CASE STUDY 1

Patient T is a white man, 42 years of age, and father of five. Twice married, his wife has become increasingly distant from him in their marriage due to her anger and hurt over his use of Internet pornography. Patient T's wife did not know that he used pornography until they were married, and every time she has asked him to stop, his use has only intensified. Now, they have experienced numerous financial consequences because he has reached the credit limit of two of their credit cards paying for pornography. Patient T's wife no longer wants him around their children because she feels that he is a bad influence.

Comments: Patient T's pornography use is clearly affecting his life. It has resulted in a damaged relationship with his wife and children, which will take significant work to repair. In addition, the financial cost of the pornography has impacted the financial stability of the family.

Patient T enters treatment recognizing that he has a problem with pornography and the accompanying compulsive masturbation. This recognition and his willingness to get better are two critical examples of intangible resources. The patient still has his job, which provides him with insurance to access treatment, and his wife has agreed to let him stay in their home while he completes his outpatient treatment (albeit in their basement guest room). These are two major examples of tangible resources. Other resources that can fall into the tangible and intangible categories both are the inspiration that his children provide him and the new friends he has met at 12-step recovery meetings. Patient T does not consider himself a spiritual person, so he does not see praying or contact with God as a resource. Moreover, his mother, who introduced him to pornography at the age of 11, does not feel he has a problem. Patient T was very young when his father left the family, and his mother gave him pornographic magazines because she felt guilty that a father was not there to teach him about sex. She stays actively involved in the patient's life to the point of enmeshment, and her presence is more of a detriment than it is a resource.

Patient T's therapist begins to work more in-depth with him; she discovers that he harbors major feelings of unworthiness and "badness," primarily due to his father's abandonment of the family when he was 4 years of age. For all of these years, Patient T has, on some level, believed that it was his fault that his father left, and that because he was unworthy of growing up with a father, he is unworthy of a better life.

Comments: Patient T displays core beliefs regarding his own worthlessness and inherent badness, which are common among sexual addicts. These feelings make it difficult for individuals to establish or sustain intimate relationships.

Like many sex addicts, Patient T believes that sex, specifically orgasm, is his most important need. Remember that the patient's mother gave him his first pornographic materials, telling him directly that she was doing this because he had no father to help him learn about sex. As such, Patient T equated the pleasure that he got from the orgasms with the sense of love and belonging that he was missing from his father. Although he has been good-natured and has always strived to be faithful to the women he was with, Patient T was very promiscuous when he was not in a relationship. When his wife would not be sexual with him, he immediately interpreted this as rejection and that she somehow did not love him. This same issue arose in the client's first marriage. Clearly, all of these beliefs must be confronted in treatment.

Comments: It also appears that Patient T has incorrect beliefs regarding sexuality and healthy sexual relationships. Because much of this information was gained in youth, the beliefs may be strongly held, but some education regarding aspects of healthy sexuality would be helpful for this client.

Patient T has followed through with his inpatient treatment and has been free of acting out sexually with pornography and compulsive masturbation for the last four months. He has recently become sexual again with his wife. It has been difficult for him to learn and adapt to healthy sexual behavior, but he is committed to maintaining his gains. Patient T and his counselor have made a decision to terminate treatment, largely because he has obtained and has been using a 12-step sponsor. Another contributing factor is that the patient's individual insurance has run out and he does not feel that he can afford to pay for continued counseling on his own, especially because he and his wife have decided to obtain couples' counseling. Patient T's counselor writes a relapse prevention plan, which consists of the following points:

Patient T will attend at least one 12-step meeting per week (in this case, Sexual Compulsives Anonymous) and have contact with his 12-step sponsor by phone no fewer than three times per week.

Patient T will keep the family computer in the public place (e.g., the family room), where it has been since he began treatment. The patient also agrees to keep pictures of his family surrounding the space around the computer.

Patient T will not use the computer if he is experiencing any of the trigger emotions that he discovered in treatment (e.g., anger, frustration, pain, sadness). Instead, the patient will call his sponsor, a member of his support team, or watch sports on television until he can reach someone by phone.

Patient T will keep the enhanced blocking software on his computer at home; only his wife and his sponsor will have access to the password. The patient agrees to let the employee assistance professional contracted by his company make random checks on his computer for the next year.

Patient T will continue working the 12 steps with his sponsor. If his sponsor feels that further outside help is needed, the patient will call his counselor to discuss getting back into individual counseling.

Patient T will continue with couples' counseling sessions with his wife three times per month.

Comments: It is vital that sex addicts create a plan to reduce the risk of relapse that addresses their risk factors. In this case, making time spent on the computer a more public activity and providing alternate plans when urges are strongest should help decrease the chance of a relapse.