Module 6
Sexual/Love Addictions
a. The Fire Down Below
There is considerable agreement in the literature as to the existence of a
condition characterized by driven and compulsive sexual behavior. Individuals with
this condition can spend an inordinate amount of time pursuing essentially
anonymous sexual encounters to the detriment of their personal life, occupational
functioning, financial well-being, and even physical health. In the context of possible
exposure to AIDS, such behavior can be life threatening. Certainly, the media is
awash with sex scandals involving politicians who seemingly risk all they have
achieved in the pursuit of repeated and largely anonymous sexual encounters; Eliot
Spitzer and Anthony Weiner are only among the latest to sacrifice their careers on the
altar of transient sexual gratification.
Nonetheless, there is considerable controversy in the literature as to how to
conceptualize such behavior, and a variety of nomenclature has been proposed,
including sexual addiction (Carnes 1991; Goodman 1998), hypersexual behavior
(Kafka 2010), and paraphilia-related behavior (Stein et al. 2000). In this, I present the
case of a man with such driven, repetitive sexual behavior and then discuss the
aspects of his presentation that reflect common features of sexually addictive
behavior, as well as those components that may be unique to his history. The
diagnostic considerations of driven and compulsive sexual behavior, particularly in
light of the construct of sexual addictions, are reviewed. The possible neurobiological
substrates of this condition are also considered, as well as treatment options.
The following is the case history of a man presenting in psychotherapy with
sexually addictive behavior. This history represents a composite of several patients
treated for sexual addiction in the past two decades. In order to preserve
confidentiality, many of the inessential details have been changed, and components
from multiple patients’ histories have been incorporated into the story.
Sam is a 42-year-old married man with two children. He was referred for
psychotherapy at the request of his wife, who was concerned about his capacity to
control his increasing urges for infidelity, which had precipitously increased after
attending a party for his oldest child’s seventh birthday. Although the patient was
initially resistant to psychotherapy, he soon acknowledged that he was desperate to
save his marriage and terrified at the thought of breaking up his family.
He reported a long history of polysubstance abuse (primarily involving
alcohol, ecstasy, and cocaine), starting in his late teens and ending 2 years into his
relationship with his wife, whom he met 10 years prior to entering treatment. With the
exception of a few small relapses, he had easily remained sober since joining
Alcoholics Anonymous (AA) 8 years previously. However, in the context of his
substance abuse, he had chronically demonstrated compulsive sexual behavior,
including promiscuous sex with women and some men, patronizing of prostitutes, and
compulsive masturbation to pornography. As a young man in his 20s, he was a
member of a fairly successful rock band and therefore had ample access to drugs and
casual sex. Whereas discontinuing his drug abuse was relatively easy, refraining from
compulsive sexual behavior was far more difficult. Although he later recognized an
underlying shame at his out-of-control behavior, he had long seen his sexuality as
ego-syntonic, a reflection of a free and honest spirit unconstrained by hypocritical
societal conventions. He also viewed his sexual behavior as consistent with his
philosophical opposition to monogamy.
In his early 30s, Sam met his future wife and wisely recognized this to be a
relationship worth preserving. At this point, he joined AA, gave up substance abuse,
and committed to living within the sexual parameters of his relationship. His wife
agreed to sexual exploration at the outset of their relationship, including a few visits
to sex clubs and one or two ménage à trois experiences with other women. After a
while, however, Sam’s wife became less accommodating to these activities,
wondering why he was not satisfied with their sexual life together. Sam’s sexual
desire for his wife waxed and waned, along with his tolerance of intimacy with her.
As treatment progressed and his comfort with intimacy and vulnerability with his wife
increased, his sexual compulsivity decreased. However, during her business trips or
when their children demanded more attention from her, Sam would develop intense
new urges to visit a massage parlor, call a prostitute, or engage in anonymous sex with
a woman he met in a casual encounter. He was relentlessly honest with his wife, but
her tolerance of such confessions diminished over time, and such conversations grew
increasingly painful for her.
At these moments, the ego-syntonic nature of these desires became
increasingly prominent, and Sam’s insistence on the normality and health of such
behavior trumped his concern about his marriage. He insisted that he felt no need for
the marriage, that such ties were artificial and overly burdensome, and that he could
easily start again if he chose to simply walk away from the relationship. Interestingly,
he spoke about his urge for sex with strangers as an uncomplicated desire for an
intimate and honest encounter.
The entrenched nature of his sexual compulsivity reflected the young age at
which Sam discovered the self-soothing properties of sexual stimulation. Sam was
born in Tehran, the only son of a successful businessman with ties to the Shah’s
government. Sam’s mother was the daughter of an English mother and an Iranian
father; her father had also been wealthy and well connected. After the fall of the
Shah’s regime in 1979, the Sam’s father felt it prudent to take his family out of the
country and emigrate to Great Britain as soon as he could safely do so. When Sam’s
parents arrived in England in the 1980s, they found themselves in a far different
environment than they had left. Although Sam’s father found work in an engineering
firm—drawing on his university education in engineering— his new position was an
enormous step down from what he had before. His parents lost their elite status, their
wealth, and their insider connections. They were exposed to racist attitudes that they
had previously never encountered. From a comfortable place at the pinnacle of their
society, they had fallen to the role of perpetual outsider. These narcissistic losses were
most painful for Sam’s father and led to distance between Sam’s parents. Soon Sam’s
father embarked on a series of extramarital affairs. Sam’s mother, who had been
pampered and protected her whole life, was unprepared for these stresses on her
family. Around this time, the family visited a beloved cousin, who was staying in a
Swiss boarding school. Sam, missing his former companion, insisted that he wanted
to join his cousin at boarding school. He was 7 years old at this time. Whereas
sending children to boarding school was a time-honored tradition among the British
upper classes and Swiss boarding schools had particular cachet, it is likely that Sam’s
mother found it convenient to send her child away so that she could devote herself
more fully to her precarious marriage. It is unlikely that Sam’s mother would have
consciously entertained this thought, although it is certainly plausible that this could
have been an unconscious incentive.
Although Sam adapted to boarding school over time, he spent the first year
away from home crying himself to sleep, as did most of the children his age. Such
naked displays of homesickness were cruelly mocked by the older boys, and Sam
soon learned to suppress his emotions in general and his attachment needs in
particular. Although his parents visited on holidays and his mother always showed
great affection and happiness to see him, he experienced her visits as a demand that he
turn his attachment to her on and off at what he perceived to be her convenience. He
found this expectation deeply enraging and insulting, cementing a connection between
attachment and humiliating powerlessness that would persist long into his adulthood.
At around the age of 10, likely at the tutelage of older boys, he discovered the
miraculous capacities of his penis and the emotional self-sufficiency afforded by
masturbation. From this point on, he utilized masturbation as a potent means of self-
soothing and an effective tool to banish homesickness and calm himself to sleep.
In his middle teens, the Sam began to engage in sexual activity with girls and a
few homosexual encounters with classmates. In his late teens, he joined a rock band,
which achieved surprising success in the following 2 years. He toured with the band
for the next 10 years, fully embracing the sex, drugs, and rock-and-roll lifestyle now
readily available to him, until the band broke up when he was 30 years old. This left
him at loose ends until he met his future wife 2 years later. Although he effectively
settled into a new life with his wife and growing family, a powerful resurgence of
urges to engage in sexually addictive behavior occurred when his oldest child turned
7, the same age at which he first separated from his family.
b. Discussion
Sam’s case is instructive as it shows the intimate connection between
regulation of negative affect and driven sexual behavior. Even though sexual outlets
give him pleasure, he feels most compelled to pursue anonymous sexual contacts in
order to master the negative emotions associated with abandonment. These urges are
so compelling for him that he will risk the possible dissolution of his family. It is also
important to consider the interpersonal meaning that his sexually addictive behavior
has for him. He discovered masturbation as a child when forced to live separately
from his parents, wrenched away from the soothing presence of his mother. In search
of a means to self-soothe in the absence of maternal comfort, he discovered that
sexual stimulation could serve that function for him, at least in part. In this way,
sexual orgasm became fused with both the need for attachment and the ability to
master that need, to be perfectly selfsufficient.
Although sexual addiction does not always develop in this way and may not
always fulfill this function, it is typical that an addiction can grow into the primary
attachment for the addict. The commitment and attachment to the drug (or behavioral
addiction) can displace any other relationship. As is not typical for many addicts,
however, Sam is fairly able to control his behavior— that is, once he is motivated to
do so. When he wants to stop, he can. However, his sexually addictive behavior is
enabled by his rationalizations and other cognitive distortions. Because of this, Sam’s
therapy focuses less on developing skills for controlling his impulses and more on
untangling his cognitive distortions and helping him identify his ultimate goals and
priorities and recognize how such behavior will interfere with having the life he wants
to have.
As mentioned in the introduction, there is a fair amount of controversy over
the construct of sexual addiction. Although this discussion can become somewhat
technical, it is important to consider diagnostic issues because it helps clarify the
nature of our patients’ driven sexual behavior and therefore helps us to design
effective interventions. Dating back to DSM-III (American Psychiatric Association
1980), repetitive, driven, and maladaptive sexual behavior has been classified as some
form of sexual disorder not otherwise specified in the “Psychosexual Disorders”
section of the manual. Importantly, such behavior does not involve an abnormal object
of sexual arousal, as with paraphilias such as exhibitionism, voyeurism, and
pedophilia, but, instead, it involves the excessive practice of otherwise normal sexual
behavior. In 1991, Carnes observed that patients with such driven, repetitive sexual
behavior showed many parallels with those who had chemical addictions.
Carnes (1991) proposed the diagnosis of sexual addictions as a behavioral
analogue of chemical addictions. He noted that the DSM criteria for substance
dependence (DSM-III-R [American Psychiatric Association 1987] at that point) could
be directly adapted to diagnosing sexual addiction. Carnes described a pattern of out-
of-control sexual behavior that 1) interfered with social, occupational, and role
functioning, 2) persisted despite negative consequences, 3) served to regulate negative
affect states, and 4) persisted despite awareness of the need for and/or unsuccessful
attempts to stop or reduce the behavior. These criteria are highly consistent with
descriptions of similar sexual conditions and are therefore relatively noncontroversial
(Goodman 1998; Kafka 2010).
However, the next two criteria, tolerance and withdrawal, are less widely
accepted and remain in need of further research. Carnes suggested that individuals
with sexual addiction meet criteria for tolerance, characterized by pursuit of
increasing levels of sexual activity over time as the prior levels no longer satisfy the
individual’s urges. Second, sexual addiction is characterized by withdrawal, such that
the cessation of the sexual activity leads to emotional discomfort and dysphoria, a
psychological if not physiological withdrawal syndrome. Goodman (1998) further
developed the concept of sexual addiction and elaborated on therapeutic interventions
adapted from the treatment of chemical addictions.
More recently, Kafka (2010) specified the construct of hypersexual behavior
in preparation for possible inclusion in DSM-5 (American Psychiatric Association
2013). In his diagnostic criteria, hypersexual behavior is characterized by a period of
6 months of recurrent and intense sexual fantasies, urges, or sexual behaviors in the
context of three of the following five criteria: 1) excessive, timeconsuming sexual
activity interfering with other important goals, 2) repetitive engagement in such
sexual activity as a means to regulate negative mood states, repetitive engagement in
such activity in response to stressful life events, 4) repeated but unsuccessful attempts
to control such activity, and/or 5) continuing the activity while disregarding the risk
for physical or emotional harm to self or others. Additionally, there must be clinically
significant distress or impairment as a result of such activity, and the sexual activity
must not be solely a result of a chemical substance. Although he did not specify the
frequency of sexual activity in his diagnostic criteria, Kafka also proposed that seven
sexual outlets (i.e., orgasms) per week marked a cut point for excessive sexual
activity, based on his review of relevant research. Ultimately, the DSM-5 task force
decided there were insufficient data to support inclusion of hypersexual disorder in
the manual. We can see that Kafka’s definition of hypersexual behavior significantly
overlaps with Carnes’ and Goodman’s constructs of sexual addiction. Importantly,
however, Kafka does not include the notion of tolerance and withdrawal, and he does
not use the term sexual addiction as such.
Stein et al. (2000) discussed three models of maladaptive repetitive behavior
through which to view “paraphilias not otherwise specified”: impulsivity,
compulsivity, and addiction. Although this is focused on an addictive model of driven
sexual behavior, it is useful to consider other possible approaches because they all
have clinical implications. Compulsive behavior is driven by negative reinforcement
and serves to decrease anxiety. The ideation is harm avoidant with an exaggeration of
the likelihood of harm. A classic example involves patients with obsessive-
compulsive disorder who compulsively wash their hands in order to reduce the
anxiety occasioned by an obsessive fear of contamination. Sexual obsessions, in
which the person is plagued by anxietyinducing thoughts about the possibility of
forbidden sexual urges and performs a compulsive behavior to reduce such anxiety,
would fall into this category. In these cases, there is actually very little likelihood of
the patient acting on the obsessive thought; rather, the problem derives from the
patient’s excessive concern about the possibility of harmful action.
Recent years have brought huge advances in our understanding of the
underlying biology of addictions. Interestingly, the same dopaminergic tracts seem to
underlie all types of addictions, both chemical and behavioral. Findings from animal
and human research have pointed to the centrality of the dopaminergic reward
circuitry, which courses from the ventral tegmental area in the midbrain through the
nucleus accumbens in the striatal system. This system serves as an all-purpose
motivation machine, active in all motivated pursuits and implicated in all disorders of
reward-driven behavior (e.g., pathological gambling, binge eating, compulsive
spending, sexual addictions). Although there are fewer data on behavioral addictions,
we know that chemical addictions dysregulate the reward system and in extreme
circumstances lead to significant deterioration of dopamine function in these tracts,
leaving the individual that much more dependent on external sources of dopamine
stimulation, such as cocaine and methamphetamine. According to a study by Garavan
et al. (2000), the addiction may co-opt the reward system, so that other sources of
reward no longer activate it as strongly as do cues related to the addictive object. This
can explain how addicts of any type can sacrifice so much of what is truly important
to them in pursuit of their addiction.
Whereas the dopaminergic reward system can explain the appetitive drive
behind sexual addiction, it cannot explain the object of the addiction. Why does
someone become addicted to sex rather than some other object or activity? With
regard to sexually addictive behavior, premature sexual stimulation seems to play a
key role. In particular, childhood sexual abuse may predispose individuals toward
sexually dysregulated behavior. There is robust evidence that sexual abuse histories
are disproportionately represented in individuals with pedophilia and other
paraphilias. Therefore, it is likely that people with sexually addictive behavior may
also have a disproportionately high rate of childhood sexual abuse histories.
This is relevant to Sam’s case as well. Although he did not experience
childhood sexual abuse per se, in that no one coerced him to engage in sexual activity,
he did engage in repeated sexual stimulation several years before he reached puberty.
It has been proposed that premature sexual stimulation can alter sexual
neurodevelopment (Cohen et al. 2010a). Two strains of evidence support this
hypothesis. As mentioned, there is robust evidence of elevated rates of childhood
sexual abuse in patients with pedophilia and other sexual disorders, in fact,
considerably more than in patients with chemical addictions (Cohen et al. 2010a).
Moreover, animal studies have shown that damage to neurobiological substrates of the
sexual behavioral system differentially impacts sexual functioning, depending on the
existence of prior sexual experience. For example, lesions in the hypothalamus
(anterior hypothalamus for males, ventromedial hypothalamus for females) will
completely eliminate sexual behavior in rats if the lesions are created prior to sexual
maturity. If the rat has already reached sexual maturity and already had sexual
experience, however, the same lesions will have much less of an impact.
This is seen to reflect the recruitment of higher-order cortical structures
involved with learning and memory following the onset of actual sexual experience.
Thus we could hypothesize that to the extent such findings can be generalized to
humans, early sexual experience may alter the development of higher-order cortical
regulation of sexual desire and behavior. Certainly, there is a failure of inhibitory
mechanisms associated with frontal control in sexually addictive behavior. Likewise,
the frequent demonstration of executive dysfunction among individuals with chemical
addictions as well those with disordered sexual behavior is consistent with this
hypothesis.
c. Treatment
Controversy remains about the diagnostic classification of driven and
repetitive sexual behavior; however, there is less controversy about treatment, and
multiple treatment options are currently available. Such options include individual
psychotherapy, group psychotherapy, and psychotropic medication. The options for
individual psychotherapy are particularly rich, and multiple modalities are available to
address different components of the sexually addictive behavior.
Cognitive-behavioral therapy (CBT) can address the mechanism of the
addictive behavior, identifying and ultimately changing the thoughts, emotions, and
behaviors that perpetuate the problematic behavior. More specifically, CBT can help
the individual identify and better attend to the triggers of the sexually addictive
behavior, the permission-giving thoughts that weaken inhibition of the behavior, and
the negative consequences of the behavior. Specific modes of CBT that have been
developed to treat chemical addictions have been modified to treat sexually addictive
behavior.
Motivational interviewing is often used with chemical addictions and serves to
help the patient consider the pros and cons of maintaining the addiction in the context
of their overall goals and priorities. Motivational interviewing is aimed less at actually
changing the behavior than in shoring up motivation to enter the change process. The
advantage of this approach is its nonconfrontational and nondirective nature, which is
seen to be more effective with those patients with low motivation to change.
Although there is less research to support psychodynamic treatment in the
field of addictions, it certainly offers advantages (Goodman, 1998). Specifically,
psychodynamic treatment can address the factors related to the individual’s unique
personal history and personality organization. It can clarify the specific meaning the
addictive behavior holds for the patient. Does sexual addiction reflect a rebellion
against a puritanical and authoritarian parent? Is it a form of self-soothing in the
context of parental abandonment, as with Sam? Does it assuage a narcissistic need for
constant affirmation of one’s attractiveness? Or is it used in a desperate attempt to
stave off feelings of emptiness? In almost all cases, however, sexually addictive
behavior reflects a disturbance in the core self-concept and/or the capacity for
intimate relationships. As deeply social animals with lifelong attachment needs, it is
inherent in the human condition to need close intimate relationships, which serve to
regulate both negative and positive emotions. Consequently, we are doomed to feel
dependent on people who remain, in large part, outside of our control. For those who
have less tolerance for this dilemma, often as a result of a maladaptive early
attachment experiences, an addictive object can provide a convenient end run around
the vulnerability and relative powerless inherent in intimate relationships with other
people. In this way, sexually addictive behavior can serve as a sort of transitional
object, a construct introduced by the British psychoanalyst D.W. Winnicott in the
twentieth century (Winnicott 1965).
Like the classic example of a toddler’s baby blanket, sexually addictive
behavior serves as a self-soothing and emotionally regulating “other” who,
nonetheless, remains under the individual’s almost total control. The sexual partners
encountered in sexually addictive behavior are rarely experienced as “subjects”—
three-dimensional people who can make an emotional impact on the sexually
addictive individual outside of his or her control. Rather, they are fleeting “objects,”
used to gratify an urge and then discarded. Paradoxically, however, by insisting on
total control over the attachment object, the sexually addictive individual actually
loses control and ends up living at the mercy of his or her addiction. Psychodynamic
therapy can help the patient to understand how these dynamics play out in his or her
life and subsequently to develop healthier relational patterns.
Group treatment has been highly effective in the treatment of chemical and
other behavioral addictions, and in some cases it is more effective than individual
therapy alone (Goodman 1998). Group therapy serves multiple purposes and probably
works through a combination of mechanisms. More specifically, group therapy
provides social support for the difficult change process, information about other group
members’ experiences and coping strategies, support for a positive new group identity,
and confrontation of the all-too-common denial and rationalizations associated with
addictive behavior.
Selective serotonin reuptake inhibitors (SSRIs) have also been investigated for
their specific efficacy with sexually disordered behavior, but data from controlled
trials are lacking. SSRIs may work to reduce compulsive thoughts because of their
antiobsessional effects. Additionally, the otherwise undesirable side effect of reduced
sexual drive and function might be considered beneficial for individuals with
hypersexuality.
When sexually disordered behavior offers grave risk to the individual or to
society, for example, as in the case of persistent and uncontrolled pedophilia,
antiandrogen therapy has been found effective in drastically reducing sexual drive.
The side effects with this class of medication are notable, however, so it is unlikely
that such medication will be used except in very grave circumstances. More recent
treatments include gonadotropin-releasing hormone analogues, including leuprorelin
and triptorelin, which provide a more advantageous side effect profile than older
antiandrogen medications. Still, significant problems with bone mineral loss suggest
the use of these medications is indicated only in high-risk situations.
Owing to ongoing depression and anxiety, Sam was treated with an SSRI to
very good effect. This led to overall improvement in all areas of his mental health,
including reduced interest in sexually addictive behavior. In this case, it is likely that
his improvement was due to effective treatment of the comorbid mood and anxiety
problems rather than of his sexual inclinations per se.
d. What’s Love Got to Do With It?
Love addiction, the term initially proposed for this, enjoys widespread
endorsement from addiction therapists and the recovery community. Outside the
recovery world, therapists are familiar with the dynamics and issues of these patients,
but therapists tend to conceptualize them within the framework of attachment
disorder, borderline personality disorder, separation anxiety disorder, and
posttraumatic stress disorder.
Support from therapists has, nevertheless, been steadily gaining momentum,
albeit often accompanied by a certain degree of reluctance. This growing trend
underscores a significant shift within therapeutic circles, where professionals are
increasingly recognizing the importance of seeking and providing support beyond
traditional means. While some therapists may initially approach new methodologies
or approaches with caution, many are embracing innovative techniques and
alternative modalities to better serve their clients.
One key factor contributing to this gradual acceptance is the evolving
understanding of mental health and wellness. As research continues to shed light on
the complexity of human psychology and the diverse needs of individuals, therapists
are expanding their toolkit to encompass a broader spectrum of interventions. From
mindfulness-based practices to somatic experiencing and expressive arts therapies,
there's a growing recognition that no single approach fits all and that personalized,
holistic care is often most effective.
Additionally, societal changes and cultural shifts are influencing therapeutic
practices. The stigma surrounding mental health is slowly eroding, encouraging both
therapists and clients to engage more openly in discussions about emotions, trauma,
and psychological well-being. As conversations around mental health become more
mainstream, therapists are increasingly encouraged to explore innovative methods that
resonate with their clients' diverse backgrounds and experiences.
Moreover, technological advancements are providing therapists with new
opportunities to connect with clients and offer support remotely. Teletherapy, online
support groups, and mental health apps are becoming integral parts of therapeutic
practice, allowing therapists to reach individuals who may have otherwise struggled to
access traditional services. While incorporating technology into therapy requires
adaptation and ongoing learning, many therapists are embracing these tools as
valuable complements to in-person sessions.
Training and education also play a crucial role in shaping therapists' attitudes
towards new approaches. As the field of psychology evolves, continuing education
programs and professional development opportunities enable therapists to stay
informed about the latest research and treatment modalities. By investing in their own
growth and learning, therapists can approach new techniques with confidence and
competence, ultimately enhancing the quality of care they provide to their clients.
Furthermore, peer support networks and professional organizations offer
platforms for therapists to exchange ideas, share experiences, and collaborate on
innovative projects. These communities foster a culture of openness and
collaboration, encouraging therapists to explore new approaches without fear of
judgment or criticism. Through shared learning and mutual support, therapists can
navigate the complexities of modern therapeutic practice and adapt to the changing
needs of their clients.
In conclusion, while some therapists may initially exhibit reluctance towards
embracing new approaches, the overall trend towards innovation and expansion
within the field of therapy is unmistakable. With a growing understanding of mental
health, societal shifts towards destigmatization, technological advancements, ongoing
education, and supportive professional networks, therapists are increasingly
embracing diverse modalities to better serve their clients' evolving needs. This
ongoing evolution reflects a commitment to holistic, person-centered care and holds
promising implications for the future of mental health treatment.
Much of the acceptance by the behavioral health field at large is driven by
advances in understanding the neuroscience of addiction; media reports about
celebrities with sex and other addictions and the resulting popular support of the
concept; and the large number of people who self-identify as love addicts.
e. Defining the Addiction
We can start to sort out the plethora of perspectives by looking at healthy,
mature love. Genuine love expresses itself through empathy, caring, and nurturing
emotions and behavior. Its energy is affirming and compassionate. Healthy love
cannot be an addiction, just as an addiction cannot be healthy love. Hence the term
“love addiction” makes little sense. In addition, some of the contradictory elements of
love addiction (and its variants) led us to think that there might be more than one type.
In search of a more accurate term, we looked closely at exactly what it is that
is craved by individuals who are in romantic relationships and who self-identify as
love addicts. We received two answers to our question: 1) One group craves the
euphoric high of new romance, and 2) the other group craves the security of a
relationship that will last “forever.” In addition, this latter group also has high hopes
—and strong expectations—that their lives will be transformed by this partner,
erasing past trauma or other attachment disasters and making them happy. The
dialectic of transformation and security is striking but beyond the scope of this
introduction. These two types of craving correspond exactly to the two phases—
attraction and attachment—of healthy love. Attraction and attachment also represent
the normal progression of healthy love in a romantic relationship. Developmental
failures such as insecure attachments, traumatic loss and separation, failure to thrive,
interrupted (or absent) bonding, physical and psychological neglect, and maternal
mental illness (including postpartum depression and psychosis) can distort that
progression. The result of attachment failure is a multitude of problems with love and
relationships. Love becomes compulsive, obsessive, addictive, and dependent, and
remains immature. It is love gone awry; it is the experience of self-identified love
addicts.
We now use the term romantic relationship addiction, defined as the
maladaptive craving for, and pursuit of, romantic relationships to experience a
euphoric high or powerful sense of security and worth that will tranquilize one’s
loneliness and related affective distress. Craving and pursuit continues despite causing
harm and negative consequences. Loss of control, tolerance, and withdrawal also
develop. Two subtypes—attraction phase and attachment phase— refer to the phase of
the relationship that the patient most craves.
In the attraction phase of this addiction, the craving is for the euphoria of a
romantic encounter. This is your brain on romance. The individual feels high, the
result of changes in the brain and, in turn, changes in mood, cognition, and behavior.
The smitten individual experiences a dizzying array of emotions best characterized as
expansive, exciting, and pleasurable. The intoxication of this phase is what people call
falling in love, limerence, or infatuation.
In the attachment phase of romantic relationship addiction, the craving is for a
sense of security and continuity in a relationship. The individual is far less interested
in the fireworks of new romance and is almost solely interested in sustaining the
relationship. Their enjoyment of the attraction phase is often, in fact, much less
pleasurable than it appears. Enjoyment may even be feigned as an investment in
eventual attachment and long-term bonding with their love interest. Many of those
with compulsive attachment have been traumatized in their early years and may have
a very difficult time tolerating, let alone enjoying, their partners’ (for example) phase-
appropriate wish for frequent sex.
Attachment is also a normal, healthy process that follows the initial period of
attraction. Healthy attachment, however, is very different from compulsive
attachment. As the passion storms of attraction start to die down from their greatest
intensity, attachment becomes more important and persistent. Deep and powerful
feelings of empathy, caring, commitment, and concern for the lover’s well-being now
emerge. The ultimate success of attachment is long-term bonding, which continues to
mature over a lifetime. Healthy attachment is most strongly determined by having had
healthy models of attachment and not having been exposed too much to adverse
childhood experiences. It also develops as the partners’ develop more sober
knowledge about each other as real people rather than as love-struck idealizations. It
is, in one sense, a falling out of love with one’s imagined ideal lover and falling in
love with a real person. Healthy attachment is not devoid of conflict, dependency, and
neurosis. All relationships, no matter how healthy or positive, contain at least some
elements of unhealthy dependency and attachment.
For those with compulsive attachment, the search for secure and loving
attachment becomes wrapped up in any and every new relationship. Unerringly, they
choose partners who are unable to express authentic intimacy. There is an expectation
that security (attachment) will follow the initial attraction. But hope and expectation
evaporate as the initial infatuation loses intensity and attachment does not follow.
Despondency, emptiness, and self-loathing—an allpervading feeling of being bereft—
emerge in the vacuum. Despite the severity of such pain (and other negative
consequences), the individual obsesses about and compulsively repeats the same
pattern, truly believing that next time, things will work out well.
The attachment phase addict is unable—despite his or her best efforts—to
maintain a relationship with a healthy individual. Their internal template of healthy
intimate relationships is simply too damaged and distorted to do so. Individuals who
are attachment driven and have endured exposures to sexual victimization may be
unable to enjoy the euphoria of a new relationship. They become overwhelmed with
fear, and if they feel unable to express their distress to their lover, they are left trying
to simply bear the touch and sexual intimacy. They may dissociate, use substances to
numb themselves, or repeat thoughts to try to convince themselves that this is an
acceptable investment in future attachment. Their emotional state is often overrun
with flashbacks of sexual trauma and panic. Finally, both subtypes tend to exhibit
some confusion about love, need, sex, and dependence. They tend, analogously, to
funnel stress, guilt, loneliness, anger, shame, fear, and envy into longing and sexuality.
The psychodynamic factors and addiction dynamics are intertwined and must be
treated together.
f. Is Romantic Relationship Addiction Really an Addiction?
The American Society of Addiction Medicine, in their new definition of
addiction (Smith 2012), no longer talks about chemicals, behaviors, and relationships
but instead talks about the brain. Having a shared, common biological basis for
addiction provides a platform to understand and accept the existence of addictions that
are not yet widely accepted.
Romantic relationship addiction is like any other substance use disorder in
DSM-5. The following criteria have close to unanimous acceptance for the diagnosis
of addiction and apply to chemical, behavioral, and relationship addictions. Repeated
use of a chemical, behavior, or relationship causes harm or suffering or impairs one’s
ability to meet adult role requirements (as father, partner, etc.). 2) Use is continued
despite negative consequences (with work, money, relationships, legal issues [fights,
arrests, driving under the influence], physical health, self-esteem, self-respect,
feelings of shame). 3) More and more difficulty stopping the behavior is experienced.
The initial euphoric promise of use starts to fade as 4) need and craving become more
pronounced, and as 5) control over the addiction increasingly falters. The chemical,
behavior, or relationship becomes increasingly central in the addict’s life until it
becomes a single-minded pursuit more important than anything else. 6) Pleasure gives
way to need as escalating use becomes necessary to get the same effect (tolerance),
and 7) highly distressing physical and psychological responses to loss of the drug or
relationship (withdrawal) close in on the addict. The progression of addiction is
accompanied by desperation, shame, ever-decreasing hope, and near total loss of
behavioral control when it comes to the chemical, behavior, or relationship.
The nature of romantic relationship addiction may be further illuminated by
the characteristics we expect to see in someone who recovers from it. Those
characteristics include, among others, realistic expectations of what a relationship can
and cannot provide; capacity to develop an independent identity, serious interests, and
meaningful personal relationships (whether or not the individual is in a romantic
relationship); autonomy; belief in one’s own individual value; honesty; trust; and the
ability to establish and maintain personal limits and boundaries.
Jenny is a 24-year-old, unemployed single woman who presents for
psychotherapy in the context of a breakup with her boyfriend. She was self-referred
after a 28-day stay at an inpatient rehabilitation center, where she was treated for
opiate dependence and codependence. It is noteworthy that although her parents were
paying for her treatment, they were otherwise not involved; she has been estranged
from them for several years prior, reconnecting with them only after a 1-year
relationship with her boyfriend came to a chaotic end.
Although Jenny entered treatment of her own accord, she presents as distant,
aloof, and moderately dissociated. Her presentation is much more consistent with that
of someone being forced into treatment against her will; she is slow to warm up and
does not become affectively engaged or connected until several months into the
treatment. There is a marked contrast between her compulsion to make immediate
connections with the men she engages with in her romantic relationship addiction
dynamic and her initial, distant presentation with her therapist. The connection she
does make is much slower and is punctuated later by sudden departure without direct
discussion with her therapist.
Jenny reports a long history of polysubstance abuse, including alcohol,
cocaine, heroin, ecstasy, and marijuana, beginning at age 13, which is significant
because it is the same age she identifies as entering puberty and becoming interested
in boys. She grew up in an affluent suburb and attended private school, where she had
significant social difficulties throughout elementary and middle school. She describes
being teased, particularly by other girls, causing her to seek out relationships with
boys and older kids outside of school. She describes her substance use at that time as
helping her feel connected to the boys she spent time with. She used drugs exclusively
when with them (i.e., she never used alone) and provided them with substances and/or
money for substances as a way to keep them close.
Jenny describes her father as overly strict, distant, and hyperlogical, and she
describes her mother as both intrusive and absent. She felt it was difficult to get her
parents’ attention, and when they did pay attention, they were punitive and
reprimanding. At an early age, she learned to suppress her needs for attachment and
emotional closeness with family and to seek it outside of her family. The parental
dynamics of alternating deprivation and intrusiveness left her hungry for genuine
intimacy, which she attempted to find through the substitute gratification of both
drugs and maladaptive relationships with men.
In 11th grade, Jenny dropped out of high school to run away from home with
an older boy named Jim from her hometown, saying this was due to her parents being
too “rigid and controlling” and her being “totally in love” with Jim. She described
feeling consumed by thoughts of Jim, uninterested in anything else and willing to give
up anything to stay in the relationship. She, in fact, gave up the physical safety and
security of her home in order to hitchhike across the country with Jim, often enduring
periods of homelessness and not having money to eat. She was also almost constantly
drinking and/or smoking marijuana at this time, simply seeing it as something that she
and Jim “liked to do together.”
Throughout her teens and early 20s, Jenny continued a pattern of intense, brief
relationships with men who physically and/or emotionally abused her. She would
relocate to a new city only to move in with another version of the man she had left
behind. When relaying her history throughout the course of treatment, she very clearly
defined herself by these relationships and used them as a way to organize her sense of
self and time. She never graduated from high school and never held a job, and she had
seemingly little awareness about the connection between this and her preoccupation
with relationships.
Jenny’s most recent relationship before entering treatment was with a man
named Alex, a moderately famous musician. They primarily used opiates together,
which she said made her feel happy, in love, and close to him. When Alex was on tour
or at work during the day, Jenny would use stimulants or “whatever she could find” in
order to distract herself from the painful feelings of emptiness that she experienced
during separations from him. When Alex ultimately left her, saying she was “too
clingy,” her substance use increased dramatically along with her feelings of loss,
loneliness, and emptiness. She initially refused to leave the apartment they shared,
isolating herself for days at a time, calling him repeatedly to try to convince him to
change his mind, and sending long, pleading text messages. When Alex took out a
restraining order against her, Jenny checked herself into an inpatient rehabilitation
center.
When Jenny left inpatient treatment and transitioned to outpatient
psychotherapy, she moved back in with her parents. Here she became reacquainted
with the familiar feelings of her childhood and young adulthood, because her needs
for attachment and connection were once again met with distance and rejection. In an
attempt to feel better, she started going to Alcoholics Anonymous (AA) and Sex and
Love Addicts Anonymous (SLAA) meetings, which were suggested by her therapist at
her inpatient treatment program. After a few days of going to both meetings, she
stopped attending SLAA meetings. She continued going to AA meetings, where she
said she reconnected with George, an old friend from high school. Jenny strongly and
repeatedly expressed that George was just a friend and that she was determined to
keep it that way. She said was afraid of becoming “codependent,” having learned this
terminology in rehab; Jenny tried to create rules for herself in an attempt to guard
against dependency.
She speaks often of her fear of becoming codependent and talks longingly
about meeting the right guy who will cure her of this. She consciously tries to set
boundaries in her relationship with George. She tries to set a weekly quota for
reaching out to women (as opposed to men) for fellowship after meetings; she sets
limits about how many days per week she allows George to drive her to and from
meetings; she sets limits about how often she can spend time with him in general; she
vows to never have sex with him. She also creates elaborate justifications about why
she specifically needs George to drive her (e.g., she doesn’t want to be a burden to her
parents, her house is on his way, etc.) and generally rationalizes that the relationship is
necessary because she no longer has any friends in her hometown.
When Jenny shares her fears of becoming too dependent with George, he
begins to pull away. In response to this, Jenny begins to feel desperate to “win him
back,” ultimately offering to have sex with him via text message as a way to entice
him to spend time with her even though she is not sexually attracted to him. She is
unable to tolerate the distance he imposes between them (and her increasing feelings
of abandonment), and in the meantime, Jenny reaches out to old boyfriends to spend
time with her, attempting similarly to entice them with drugs and/or sex.
Shortly thereafter, Jenny's abrupt termination of treatment without informing
or discussing it with her therapist reverberated through the therapeutic community,
sparking discussions about the complexities of client autonomy and the challenges of
continuity of care. While such occurrences are not uncommon in the field of mental
health, Jenny's case prompted therapists to reflect on the nuances of their relationships
with clients and the importance of fostering open communication and trust.
As the therapist later learned that Jenny had checked herself into an inpatient
rehabilitation center for the second time, it raised questions about the efficacy of the
therapeutic interventions provided and the adequacy of the support network
surrounding Jenny. Therapists engaged in introspection, considering whether they had
adequately addressed Jenny's underlying issues and whether there were missed
opportunities for intervention.
The incident also highlighted broader systemic issues within the mental health
care landscape, including gaps in access to comprehensive services and the limited
availability of intensive treatment options for individuals facing complex mental
health challenges. Therapists grappled with the limitations of outpatient care in
addressing severe and persistent conditions, advocating for greater integration
between outpatient therapy and intensive treatment programs to provide seamless
transitions for clients like Jenny.
Furthermore, Jenny's experience underscored the importance of
interdisciplinary collaboration in addressing the multifaceted needs of individuals
with mental health concerns. Therapists recognized the value of working closely with
other healthcare professionals, such as psychiatrists, primary care physicians, and
addiction specialists, to ensure comprehensive assessment and coordinated care
planning for clients with complex presentations.
Ethical considerations also came to the forefront of discussions surrounding
Jenny's case. Therapists deliberated on their professional responsibilities in situations
where clients disengage from treatment abruptly, weighing the need to respect client
autonomy against the duty to ensure their safety and well-being. The incident
prompted a reevaluation of informed consent practices and the development of
protocols for managing client terminations to minimize the risk of adverse outcomes.
Moreover, Jenny's journey through the mental health care system highlighted
the importance of ongoing support and follow-up care beyond the confines of
individual therapy sessions. Therapists emphasized the need for robust aftercare
planning and collaboration with community resources to facilitate smooth transitions
between different levels of care and to provide ongoing support for clients as they
navigate their recovery journeys.
In response to Jenny's case, therapists engaged in professional development
activities focused on enhancing their skills in crisis intervention, relapse prevention,
and trauma-informed care. They also advocated for increased investment in mental
health services, including expanded access to residential treatment programs and
greater availability of long-term support services for individuals with complex mental
health needs.
Ultimately, Jenny's experience served as a catalyst for reflection and growth
within the therapeutic community, prompting therapists to reexamine their practices,
advocate for systemic change, and reaffirm their commitment to supporting clients
through every stage of their recovery journey. Through collective learning and
collaboration, therapists strive to continuously improve the quality and effectiveness
of mental health care, ensuring that individuals like Jenny receive the comprehensive
support they need to thrive.
g. Diagnostic Considerations
Romantic relationship addiction would be our primary diagnosis of choice for
this patient were it included in DSM-5. However, the new definition of addiction of
the American Society of Addiction Medicine (Smith 2012) boldly focuses on the
neurobiological foundations of chemical and behavioral addictions rather than
focusing on the specific chemical or behavior.
This development provides compelling support and legitimacy for the
diagnosis of behavioral addictions, marking a significant step forward in the
recognition and understanding of these conditions within the mental health
community. The acknowledgment of new behavioral addictions not only enriches our
understanding of human behavior and psychological health but also underscores the
evolving nature of psychiatric classification systems such as the Diagnostic and
Statistical Manual of Mental Disorders (DSM).
The inclusion of additional behavioral addictions in the DSM would represent
a culmination of years of research, advocacy, and clinical observation, reflecting a
growing consensus among mental health professionals regarding the existence and
impact of these conditions. It would signal a paradigm shift in how we conceptualize
and approach addictive behaviors, moving beyond substance-related addictions to
encompass a broader spectrum of compulsive behaviors that significantly impair
individuals' functioning and well-being.
Furthermore, expanding the scope of the DSM to incorporate behavioral
addictions acknowledges the complex interplay between biological, psychological,
and environmental factors in the development and maintenance of addictive
behaviors. By recognizing behavioral addictions as legitimate psychiatric disorders,
the DSM would provide a framework for clinicians to accurately diagnose and treat
these conditions, thereby reducing stigma and facilitating access to appropriate
interventions and support services.
Moreover, the inclusion of additional behavioral addictions in the DSM would
have far-reaching implications for research, public health policy, and clinical practice.
It would stimulate further investigation into the epidemiology, etiology, and treatment
of these conditions, paving the way for the development of evidence-based
interventions and prevention strategies. Additionally, it would enable policymakers to
allocate resources more effectively to address the growing prevalence of behavioral
addictions and mitigate their societal impact.
However, the process of revising the DSM to incorporate new diagnostic
categories is complex and multifaceted, requiring careful consideration of empirical
evidence, clinical utility, and stakeholder input. Mental health professionals must
engage in rigorous debate and peer review to ensure that any proposed changes reflect
the most current scientific knowledge and align with established diagnostic criteria
and principles.
Furthermore, the inclusion of behavioral addictions in the DSM must be
accompanied by comprehensive guidelines for assessment, diagnosis, and treatment to
guide clinicians in their practice. This necessitates the development of standardized
assessment tools, treatment protocols, and training programs to equip mental health
professionals with the necessary skills and knowledge to effectively identify and
manage these conditions.
Additionally, it is essential to address concerns regarding potential
overdiagnosis and medicalization of normal behaviors, as well as the risk of
pathologizing culturally specific practices or activities. Mental health professionals
must exercise caution and clinical judgment in applying diagnostic criteria for
behavioral addictions, taking into account individual differences, cultural norms, and
contextual factors.
In conclusion, the inclusion of additional behavioral addictions in the DSM
holds promise for advancing our understanding and treatment of these complex
conditions, providing validation and recognition for individuals struggling with
compulsive behaviors. However, it is imperative that any proposed changes undergo
rigorous scrutiny and adhere to established diagnostic standards to ensure their
validity, reliability, and clinical utility. Through collaborative efforts and ongoing
research, mental health professionals can continue to refine our conceptualization of
behavioral addictions and improve outcomes for those affected by these disorders.
Posttraumatic stress disorder should be investigated further. Jenny revealed a
pattern of repeated relationships in her late teens and 20s in which she was physically
and emotionally abused. There is no mention of childhood physical abuse, but clearly
there was neglect. Abuse, coupled with her manifestation of dissociation in treatment,
suggests that further exploration of posttraumatic stress could be quite useful.
Borderline personality disorder should be a diagnostic consideration because
of Jenny’s fear of abandonment, stormy interpersonal relationships, and impulsive
substance abuse. Her identity disturbance is demonstrated by the fact that her interests
and behaviors have been chosen according to what her lovers found appealing or what
she thought would endear her to them, not for her own development. She felt that she
was not accepted for whom she really was, so Jenny worked on becoming accepted
for what others wanted.
The best available diagnosis, in lieu of love addiction or romantic relationship
addiction, is separation anxiety disorder, a disorder that involves a “developmentally
inappropriate and excessive fear or anxiety concerning separation from those to whom
the individual is attached”. Jenny meets the requisite number of diagnostic criteria,
including 1) “recurrent excessive distress when anticipating or experiencing
separation “persistent and excessive worry about losing major attachment figures”;
and 3) “persistent and excessive fear of or reluctance about being alone or without
major attachment figures”.
Finally, Jenny’s history is significant for abusing alcohol, cocaine, cannabis,
heroin, and ecstasy. Drug use has been, for her, “a way to connect.” She would use
“whatever she could find” in order to distract herself from the painful feelings of
emptiness that she experienced when separated from her compulsive love
relationships. Her use of substances has always been secondary to her compulsion for
attachment and fear of separation.
Nevertheless, Jenny's case presents a complex diagnostic challenge, as she
meets the DSM-5 diagnostic criteria for multiple substance use disorders, including
alcohol use disorder, cocaine use disorder, cannabis use disorder, heroin use disorder,
and ecstasy use disorder. This diagnostic conundrum underscores the intricate
interplay between multiple addictive behaviors and highlights the need for a
comprehensive and nuanced approach to assessment and treatment.
Jenny's simultaneous manifestation of substance use disorders across various
classes of drugs reflects the heterogeneous nature of addiction and the diverse
pathways through which individuals can develop problematic patterns of substance
use. Each substance carries its own unique set of risks, consequences, and
neurobiological mechanisms, yet individuals like Jenny may find themselves
entangled in a web of polydrug use, further complicating their clinical presentation
and treatment needs.
Furthermore, Jenny's concurrent diagnosis of multiple substance use disorders
raises questions about the underlying factors driving her addictive behaviors. While
genetic predisposition, environmental influences, and psychological vulnerabilities
likely play a role, clinicians must carefully examine the specific motivations, triggers,
and consequences associated with Jenny's substance use to formulate an accurate
understanding of her clinical profile.
Moreover, the co-occurrence of multiple substance use disorders in Jenny's
case underscores the importance of addressing underlying comorbidities and risk
factors that may contribute to her addictive behaviors. Comorbid psychiatric
disorders, such as depression, anxiety, or trauma-related conditions, often intersect
with substance use disorders, exacerbating their severity and complicating treatment
outcomes. Clinicians must conduct thorough assessments to identify and address these
underlying comorbidities in conjunction with substance-related issues.
Additionally, Jenny's polydrug use pattern highlights the need for integrated
and multidisciplinary treatment approaches that address the complexity of her
substance use behaviors comprehensively. Effective treatment planning may involve a
combination of pharmacotherapy, psychotherapy, behavioral interventions, and
psychosocial support services tailored to address Jenny's unique needs and
circumstances. Collaborative care coordination between different healthcare providers
and community resources is essential to ensure continuity of care and optimize
treatment outcomes for individuals with complex substance use disorders.
Furthermore, Jenny's case underscores the importance of ongoing monitoring
and relapse prevention strategies to support her long-term recovery journey.
Substance use disorders are chronic and relapsing conditions characterized by periods
of remission and recurrence, necessitating a proactive and holistic approach to
managing relapse triggers, enhancing coping skills, and promoting sustained
behavioral change.
In conclusion, Jenny's concurrent diagnosis of multiple substance use
disorders poses significant clinical challenges that require a comprehensive and
multidimensional approach to assessment and treatment. By addressing the underlying
factors driving her addictive behaviors, implementing integrated treatment strategies,
and fostering collaborative care coordination, clinicians can provide the support and
resources needed to help individuals like Jenny achieve sustained recovery and
improved quality of life.
h. Treatment
The conversation with patients about compulsion, attachment, and addiction
should always start with getting enough information about a patient that the clinician
can mirror the patient’s language and use terms that the patient feels most at ease
with. What does “romantic relationship addiction” mean to the patient? What
language feels most comfortable? Is there another term that feels more fitting for that
person? How has this problem manifested itself in his or her life, and how has it
interfered? How has it changed over time? For example, Jenny’s involvement in
addiction treatment 12-step groups provides a shared language for discussion.
“Techniques are what you do until the therapist gets there” (C.A.Whitaker,
personal communication, University of Connecticut School of Medicine, September
1975). So get there. Before any techniques—old standards or exotic new ones—are
employed, put down your pen and move out from behind your desk and away from
the computer and electronic medical record. Sit facing your patient with nothing in the
way. Look at him or her. Make contact. Find out who this person is. Find out what is
motivating him or her and what he or she really wants from treatment. Remain aware
of how he or she affects your gut. When you have done that, you can use almost any
technique, but do not lose sight of how you started. In psychotherapy, it is the
relationship that heals.
Psychodynamic psychotherapy expands a patient’s awareness and insight. The
therapist sparks and encourages the patient’s curiosity about the origins and dynamics
of his or her thoughts, emotions, and behavior. Unconscious dynamics and influences
are exposed to scrutiny, especially how they express in the external world of the
patient’s interpersonal life and in the therapeutic relationship
Some of Jenny’s difficulties resulting from her compromised development
include the following: anger about her parents’ neglect of her; overwhelming feelings
of loneliness, emptiness, inadequacy, and unworthiness; perception of others as part-
objects; and self-loathing. These issues are responsive to psychodynamic
psychotherapy.
Cognitive-behavioral therapy (CBT) and CBT-related therapies can help
individuals identify distortions and errors in thinking and mistaken, irrational beliefs
that underpin current maladaptive functioning. Patients learn to identify these
distortions by, among other things, monitoring their internal dialogue (e.g., “you can’t
do that,” “don’t even try”) and remembering childhood pronouncements (e.g., “you’ll
never amount to anything,” “you’re lazy and stupid”) that compromise current
functioning. Assessing the validity of patients’ conclusions and considering different
ways to view themselves and their capabilities are both potent CBT interventions.
Finally, through role playing or in vivo exposure, they can experiment with alternative
views and behaviors. CBT-based approaches also teach coping skills, symptom
management, relapse prevention (for addictions), impulse control, and anger
management.
Motivational interviewing is a systematic, evidence-based approach to
complex behavior change. It is unique in eliciting and exploring patients’ own
arguments for change, evoking intrinsic motivation, and helping the patient to resolve
his or her ambivalence about change (Miller and Rollnick 2002). Motivational
interviewing is a directive but nonconfrontational method, bypassing unproductive
struggles. The therapist engages the patient through empathic listening, open-ended
questions, reflective statements, affirmations, and summary statements. This method
decreases denial and enhances motivation. It is a very pragmatic, practical approach
focused on actual change. For Jenny, it can provide psychological space for her to
make her own decisions.
Group psychotherapy is the treatment of choice for a number of disorders,
including chemical, behavioral, and relationship addictions. Therapists who do not
practice group therapy sometimes consider it superficial compared with individual
therapy or only an adjunct to individual therapy. The work often goes much deeper
than imagined. Group therapy provides support for change; reductions in isolation,
stigma, guilt, and shame; opportunities to rehearse new behaviors; feedback to
support a more authentic self-image; a way to overcome denial through listening to
others describe similar situations; sharing of coping skills; and confrontation without
shame, because other group members have also “been there.
There are no accepted psychopharmacological interventions currently
available for romantic relationship addiction. Psychotropic medication might be used
to target specific symptoms for these patients—such as insomnia—as well as
cooccurring disorders. That said, recent research suggests that adjunctive drug-based
therapies may help facilitate the treatment of romantic relationship addiction by
working on neurochemical substrates. Three emotion-motivation subsystems have
been identified that may be involved in destructive love patterns: lust, attraction, and
attachment. Differential pharmacotherapies are proposed to target each area.
Examples include the following: 1) oral naltrexone as an antilust treatment targeting
craving; 2) obsessive-compulsive disorder medications as an anti-attraction treatment
targeting obsessive romantic thinking; and 3) oxytocin/dopamine antagonists as an
anti-attachment treatment.
Earp et al. (2013) outlined several conditions for the ethical use of “anti-love
technologies.” These conditions include 1) establishing that clear harm results from
the addictive relationship; 2) confirming informed consent; 3) establishing that the
treatment can decrease impulsiveness and help the person follow higher-order goals;
and 4) noting that other, nonbiotechnological methods have failed and/or have been
considered. Safety and efficacy of these potential treatments need to be established
prior to their use.
There are tens of thousands of people who identify themselves as addicts of
various types. In 12-step meetings across the country and online, they bring and share
many decades of collective experience with the struggle, suffering, and recovery of
their particular addiction. They are not therapy groups—although therapeutic effects
are reported—and they are led by members, not therapists. A 12-step program is a
fellowship in which participants share their experience, hope, and strength in order to
help themselves and others. The 12 steps are a set of suggestions that enhance
addicted individual’s ability to remain abstinent “one day at a time” from their
addictions. The steps have to do with acknowledging the many things we have no
control over, acknowledging a power greater than ourselves, honesty, forgiveness,
making amends for past transgressions, and service to others.
SLAA is a 12-step program specific to love and sex addictions. Forming
meaningful connections with others in the context of recovery can diffuse the
complete reliance on one central attachment figure, which is so prominent in romantic
relationship addiction. These connections may also result in decreased feelings of
dependency. When Jenny began to attend meetings (AA and SLAA, at first, then AA
only), she set goals for herself to spend time with females in recovery as opposed to
looking for another relationship with a man. This is but one example of how the
program can help.
