...and A Small Town Private Practice
The following is a conversation between Michael Zahab, a public relations manager at recovery facility, and the husband-wife team of Paul Hartman, M.S., Marriage & Family Therapist, and Ginnie Hartman, M.A., L.P.C. The Hartmans have worked together in private practice since 1991 at the Healing Center in Spring Lake, Michigan. Paul and Ginnie began their counseling careers in 1981 and 1985, respectively. They recently completed training with Patrick Carnes, Ph.D., for the treatment of sexual anorexia.
Michael Zahab (MZ): Please tell me about your professional background and your current practice.
Paul Hartman (PH): I'm a Marriage and Family Therapist in private practice, specializing in addiction issues. In many years of working with recovering alcoholics, I've tried to help those people who are physically dry move on to a higher level of recovery by dealing with family of origin issues as well as doing Twelve Step recovery work. Despite seeing much progress in my clients, I've continued to feel that something was missing in my work.
I've discovered in the last couple years that the issue I've seldom, if ever, addressed is sex addiction. So, after training with Pat Carnes, I began to do groups that specifically focused on this area. Most participants have been people who were already in recovery from another addiction-long-term recovery for some-but all were still having relationship problems and experiencing pain in their life. Once I began to address sex addition issues, once I made it the primary thrust of therapy, I began to see a tremendously positive response among some of my clients. I'm very excited about the outcomes I continue to see.
Ginnie Hartman (GH): My work for many years has focused primarily on individual families that have been affected by addiction. I have done a lot of group work on family of origin issues and have seen remarkable progress. After my training with Patrick Carnes, however, I began to look for and talk about sexual anorexia-and I have been amazed by the number of people-women, primarily-who struggle with this problem. I've long believed that when substance addiction is present in a relationship, sexual function is usually distorted. But I never understood the dynamics involved until I worked with Pat [Carnes]. I am so excited as I watch the participants in women's groups that have been together for quite a while bloom as they discover and explore their sexuality for the first time.
MZ: Do you believe that this is a new problem, or is it something that we've simply overlooked for many years?
PH: Awareness has been building for some years, beginning for us with the model Claudia Black developed in the early 1980's when she published, It Will Never Happen To Me. We've also had Pia Mellody's work to draw from. I was familiar with Pat Carnes' work through his books, but it wasn't until training with him that I set up groups explicitly focused on treating sex addiction.
This is an important point. Previously I put all my clients together in groups; I didn't differentiate. Generally, the clients in such groups became, after several months, became good friends. They felt safe enough with one another to disclose family secrets, but what they didn't do was talk about sexual issues. No matter how safe the environment, these issues never seemed to come out mixed groups.
My first (sex addiction) group was composed of men who had at least two of years of recovery and had done a lot of group work. When they came together in a sex addiction group, experiences came out that they had never before talked about. It's been the missing treatment piece for these men.
Frankly, I'm coming to believe more and more that the so-called primary addictions aren't truly primary addictions. I'm seeing more and more men for whom the primary addiction is sex addiction. The other addictions are secondary to sex addiction.
MZ: Spring Lake, Michigan, is not a large community. Has it been difficult to pull together enough people to conduct groups which address sex addiction?
P.H.: When I came back from the training, I wondered about this same question. As soon as word got out around the community that I was doing this, however, people were calling and asking to get in the group. Now I have two groups running concurrently, and could easily do one every night of the week if I had the time.
MZ: Ginny, what was your experience coming away from the training? Are you finding a similar situation among the women with whom you work?
GH: Although I've always treated some sexual dysfunction, I'm now just much more aware of the problem. After evaluating my clients more carefully, I realized that those who were in a relationship with an addict had invariably shut down sexually in some way and disowned their sexuality. Several women, when first approached about sexual anorexia, responded with such comments as, "I'm not sexual, and I could care less if I ever have sex again. I'm fine without it. I don't feel anything is missing." Other were being sexual with their partner, but only for their partner, not for themselves.
Each of these women had done family of origin work, a lot of recovery work, and were in a Twelve Step program. I had to really help them understand that they would not be fully recovered until they could embrace their sensual and sexual being. After announcing the group and suggesting Pat Carnes' book, Sexual Anorexia, I had a group of ten before I knew it. As word spread in the recovering community, I had another group of ten-and now I have people on a waiting list.
MZ: Do the women in group meet the criteria for sexual anorexia more than the criteria for any of the other sexual disorders?
GH: It seems so. The typical woman who has been in relationship with an addict has totally disowned her sexuality. She's decided she doesn't want or need sex any longer. This represents a shift to an extreme; these women have not had a lifetime of sexual anorexia. There are, of course, women who have been shut down sexually most of their lives, but that doesn't seem to be the norm among those I've seen.
MZ: Do the couples or individuals with whom you've worked have sexual or relationship issues, but no other apparent dysfunction?
PH: We occasionally see people like this, but, they're not our typical couple client. Generally speaking, our typical couple is in their late 30's or 40's and has been in Twelve Step recovery for six, seven, or eight years. The husband is an alcoholic with seven to eight years of sobriety and he's been active in A.A. During this time, his spouse has been working a good Alanon program.
When they come to us, we hear such stories as: "We're doing everything the program tells us to do. We're working the Steps; we've got a sponsor; we're not into our addiction, but our relationship is terrible and we're thinking of getting a divorce." After a deeper assessment of such couples, we quickly get into the issue of sexual satisfaction and dissatisfaction-and there it is.
MZ: Among the dysfunctional behaviors, are the Internet and pornography a factor? Tell me about this.
PH: I'd put this right on the top of the list. I continue to be amazed each week as people come in and disclosing the ways they use sexually explicit materials on the Internet for arousal and masturbation and how they go to chat rooms and how they then go out to meet people from the chat rooms. That's got to be one of the top issues we deal with in our marital therapy work. This is something that, two years ago, I never asked about. Now, I ask routinely.
GH: I can't tell you how many women who have come into therapy saying, "My marriage is falling to pieces, I don't know what's happened, my husband is up all night on the computer, on the Internet." They have no idea what's going on. As a therapist, you simply have to be aware of this problem.
MZ: How has the training affected your clinical approach and work?
GH: Understanding the anorexia cycle (preoccupation, distance strategies, sexual aversion, despair) has been so important for us and for our clients. It's so much easier to identify how sexual addiction has affected individuals and their intimate relationships. Previously, I recognized that some kind of cycle was in place, but I didn't have a term for it. The term "sexual anorexia" fit perfectly. Clients understand it, too. They know immediately what we're talking about. Consequently, it's much easier to then help clients see how that cycle had interrupted their own sexual maturity and growth. It's made all the difference.
PH: Our work in addictions has long had this basic premise: all current dysfunction is tied in to dysfunction in the family of origin-and that dysfunction often took the form of child abuse. One way people survive that kind of experience is to shut down emotionally. The focus of our work has been to help people access those repressed feelings and express them, and the result has been healing.
In contrast, whether it's Ginnie's sexual anorexia group or my sex addiction group, we focus explicitly on the sexual issues and the thoughts, feelings and behaviors that accompany them.
The other difference is that every week, the group is focused on something that is explicitly sexual. We really follow the outline we received at the training, starting with denial and going right through that outline, you have a subject and it just builds-it just provides the program.
We have a large population of clients who have been extensive family of origin work, so not all are starting from square one-but some are. Initially, I was concerned abut how I could take two divergent groups and treat them together. I decided to deal with child abuse early in the process. That piece of it was repetitious for some, but they didn't object. And those who hadn't dealt with these issues found it very revealing and helpful.
MZ: How did you implement what you learned in the training?
GH: I began evaluating my clients to discover those who had sexual disorder issues, and gave those who did some of the literature to read. I also checked with clients who had finished family of origin work and suggested they do some reading on the topic, too. Many more than I expected called back immediately asking to be in the group.
PH: It hasn't worked that well for me on the sex addiction side. I typically recommend Out Of The Shadows or Don't Call It Love. For a person who is in denial of their sex addiction, my experience is that those books don't do a lot to bring them out of denial. When reading about the behaviors that Patrick describes, many men focus on what they don't do.
One-on-one therapy, however, has help enormously. Through it, these men begin to understand that if they're spending an inordinate amount of time fantasizing about sex and/or objectifying women-regardless of what acting out behaviors they have-this alone is enough to make the diagnosis of sex addiction.
I also stress that such a diagnosis is important, not to put a label on them, but to help us know how to help. Some of these guys have been all over the mental health community looking for help, but haven't gotten it. They've been treated for anxiety disorders, depression, obsessive-compulsion disorder, you name it. Many of them have been on medications, especially the SRI's (seratonin reuptake inhibitors) with some improvement. But after all the treatment and all the Twelve Step experiences, they're still coming back saying, "Is that all there is?"
MZ: As a member of the group progresses, what indications or changes do you see?
PH: These male sex addicts have been carrying an enormous level of shame. I believe now that more shame is associated with sex addiction than any other dysfunction. Because of the shame, there's an extra need for secrecy. In treatment, we work to reduce their level of shame, and that alone has an enormous impact on their lines. As their shame decreases, their self-esteem increases. They start to believe, often for the first time in their lives, that they are valuable people. To me that's been the biggest change that I've seen emerge from this group. These men are beginning to really love themselves. They seem themselves as worthwhile, good men. It's so powerful.
GH: I think one of the changes I see is people rediscovering their passion for life. When you shut down any part of your being-particularly your sexuality-you just lose some of the passion and vitality for life. I see life back in their eyes, color in their face. I see a lot of physical changes in female clients. They move differently, they are able to wear feminine clothes again, and they report learning once again to enjoy touching and being touched.
PH: Ginny and I have seen similarities in progress and healing in both our male and female clients, but we have see one significant difference: the progress women make seems to be quite steady and straight ahead. The men in my group, however, initially made good progress breaking through denial. They could identify their dysfunctional sexual behaviors, and, I believe, genuinely wanted recovery. Yet week after week they came to group talking about slipping-going back to their dysfunctional sexual behaviors. I think what Patrick has learned about this in his research is that it's very typical in the first year recovery from sex addiction.
MZ: How is the support community where you practice?
PH: That was another concern I had. We have a very strong A.A. recovery community, but other Twelve Step programs are not widely available. There were no S.A. groups in our area, which meant clients had to drive 45 minutes to less than ideal groups. I'd advise therapists who try this approach to encourage your own clients to start a Twelve Step group-which is what we did. Attendance is typically twelve to sixteen people, and they've just recently expanded to an additional evening night. Both are well-established and well-attended. GH: All of the women I see are in Twelve Step groups, too. Two or three women have sought help for more family of origin issues. And when they finish this group (sexual anorexia) they too will probably go into one of our family of origin groups.
MZ: How critical is to have members of the family of origin geographically close with regard to progress with therapy and recovery?
GH: We have found, since we use experiential and psycho-drama techniques, that it isn't necessary for the family to be physically available.
PH: I agree. Today's treatment techniques enable people to heal whether or not they have direct access to family. A typical dysfunctional response is to cut off relationships-from parents, from siblings, from adult children. I think as long as those severed relationships continue, a certain amount of woundedness lives on inside the person. After they learn how to set boundaries, clients can go back and sustain family relationships-even with a member who has not been through recovery-most, but not all, of the time.
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