and behaviors that may be contributing to the addiction, and are more willing to provide support throughout the recovery process (Schneider & Schneider, 1996). Substance abuse treatments have also acknowledged the role and effectiveness of including the partner in treatment (Fals-Stewart & Birchler, 2001; Fals-Stewart, Lam, & Kelley, 2009; Kelly & Fals-Stewart, 2002; Naylor & Lee, 2011; Stanley, 2012; Thomas & Corcoran, 2001).

Emotionally focused therapy (EFT)

With 20 years of outcome and process research to draw upon, emotionally focused therapy (EFT) is one of the most empirically validated approaches to couples therapy (Johnson, 2004, 2008). This brief systemic approach typically consists of 8-20 sessions; however, the proposed theoretical model does not include an estimated range of sessions due to the complexity of sexual addiction. EFT is understood in the framework of adult attachment theory (Mikulincer & Shaver, 2007) and presumes couple distress is maintained by the ways in which partners organize and process their emotional experien- ces as well as the patterns of interaction they engage in. EFT conceptualizes emotion (both “primary” – vulnerable and deep emotions – and “secondary” – reactive and protective emotions) as essential in the creation and organization of attachment behaviors and how partners view and experience self and others in romantic relationships. The ultimate goal of therapy in EFT is to create a secure bond between partners, which is accomplished by accessing and reprocessing emotional responses and creating new interactions between the couple (Johnson, 2004, 2008).

EFT and addictions

Although EFT is becoming a more preferred and successful type of therapy for treating distressed couples, its application to sexual addictions specifically, rather than in the con- text of infidelity and sexual affairs, is significantly absent in the literature. To date, there has been only one published article discussing EFT and hypersexual behaviors in the treatment of afflicted couples (Reid & Woolley, 2006). Furthermore, Landau-North, Johnson, and Dalgleish (2011) have developed a model for the treatment of a substance addiction utilizing EFT. Nevertheless, specificity towards the treatment of sexual addiction remains absent in these models despite the similarities between sexual addiction and sub- stance addictions.

Relationship problems and sexual addiction are complementary and self-reinforcing. Not only are addictions toxic for relationships, but negative relationships make individu- als vulnerable to stress and engage in less functional coping styles, and thus more likely to engage in addictive behaviors (Landau-North et al., 2011) such as unhealthy sexual con- duct. Addiction can be conceptualized as a consequence of and dysfunctional solution to the absence of having satisfying close relationships. Focusing on intimate relationships, EFT predicts that individuals who did not experience a safe haven and secure base rela- tionship with a caregiver as children become more vulnerable to the negative impact of stress and trauma (Landau-North et al., 2011). Consequently, the individuals are less able and less likely to cope with this stress by turning to significant others for support, and thus are more likely to turn to addictive substances and behaviors (e.g. sexual behaviors) to regulate emotions. In couples, the (sexually) addictive behavior, rather than the partner, becomes the safe haven and secure base for the addicted partner (Landau-North et al., 2011).

Secure attachments foster a positive and functional way of meeting individuals’ needs for comfort, positive emotions, soothing and relief from pain, and a view of themselves as valuable and strong. As such, secure attachments can be conceptualized as an antidote to addiction (Landau-North et al., 2011). The ultimate goal of EFT is establishing a secure attachment, in which the partners are able to turn to the other as a safe haven and are also able to provide a secure base that allows for resilient coping in their lives. This secure bond makes the partners stronger and less vulnerable to becoming caught in the vicious web of addictive activities (Landau-North et al., 2011).

Widely written about in couple’s addiction treatment (e.g. Cox, Ketner, & Blow, 2013), codependency is a necessary component to address in the treatment of sexual addiction within the couple. The concept of codependency was originally developed from AA (Asher & Brissett, 1988) to describe the overzealous helping that a spouse or parent exhib- its to support the addictive behavior of another, and has been expanded to include addic- tive behaviors in sexual disorders (Carnes, 2001b). From an attachment perspective, codependency is a strategy that people learn in intimate relationships to meet their emo- tional needs (Hogg & Frank, 1992). By focusing on creating and strengthening attachment security within the couple, fostering emotional safety within the relationship, and encour- aging the exploration and expression of emotional needs, EFT may dually address poten- tial codependency in the PSA’s partner.

As previously discussed, disclosure about the sexual addiction can lead to an attach- ment injury (Zitzman & Butler, 2005). Attachment injuries (Johnson, 1998; see Johnson, Makinen, & Millikin, 2001 for a detailed conceptualization) have been effectively treated and resolved in couples utilizing EFT by focusing on the meaning of the attachment injury event, exploring the impact it had on the couple’s relationship bond, and restoring trust within partners (Makinen & Johnson, 2006). These EFT processes can be applied to the treatment of sexual addiction in the couple by explicitly focusing on the meaning of and exploring the impact of the sexually addictive behaviors/acts on the attachment bond.

To facilitate and restore trust in the relationship, the PSA must acknowledge responsibility through the expression of sympathy, remorse, and regret.

Treatment model

The authors propose a theoretical model that utilizes substance-focused addiction treat- ments (Landau-North et al., 2011) in collaboration with EFT (Johnson, 2004, 2008) and apply these practices to treatment of sexual addiction. The proposed model does not man- date total abstinence from sexually addictive behaviors for a couple’s success in this thera- peutic approach; rather, the model follows Landau-North et al. (2011) in asserting that the PSA needs to take responsibility for the sexual addiction and its consequences in order for this treatment approach to be effective. The PSA is highly encouraged to have acknowledged the sexual addiction and to have already taken or currently be taking active steps to address the sexual addiction prior to beginning couple’s therapy. Furthermore, this treatment approach is not intended for use with partners who are currently experiencing violence in their intimate relationship. Therapists utilizing this approach should be vigilant in assessing the appropriateness of this treatment approach for couples experiencing a sexual addiction.

Stage 1 (Steps 1–4): cycle de-escalation

The first stage of EFT focuses on the therapist creating a process for understanding, accepting, and de-escalating the couple’s distress facilitated by the PSA’s sexual addiction. Steps 1 and 2 in this treatment process consist mainly of assessment, which is carried out through conjoint sessions followed by individual sessions as the therapist deems appropri- ate. In Step 1, the therapist creates an alliance and validates both partners equally to ensure both feel safe and accepted. The therapist validates the PSA by accepting that the PSA has understandable reasons for the sexual addiction, and that behaviors towards the sexual addiction were the best solutions that could be found amongst the experience of the romantic relationship. For example, the therapist may say, “It sounds like what you’re saying, Jordan, is that when you are stressed, you don’t feel as though you can tell Alex, which leads you turn to pornography or sexual exchanges with strangers on the internet to relieve the stress.” The therapist validates the PSA’s partner by conveying the message that the emotions and responses towards the PSA are legitimate and understandable. For instance, “It seems that you felt betrayed and purposely tried to avoid deep conversations with Jordan; you didn’t understand why Jordan was spending so much time at strip clubs instead of home with you.” The practical acceptance of each individual is essential to forming a strong therapeutic alliance with both partners.

Along with establishing a therapeutic alliance with both partners, the therapist simulta- neously identifies the toxic impact of the sexual addiction on the PSA, the partner, and the relationship itself as a whole. Utilizing an attachment perspective, the therapist explores each partner’s family of origin, including the type of attachment experienced in child- hood. It is noteworthy to emphasize that partners who struggle with addictions are more likely to report having parents who also suffered from addiction, and that the children of such parents report higher levels of attachment insecurity with romantic partners (Brennan, Shaver, & Tobey, 1991; Kelley et al., 2005).

In Step 2, the therapist initiates the de-escalation process by identifying the problem interactional cycles between the couple that stem from the sexual addiction and maintain attachment insecurity and couple distress. By tracking and reflecting interactions, the therapist focuses specifically on typical behavior sequences related to the sexual addiction that seem to define the relationship and reflect attachment issues. The therapist may track and reflect a behavior sequence by saying, “So because Alex does not enjoy watching por- nography with you, you interpret that message to mean you are not sexually compatible and maybe even abnormal, so you hide the fact that you are watching pornography alone?” The therapist engages in empathic reflections of each partner’s experience of the relationship, including the positive and negative interactions that the couple engages in in response to the sexual addiction. The therapist also uses evocative reflections and ques- tions to clarify how each partner perceives and experiences the sexual addiction in the relationship. For example, the therapist may say, “What has it been like to hear Jordan say that the relationship doesn’t feel safe, so engaging in sexual behaviors with others is a method of escaping?”

Step 3 focuses on accessing unacknowledged primary emotions underlying the interac- tional positions of both partners (i.e. sadness, hurt, fear, shame). The therapist guides the partners in identifying and experiencing these emotions that have been unacknowledged in the relationship through reflection and validation. For example, the therapist may state, “So, Alex, what you are saying to Jordan is: I don’t feel that you want me or need me when you masturbate. What I see and hear is that I’m not attractive, sexy, and good enough for you. I feel hurt and unwanted. Is that it?” These primary, more vulnerable emotions are usually hidden underneath the PSA’s partner’s secondary emotions of anger and con- tempt, which often serve to mask the real source of pain and fear. The therapist reflects and validates each partner’s feelings and acknowledges their experiences. This builds a secure base in therapy and allows the partners to express themselves openly in therapy and explore, detect, and express primary emotions. Evocative reflections and questions are used as an intervention to open up and expand each partner’s emotional experience of the sexual addiction.

The final step in Stage 1 (Step 4) de-escalates the distress around the sexual addiction by reframing the addiction in terms of the maladaptive cycle the couple engages in and the primary emotions and attachment needs of each partner. The therapist places prob- lematic compulsive responses and patterns relating to the sexual addiction in the context of recurring negative interaction patterns, such as demand-withdraw, that persistently confirm the PSA’s attachment insecurities, which consequently triggers maladaptive sex- ual behavior. The sexual addiction is framed as part of the couple’s negative interaction cycle and as the “enemy” in the couple’s relationship that they can only successfully defeat together. The therapist also outlines the specific effects of the sexual addiction, such as the PSA partner’s vigilance for cues that the sexual addiction is still present, and frames these effects in a couple’s general cycle of distress. As the therapist validates the typical positions that the partners take in relation to the sexual addiction, the couple is able to begin to rec- ognize the powerful role that their negative cycle plays in keeping them from the connec- tion they are seeking.

By the end of Step 4, the partners are engaged in and express a new kind of dialogue about emotions, attachment issues, and interaction cycles. Cycle de-escalation results in a general decrease in each partner’s reactive responses to the sexual addiction and an increase in perceived security between the couple. With the de-escalation stage complete, therapy can now be seen as a secure base where greater emotional risks regarding the sex- ual addiction and relationship can be taken and a new level of emotional engagement can be elicited.

Stage 2 (Steps 5–7): restructuring interaction patterns

In Stage 2, primary emotions are explored, extracted, and shared in ways that create more open, responsive interactions between the partners. The therapist must therefore balance the risks involved in working through issues related to the sexual addiction and reaching for the other partner, while also managing the risks of emotional flooding and subsequent relapse by the PSA into the sexually addictive behaviors. Stage 2 is frequently the most challenging for couples, as it attempts to promote lasting changes in the couple’s interac- tional patterns.

The goal of Step 5 is to help the couple identify ignored needs and aspects of them- selves, and to begin to integrate these into the relationship patterns. This step is the most impactful on the success of therapy. As the couple proceeded through the first four steps, each partner will have become aware of the emotions they are feeling in the context of the relationship interactions. In Step 5, the partners discuss the attachment needs that are associated with the emotions each partner has been experiencing. For instance, the PSA may have felt rejected or “pushed away” when attempts were made to be intimate with the romantic partner. Another example may be the PSA’s partner verbalizing feelings of hurt and “disgust” when the PSA engages in the preferred sexually addictive behaviors. When asked by the therapist what those emotions do to the PSA’s partner, the partner may reply, “I feel like shutting Jordan out and not letting Jordan hurt me anymore.” Given that sexual addiction frequently has roots in unmet attachment needs, this is a likely inter- action sequence for couples recovering from sexual addiction.

During Step 5, the therapist focuses on engaging whichever partner who withdraws the most often. This is crucial because there is an extreme level of vulnerability being dis- played and the partner who is not currently sharing must be present and able to try to understand the new position of the vulnerable partner. For instance, the PSA may describe feeling shameful or guilty from engaging in the sexual addiction, and may describe needing to feel worthy of being in the relationship. If the PSA’s partner with- draws or reacts negatively (e.g. “You’re just saying that, you don’t want to stop what you’re doing.”), the therapist will need to intervene and redirect the interaction back to the PSA’s vulnerability (e.g. “Hang on, what Jordan was just saying was very vulnerable and new. It must be difficult to hear Jordan say something so different. What was going on for you as Jordan told you that the sexual addiction makes Jordan feel guilty and unworthy of the relationship?”). This prompts emotional exploration for the less engaged partner, which in turn can be used to discover that partner’s own ignored needs.

This process leads to Step 6, which promotes each partner’s acceptance of the changes and thus the new interactional patterns. By helping both partners focus on their own emo- tions and needs in the therapy room, they are able to express these emotions and needs to the other partner. This step provides the opportunity for both partners to identify with aspects of themselves that are not associated with the sexual addiction. The couple may experience difficulty in this identification process, particularly if the sexual addiction has played a role in the majority or all of the romantic relationship. For example, the PSA’s partner may begin to perceive the PSA as someone who does not know how to ask for love, and therefore does not take that risk, instead turning to the sexual addiction. This drastic change in perspective provides the opportunity for less blaming and more accep- tance, thus shifting the interaction sequence.

Step 6 requires significant support from the therapist for each partner. The PSA’s part- ner is prone to blame and express doubts about the PSA’s emotions, and is not unjustified in doing so. It is important for the therapist to help the PSA’s partner listen to, process, and respond to the emotional sharing that the PSA is engaging in. By supporting both the sharing and listening partner, the therapist is teaching the partners how to develop sensi- tivity towards each other. As each partner starts to listen to and accept one another, a secure attachment begins to form. The therapist should be aware that this might be the first secure attachment one or both of the partners have ever developed, and treat the part- ners with the sensitivity that entails.

Step 7 is the last of Stage 2 and focuses on full emotional engagement of each partner. During the course of Step 7, both partners are made able to begin to request that their needs be met in a way that guides the partner towards them and allows the partner to respond. Each partner should now be more aware of his or her own needs, and be able to ask for these needs to be met by their partner in an open, non-blaming manner. This is particularly important for PSAs and their partners because they frequently have experi- enced their needs not being met in the relationship. The PSA previously attempted to have emotional needs met through engaging in preferred sexual addiction behaviors. The PSA’s partner may have previously dealt with needs not being met by not acknowledging the needs, or by turning to others outside the relationship (e.g. parents, siblings, friends, etc.). By helping both partners acknowledge that they each have specific needs, and by providing a secure space where those needs can be asked for within the relationship, the partners are then able to turn to each other instead of outside the relationship to have their needs met. This strengthens the secure attachment and helps the couple battle the sexual addiction as a team.

Stage 3 (Steps 8 and 9): consolidation

By Stage 3, the changes that have previously taken place in therapy should now be preva- lent in the couple’s daily life. Step 8 focuses on the couple revisiting unresolved conflicts. While the couple is solving a problem, the therapist can validate the couple’s new and more positive interactions in the moment, and then reflect on their prior negative interac- tions. This allows the therapist to continue to foster a secure attachment in the couple and allow them to begin to identify their new patterns on their own. Change is evidenced by the couple’s ability to solve problems in a trusting, vulnerable, and secure way where attachment insecurities were once present. Negative interactions regarding the sexual addiction now have less effect on the couple’s relationship and are processed in a different, more positive way.

Step 9, the final step, is important in regards to a successful termination. The thera- pist helps the couple develop a story or narrative to depict their therapeutic process. Creating a story together allows the couple to define how the sexual addiction previ- ously affected them, collaborate on the meaning of their new relationship, and promote a sense of closure in regards to the sexual addiction. Formulation of this story continues to build a secure attachment by showing each partner’s adaptability to the other. With the help of the therapist, establishing this story can help reinforce new interaction pat- terns and motivates the couple in their future. During Step 9, the therapist should com- pliment each partner on risks that were taken and shifts that were developed around the sexual addiction (i.e. displaying vulnerability by discussing primary emotions and acceptance of the reframed sexual addiction), as well as highlight the couple’s bravery and willingness to work towards a secure attachment. When it is evident that the couple is capable of continuing recovery without therapeutic intervention, termination should be discussed.

It is normal for couples to fear termination of therapy. It is up to the therapist to not only reassure the partners that they are qualified to leave the secure base of therapy, but also equip the couple for the possibilities that lie ahead. Potential triggers should be dis- cussed in addition to strategies that can be implemented to cope with the identified trig- gers. The therapist should prepare the partners for possible relapses and have them discuss a plan in the case of a relapse. This encourages the partners to turn to each other when conflict or crisis arises.

Limitations

The presented model has not been clinically implemented and is therefore a major limita- tion; however, this theoretical treatment model for couples experiencing a sexual addic- tion was developed using empirically validated treatments from addictions literature. Although prominent research on sexual addictions exists in present literature, sexual addiction is not currently listed as a clinical diagnosis in the DSM 5. Current research on this topic has a strong focus on males as the individual with the sexual addiction as well as sexual addictions existing in heterosexual relationships. Consequently, minimal research exists on heterosexual females, lesbians, gays, or bisexuals as the individual with the sexual addiction. Furthermore, a considerable portion of the available research does not explicitly state the gender of the individual exhibiting the behaviors. Lastly, as previ- ously mentioned, EFT is not intended for partners currently experiencing violence in their relationship.

Conclusion

Sexual addiction and the distress that it causes can no longer be viewed as an individual concern in the context of romantic relationships. Despite the fact that a sexual addiction is most often exhibited by one individual rather than both partners in a relationship, the causes of such a distressing habitual and compulsive habit cannot be solely attributed to the individual. Although this model relies on the PSA engaging in individual treatment prior to the inclusion of the romantic partner, it is recommended the couple engage in treatment together to fully heal from the trauma of the addiction. The proposed treatment model identifies and explores the effects of sexual addiction on the romantic relationship and facilitates the couple’s recovery from the addiction through the formation of a secure attachment.

Disclosure statement

No potential conflict of interest was reported by the authors.

Notes on contributors

Heather Love is a graduate student in the Marriage and Family Therapy Program at Purdue Uni- versity Calumet. Her research interests include couples experiencing distress, sexuality, addictions, internalizing behaviors, and suicide. She is interested in examining the effects of self-harm, suicide, and trauma on family and romantic relationships.

Rachel Moore is a graduate student in the Marriage and Family Therapy field. Her research inter- ests include attachment theory, addictions, identity development and adoptive family relationships. Using EFT as a framework, she investigates her interests within this attachment driven theory and how sexual addictions affect intimate relationships.

Natalie Stanish is a current graduate student at Purdue University Calumet pursuing her Master’s degree in Child Development and Family Studies, with a specialization in Marriage and Family Therapy, as well as her Certified Advanced Alcohol and Drug Counselor (CAADAC) licensure. Ms. Stanish’s research interests include stepfamilies, relational attachments and couples, families, adolescents and young adults struggling with addiction.

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