Attachment, intimacy, and therapy for out-of-control sexual behaviour (OCSB)

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1 Attachment, intimacy, and therapy for out-of-control sexual behaviour (OCSB) Addiction Symposium - April 29th, 2016 Dr Karen Faisandier Wellington, New Zealand Research Supervisors: Dr Joanne Taylor, Dr Shane Harvey (Massey University) & Robyn Salisbury.

2 Sexual behaviour that is out-ofcontrol How much sex is too much? How much is enough? And who decides? (Groneman, 2000, pp.151) (disclaimer) 2

3 (Distress (self/others), loss of control, negative consequences (self/others), shame/guilt) great variability of OCSBs 3

4 Working Definition of OCSB Difficulty in regulating sexual thoughts, feelings, or behaviour to the extent that negative consequences are experienced by the self or others. The behaviour causes significant personal or interpersonal distress and may include activities that are incongruent with personal values, beliefs, or desired goals. The behaviour may function as a maladaptive coping mechanism and may coincide with other psychopathology or neurological impairments. (Reid & Woolley, 2006, p. 220) 4

5 Who has OCSB? OCSB peaks between ages 20 and 30, with a typical age of onset during adolescence (?) 3-6% of the population is affected (?) Particularly homosexual or bisexual individuals (? gay or bisexual men are commonly studied) Mostly men (?) There may be gender differences in its presentation (?) If the media is anything to go by it disproportionately affects politicians, actors, and famous sports-stars! 5

6 What causes OCSB? Multiple interacting factors A variety of frameworks have been used to conceptualise OCSB: Addiction model using DSM-IV dependence criteria Impulse control disorder to seek pleasure, relief, gratification (followed by regret/shame/self-reproach) Obsessions/fantasies of a sexual nature cause tension/stress and a compulsion to reduce this through following through with the act Hypersexuality inability to feel sexually satisfied/ excessive sexual activity Impaired affect regulation self-soothing, loneliness, alexithymia, sexual abuse/trauma, insecure attachment, suggested to be an intimacy disorder 6

7 Attachment The early work of Dr John Bowlby and Mary Ainsworth (1950 s) 7

8 Attachment styles Secure Preoccupied - anxious Dismissing - avoidant Disorganised fearful (Main & Soloman, 1990) Adaptive responses to manage the caregiving relationship experiences 8

9 Adult Secure Attachment Effectively self-soothe and/or effectively seek comfort at times of distress Provide comfort at times of others distress Feel comfortable with an autonomous self Accept the autonomy of close others Ability to negotiate the needs for closeness with others (Cassidy, 2001) 9

10 Sexual behaviour Secure attachment is associated with fewer sexual partners, the desire for monogamous relationships, positive affect towards sexual experiences, getting pleasure from expressing affection, safe sex. and sex that involves mutuality, caring, and commitment. Secure attachment leads to sexual behaviour that is less likely to result in distress or impairment for themselves or others 10

11 Preoccupied Attachment Behaviour: hypersensitive, anxious, heightened emotional arousal, increased reassurance seeking, difficulties selfregulating when distressed. Self = worthless, ineffective, dependent. Others/world = neglecting, insensitive, unpredictable, unreliable. 11

12 Preoccupied Attachment More frequent infidelity, earlier age of first intercourse, more lifetime partners, difficulties maintaining a relationship. Difficulties resisting pressure to have sex, less condom use, uses sex to avoid abandonment/seek reassurance/elicit a caring response/ or defuse a partners anger. 12

13 Dismissing Attachment Behaviour: cognitive strategies to minimise intimacy despite internal physiological stress. Uses disconnection or avoidance of emotions (may have alexithymia). Self = unloved but self-reliant Others/world = rejecting, intrusive, unable to meet needs. 13

14 Dismissing Attachment Minimises intimacy. Less restrictive sexual beliefs, more casual sex outside of a relationship, more solitary behaviours (such as porn watching/masturbation). Uses sex to avoid a partners negative affect, reduce stress, increase prestige amongst peers. Sex = used to get close and stay far away 14

15 Disorganised Attachment Considered the most severe - associated with trauma (safe base = source of danger). Confused behaviour - biology competes - fight to survive against the fight to seek comfort (from safe base who is also dangerous). 15

16 Disorganised Attachment Behaviour: chronic heightened emotional arousal. Fluctuates between preoccupied and dismissing styles with neither successfully alleviating distress. Tends not to form attachments to others due to this. Self = unloved, self-reliant Others/world = rejecting, threatening, unpredictable, dangerous. 16

17 Disorganised Attachment Less researched than the other styles in terms of sexual behaviour but either of these can occur: 1. Short-term mating (multiple sexual partners, brief sexual relationships, causal sex) 2. Alternatively may have low sexual desire/activity. 17

18 A last Word on Attachment Is a complex area that relates to the development of skills required for successful intimate relationships. There are problems with capturing attachment style in adults for research purposes due to the dynamic nature of attachment e.g., in relation to close others; requires attachment system activation = self-report is limited and AAQ interview takes time, money, and training to administer. 18

19 Intimacy Securely attachment individuals tend to develop the capacity for intimacy (good emotion regulation, selfsoothing skills, empathy and relating skills, giving and receiving of compassion and affection etc). Insecure attachment leaves people with some difficulties in obtaining intimacy and closeness with others. Similarly to the problems inherent in measuring attachment; how to measure the dynamic and relational capacity for intimacy for research purposes or in therapy assessment? 19

20 Intimacy focused therapy Is an integrated biopsychosocial approach incorporating motivational, social, cognitive, behavioural interventions as required. What sets it apart is the core focus of assessing any intimacy deficits and developing the capacity for these (Salisbury, 2008). This part is threaded through each aspect of treatment with 3 distinct components 1) intimacy with therapist (non-sexual), 2) intimacy with self, 3) intimacy with others. 20

21 Other treatments for OCSB 12-step models (based on AA) residential programmes- CBT/addiction models group therapy - CBT and psychodynamic CBT Online programmes - CBT pharmacological - SSRIs ACT (Acceptance & Commitment Therapy) An intimacy based approach 21

22 OCSB Treatment Effectiveness & Efficacy Research on (rigorously evaluated) effective treatments for OCSB is in its infancy (Reid, 2013). 11 studies stating to be OCSB psychotherapy treatment evaluations to date (2016), not all used robust methodologies. ACT Twohig & Crosby No gold standard or best practice yet We need to grow the treatment outcome literature 22

23 Evaluating Intimacy- Focused Therapy for OCSB 23

24 Method Selection Research on treatment outcomes has tended to favour group-based designs (E.g., RCT s). RCT strengths: compare mean differences between groups or changes within a group but over different conditions - establishes efficacy (how well something works compared to a control). 24

25 RCT limitations Unable to look at results for individuals as focuses on statistical and not clinical significance (the effect on everyday life for the individual). Participants are heavily screened for co-morbidity and severity, thus may not be representative of real world clients. Do not lend themselves to non-structured therapies (i.e., unable to be easily manualised due to being more dynamic and tailored). Can be expensive and time-consuming to run. 25

26 Alternative Methodologies Non-group based methodologies have been suggested to be pertinent in exploratory research before considering comparisons against other treatment conditions. Single-case design, with multiple baselines allow a robust methodology for examining individual outcomes and effects of therapy over multiple replications. 26

27 Single-Case Design Is whether or not a therapy approach works in everyday settings, including clients with co-morbidity. Can be used with non-structured therapies. Has guidelines on making sure the evaluation is methodically sound (stability of baseline, 3 replications required etc). Participants are their own control - baseline phase. Comparing baseline with treatment phase and can include a follow-up phase to determine the longevity of effects. 27

28 Study Aim & Hypotheses To evaluate IFT for OCSB (in 12 men seeking help) looking at pre-post-therapy, weekly behavioural tracking, and follow-up outcomes. 1.OCSB related distress and negative consequences would reduce. 2.Problematic sexual behaviour frequency/duration would reduce. 3. Intimacy and secure attachment would increase. 4. Insecure attachment would reduce. 28

29 Participants 12 men with self-identified OCSB able to be seen for therapy in Auckland or Palmerston North (1 of these dropped out 1 did not complete measurement). Age range 27-57, most NZ Euro/ Two Maori. Most heterosexual, three bisexual, one homosexual. Mostly in a relationship (ranging 3 months - 29 years). Highly educated, greater than average income. (Quotes) 29

30 Method Offered up to 12 sessions of IFT at half cost due to funding grant (IFT was formalised into treatment guidelines for the purposes of this research). Three Clinical Psychologist Sex Therapists (2 Auckland/1 Palmerston North). Completed measures over a baseline phase, therapy phase, and over 3 months of follow-up. Completed weekly monitoring of sexual behaviour and distress over baseline, therapy, and at the follow-up points. Used time-series graphs and modified Brinley plots to visually analyse behavioural data, and effect size algorithms were applied. 30

31 Psychometric Measures Administered pre-therapy, post-therapy, and 1,2,3 month follow-up: Compulsive Sexual Behaviour Inventory (Control Scale) - CSBI Compulsive Sexual Behaviour Consequences Scale - CSBCS Fear of Intimacy Scale - FIS Relationship Scale Questionnaire - RSQ 31

32 7 Day Self-Report Duration of Sexual fantasy Viewed pornography Used the Internet for sex Frequency of Partner sex Masturbated Sex in public Paid for sex Level of distress about sexual behaviour SUDS scale

33 Data Analysis Used time-series graphs to visually analyse behavioural data, and effect size algorithms were applied. Compared pre, post, and follow-up scores on psychometrics and presented these using modified Brinley plots A treatment adherence measure was also used to ascertain the degree to which therapists followed IFT guidelines in therapy. 33

34 Results 34

35 35

36 36

37 Frequency Assessment Point 37

38 Duration Assessment Point

39 Distress about sexual behaviour in past 7 days Assessment Point 39

40 Effect Size Analysis SMD (full data) and SMD 3 (last 3 sessions) High variability in effect sizes as well as overinflated effects were found, which was consistent with previous research findings. SMD 3 effects were higher than SMD showing end of therapy had greater improvement than over the full duration of therapy. 40

41 Findings IFT reduced OCSB for men in terms of increasing their sexual control, reducing some sexual behaviours, as well as distress and negative consequences resulting from sex. But client goals were not elicited and thus unclear whether results mapped onto change that was desired by clients. There was no clear impact of IFT on changing intimacy or attachment. Why was this? 1.IFT does not increase intimacy or attachment (maybe therapy in general can t do this?) sessions were not enough to effect change in intimacy and attachment? 3.The measures did not capture intimacy and attachment effectively? 4.As intimacy skills were being applied perhaps fear of intimacy/attachment did not reduce as less avoidance was occurring and more anxiety may have resulted? 41

42 Limitations and Future Research Oops - ask participants what changes they are aiming for in any future research on treating OCSB!! Measure OCSB self-report more simply when using single-case design (e.g., perhaps in hours or incidences per day) so as to be able to ascertain (stable) baseline of only one variable. Need to establish how to measure adult attachment more robustly. Use of collateral sources including AAI, therapist rating, and partner ratings may be helpful? The same for intimacy lack of measures available. Map secure attachment and intimacy skill development in clients to the IFT guidelines in order to establish whether this particular therapy impacts on this dynamic and complex process. Consider the role of the partner? 42

43 Implications Clients will present with sexual behaviour concerns no matter whether or not the literature concurs on nosology or definition. Simply monitoring and reporting sexual behaviour each week may be useful to clients (i.e., The Hawthorne effect) Elicit clients sexual behaviour goals/valued behaviours rather than subjective notions of what is considered abnormal. Behaviour duration/frequency doesn t always have to change in order for distress/negative impairment to reduce. In those who insecure attachment is not an issue a brief intervention can be helpful (e.g., assessment/formulation only, psychoeducation, opportunity to discuss concerns) When change to sexual behaviour frequency/duration/type occurs this may happen quickly however the development of intimacy skills may be longer term/more complex work more research is needed. 43

44 Related Publications Faisandier, K.M., Taylor, J.E., & Salisbury, R.M. (2012). What does attachment have to do with out-of-control sexual behaviour? New Zealand Journal of Psychology, 41, Faisandier, K.M., Taylor, J.E., Salisbury, R.M., & Harvey, S.T. (2016) Is intimacy-focused therapy an effective treatment for out-of-control sexual behaviour? A treatment outcome study. (Manuscript in preparation). Salisbury, R.M. (2008). Out-of-control sexual behaviours: A developing practice model. Journal of Sexual & Relationship Therapy, 23, Salisbury, R. (2009). Staying in love. Random House: New Zealand. (therapy resource) 44

45 I would like to acknowledge the courage of the study participants who willingly lent their most private and intimate details to the research process. My gratitude goes to my team of supervisors: Dr Joanne Taylor, Robyn Salisbury, and Dr Shane Harvey. My additional thanks to: The Oakley Mental Health Foundation Te Rau Matatini Massey University The co-directors of Sex Therapy NZ Ltd 45

46 Questions/Comments? 46

Dr Angela Busuttil Head of Psychology in Physical and Occupational Health Sussex Partnership NHS UK

Dr Angela Busuttil Head of Psychology in Physical and Occupational Health Sussex Partnership NHS UK Richmond Foundation Malta October 2012 Definitions Overview of attachment theory and its developments