Stanton reviews a new medical tome on sexual addiction, by psychoanalyst Aviel Goodman. Yes, people become addicted to sex; no, it is not a medical disease best treated by the 12 steps.
Contemporary Psychology, 44:154-156, 1999
Is Sex Really Addictive?
Review of Sexual Addiction: An Integrated Approach, by Aviel Goodman
Sex can be addictive. Addictive sex and love are culture bound, and are especially prevalent in the United States and some other Western societies. Sexual addiction is not a disease. Addictive sex occurs on a continuum, with a large part of the population displaying some degree of sex addiction over their life spans. Sexual addiction is resolved when people believe they canand have the resources toachieve sufficient gratification from activities inconsistent with compulsive sex.
One who wishes to deal with addictions other than drugs or alcohol can either approach the topic phenomenologically or behaviorally (cf. Marlatt & Gordon, 1985; Peele & Brodsky, 1975/1991; Peele, 1985/1998) or else claim that somehow the observed behavior implicates biological systems that can be linked to addiction (see Peele, 1981). Today, the National Institute of Mental Health, National Institute on Drug Abuse, and National Institute on Alcohol Abuse and Alcoholism are all committed to uncovering a fundamental neurobiological "cause of addiction" (Hyman, 1996).
The most common and influential current of thought about addiction in the United States has grown from the 12-step philosophy originally developed and presented by Alcoholics Anonymous (AA). AA is a folk movement that adopted the symbolic position that alcoholism is a disease. But the 12 steps' constant reference to a higher power and AA's use of group sessions resembling religious confessionals have created a peculiarly American system of hospital and auxiliary chemical dependence treatment based almost exclusively on a spiritually oriented approach to behavior change. To the extent that the 12 steps are practiced as a systematic treatment, they comprise a behavioral-experiential therapy. Opportunistically, however, many 12-step advocates claim that alcoholism is completely biological in its genesis. Meanwhile, the 12-step approach has been applied to a host of behaviors, including compulsive gambling, shopping, sexuality, and so on.
Aviel Goodman, a psychoanalytically oriented psychiatrist, is by experience, personal orientation, and treatment approach in the experiential and behavioral realm. Yet he seeks to justify the reality of his clients' experiences of intense suffering brought on by compulsive sexual behavior by claiming its source is biological. Goodman also identifies as his direct predecessor in labeling sexual addiction Patrick Carnes (1983), someone steeped in AA and the so-called "Minnesota Model" of 12-step treatment.
Goodman discursively cites a large body of research he believes demonstrates a biological etiology for compulsive masturbation, promiscuous sexual encounters, and resorting to prostitutes for sex. Nonetheless, Goodman does not sacrifice his independent perspectivehe argues that psychological and biological perspectives are equally valid. In this light, his encyclopedic references represent an effort to give credit to and to learn from the entire range of professional orientations and bodies of research that contribute to addiction theory.
Of course, even many who follow the 12-step ideology or who search for medical cures for most human maladies might view sexual addiction as falling outside their purview, particularly given the ironclad 12-step, disease-treatment requirement of abstinence. Cases like food or sex, in which the problem behavior cannot totally be eliminated from a person's repertoire, seemingly demand transcendence of 12-step boundaries. Goodman does so easily and sensibly, for instance by directing his clients to confront internal conflicts that he believes underlie their compulsive sexual behavior. He also understands the concept makes the most sense in its adverbial form:
Any behavior that can function both to produce pleasure and to relieve painful effects can be used addictively; and the more effective a behavior is at producing pleasure or at relieving painful effects for a particular individual who is predisposed to use behaviors addictively, the more likely is the individual to engage addictively in that behavior. (p. 19)
However, Goodman's success at integrating all factors contributing to addiction is questionable. Goodman asserts that addicts are neurobiologically predisposed to addictionor, indeed, to affective, anxiety, personality, and attention-deficit disorders as well as every possible kind of addiction, from gambling to drugs to bulimia, and, underlying all these, to obsessive-compulsive and affective-spectrum disorders. (From an evolutionary genetics standpoint, how did such a genotype survive?) The particular outlet for this predisposition is then determined by experience"In the presence of these underlying vulnerabilities, bulimics seem to select the eating of food as their prosthetic self-regulatory behavior primarily because food is unconsciously identified with the mother" (p. 167). Goodman's resolution of the biological and psychological, although hopeful"We can see that the psychological formulation of the addictive process and the neurobiological formulation of the addictive process are consistent with each other; that they are moreover, to a great extent, isomorphic with each other" (p. 219)includes a lot of unexamined philosophical turf.
Goodman makes more sense in combining two more closely-related areas of theorypsychoanalytic and social learning: "Impaired internal regulation of their subjective states leads individuals to depend on external actions to regulate their subjective states and to cope with the subjective consequences of internal dysregulation" (p. 175). His citation of cognitive-behavioral alcohol and other addiction research is sound, but the theorists with whom Goodman is most inward are psychoanalytic thinkers not central to addiction theoryLeon Wurmser, Otto Fenichel, Robert A. Prentky, Eric Hollander, Ismond Rosenand one who is, Edward Khantzian.
Goodman is not forceful enough in confronting the inherent conflicts between his own perceptions and treatment approach and medical and biological perspectives (as in his fatuous repetition of the claim that "psychotherapy is a biological treatment"). The universality of sex gainsays deterministic addictive models that entail the stimulation of neuroreceptors and endorphins to explain how daily activities implicate fundamental addictive mechanisms. The obvious question is always, Why then does not everyone who engages in the activity become addicted to it? The idea of "born addicts" ordained by genes to react addictively to narcotics (or something or everything else) is quickly refuted by standard epidemiological surveys showing tremendous variability in the individual's tendency to be addicted over time and in different settings. Neurochemical and genetic theories are not economical ways to explain how it was that so many heroin addicts in Vietnam came home to use narcotics nonaddictively in the United States (Robins, Davis, & Goodwin, 1974).
Indeed, sexual addiction should be a primer for understanding how ordinary people can sometimes find a basic experience powerful and often overwhelming. Many (perhaps most) people give a good rendition of sexual addiction in their youth. But a substantial majority overcome this tendency with growing maturity, responsibility, and self-knowledge. Nonetheless, many level-headed, mature individuals once again experience and express overwhelming sexual infatuation and yearning when they are thrust out of their familiar environments (by, say, divorce). Bill Clinton's risky dalliance with Monica Lewinskyor affairs by his leading Republican antagonistsdon't prove that they are all congenital addicts. Many humans show at various times both the urge towards and the ability to overcome sexual addictiona statement that also holds for drug and alcohol addictions.
The trick is to approach addiction reasonably and sensibly, by identifying it as a meaningful and useful concept without either falling prey to the alluring simplicity of reductive biological models or failing to recognize that addiction is a convenience of labeling, a culturally influenced and individually variegated phenomenon rather than a hard-wired naturally preordained mechanism. And this approach would seem inexorably to move the observer and scientist into the individual's experiential realm (as it does for Goodman)why does this particular person at this time find a given involvement all-encompassing, painful, and inescapable?
Goodman does not explore the continuum between addictive and ordinary behavior. He is a psychiatrist and a therapist; his cases all involve therapeutic interventions. There is still a need, just as when I wrote Love and Addiction (1975/1991), to show that very fundamental and everyday experiences like love and sex fuel what are among the most compulsive, destructive, and violent involvements humans experience. For many, the idea that such behaviors are akin to heroin addiction is still a conceptual leap impossible to make. This recognized, people do experience sexual and love abysses without becoming clinical basket cases. Three out of four alcohol-dependent individuals do not attend any alcohol therapy, along with a higher percentage of those with lesser drinking problems, and most of these individuals achieve remission without treatment (Dawson, 1996). Natural remission figures are higher for those with addictive sexual experiences. For one thing, overwrought love and sexual entanglements are accepted and even idealized in our culture, making it less likely that those experiencing them will seek therapy.
While Goodman does not insist on 12-step group attendance, four of his five case examples involve 12-step groups. This is understandable for one dealing professionally with patients in the state that gave "the Minnesota Model" its name. But in the broader view of addictive behavior that Goodman embraces, we see that the majority of addictive behavior arises and is overcome outside clinical settings. Goodman fails to deal with the large epidemiologic literature showing that natural remission is by far the most common path out of compulsive behaviors (Peele, Brodsky, & Arnold, 1991). This unfamiliarity likewise explains why Goodman is not able fully to accept the existence of nonabstinent outcomes in alcoholism.
Goodman's eclectic approach could also logically lead take him in two other directions he chooses not to follow: (1) Why not deal with a pervasive phenomenon like sexual addiction among a larger pool of compulsive behaviors of which it is one common example, rather than to identify it as a separate addictive category? (2) Why not see sexual addiction as a culturally bound behavior that might be completely nonexistent in the form we identify it in other cultures where sexual fidelity and self-definition take far different forms than in the United States and the Western World at large?
As for the former, Goodman has published work on addiction as a broader category, work which informs this book in the introductory, definitional sections. And, too, he is intellectually honest in citing reasoned critiques like that by Levine and Troiden (1988): "sexual addiction and sexual compulsion represent pseudoscientific codifications of prevailing erotic values rather than bona fide clinical categories" (p. 349). But Goodman does not deflect this criticism by saying that, "Contrary to Levine and Troiden's assumption, the concept of sexual addiction does not entail that any form or pattern of sexual behavior is itself defined as an addiction" (p. 33). Nor is it a sufficient answer to say that many people he treats are deeply hurt by their sexual behavior and desperately want helpful attention.
What is lost through this omission, I think, is a full sense of people's own great self-ameliorative powers, of the critical importance of age and setting in determining compulsive behavior, of the great diversity and malleability of such behavior around the world, of the value judgments inherent in clinical approaches, and of the fundamentally self-serving idea that people, in all aspects of their beings, must be identified primarily in terms of a set of health care needs. Finally, what may be most lacking in this book is any systematic review of data on the effectiveness of various sexual addiction treatments, the author's included, or of treatment for addictive problems altogether.
But what is gained from Goodman's book is valuable. His identification of the centrality of subjective experience as a key to analyzing addictions, his recognition of the range and depth of the sources of human pain, his respect for his clients' individuality and capacity to take responsibility, his refusalwhile avoiding open conflict with prevailing quasi-medical views of addictionto simply kowtow to these and to deny the implications of his own observations and thinking, are all admirable beyond words in the current atmosphere of groupthink and neurochemical totemism (I think of the talk show host pointing to her head and saying, "It's all in the brain somewhere").
Goodman's work will be well-cited as the best comprehensive guide to an area heretofore viewed by serious empiricists with distaste as some add-on service for addiction therapists to deliver. But Goodman's is not a groundbreaking or reorienting work. It does not resolveor even recognizemany central issues with which addiction theorists, clinicians, and researchers must grapple.
Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis: CompCare.
Dawson, D.A. (1996). Correlates of past-year status among treated and untreated persons with former alcohol dependence: United States, 1992. Alcoholism: Clinical and Experimental Research, 20, 763-779.
Hyman, S.E. (1996, August 2). Shaking out the cause of addiction. Science, 273, 611-612.
Levine, M.P., & Troiden, R.R. (1988). The myth of sexual compulsivity. Journal of Sex Research, 25, 347-363.
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Peele, S., & Brodsky, A., with Arnold, M. (1991). The truth about addiction and recovery. New York: Simon & Schuster.
Robins, L. N., Davis, D. H., & Goodwin, D. W. (1974). Drug use by United States Army enlisted men in Vietnam: A follow-up on their return home. American Journal of Epidemiology, 99, 235-249.