Authored by Travis Smith*
Abstract
In this interview, Patrick Carnes, the world’s leading expert on sexual addiction, shares his expertise on the topic of sexual addiction and the nuances and evolution of this prevalent issue. Dr. Carnes discusses the history of sexual addiction, along with gender differences and best practices when treating couples. Dr. Carnes also presents research supporting sex as an addiction, and how this influences treatment. In addition, Dr. Carnes also discusses the importance of disclosure in the process of restoring trust in relationships where sexual addiction has been present.
Keywords: Sexual addiction; Addiction recovery; Infidelity
Biography
Patrick J. Carnes, PhD, is the founder of the International Institute for Trauma and Addiction Professionals (IITAP) and Gentle Path Press. His extensive background in the field of addiction therapy led Dr. Carnes to develop multiple cutting-edge recovery programs aimed at treating addictive disorders. He serves as executive director of the Gentle Path Program, a residential treatment program for sexual addiction in Wickenburg, Arizona.
With more than 30 years in the sexual addiction treatment field, Dr. Carnes continues to spread his extensive knowledge as a speaker, presenter and interview subject. His assessment tools and related materials deliver an unprecedented approach to addiction recovery for practitioners of addiction treatment and sexual addicts.
Historical Context and Development of Sexual Addiction
Smith: Dr. Carnes, I want to thank you for your time. I understand you are very busy, but I think this piece that I am working on is important and having your expertise and experience will be so helpful to many trying to treat this particular issue. So, the first question that I have for you is, Dr. Carnes, when did you first become aware of the issue of sexual addiction?
Carnes: Well, I can give you the standard answer, which is in 1973 I was working with adolescents in the street and I went to my psychiatrist at the time and said, “ I think sex can be an addiction”, and my psychiatrist said, “I know that’s true,” and he helped me get a grant, and we wrote about it. The essence of that became eventually known as a book called Out of the Shadows [1].
A significant part of it was just by watching patients in a crisis intervention center, I was seeing sexual addiction in the street and at that clinic. I also started seeing patient’s that that were very affluent, so I had a perspective that showed the existence of it on both sides.
I got involved with a group for sexual recovery in ‘77 and could see how 12-steps were really helping people with therapy and I was in a group where of the 10 members of that group, nine were therapists and the 10th was a judge.
Smith: So, 1973, and Out of the Shadows came out in 1983. You worked on that for quite some time.
Carnes: Well, actually it was more about fear, I think. I would take the paper and do in-services, and it was like an underground document.
The first public event where I was actually talking about the book, I expected it to get all kinds of flack. As it turns out, people who were there were either people seeking help or clinicians that had clients they didn’t know how to treat this sexually based problem. There was no contention, they just said, “What do we do?” But, the kicker in the story is, I got on the plane to go home and I am in the front seat of, coach section and I was sitting in the middle seat and the guy next to me said, “Well, what brings you to Washington?,” and I wasn’t comfortable talking about it. I said, “Well, I came here to do some work.” He says, “Well, what do you do?” I said, “Well, I’m a psychologist.” And, he says, “So, what did you speak on?” and I just finally unloaded it on him and let him have it. I said, “The workshop was on sex addiction, I just wrote a book about it,” and he says, “Oh, I’ve got that book,” and he reached into his briefcase and he pulled it out, and
he said, “You know, this is a very important book, but the publisher did it wrong.” At that time, it was titled The Sexual Addiction.
And he said, “What they need to do is they need to retitle it, because write now if somebody buys it, it is like they are going to the cashier and facing the young lady there admitting they have a problem”
He went on to say that he thought the book needed to be a successful book, but needed to be totally redone. He asked if he had my permission to call this publisher and say, “You’re missing the boat here,” and I consented. Two days later the publisher called and said, “We spent the day on the phone with him and we have completely redone the book, and we would like to try some titles out on you, and the first one we would like to try is Out of the Shadows, Understanding Sexual Addiction.” They redid the book and, millions of copies later, the rest is history.
Smith: So, even during the time, people struggled with compulsive sexual behavior, that is not the question; it’s how do I present the idea to the masses in a way that is soft enough for them to hear it or consider it?
Carnes: Absolutely, and it still to this day is a problem, and there is a pioneering group in Canada that realized that the how to talk to the public about sex addiction is really key. They hired a Washington think tank called Frame Works and started cable and radio-based health series on addiction, and the impact it has on the brain. If you start with the brain and you talk about it as a brain disease and not food, sex, gambling or the like. So, in every hospital, every train station, and on cable TV people could watch this. After a period, they randomly checked to see if the public changed its attitudes about addiction and they did. The number one service that they thought was necessary was sex addiction.
Defining Sexual Addiction
Smith: How do you define sexual addiction?
Carnes: Now to underline why that is important is that in North America addiction is our number one public health problem. If you look at substance abuse, alcoholism, abuse of prescription drugs, which is huge because over two-thirds of American adults have used a pain killer like hydrocodone for nonmedical purposes, and then you add in a third of our population is obese, which is about compulsive overeating and an addiction problem; and then you add in the sex addiction and nicotine, and I mean you mix it all together, that is why we have things like the costs that we do.
If you start from the point of view of it’s a brain disease and, once people understand that food and gambling become addictive and that it doesn’t have to be a chemical, the sex part becomes easy. That is important from a public policy point of view, because it helps us to understand how people can make sense of something more than just character issues.
We use many different definitions of sex addiction. It’s a little bit like physics and defining light. In one way it’s a set of particles, another way it’s a set of waves. So, you ask which is it and the physicist will tell you it’s both. ASAM (American Society of Addiction Medicine) has a definition that they have come to, is that the neurobiology of addiction is becoming very, very clear. And, so, they define it as a brain disease in which the brain is fundamentally altered and rewires itself so that the individual then makes consistently recursive poor choices around food, sex, money, alcohol, drugs. ASAM includes process addictions in their general definition of addiction, which is important on many levels.
Smith: So, when you talk about addiction and brain disease, you’re talking about neuroplasticity?
Carnes: Neuroplasticity is key to that. One theoretically framework is that there is brain damage, which is visible and measured through imaging. We use the same standard 10 criteria that have been used for disordered gambling and substance abuse; they also work for sex addiction. Criteria like loss of control, consequences because of acting out behavior and yet you do it anyway, feelings of regret or guilt and repeated attempts to quit are hallmarks of addiction.
I have just finished a paper in which we had 4400 people participating that were sex addicts, inpatient/outpatient, that fit the 10 criteria. Now, in the DSM it is a theoretical. It is like depression where you can assess for depression, but you can have lots of different reasons that you think that depression is there. Sex addiction, of course, is that same way, except in the addiction’s case the neurobiology of this is starting to take over things. But it is also a maladaptive response to trauma because we know people who were abused as children, the more abused they were, the more addictions they tend to have as an adult. In the mid 90’s Bruce Perry did a series, The ACEs survey, which found the same thing, that early childhood, early attachment, was a predictor [2]. It’s a mental adaptor response to stress. It is also a family issue and multigenerational. It is also a failure to bond, and an attachment issue. Only 8% of sex addicts test out as a secure attachment. So, these issues, family dynamics and family history of addiction, child abuse, sexual abuse and attachment styles are all essential aspects of treatment.
Smith: Can you speak to the impact the Internet has had on the prevalence of sexual addiction in the general population?
Carnes: There are these different things that are all true about sex addicts that we know. A factor, that is a game changer in this whole thing, is that the Internet has made such an extraordinary change in everything, but in our sexual behavior, it truly is changing our sexuality as we speak.
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