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Structural Therapy With a Couple Battling Pornography Addiction

JEFFREY J. FORD Private Practice, St. George, Utah, USA

JARED A. DURTSCHI School of Family Studies and Human Services, Kansas State University, Manhattan,

Kansas, USA

DARRELL L. FRANKLIN New Leaf Resources and Ivy Tech Community College, Lansing, Illinois, USA

Pornography increasingly affects couples’ relationships commen- surately with the increasing availability of pornographic material. Relationships can be adversely affected by the addictive influences of pornography, and therefore therapists are likely to encounter this concern with their clients. It is suggested that addiction to pornog- raphy can be characterized by withdrawal and tolerance, and can have neurological impacts and negatively influence relationships. However, clinicians sometimes fail to recognize pornography ad- diction to be equally as troublesome as other addictions. This paper explores the implementation of successful structural therapy treat- ment of pornography addiction using an actual case study with a married couple.

Recent estimates suggest that there are as many as 225 million Internet users in the United States and Canada (Goldberg, Peterson, Rosen, & Sara, 2008), and that 31% of these users visit sites with sexual content (Cooper, Del- monico, & Burg, 2000). This translates into an estimated 69.7 million people using the Internet for sexual purposes (Goldberg et al., 2008). Although no universal definition of pornography exists, in the present article pornogra- phy was defined as the intentional viewing of sexually explicit material (e.g., movies, Internet sites, and magazines) designed to sexually stimulate oneself.

Marriage and family therapists are likely to see couples presenting in therapy with problems related to pornography, despite the general lack of

Address correspondence to Jeffrey J. Ford, 393 East Riverside Drive, Building 3A, St. George, UT 84790. E-mail: [email protected]

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information on this topic. In two recent surveys of clinical members of the American Association of Marriage and Family Therapists, pornography was found to be a common concern for their clients (Ayers & Haddock, 2009; Goldberg et al., 2008). Ayers and Haddock found that 74% of the 99 ther- apists surveyed had seen couple clients dealing with pornography issues in the past year. Very recently a great deal of attention has been placed upon pornography by marriage and family therapists. Researchers have in- vestigated emotional and sexual infidelity online (Whitty & Quigley, 2008), and surveyed therapists’ about how they assess and treat Internet infidelity (Hertlein & Piercy, 2008). Despite this recent attention, there is a dearth of theoretically driven recommendations for how to treat this burgeoning clinical population.

Widespread use of pornography and online sexual content is commonly a primary concern to clinicians. However, most therapists report inadequate training in graduate programs for this growing problem. For example, one survey found that 47% of therapists reported no training on pornography during their graduate work, while 31% reported receiving little training on the topic (Ayers & Haddock, 2009). Perhaps training programs are uncom- fortable discussing this private and often covert topic, or are not aware of the prevalence of pornography as a presenting concern in the population.

The pervasive use of pornography in our society creates fertile ground for addiction to pornography and can cause problems for some couples. Additionally, many therapists report inadequate training and competence when working with this type of presenting concern. The purpose of this paper is to discuss the topic of pornography, explore the mechanisms of how pornography use may become addictive, and to provide a case study of successful treatment using structural family therapy (Minuchin, 1974). The present article will suggest specific, theoretically driven ways therapists can work with couples troubled by the use of pornography.

PORNOGRAPHY ADDICTION

Pornography shares similar characteristics of addiction with other addictive behaviors, such as gambling and substance use (Carnes & Wilson, 2002). Goodmann (1993) proposed the pattern of pornography use can meet the diagnostic criteria common to all addictive disorders. Pornography addiction has been defined as behavior that has caused significant personal distress or significant personal consequences such as loss of a relationship, legal problems, or job-related problems (Kafka, 2000). Three factors have been proposed to operationalize pornography addiction, including: (a) viewing pornography to cope with stress, (b) participating in activities that would not be otherwise engaged in, such as paraphilias, due to viewing pornography,

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and (c) spending more than 11 hours per week viewing pornographic ma- terial (Cooper, Griffin-Shelley, Delmonico, & Mathy, 2001).

In attempts to identify prevalence rates of pornography addiction, it has been noted that approximately 9% of the several million users of Internet pornography spend over 11 hours a week searching for and accessing porno- graphic sites (Cooper et al., 2001). Further, according to the National Council on Sexual Addiction and Compulsivity, 17% of online Internet pornography users are estimated to be addicted (Cooper et al., 2001). Thus, not all viewers of pornography are addicted, but there is the potential for an addiction to occur. Because pornography use is frequently clandestine, the actual number of addicted individuals is likely to be substantially higher, making the actual prevalence rates very difficult to ascertain.

Tolerance

Tolerance and withdrawal are distinctive factors of addictive behaviors and are apparent in pornography addiction. The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition, Text Revision (DSM-IV-TR) defines toler- ance as a need for significantly increased amounts of a substance to achieve arousal or the desired effect; or markedly diminished effect with continued use of the same amount of the substance (American Psychiatric Association, 2000). For example, heroin users initially achieve a high from the drug with a lesser portion than they would require as their addiction progresses. Thus, in order to achieve the desired effect, the individual must increase the amount of heroin he or she uses. Similarly, tolerance can also develop to pornog- raphy. After prolonged consumption of pornography, excitatory responses to pornography diminish; the repulsion evoked by common pornography fades and may be lost with prolonged consumption (Zillman, 1989). Thus, what initially led to an excitatory response does not necessarily lead to the same level of enjoyment of the frequently consumed material. There- fore, what aroused an individual initially may not arouse them in the later stages of their addiction. Because they do not achieve satisfaction or have the repulsion they once did, individuals addicted to pornography generally seek increasingly novel forms of pornography to achieve the same excitatory result.

For example, pornography addiction may begin with non-pornographic but provocative images and can then progress to more sexually explicit im- ages. As arousal diminishes with each use, an addicted individual may move on to more graphic forms of sexual images and erotica. As arousal again diminishes, the pattern continues to incorporate increasingly graphic, titil- lating, and detailed depictions of sexual activity through the various forms of media. Zillman (1989) states that prolonged pornography use can fos- ter a preference for pornography featuring less common forms of sexuality (e.g., violence), and may alter perceptions of sexuality. Although this pattern

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typifies what one would expect to see with pornography addiction, not all pornography users experience this cascade into an addiction.

Withdrawal

The DSM-IV-TR states that withdrawal is manifested by (a) the development of a specific syndrome due to the cessation or reduction in use that has been heavy and prolonged; (b) causes clinically significant distress or impairment in social, occupational, or other important areas of functioning; and (c) the same or closely related stimuli are taken to relieve or avoid withdrawal symp- toms (American Psychiatric Association, 2000). For example, a person that is addicted to nicotine commonly experiences withdrawal symptoms such as shaking, mood changes, and increased appetite. Withdrawal symptoms from pornography use may include depression, irritability, anxiety, obses- sive thoughts, and an intense longing for pornography. Due to these often intense withdrawal symptoms, cessation from this reinforcement can be ex- tremely difficult for both the individual and the couple’s relationship.

Neurobiology of Pornography Addiction

Landau, Garrett, and Webb (2008) recently elucidated how the neurobiol- ogy of sexual arousal parallels that of cocaine, in that both are associated with dopamine, the brain’s neurotransmitter connected to pleasure. Thus, dopamine can be released into synapses in the brain through substance use, such as cocaine, and also through the viewing of pornography. Thus, when there is a reward such as sex, gambling, eating, or shopping, there is the presence of dopamine and the risk of the development of a compulsion (Landau et al., 2008).When this perceived “high” from pornography use has ended or is absent, a person may feel the need to recapture that positive feeling by returning to pornography. This can become addictive if pornog- raphy becomes a primary coping mechanism, and can inhibit one’s ability to function in his or her respective roles. This process becomes dangerous for the couple subsystem when rigid structural patterns develop that obviate the possibility for partners and spouses to have a meaningful relationship with each other. This danger can result from one or both partners seeking sexual fulfillment and coping with anxiety through means outside of the relationship, using pornography.

Comorbidity

People with paraphilia related disorders have been shown to experience multiple lifetime comorbidity with mood, anxiety, psychoactive substance abuse, and/or other impulse diagnoses (Kafka, 2000). People addicted to pornography also commonly manifest comorbidity (i.e., depression or

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anxiety disorders) and may use pornography to self-medicate (Black, Kehrberg, Flumerfelt, & Schlosser, 1997; Kafka, 2000; Kafka & Prentky, 1994, 1998). Pornography can be a way for people to self-medicate for sleep, anx- iety, pain, and other family and life problems (Carnes, 1991). Similarly with paraphilia related disorders, pornography may also be comorbid with many Axis I diagnoses. Therefore, assessment of pornography addiction is advised with a variety of presenting problems with individuals and couples.

Systemic Influence

The systemic influence of pornography addiction on the individual and the couple is substantial. Pornography addiction is a problem that affects multi- ple aspects of the individual and the couple’s life through mood disorders, anxiety, substance abuse, and other impulse disorders. As an individual struggling with a pornography addiction self-medicates with more pornog- raphy, this temporary reduction in symptoms may perpetuate the problem and become a rigid pattern. This can become a rigid coping mechanism that may have detrimental influences on the couple’s relationship as one partner turns outside of the relationship to cope with individual and relationship challenges. Pornography can have detrimental influences on romantic re- lationships and is often perceived negatively by the partner who refrains from using pornography. If the individual addicted to pornography keeps his or her addiction a secret from his or her spouse, it often creates a power imbalance (Glass, 2002).

STRUCTURAL THERAPY

Structural family therapy (Minuchin, 1974; Minuchin & Fishman, 1981) as- sesses family systems from an organizational standpoint. This theory posits that individual psychopathology is maintained, and sometimes generated, not through personal pathology but rather through defects in a family’s or- ganizational design. Structural family therapists do not focus on resolving an individual’s problem as much as they work to change the family’s or- ganizational structure. Once that family structure has been changed, family members are then able to relate to one another in innovative ways that help them to solve their own problems (Minuchin & Fishman, 1981). Essential to pornography cessation is the couple’s ability to be organized in such a way that they can solve the problem themselves. Therefore, structural theory can be very effective because it can help the couple subsystem organize itself in a way that empowers them to solve their own problems.

One of the fundamental tenets of structural therapy focuses on the proper functioning of subsystems in the family structure. Attention is placed upon the system’s boundaries, and the appropriateness of coalitions,

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triangles, and alliances. Dysfunction occurs in the couple when one or both partners are dissatisfied with the organization of the dyad or when bound- aries are violated. Typical difficulties occur in the relationship when detri- mental coalitions, triangles, and alliances are formed, which affect subsystem boundaries. Outside coalitions may create a systemic imbalance in the re- lationship by creating a triangle with an inappropriate third member. The structural perspective seeks to enable a couple to restore structural integrity by reinforcing functional boundaries of the subsystem. When a third party is triangled into the romantic relationship it can create an imbalance. For example, pornography can be triangle into a marriage and the strength of the couple subsystem diminished.

Pornography creates a coalition against the partner who is not addicted. This coalition weakens the couple’s relationship and creates a structural im- balance. Structural family therapy reorganizes the family’s structure to align the couple or to create a coalition with the couple against the pornog- raphy. This act changes the boundaries that make pornography cessation possible. Relational psychopathology is theoretically maintained and gener- ated because pornography acts as a third member in the couple’s sexually exclusive relationship. Thus, the relational pathology or defect is the organi- zational design. The goal in structural family therapy is the realignment and restructuring of the couple to create opportunities for more intimacy and closeness between spouses that can become reinforcing to each spouse and self-perpetuating. As couples learn to turn towards each other, instead of to outside sources to handle problems, they are more likely to be satisfied and remain in intact relationships (e.g., Gottman, 1994).

CASE EXAMPLE

Presenting Problem

John and Mary began therapy complaining that their relationship was ad- versely affected by pornography. John and Mary were married for 10 years, and had a 3-year-old son. Mary (age 35) was a server and John (age 30) was a computer technician. John and Mary frequently fought about John’s use of pornography, and Mary’s obsessive searches through the house for pornogra- phy. At the beginning of their marriage, John and Mary viewed pornography together while having sexual relations. Initially, Mary was apathetic about that type of pornography use; however, John began to be secretive about his increasing time spent alone viewing pornography. Further, Mary was worried about the type of pornography John was viewing. John also was secretly stashing pornography all around the house, which their 3-year-old son had stumbled upon. Mary was so concerned that she began to search for and destroy any pornography she found, which caused John to become more secretive and underground, (e.g., using pornography at work, or when

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Mary was not home). Accordingly, John would promise Mary that he would not look at pornography anymore. This transactional process characterized the last eight years of their marriage. Mary stated that she no longer trusted John because he had lied to her so many times regarding his cessation of pornography use. Consequently, Mary also threatened to end the marriage because of this problem. John and Mary sought previous therapy for help re- solving their concern with this problem. The previous therapist attempted to encourage John’s autonomy and independence by helping him to preserve his right to look at pornography, and challenged the negative meaning Mary ascribed to the pornography. However, this did not bring about John and Mary’s desired changes to their relationship, thus, they sought therapy from another source.

Therapist Hypothesis

When the couple came to the present therapist (JF) and a female cothera- pist, they hypothesized that Mary’s distrust was not only related to John’s dishonesty about pornography, but also simply by his use of pornography. John was addicted to pornography, and neither spouse recognized it. For example, John incessantly promised to stop using pornography, yet found he could not stop. Further, a sex history related to pornography was conducted that revealed John had started with soft pornography, and had advanced into more graphic and novel forms of pornography. The previous therapist’s approach was not as helpful to this couple because it did not address John’s pornography addiction. Instead, the present therapist chose to first focus on the addiction prior to working on relationship concerns. In a similar way, many therapists suggest addressing substance use addictions as a precursor to doing couple work. Theoretically, once the pornography addiction had ceased and the couple’s system was restructured without pornography, they would then be better equipped to improve their marital functioning.

A structural approach was helpful to dissolve the coalition that John had with the pornography, and to restructure a new coalition by uniting John and Mary against the pornography. The pornography involved in this relationship had imbalanced the spousal-subsystem, and needed to be rebalanced by jointly overcoming the addiction. In addition to the dysfunctional coalition between John and pornography, a triangle had been in place for 8 years among John, the pornography, and Mary. During these years where this triangle had been a significant part of their relationship, the relationship between John and the pornography strengthened, while concomitantly the relationship between John and Mary weakened. Further, John turned to pornography for comfort and soothing more often than he turned to Mary for comfort and soothing. This dysfunctional system involving John, Mary, and the pornography had been taking a destructive toll on their relationship.

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Therapy Process

In the midst of an early session, the present therapists structurally dia- grammed the marriage as a triangle by explicitly drawing the transactional process for the clients to objectively observe and identified pornography as a real third member in their marriage. The idea of pornography being a third member in John’s marriage was very alarming and dissatisfying for John. John stated, “I feel like I am cheating on Mary.” Mary responded, “Yeah, I feel like there has always been a mistress in the house.” Mary agreed that pornography cessation would increase trust in their relationship. The therapists also agreed and new goals were set.

In early sessions, the importance of trust in a relationship and what constituted a betrayal of trust was discussed. Further, therapists and clients discussed how John’s use of pornography was akin to having a relation- ship with a real woman. They indicated things such as coming home late, cheating, lying, and secretive behaviors. For example, John was secretly viewing pornography and attempting to cover up this action from Mary, which was perceived by the clients as equivalent to secretly meeting with another woman. The therapists then superimposed that discussion with the integration of pornography as being the vehicle that created distrust in their relationship. During this session, John decided that he wanted to become open and honest about his pornography use and that he wanted to stop using pornography completely. John developed a realization that he was addicted to pornography and that this addiction was hindering his marital relationship. Although John realized that breaking his pornography addiction would be difficult, he was comforted and empowered by Mary’s commitment to help and understand him.

After this realization, therapists instructed John to gather all of his pornography (i.e., magazines, videos, disks) and place it in a box in the corner of their basement. Mary was extremely satisfied with this decision, and it pleased John that Mary was so happy. This intervention contributed to one of Mary’s original therapeutic goals of not searching for pornography around the house. This also opened the door for Mary to begin to trust John more. John then promised that he would only look at items in the “porn box” with Mary’s permission. After a few weeks of this change, John decided that he wanted to throw all of his pornography materials away. Future sessions were held to discuss and plan how this process would be implemented and attention was placed upon healing the wounds that pornography had inflicted upon their marriage.

John and Mary formed a coalition against pornography, opening the boundary between the two of them while closing off the boundary between John and pornography. John was able to maintain and keep his promise for many weeks. Upon follow-up, John and Mary indicated an increase in marital satisfaction. In fact, they stated “Our marriage is happier now than it has been in the previous ten years.” John was able to receive help and comfort from

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Mary to overcome his addiction and the urge to use pornography. Mary similarly received help from John as he provided comfort and consolation for the pain she had endured while pornography was a part of their marriage.

DISCUSSION

Pornography is becoming increasingly prevalent and frequently viewed by those in romantic relationships. Some individuals are susceptible to develop- ing an addiction to pornography and may experience symptoms of tolerance and withdrawal, associated with a neurobiological component compounding the addiction. Therapists are increasingly likely to encounter couples who desire treatment to help them in their struggle with using pornography. How- ever, therapists often report being inadequately trained and perhaps unsure of possibilities for treating this population. Thus, in response to this clinical need and the present gap in the literature, a successful theoretically driven case study was provided in addition to ideas for specific interventions with this clinical population.

Structural Family Therapy and Pornography as Infidelity

Several aspects of structural family therapy (Minuchin, 1974) make this an effective treatment for couples experiencing difficulty with pornography ad- diction. First, the structural diagram (also called family mapping) was a turn- ing point in therapy and very useful in helping this couple to recognize the covert role and function pornography was playing in their marriage. This couple’s process was able to become overt when each spouse recognized the insidious role pornography was playing in their marriage, and neither spouse was happy with that structure. This couple’s alarm at this structure and seeing pornography as an affair is similar to others’ reports that both men and women perceive online sexual activity as an act of betrayal that is as authentic as any other form of infidelity (Whitty, 2003). Others found that women “overwhelmingly” felt cyberaffairs were as emotionally painful to them as live or offline affairs, and many viewed the online sexual activity to be just as much cheating as a regular affair (Schneider, 2000). Similarly, most women partnered to people addicted to pornography view Internet affairs in a similar way as face-to-face affairs (Cooper, Delmonico, & Burg, 2000).

Therapists may be aided in their clinical work by conceptualizing pornography addiction with some couples as infidelity, due to many people perceiving pornography use similarly to infidelity. Researchers have pro- vided useful reviews on infidelity (Blow & Hartnett, 2005a, 2005b) and offer suggestions for marriage and family therapists’ treatment in the aftermath of infidelity (Blow, 2005; Dupree, White, Olson, & Lafleur, 2007). Many of these ideas could also be incorporated into the therapeutic treatment with

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couples struggling with pornography use, including, (a) therapists directly addressing pornography, (b) for the offender to adapt an apologetic stance, (c) for the partner to move away from criticism towards an open expression of hurts, losses and fears, and (d) eventually forgiveness (Blow, 2005).

It is useful for therapists to think of couples experiencing pornography addiction from a structural framework. This framework includes important variables such as coalitions and triangles, which are useful when evaluating the impact of pornography addiction on some couples. Other theories may focus on the individual, or try to impose their own values (e.g., reality) onto the clients by telling them that the pornography addiction is not a problem, despite the clients reporting it is a problem for them. For example, 34% of therapists responded to a similar clinical vignette to the present case study by pathologizing the concerned partner not viewing pornography by describing her as: rigid, failing to take her husband’s needs seriously, pressuring him, overreacting to his pornography use, lacking sexual availability, and having low self-confidence (Ayers & Haddock, 2009).

Sexual issues have been identified as the area where therapists’ value judgments are the strongest (Hecker, Trepper, Wetchler, & Fontaine, 1995) and it may be difficult for some therapists to adopt the clients’ reality of the problem and help them towards their goals if it differs from their own (Durtschi & McClellan, 2009). For example, Ayers and Haddock (2009) found that about one in five therapists normalized pornography addiction or did not address it at all, while 25% of the therapists did not mention any connec- tion between the pornography use and the couple’s relationship problems. These authors also suggest that therapists’ own positive or neutral values and attitudes towards pornography may prevent some therapists from rec- ognizing pornography as a potential problem for couples (Ayers & Haddock, 2009), which likely influences how these therapists go about assessment and treatment.

Second, the physical removal of the pornography to one location in the home was a less maladaptive pattern than secretive pornography use. Associated with this was John’s promise to only view the pornography with Mary’s permission. This was especially helpful because it served as a cohesive agent for John and Mary to put them in charge of the pornography; thus, strengthening the spousal sub-system versus the sub-system of John and pornography. This change also helped to strengthen Mary in her position in the relationship because it gave her some control. In structural family therapy, Minuchin felt that it was important to make other family members into co- therapists, thereby making the larger unit the matrix for healing (Minuchin, 1974). In this case, the couple became co-therapists by comforting, consoling, strengthening, and encouraging each other in their joint healing process.

Finally, structural therapy is beneficial in this case because of the structural-systemic change that can take place in strengthening the spousal- subsystem. This approach also eliminates the detrimental third member in

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the relationship, thereby facilitating lasting, systemic change (i.e., second order change). The strength of this approach is that it does not focus ex- clusively on the individual problem of the addiction. Rather, it focuses on reinforcing the structure of the subsystem against the pornography which thereby strengthens the spousal subsystem.

CONCLUSION

Pornography is becoming increasingly prevalent and relatively easy to ac- cess. Therefore, pornography addiction may become even more common. Thus, family relationships will also be increasingly affected by pornography addiction. Presently, family therapy graduate training programs have not suf- ficiently addressed the concern of pornography addiction in relationships. Structural therapy appears to be an effective treatment for couples that expe- rience distress due to pornography addiction. Further research and outcome studies are suggested to verify the utility of structural family therapy as a theoretical approach to overcoming pornography addiction.

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