Community Ment Health J DOI 10.1007/s10597-016-0034-2

BRIEf REPORT

Clinicians’ Beliefs, Observations, and Treatment Effectiveness Regarding Clients’ Sexual Addiction and Internet Pornography Use Mary B. Short1 · Chad T. Wetterneck2 · Steven L. Bistricky1 · Tim Shutter3 · Tannah E. Chase4

Received: 19 March 2015 / Accepted: 7 June 2016 © Springer Science+Business Media New York 2016

Abstract  This study addressed how sex addiction and problematic IP use present to mental health professionals (MHPs), and how MHPs conceptualize and treat these issues. MHPs (N = 183) reported on beliefs about, experiences with, and treatment of problematic sexual behaviors (PBS). Most MHPs saw clients with PBS, but most do not feel competent to treat PBS. Specialized MHPs endorsed seeing more clients with PBS and feeling more effective than nonspecialists. Sexual addiction and problematic IP use share similarities, but differ in etiology and co-occurring problems. Diagnostic ambiguity, insufficient knowledge, and limited dissemination may hinder MHPs ability to assess and treat PBSs

Mary B. Short [email protected] Chad T. Wetterneck [email protected] Tim Shutter [email protected] Tannah E. Chase [email protected] 1

University of Houston-Clear Lake, 2700 Bay Area Blvd, Houston, TX 77058, USA

2

Rogers Memorial, 34700 Valley Road, Oconomowoc, WI 53066, USA

3

Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030, USA

4

University of Houston, 126 Heyne Building, Houston, TX 77204, USA



Keywords  Sex addiction · Hypersexual disorder · Internet pornography use · Sexually explicit material · Perceived competence

Introduction Sexual activity is a normal and healthy part of intimate romantic relationships. However, for some individuals, sexual behavior can be problematic when specific aspects of these behaviors disrupt or impair important areas of functioning. Although a diagnosis of hypersexual disorder was recently proposed and rejected, there is a longer history of factions in mental health trying to characterize a subset of problematic sexual behavior as “sex addiction” (e.g., original DSM-III version) that still pervades clinical lore and literature. Hence, the present study focuses on the latter term. Sex addiction is conceptualized as a chronic disorder characterized by recurrent sexual urges, thoughts, and behaviors that cause significant distress and persist despite negative consequences, including impairment to interpersonal and occupational functioning, and even physical health in some cases (Gold and Heffner 1998; Levine 2010; Schaeffer 2009). In addition, sex addiction also is marked by continuous, but unsuccessful, attempts to escape unpleasant emotional states and reduce or control sexual thoughts or compulsions (Black et al. 1997; Gold and Heffner 1998; Schaeffer 2009; Schneider 1994). Even though commentators have tried to classify “problematic sexual behavior” as an addiction, there are still complications with defining “problematic”. First, sexual behaviors can be problematic without being associated with the addiction label. For example, people can engage in sex-line talk or internet pornography (IP), not be addicted to either, but these behaviors still may cause problems in

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their lives. Second, it is unclear how to specify when sexual behaviors become problematic. In general, research has focused on variables associated with frequency (too much), control (little to no control over behavior), and risk-taking (behavior despite probable negative consequences) (Giugliano 2008; Levine 2010). However, other variables that may be important when understanding “problematic levels” are not always measured. Thus, a precise distinction between healthy and problematic sexual behavior has yet to reach consensus. Even if this objective distinction were achieved, evidence suggests that that subjective personal beliefs (e.g., religious or other moral disapproval) of a client or therapist influence whether sexual behaviors are labeled as problematic. This, in turn, influences presentation, assessment, and treatment planning in mental health settings (Grubbs et al. 2015). For this reason, the present research examines presentations, therapist beliefs and psychotherapy approaches used to treat certain problem sexual behaviors among frontline psychotherapists. This article will concentrate on two prevalent and problematic behaviors, sexual addiction and IP use, termed “problematic sexual behaviors” for the purposes of this article. Research has shown that sexual addiction can be related to a number of negative characteristics, including personality difficulties, depression, anxiety, substance abuse, attention deficit/hyperactivity disorder, relationship/intimacy difficulties, and family problems (Bancroft and Vukadinovic 2004; Schneider 2000a, b; Dodge et al. 2004; Raviv 1993; Reid et al. 2010, 2012). It also corresponds with career and financial problems (Kafka 2010a, b), as well as risky sexual behavior (Reece 2003). By comparison, the role of IP in problematic sexual behavior is an area that needs increased research attention. With increased accessibility and anonymity, IP provides an array of opportunities for individuals to engage in problematic sexual behavior (Young 2008). Accordingly, reported acceptance and use of IP have been on the rise (Boies et al. 2004; Carroll et al. 2008; Goodson et al. 2001), as has problematic use (Mitchell et al. 2005). As many as 87 % of young men and 31 % of young women report using IP, with a significant proportion engaging in weekly or monthly use (Carroll et al. 2008). Even among adolescents, who are just beginning to develop sexual attitudes and behaviors, 71 % of males and 40 % of females report recent exposure to IP (Peter and Valkenburg 2006a). This is important because mediational analyses have suggested that greater IP use (particularly in males) leads to greater perceived realism of IP content, which could be problematic if it leads to more risky sexual behavior and attitudes (Peter and Valkenburg 2006b). These IP theme-consistent perceptions and attitudes, focused on independent physical pleasure over relational aspects of sex (Mehta 2001) may contribute to the relationships found between increased IP use and problems of living.

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Although not all IP use patterns may be problematic (Cooper 2000; Twohig et al. 2009), increased levels of IP use have been associated with depression, anxiety, relationship/intimacy difficulties (Philaretou et al. 2005), career difficulties, financial losses (Schneider 2000a, b), and risky sexual and substance use behaviors (Braun-Courville and Rojas 2009; Carroll et al. 2008; Häggström-Nordin et al. 2005; Morrison et al. 2004; Peter and Valkenburg 2008). Given the increasing widespread use of IP and its associated impairment of functioning, problematic IP use is becoming a sexual behavior that clinicians must understand and address competently. Unfortunately, similar to the sexual addiction literature, there is a paucity of empirical research exploring clinically relevant factors and pathology associated with IP use (Short et al. 2012). Although problematic IP use has been described as any use that yields personal, social, or occupational difficulties (Twohig et al. 2009), research has yet to classify and define objective distinctions between “normal” and problematic IP use behaviors (Grubbs et al. 2015). Thus, it is likely difficult for practicing clinicians to identify and understand at which points and in which contexts IP use may interfere with functioning and well-being. Given the difficulties related to problematic sexual behaviors and the facilitation of these behaviors by widespread increasing online activity, mental health professionals (MHPs) seem increasingly likely to see clients presenting with these problematic sexual behaviors. A few studies have examined the prevalence of problematic sexual behavior and IP use among clientele observed by MHPs; however, information about these MHPs’ age, professional disciplines, levels of training, and areas of specialization— variables that could impact problem presentation and treatment—has been lacking. In one large-scale study MHPs reported that use of pornography was the most frequently reported presenting problem for both youth and adult clients seeking mental health care for problematic internet experiences (Mitchell and Wells 2007). In another large study, 56 % of clinicians reported problems associated with IP use within their clientele (Mitchell et al. 2005). By comparison, a study that surveyed mid-to-late-career marriage and family therapists (average age = 56) found that 76 % of clinicians had seen clients presenting with pornography-related issues in individual therapy, and 74 % of clinicians had seen clients with pornography-related issues in couple’s therapy (Ayres and Haddock 2009). These findings are consistent with theory and evidence that IP use itself or the stigma of using ca n possibly crea te rela tionship rela tional problems, and thus, these problems frequently present in marriage and family therapy. Further, the percentage contrast between these last two studies’ suggests that some MHP disciplines or specializations may be more or less likely to encounter clients seeking help for problem IP use.

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A single study that could directly examine this hypothesis would be informative, as it might have implications for competent practice and training. Despite how frequently problems with sexual behavior and IP use present, research has illustrated that a majority of clinicians have received little to no training in the treatment of these problems. Of these clinicians, many do not feel competent or comfortable treating such issues (Ayres and Haddock 2009; Reissing and Giulio 2010). Although most MHPs report beliefs that IP use and sex related issues are a problem (Ayres and Haddock 2009; Swisher 1995), the lack of training and education about these issues may affect MHPs’ attitudes, perceptions, and beliefs toward them. For instance, MHPs may develop misperceptions about the difficulties associated with problematic sexual behavior (e.g., intimacy, history of abuse or sexual trauma), how to recognize these issues, or what factors to target in treatment. Moreover, some MHPs may avoid addressing such issues in therapy if they are uncomfortable with the topic, have ethical concerns, or if discussing sexual behaviors are against their morals and beliefs. The current study seeks to increase understanding by surveying MHPs regarding how sex addiction and IP-related issues present among their clientele. The present study also assessed MHPs’ attitudes and beliefs regarding these issues, as well as the methods of treatment they choose to utilize. To our knowledge, no prior investigation has examined presentation rates, attitudes, and treatment approaches regarding both sex addiction and IP-related issues on the basis of various relevant MHP characteristics. Thus, the present study assessed MHPs’ professional discipline, levels of training and experience, as well as professional specialty, yielding comparisons in terms of exposure to, training for, and treatment of clients with sex addiction or problem IP use. The present study also sought to compare clinicians’ perceptions of the two concepts. In contrast to prior research, the present study also asked therapists about specific symptoms, characteristics, and areas of dysfunction (e.g., financial, legal, interpersonal) observed to be related to sex addiction and IP issues. By evaluating the typical observations, beliefs, and treatment approaches of MHPs in conventional mental health settings, the present study aims to facilitate increased understanding and awareness of characteristics and problems associated with problematic sexual behaviors, so that these issues may be more adequately identified and treated. Based on studies suggesting that marriage and family therapists (MFTs; Ayres and Haddock 2009) may see a higher rate of clients with problematic IP use than undifferentiated MHPs (Mitchell et al. 2005; Mitchell and Wells 2007), we hypothesized, more generally, that therapists with relevant expertise (i.e., marriage and family therapy, sexual disorders, and substance abuse) would be more likely to have

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seen clients with sex addiction or problematic IP use. We also hypothesized that therapists with relevant expertise or experience would hold different beliefs and more frequently perceive themselves as effective at treating clients with sex addiction and problem IP use, as compared to those without relevant expertise. Lastly, in that IP use can be private and might incur fewer social risks, we hypothesized that sex addiction would be more strongly and broadly linked to a range of life difficulties, compared to problematic IP use. It should be noted that this study was approved by the Institutional Review Board for the University of HoustonClear Lake.

Methods Subject Characteristic Participants were 183 MHPs, of which 84.7  % were licensed. Those unlicensed were either in the process of gaining licensure or were currently involved in an internship or practicum program through an affiliated university. Two participants had never practiced and were eliminated from analyses. Of the participants who had practiced, the mean number of years in practice was 10.9 (SD = 10.8). The majority (67.1 %) practiced full-time, with the remainder practicing part-time. Licensure data indicated that the predominant group was master’s level counselors trained in counseling or clinical psychology. The next largest groups were school psychologists and marriage and family therapists. For specific information regarding participant demographics, education level, full-time/part-time practice breakdown, and practice settings, refer to Table 1. Procedure The study was conducted over a 15-month period. Participants were recruited for the study in three ways: face-toface through the community, online recruitment posting, and online word-of-mouth (snowballing). For face-to-face recruitment, investigators attended local continuing education conferences and meetings that targeted practitioners in the community. These participants included professionals working in the local community, and most were licensed or license-eligible at a master’s or doctoral level (see Table 1 for license and education information). Participants recruited through the community were asked to complete the questionnaire during the meeting or conference. If they agreed to participate they were handed a consent form and questionnaire. Per IRB approval, signature for consent was waived. However, when forms were handed to the participants, they were asked to read the consent form, which

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Table 1  Sample demographics, education, and professional characteristics Demographics Mean age (SD) Percent female Ethnic/racial breakdown Caucasian African American Hispanic Other Education level of training Doctorate degree Master’s degree Bachelor’s degree Professional discipline by licensure LPC (master’s in counseling or clinical) LSSP LMFT Licensed psychologist LPA (psychological associate) LMSW LCDC LPCi (intern pre-licensure) LCSW Professional mental health setting High school setting Private practice Hospital Community centers and non-profits Prison University and research settings Other

41.4 (14.8) 65 % 80.9 % 8.2 % 6.6 % 4.3 % 24.6 % 71.0 % 4.4 % 44.1 % 19.9 % 15.4 % 5.9 % 5.1 % 3.7 % 3.7 % 1.5 % 0.7 % 29.1 % 17.2 % 13.2 % 10.6 % 9.3 % 6.6 % 20.6 %

explained that completing the questionnaire indicated their consent to participate. Online recruitment involved posting the link to the survey on list-serves, forums, and websites that target practitioners. The link to the survey was also posted on walls for social networking groups targeting MHPs on the professional networking site, LinkedIn. The third method involved a snowballing method to promote the study link to MHPs. The researchers emailed the link to personal MHP contacts and then asked them to forward the email containing the link to their personal MHP contacts. For those recruited through the internet, the questionnaire was administered online via the surveymonkey.com. After reading a consent form, they would check a box to agree that they understood the terms of consent. If they did not agree to participate, the questionnaire ended. After giving consent, the participants completed the survey, which took approximately 30 min.

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As reimbursement for participation, all participants were offered the opportunity to provide contact information, separate and secure from their research survey data, to enter a raffle to win one of two $20 gift certificates to a national restaurant. Measures All questions used for this study were generated by the researchers. Each item was delivered in either fill-in-the blank or Likert-type scale form. The questionnaire included a variety of demographic questions assessing for age, race, ethnicity, and education. Information regarding MHPs’ professional experience, history, specialization, licensing information, and theoretical orientations were gathered as well. The participants were also asked about their professional experience, beliefs, and observations regarding IP and sexual addiction. These questions included prevalence of these issues in their practice, clients’ problems associated with these issues (e.g., financial losses, interference in daily activities), and treatment methods utilized when dealing with these issues. Data Analysis Data was analyzed using SPSS 17.0. Descriptive statistics were used for most of the data. In order to understand differences across gender, education, years of experience, and specialization, Fisher’s exact tests, Chi-square tests, independent sample t tests, repeated-measures analysis of variance, and correlational analyses were run.

Results Therapist Characteristics Of the practicing therapists, 63.3 % reported working primarily with individuals, 13.6 % of participants worked with couples, 12.9 % worked with both individuals and families, and the rest (10.2 %) worked with other combinations of individuals, families, groups, and couples. Of the 60.5 % of therapists who specialized, most specialized in mood disorders (14.4 %), 12.7 % specialized in substance-related disorders, and 12.7 % specialized in anxiety disorders. Only 5.5 % of therapists specialized in sexual disorders. The primary theoretical orientation of the participants was Cognitive Behavioral (CBT 35.5 %), followed by eclectic (26.5 %), Behavioral (BT 14.2 %), Family Systems (7.7 %), Psychodynamic (7.1 %), Solution-Focused (5.2 %), and Humanistic (3.2 %) orientations.

Community Ment Health J

Therapist Experiences When asked if they ever had seen a client with sexual addiction, 39.4 % indicated that they had, while 21.3 % reported currently seeing clients presenting with sex addiction. The reported mean number of clients that clinicians had ever seen present with sex addiction was approximately 4.2, with a reported mean of 0.4 clients currently presenting with sex addiction per week. Nearly half of the sample (48.8 %) reported that they had seen clients presenting with problematic IP use, and 26.2 % reported that are currently seeing clients with problematic IP use. Therapists reported a mean of 6.1 clients that had ever presented with problematic IP use, with a mean of 0.7 clients currently presenting with problematic IP use per week. Comparing how these problems present with respect to professional discipline and specialization yielded multiple findings. First, therapists specializing in sexual disorders were more likely than non-specialists to have seen a client for sex addiction (70.1 vs. 37.1 %) and were more likely to be currently seeing clients with sex addiction (50 vs. 19.6 %) or problematic IP use (60.0 vs. 24.4 %) (Fisher’s exact tests all p < .05). Sexual disorders specialists also showed a marginal trend toward being more likely to have seen a client for problem IP use overall (70.0 vs. 47.4 %, Fisher’s exact test p = .10). Second, and closely related, LMFT’s specializing in sexual disorders were more likely than non-specialists to have to have seen a client for sex addiction (75.0 vs. 34.1 %) or problematic IP use (71.4 vs. 45.6 %) and were more likely to be currently seeing clients with sex addiction (40 vs. 18.5 %) (Fisher’s exact tests all p < .05). LMFTs showed a marginal trend toward being more likely to be currently seeing a client for problem IP use overall (42.9 vs. 23.8 %, Fisher’s exact test p = .06). Notably, 60 % of therapists specializing in sexual disorders were not LMFTs. Thus, these are distinct but overlapping professional groups that clients may preferentially seek out to address sex addiction or problematic IP use. Third, MHPs who specialize in substance abuse were more likely than non-specialists to have seen clients with problematic IP use (x2 = 6.74, p < .01), as well as to have seen and currently be seeing clients for sex addiction (both x2 > 3.93, p < .05). Finally, although some Licensed School Psychologists (LSSP) had seen clients with sex addiction (7.7 %) or problematic IP use (11.1 %), as a group LSSPs were less likely than non-LSSP’s to have seen such clients (Fisher’s exact test scores both p < .05). Therapist Beliefs When presented with questions in a dichotomous format (yes/no), the majority of MHPs endorsed the belief that sex addiction is a valid diagnosis (70.1 %). However, this belief

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was stronger among non-specialist therapists (72.2 %) than among therapists who specialize in sexual disorders (40 %), Fisher’s exact test p < .05. No differences were found based on whether or not participants were LMFTs or therapists specializing in substance use disorders. Additionally the majority of the full sample also endorsed that problematic IP use should be categorized as a sexual addiction (68.3 %), a belief that did not vary significantly by specialty area. Therapists were also asked to rate the likelihood that various factors influence the development of sex addiction or IP use (see Table 2). Overall, therapists believed there are a variety of contributory factors related to sexual addiction and IP use, with self-esteem issues and relationship problems being most frequently endorsed as somewhat likely or most likely. Some differences emerged when examining beliefs about contributory factors by experience working with these types of presentations, specialization in sexual disorders, or LMFT professional discipline. Those who had seen clients for sex addiction were far less likely to believe that a lack of sex is a causal contributor [t(90) = 3.69, p < .001]. On the other hand, those who had seen clients for problematic IP use were less likely to believe that relationship problems are causal contributors [t(111) = 2.39, p < .05]. Therapists specializing in sexual disorders were less likely to believe that relationship problems or miscommunication contribute to sex addiction (t’s both >2.70, p < .05), and they were less likely to believe that miscommunication or social ineptness contribute to problematic IP use (t’s both >2.33, p < .05). However, no differences were found on the basis of being an LMFT or not. The vast majority of MHPs indicated that they believed that IP use can have negative effects (81.0 %). Therapists specializing in sexual disorders and LMFTs endorsed this sentiment in relatively equal proportion. Additionally, 63.9 % of therapists believed that IP use could not be beneficial for clients, and 68.5 % reported that they would never recommend using IP for therapeutic reasons. In contrast, sexual disorder specialists were more likely than non-specialists to endorse that IP can be beneficial (70.0 vs. 34.4 %) and that they could conceive of recommending using IP for therapeutic reasons (60.0 vs. 30.1 %, both Fisher’s exact tests p < .05). Sex Addiction, IP, and Associated Dysfunction When asked about comorbidity, 88.3 % of clinicians felt like clients with problematic sexual behaviors also had comorbid diagnoses, of which mood disorders were most often observed (69.2 %), followed by anxiety disorders, impulse-control disorders, and substance abuse (40.4, 38.5, and 38.5 %, respectively). MHPs reported similar patterns of comorbidity in clients with problematic IP use. For instance, comorbid diagnoses were observed by the

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Table 2  Response percentages of clinicians’ ratings of perceived factors causing/contributing to sex addiction and/or IP use Factors

Relation to sex addiction or problematic IP use

Not likely at all to somewhat Neutral (%) unlikely (%)

Somewhat likely to most likely (%)

Self-esteem issues

Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex Addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use

16.7 21.3 29.4 35.7 22.3 26.2 20.7 16.7 37.3 40.9 28 20.7 49.4 41.3 47.1 49 25.2 26.2 58.3 51.8 29.2 42.1 25.5 37.8

61.1 50 37.3 30.3 42.7 40.2 62.2 62.2 30.2 26.2 44.1 59.4 25.2 39.2 17.2 25.5 48.6 47.5 9.9 13.7 46.2 27.4 36.8 32

Depression Other mental health condition Relationship problems Financially feasible Social ineptness Lack of sex Miscommunication Early exposure to porn Distant mother Attachment issues Trauma (i.e., rape, incest, assault)

majority of therapists (95.1 %), with mood disorders most often observed (63.3 %), followed by anxiety disorders (57.7 %), substance abuse (42.3 %), and impulse-control disorders (32.1 %). The most prominent difference between the two presenting problems was the greater percentage of anxiety disorders associated with IP use than with sex addiction. MHPs were also asked about their observations of problems and characteristics commonly related to sex addiction or IP use in clientele (see Table 3). Overall, MHPs reported that sexual addiction or IP use were associated with several problems, which occurred often or very often. The most frequently associated problems included interference with relationships, preoccupation with sexual activity, and failure to control sexual behaviors, including continued sexual behaviors despite negative consequences. Although a visual scan of results suggest that these problems occurred frequently in both sex addiction and problematic IP use, they occurred more frequently with sex addiction than with problematic IP use (all F’s > 18.12, all p’s < .001). Differences in frequency were especially pronounced for financial problems, interference in everyday activities, need for increasing sexual behavior to obtain a desired result, and legal charges

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22.2 28.7 33.3 33.9 35 29.9 17 21.1 32.6 33 26.9 19.8 25.3 19.6 35.6 25.5 26.2 26.3 31.9 34.5 24.5 30.4 37.7 29.1

(all F’s > 17.55, all p’s < .001), always with sex addiction showing stronger associations than problematic IP use with specified problems. Similarly, although therapists tended to endorse that both clients with sex addiction and clients with problematic IP use experienced distress if they could not act on their sexual thoughts and expressed thoughts or actions to quit acting on their sexual impulses, therapists indicated these phenomena were more strongly related with sexual addiction (both F’s > 8.47, p’s < .01). Therapeutic Effectiveness and Methods Next we assessed clinicians’ perceived competence and success, and methods they used in treating individuals with sex addiction and/or problematic IP use. The majority of therapists reported that they did not feel competent to treat clients with sex addiction or problematic IP use (62.6 and 58.9 % respectively). However, LMFTs and therapists specializing in sexual disorders or substance abuse more frequently endorsed feeling competent than non-specialists and nonLMFTs, respectively (Chi square and Fisher’s exact tests all p < .05). Also, participants whose highest degree earned was a doctorate were more likely than those whose highest

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Table 3  Response percentages of clinicians self-reported observations of problems and characteristics associated with sex addiction and IP use Item

Type

Not at all to very rarely (%)

Sometimes (%)

Often to very often (%)

Preoccupation with sexual activity

Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use Sex addiction Problematic IP use

3.8 6.2 3.8 8.9 5.3 14.4 10 27.4 20 51.7 3.1 4.8 3.8 5.5 3.8 4.1 5.4 9.6

10.6 15.1 15.9 17.1 22 28.8 34.6 39.7 36.9 33.1 14.6 16.4 12.3 17.1 9.2 20.5 16.9 28.8

85.6 78.8 80.4 73.9 72.7 56.9 55.4 32.8 43 15.1 82.3 78.8 83.9 77.4 87 75.4 77.7 61.6

Strongly disagree to slightly disagree (%)

Neutral (%)

Slightly agree to strongly agree (%)

3.1 6.2 4.6 5.5

9.9 18.6 8.5 13.1

87 75.2 86.9 81.4

Recurrent failures to control sexual activity/ behaviors Interference in everyday activities Financial problems related to the cost of sexual activity/material Legal charges due to sexual activity or behaviors Sexual activity or behavior that lasts longer than intended Continuation of sexual activity/behavior despite negative consequences Interference with relationships Need for more sexual activity/behavior to obtain desired result

Physical or psychological distress if unable to act on sexual thoughts (i.e., anxiety, depression) Thoughts about quitting or attempts to quit acting on sexual thoughts/behaviors that are unsuccessful

Sex addiction Problematic IP use Sex addiction Problematic IP use

degree was a master’s degree to report feeling competent to treat problematic IP use (x2 = 5.57, p < .05), but less likely to report feeling competent in treating sex addiction (x2 = 0.70, p = .40). Consistent with reported inexperience or perceived lack of competence in treating these presenting problems, 50 % reported they would most likely refer out clients presenting with sex addiction, and 38.8 % reported they would refer out clients presenting with problematic IP use. Therapists who had seen clients for sex addiction or problematic IP use were asked to rate on 5-point Likert scales how successful (effective in decreasing the problem behavior) they were in treating the respective presentations, in comparison to other presenting problems they treat. Regarding sex addiction, 50.0 % of MHPs endorsed being slightly successful, and only 13.2 % endorsed being strongly successful. Regarding problematic IP use, 34.9 % of MHPs felt slightly successful in treating IP use, and 9.3 % felt strongly successful. Participants’ degree level and number of years in practice did not differentiate perceived success in treating this population. However, those who specialize in sexual disorders and LMFTs rated themselves

as having greater success (averages in slightly successful range) than non-specialists and non-LMFTs (averages in neutral-to-slightly successful range) in treating problematic IP (t’s > 2.60, p’s < .05). There were no significant differences regarding treating sex addiction. In contrast to LMFTs and sexual disorders specialists, therapists who specialize in substance abuse perceived no more success or failure in treating sex addiction and problem IP than non-specialists (t’s < 0.42, p’s > .67). MHPs were then asked what treatment would be most effective in treating sex addiction and problematic IP use. CBT was the most frequently recommended treatment for both, with 43 % endorsement for sex addiction and 58.8 % endorsement for problem IP use. The second most highly recommended treatment for both sex addiction and IP use was eclectic, with 18.2 % endorsement for sex addiction and 16.9 % endorsement for IP use. The 12-step program followed these two treatments among the top three interventions that received the highest recommendations by MHPs, with 12.4 % endorsement for sex addiction and 8.8 % endorsement for IP use. Not surprisingly, LFMTs were more

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likely to endorse family therapy for problem IP use (11.1 %) and sex addiction (22.2 %) than non-LMFTs (0 and 1.9 %, respectively). However, no other differences in preferences were found based on LMFT status, based on whether participants had previously seen clients with problem IP use or sex addiction, or whether they were sexual disorder specialists or not.

Discussion The present study was conducted to increase understanding about how sex addiction and IP use-related problems present to various MHPs, and how MHPs conceptualize and treat these issues. A sample of mostly mid-career MHPs were surveyed about their areas of professional focus, their experiences, beliefs, observations, and chosen therapeutic methods. In general, this study found that a large proportion of MHPs see clients with sexually problematic behaviors, consistent with previous research (Ayres and Haddock 2009; Mitchell et al. 2005; Mitchell and Wells 2007). This set of MHPs also believed that cognitive behavioral and eclectic approaches are most effective in treating these presenting problems, but the majority of MHPs indicated that they personally do not feel competent to treat them, which was also consistent with previous research (Ayres and Haddock 2009; Reissing and Giulio 2010). Although these findings are informative and useful, the most novel, and perhaps the most significant findings from the current study, suggest that beliefs, observations, and some practices regarding sex addiction and IP use vary significantly based on MHPs’ professional discipline, specialization, and experiences treating clients with these presentations. Overall, we hypothesized that therapists, with relevant expertise (i.e. marriage and family therapy, sexual disorders, substance abuse training and experience), would be more likely to have seen clients with sex addiction or problematic IP use. We also hypothesized that therapists with relevant expertise would perceive themselves to be competent at treating clients with problematic sexual behaviors than those without relevant expertise. Study findings supported both of these hypotheses. Similarly, among MHPs who had seen clients with sexual addiction and IP use, those with relevant expertise endorsed higher levels of perceived treatment success, with the exception of substance abuse specialists. MHPs in this study indicated that for their clients, both sexual addiction and problematic IP use are frequently related to relationship problems, disruptive preoccupation, and behavioral dyscontrol. However, compared to IP use, sex addiction was linked with more frequent co-occurrence of problems across the board, with these effects most prominent in associations with legal and financial problems, and

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an apparent quality of tolerance (i.e., needing more of the behavior to obtain desired result). MHPs in this study also reported high rates of psychiatric comorbidity in the clients who have these problem sexual behaviors. It should also be noted that anxiety disorders were comorbid with problematic IP use at a higher proportion than sex addiction. Complementary research findings have indicated significant relationships between IP use, sexual impulsivity, and compulsivity (Cooper et al. 2000; Wetterneck et al. 2012). For individuals who struggle with anxiety, impulsivity, or compulsivity, easy access to IP may facilitate faster and more frequent attainment of the reinforcing consequences (e.g., sexual gratification, abated anxiety) of IP use behaviors; whereas, sexual activity involving human contact may be more cumbersome or anxiety-provoking to obtain.1 Overall, the present study’s findings underscore the need to assess for a range of co-occurring life problems and psychiatric comorbidities, which may co-occur with sex addiction and IP use with different frequency. Additional differences emerged in how MHPs conceptualize IP use. First, most MHPs believed that IP use has negative consequences and no clinical utility. However, sexual disorders specialists were far more likely to endorse that IP use could also have positive effects and clinical utility. These specialists may have been more cognizant of ways that sexually explicit materials can facilitate assessment and treatment of sexual dysfunction and paraphilias, improve client-partner communication, and reduce client misconceptions, anxiety and shame about healthy sexuality (e.g., Annon and Robinson 1978; Robinson et al. 1999). Second, while a significant proportion of the MHPs conceptualized problem IP use as a form of sex addiction (consistent with Egan and Parmar 2013; Kafka 2010a, b; Kaplan and Krueger 2010), MHPs viewed problematic IP use as more influenced by a lack of social skills and lack of sexual contact with others, and sex addiction as more influenced by attachment issues. It should be noted that therapists without relevant expertise or experience posited diffuse, ambiguous set of factors contributing to problematic sexual behaviors. Maintaining the lack of clinical expertise across the field, the current state of the literature on sex addiction and IP use has inhibited understanding of presenting phenomenology, treatment development, treatment dissemination, and general MHP effectiveness. Although there have been recent efforts to increase understanding of biopsychosocial factors associated with sex addiction (Samenow 2010), an evidencebased understanding of etiological and maintenance factors of hypersexuality or problematic IP use is rudimentary at 1

  Unfortunately, the recruited subsample of clinicians endorsing specialization in impulse-control problems was too small to examine possible differences in the experiences, attitudes, observations and practices of these MHPs.

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best. The wide variety of contributing factors hypothesized by MHPs in this study may reflect significant gaps in the empirical literature, varying levels of exposure to clinical lore and experiences, and in some cases, uninformed judgments (Moser 2011). Hypersexual disorder (a replacement term for “sex addiction”) was recently proposed for inclusion in the DSM-5 as a condition to be further researched to help close gaps in understanding. However, after heavy debate over the appropriateness of this diagnosis (Kafka 2010a, b; Reid 2013; Moser 2011), it was ultimately rejected (American Psychiatric Association 2010), partly on insufficient evidence. This rejection will likely inhibit the pace of research on this presenting problem had it been incorporated into DSM-5. For now constructs such as “sex addiction” will need to suffice. In this study, an overwhelming majority of MHPs surveyed believed that “sex addiction” is a valid diagnosis, so there is a clear gap between the primary diagnostic classification system MHPs are tasked to use and what they are perceiving in clients. The lack of an available diagnosis can result in other problems. First, problem sexual behaviors might be overlooked, unless they are severely impairing. The fact that comorbidity rates were so high in the present study is consistent with the possibility that for some, treatment for IP use or sex addiction is not sought until comorbid psychiatric distress is present (Halpern 2011). Second, in so far as diagnosis directs treatment selection and implementation, the lack of an available diagnosis may decrease MHPs’ comfort and level of perceived competence in treating these disorders. Third, those willing to see these clients, whether they are competent or not, would be operating on clinical lore or on the outer frontiers of evidence-based practice. Interestingly, in this study there was relative agreement, regardless of expertise or experience, about the most effective ways of treating these presenting complaints. However, there may have been a specificity gap between MHPs’ comfort and general knowledge of CBT or eclectic principles and how these treatment techniques are specifically applied to sex addiction and problematic IP use. It is also important to note that this study measured perceptions of competence and success rather than empirical outcome data. MHPs’ perceptions may be not always be accurate. Thus, more research is needed on actual treatment outcomes, and practicing MHPs and trainees will need up-to-date, quality training about these presenting problems, even if diagnostic classifications are not forthcoming. Generating and disseminating a data-driven understanding of sex addiction and problematic IP use will also be important to counteract non-scientific, empirically-unsubstantiated claims that have historically influenced training and practices (Reid et al. 2011; Samenow 2010). For instance, a significant proportion of individuals engage in IP

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use or other online sexual behaviors, but only a small fraction of that population demonstrates problematic use (Cooper 2000). However, extant data suggest that individuals’ moral attitudes about sexual behaviors (“addiction” to IP use or sex) predict their perceptions of pathology as well or better than actual sexual behaviors (Clarkson and Kopaczewski 2013; Grubbs et al. 2015). By default, MHPs treat a client’s presenting complaint, and in some cases a client’s perceived pathology may not be objective pathology. This becomes a greater concern if MHPs’ personal morality results in pathologizing clients’ relatively normative behaviors. This likely happens, despite the fact that MHPs are typically trained in objective assessment procedures. For example, research indicates that highly religious MHPs diagnose sex addiction in their clients more often than less-religious MHPs. Although the discrepancy between a client’s values and behavior is appropriate material for therapy, diagnosing the presentation as pathological is not always necessary and could even be counter-therapeutic in some cases. Thus, it is important for the field to identify more clearly attributes and thresholds where normative sexual behaviors or IP use shift to interfere with individuals’ functioning and well-being. Related to this, sex addiction and problem IP use correlate with many other problems or vulnerabilities, but the directionality of these relationships is not well-established. For example, in the current study, it was unclear if problematic IP use leads to anxiety or if anxiety leads to IP usage or if they both merely correspond with a third variable (e.g., lack of a satisfying marriage). Further, these results may show that IP use only exacerbates existing problems or vulnerabilities (Southern 2008). Prospective research designs examining temporal relationships with sexual behavior presentations and their correlates would be valuable to the literature. Furthermore, answers to questions of directionality would have clear implications for effective assessment and treatment planning practices. Unfortunately, our study findings suggest that MHPs may be only vaguely familiar with the state of evidence-based practices for sex addiction and problem IP use. Although it is beyond the scope of this article to review this literature thoroughly, we note that other commentators have described specific criteria or measures that can be used to assess offline and online sexual behaviors, including IP use (Grubbs et al. 2015; Reid et al. 2012). Regarding treatments, several psychosocial interventions have shown promise for treating sexual addiction (Bird 2006; Fong et al. 2012), including cognitive behavior therapy, mindfulness, 12-step programs, and couples therapy (Bird 2006; Carnes 2000; Goodman, 1992; Parker and Guest 2002; Reid and Woolley 2006). The pharmacological agent naltrexone has also shown some success (Grant and Kim 2001; Raymond et al. 2003). However, as of yet, there is limited research regarding these treatments or other options for clients with problematic IP

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use (Bostwick and Bucci 2008; Twohig and Crobsy 2010). This study’s findings suggest a need for increased education and training regarding problematic sexual behaviors for all MHP disciplines and particularly for identified groups of MHPs who see more of these clients. The present study had limitations worth considering, while interpreting these findings and formulating future research. First, study findings may have limits to their generalizability. Recruiting took place at local continuing education conferences and meetings that targeted practitioners in the community, and the majority of participants were masters’ level clinicians; only a quarter were doctoral-level clinicians. Also, the sample included school psychologists and other clinicians who see predominantly adolescents. Given that adolescents less-frequently present with these issues, the full sample data presented might be skewed compared to a sample of MHPs that treat exclusively adults. Second, because questionnaires asked about clients presenting to treatment, these results may not accurately reflect prevalence rates in the overall population. Third, the present study did not assess for MHP’s amount of specific training related to sex addiction or problematic IP use. This would be a variable of interest in future research about conceptualizing and treating these presenting problems. Lastly, this study did not assess for different ways that clients were referred to MHPs. It is possible that referrals from different sources (by self, partner, employer, other health care or social worker, religious leader) could be associated with different perceptions, treatment motivations, and objectives. In conclusion, sexual addiction and IP-related issues appear to be problems that occur frequently in the clinical population, and evidence indicates that assessment, treatment, and training are currently inadequate to meet the need for effective services. These discrepancies represent significant problems that the MHPs need to address. MHPs with specific expertise or increased general training may be more effective in addressing sexual addiction and problem IP use; however, most MHPs do not feel competent to work with these presenting complaints. Additionally, existing data suggest that sexual addiction and problem IP use may share conceptual and phenomenological similarities, but may they also may differ in terms of etiology and severity of co-occurring problems. Although this descriptive study adds to a steadily growing literature, far more research is needed to fill gaps in understanding characteristics and treatment of sex addiction and problematic IP use. Beyond the gaps in research, it seems apparent that an important point of the current study is to highlight the need for training and education for clinicians. Clinicians need training in not just the treatment of these issues, but they need training identifying symptoms, the function of those symptoms, and comorbid diagnosis.

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