UNNERSITYotNORTHERN BRITISH COLUMBIA UBRAAy Prince George, B.C. A CBT BASED GROUP FOR INDIVIDUALS WITH A SEXUAL ADDICTION by Kaila McAnulty B.A., University of British Columbia-Okanagan, 2008 PROJECT SUBMITTED IN PARTIAL FULLFILLMENT OF THE REQUIREMENTS OF THE DEGREE OF MASTERS OF EDUCATION COUNSELLING UNNERSITY OF NORTHERN BRITISH COLUMBIA April2014 © Kaila McAnulty, 2014 11 Abstract The purpose of this project was to develop a manual for therapists to facilitate a cognitive behavioral therapy influenced group for individuals who have a sexual addiction. A summary of the literature on sex addiction including the history, treatment options, benefits of implementing a group, and a description of the sub-categories of sex addiction is provided. The format and content of the group are discussed as well as any ethical considerations. Finally, a detailed example of the group, outlining the intended schedule, activities, and discussions is provided. 111 TABLE OF CONTENTS Abstract 11 Table of Contents 111 Acknowledgements v Chapter One Chapter Two Chapter Three Introduction 1 Purpose 5 Clarification of Terms 6 Personal Location 8 Summary of Chapter One 9 Literature Review 11 Background/History 11 Treatment Objectives and Options 15 Benefits and Challenges of Group Therapy 23 Sub-Categories of Sex Addiction 28 Therapist's Role 31 Summary of Chapter Two 33 Target Audience 34 Group Goals 34 Cognitive Behavioral Therapy 34 Group Counselling 35 Ethical Considerations 37 Group Schedule and Topic List 38 Summary of Chapter Three 47 lV Chapter Four The Facilitator' s Manual 48 Introduction 48 Screening Interview 48 Session One: Exploring Sex Addiction 49 Session Two: Etiology, Treatment Options & Goals 72 Session Three: Shame, Guilt & Cognitive Processes 84 Session Four: Cycle of Addiction 99 Session Five: Decision Making & SelfWorth 113 Session Six: Developing a Healthy Lifestyle 127 Session Seven: Relapse Prevention 139 Session Eight: Closing 155 161 References Appendix A Screening Interview 167 Appendix B Check-In 168 Appendix C Informed Consent 169 Appendix D Group Norms 170 Appendix E Self-Evaluation Part 1 171 Appendix F Check-Out 172 Appendix G Hall's Six Phase Cycle of Addiction 173 Appendix H Self-Evaluation Part 2 176 Appendix I Evaluation 177 Appendix J Resources for Facilitators 179 v Acknowledgements I would like to express my sincere thanks to my professor and supervisor, Dr. John Sherry, for his patience, flexibility, and sense of humor throughout this long process. It is important that I also recognize my committee members, Dr. Linda O'Neill and Jeff Talbot for their time and valuable input. I would also like to thank my friends and family for all of the help and support I received during my studies at UNBC. Thanks to my incredibly patient and understanding husband Dustin, for always encouraging and supporting me to achieve all of my goals. I would also like to express my appreciation to my parents Kathy and Dennis Mayer, my Aunt and Uncle Donny and Michele Chartrand, my mother-in-law Cathy Dupuis, my sister-in-law Jessica Mayer, and my niece Madison Mayer for driving to Prince George on numerous occasions to help babysit my daughter Kenzie so I could work on my project. Lastly, I would like to thank all of my friends who also helped me with Kenzie so I could complete my project on time. I wish to dedicate my project to my brother Daniel Mayer. He has been an inspiration to me in more ways than one and I hope he is as proud of me as I am of him. I also dedicate my project to my beautiful daughter Kenzie McAnulty and my future children. I hope that by completing not only my project but my Masters in Counselling, that they will one day be inspired to work hard to accomplish anything their little heart's desire. I hope that by the time they are old enough to read this, if they' re not too embarrassed, that they will be proud of their Mom. 1 Chapter One Introduction The term sex addiction can be defmed in a vast number of ways. It is a particularly difficult term to define from a diagnostic point of view because there has not been sufficient reason to defme sex addiction as a psychiatric disorder in the DSM (Levine, 2010). Hall (2013) provided a simple and clear defmition of sex addiction as any uncontrollable pattern of sexual behavior that has negative repercussions in one' s life. Additionally, if one continues this out of control behavior and becomes dependent on it, despite the problems it causes in one ' s life, they are addicted. For example, if a particular sexual behavior, such as viewing pornography, begins to have adverse effects on an individual ' s relationships, finances, occupation, or health etc., it would be considered an addiction. Sex addiction has also been described as the "athlete ' s foot of the mind" in that it is something that never goes away; it always needs to be scratched which, in turn, promises relief(Carnes, 2001). To scratch this itch, however, also causes pain and intensifies the itch. The itch is described as the rationalizations, lies, and beliefs one has about oneself and the addiction. Despite the costs and negative impacts that sex addiction has on the individual ' s life, they overlook it and focus on the immediate warm gratification that scratching the itch gives them. Others have described sex addiction as being similar to chemical addictions. It has been suggested that, like chemical addictions, sex addictions consist of: experiencing a recurrent failure to resist impulses to engage in a specific sexual behavior, an increased sense of tension immediately prior to initiating the sexual behavior, and pleasure or relief at the time of engaging in the sexual behavior (Garcia & Thibaut, 201 0). Like chemical addictions, 2 sex addiction also includes an escalation of sexual behaviors as the disorder progresses, withdrawal symptoms such as depression, anxiety, and guilt related to a reduction of sexual activities, as well as difficulty stopping or reducing the frequency of sexual behaviors (Garcia & Thibaut, 2010). Lastly, Kafka (as cited in Garcia & Thibaut, 2010) defmes sex addiction as "hypersexual disorder." Kafka proposed that one must experience, over a period of at least six months, recurrent and intense sexual fantasies, urges, and behavior in association with four or more of the following five criteria: a great deal of time consumed with sexual fantasies and urges, including planning for and engaging in sexual behavior; repetitively engaging in these sexual fantasies, urges, and behaviors in response to dysphoric mood states (e.g., anxiety and depression); repetitively engaging in sexual fantasies, urges, and behaviors in response to stressful life events; repetitive but unsuccessful efforts to control or significantly decrease these sexual fantasies, urges, and behaviors; and repetitively engaging in sexual behavior while disregarding the risk for physical or emotional harm to oneself or others. The individual also has to experience significant personal distress or impairment in social, occupational, or other important areas of functioning associated with the frequency and intensity of these sexual fantasies, urges, and behaviors and these sexual fantasies, urges, and behaviors are not due to the direct physiological effect of an exogenous substance such as a drug of abuse or a medication. Kafka proposed this criterion for the fifth edition of the DSM (DSM-V), however it was denied due to lack of research supporting this argument. This group focuses on those who feel their sexual behaviors are having a negative impact on their lives. It offers particular skills, homework and reflective pieces for 3 individuals to learn in a group setting but participants are also encouraged to practice these skills in their everyday lives. It is important to mention the distinction between a paraphilia and a paraphiliarelated disorder because this particular group focuses primarily on paraphilia-related disorders. Paraphilias are defined as repetitive, constant, socially deviant sexual arousal that leads to negative psychosocial repercussions, whereas paraphilia-related disorders are similar but are not considered socially deviant. Examples of paraphilia-related disorders include cybersex dependence, pornography dependence, compulsive masturbation, telephone sex dependence, protracted promiscuity, severe sexual desire incompatibility, and paraphiliarelated disorder not otherwise specified (NOS) (Kafka, 2001). Further distinctions are discussed in the clarification of terms section. There is some confusion as to what type of disorder sex addiction falls under in the DSM and, in some instances; sex addiction has been labeled as a paraphilia-related disorder (Kafka, 2001). Garcia & Thibaut (2010) argue that sex addiction is an impulse control disorder or an obsessive compulsive disorder. Sex addiction has been labeled as an impulse control disorder due to the fact that one often fails to resist the drive, impulse, or temptation to act out the behavior that may be harmful to oneself or others. It has also been thought to be an obsessive compulsive disorder because the sexual compulsions, while often resisted, are completed to decrease anxiety and are usually followed by feelings of distress. Sex addiction is often compared to food or eating addiction. For example, in healthy people both food and sex are natural and innate needs, but when the relationship to food or sex becomes unhealthy, sex addiction has no more to do with a person ' s sex drive than an eating disorder has to do 4 with hunger (Hall, 2013). Sex addiction is much more complex than just being sexually active with a lot of partners. Like most addictions, sex addiction is often used as a coping mechanism: a way to deal with life. Those with a sex addiction use their addiction as a way of relieving stress and alleviating negative emotions with the goal of creating positive emotions (Hall, 2013). Sex addiction is similar to chemical addiction in that there are often recurrent failures to resist impulses, a sense of pleasure or relief at the time of acting out on the behavior, and symptoms of withdrawal when the behavior de-escalates (Garcia & Thibaut, 2010). Sex addiction, like most other addictions, can also have negative effects on an individual's life. ln one study of individuals addicted to sex, approximately 71% developed feelings of shame, 65% reported low self-esteem, 4 7% had lost a relationship, 4% had lost means of employment, 16% reported physical health problems, 50% reported mental health issues, 15% had accumulated substantial debt, and 6% had some sort of legal action against them (Hall, 2013). As with other addictions, if a behavior is damaging your life but you still continue to do it, you are most likely addicted to the behavior. ln regards to groups for sex addiction, there are few available nationally, and none in northern British Columbia. One of the most popular groups available nationally is known as Sex Addicts Anonymous (SAA). Sex Addicts Anonymous is a support group and follows a 12 step model. Meetings are forums which help individuals learn how to integrate the 12 steps into their lives. The SAA model suggests that, by following the 12 steps, one will experience a spiritual transformation resulting in sustainable relief from addiction. The idea behind the 12 steps is that, over time, these spiritual principles will become integrated into one's thoughts, feelings, and behaviors. The steps are viewed as more than just a series of 5 exercises, they are there to provide basic principles of living (Sex Addicts Anonymous, 2013). There are no requirements for membership nor are there any fees to attend. They encourage strict anonymity and confidentiality, and the meetings are held at a safe and secure location. The nearest SAA group to Prince George is offered in Kamloops, British Columbia. Although it has been suggested that group therapy is an effective form of treatment for various intrapersonal and interpersonal concerns and for helping people change their behaviors, there is very little sex addiction focused group therapy available in British Columbia and none in the North (Corey, Corey, & Corey, 2010). In Prince George, the closest form of group therapy is a relapse prevention group for those with addictions, but its focus on sex addiction is very broad and it acts as more of a support group than a psychoeducational group. As a practicum student at Adult Mental Health and Addictions, it was brought to my attention the high prevalence of people in the North who would benefit from a therapeutic group that focuses on healthy sexual behavior. Most often, clients are referred to individual therapy or to the city ofVancouver because of its abundance of resources in sex therapy. My goal is to develop and implement a therapeutic group for people who have a sex addiction in the North and other remote areas. Purpose The purpose of my project is to develop a manual for therapists so they can facilitate a short-term, closed, psychoeducational group for individuals with a sex addiction living in remote areas. The group follows an integrative model with an emphasis on a cognitivebehavioral theoretical model. To the best of my knowledge, there are no therapists in the North who specialize in any form of sex therapy. In addition, there are few resources for people with sex addiction in 6 the North yet, according to the adult mental health team in Prince George, there is a high need for treatment for people with sex addiction. As mentioned previously, Prince George offers a relapse prevention group and individual counselling, however, there are no qualified sex therapists doing the counselling. During my practicum at adult mental health, I saw several clients who struggled with sex addiction and yet I had little to no resources to offer them. At one point, I even had a psychiatrist coming to me, a student focusing in sex therapy, for feedback on their clients. After talking to the receptionist at adult mental health about my area of focus, she informed me that they frequently receive phone calls from individuals who are seeking treatment for sex addiction as well as other sexual disorders and yet she has no local resources to offer them. Based on this need and the lack of local resources, it seems that implementing a therapeutic group to help treat sex addiction locally would be a great asset to our community. The primary goal of this manual is to offer those interested in facilitating a sex addiction group the necessary information and guidance to do this type of work. Clarification of Terms There a number of terms one should become familiar with when facilitating this particular group on sex addiction. The term sexuality pertains to the idea of having sex, being sexual, or physical relations between the sexes (Weeks, 2011). An addiction is described as the inability to consistently abstain from a behavior including difficulty in behavioral control, craving, and decreased recognition of significant issues with one's behaviors and interpersonal relations leading to dysfunction in one's daily activities (Smith, 2012). Sex addiction is viewed as a behavioral addiction where one engages in repetitive and increasingly risky sexual behaviors which can be nonparaphilic, paraphilic, or both (Woody, 2011). People who are described as having a sex addiction are often referred to as being 7 hypersexual. Hypersexuality is characterized as any sexually arousing fantasies, urges, or behaviors that are mostly aspects of normal sexual arousal and activity but which increase in intensity or frequency (occurring for more than six months) and which significantly interfere with the capacity to reciprocate affectionate activity (Kafka & Hennen, 1999; Krueger, 2010). Also under the sex addiction umbrella, fall paraphilic disorders and paraphilia-related disorders. Paraphilic disorders are sexual disorders characterized by constant, repetitive, socially deviant sexual arousal that has adverse repercussions (Kafka, 2001). To be diagnosed with a paraphilic disorder, the DSM-V requires that individuals with these interests feel personal distress about society' s reaction to their interests. The individual must also have a sexual desire or behavior that involves another person' s psychological distress, injury, or death or a desire for sexual behaviors involving unwilling persons or persons unable to give consent (Paraphilic disorder fact sheet, 2013). An example of a paraphilic disorder is pedophilia which would be considered socially deviant. A few other paraphilic disorders include: voyeurism, exhibitionism, and sexual sadism or masochism. The group I am proposing will focus significantly more on paraphilia-related disorders than paraphilic disorders. Paraphilia-related disorders are also known as non-paraphilic disorders. Paraphilia- related disorders or non paraphilic disorders are similar to paraphilia disorders with the only major distinction being that paraphilia-related disorders are not socially deviant (Kafka, 2001). They are often described as consistent, intense sexually arousing fantasies, urges, or activities that mainly involve normative aspects of sexuality but cause distress or significant psychosocial impairment (Leiblum, 2007). Compulsive masturbation, pornography 8 dependence, and protracted promiscuity are all examples of paraphilia-related disorders. It is important to reiterate that, like other addictions, it is when these behaviors cause distress in one's life that they are considered problematic enough to seek help. Personal Location I have spent most of my academic experience researching sexual behavior and I am currently working towards becoming a sex therapist. My academic endeavors in this area include four years of research in sexual deviance, two years of research in sex addiction, and a certification in sex therapy from the University of Guelph. I have worked in numerous locations around British Columbia and have found there are limited resources for people with sexual issues or disorders, especially in the North. Although there are support groups such as Sex Addicts Anonymous in British Columbia, there are no other types of groups offered specifically addressing sex addiction. In searching for statistics on sex addiction in Canada, I found very little. However, one article stated that, in North America, sex addiction and compulsivity affects approximately three to five percent of the population (Parks, 2008). This article also suggested that the statistics are probably higher as this study was based only on those who sought treatment for sex addiction or sex compulsion. My interest in sex addiction transpired while completing my practicum in the North. I realized that therapists, most likely due to lack of experience and training, often felt at a loss when they were faced with a file that indicated any form of sexual concern. On occasion, a therapist with a special interest in this area would take a case, but typically, clinicians shied away from this work. Furthermore, conversations with colleagues at my practicum site confirmed my observation regarding the need for resources to address sex addiction in the North. 9 The group I plan to implement is different than the usuall2-step groups such as the Sex Addicts Anonymous support group because it is a psychoeducational group focused on providing clients with tools to help them manage their addiction. I chose to borrow principles from cognitive behavioral therapy (CBT) because studies have shown it is successful in treating those with compulsive behavior. Cognitive behavioral therapy is a beneficial treatment method for addiction because it encourages the development of more positive thought patterns, enhances self-esteem, and is cost-effective (The Ranch, 2013). Many of the techniques and activities I use in the group have empirical support showing change in sexual thoughts, feelings, and behaviors (Sbraga & O'Donohue, 2003). It is expected that all clients who attend the group will view sexual addiction as a problematic issue in their life and will be interested in changing that aspect of their life. In addition to group work, one of the guiding principles of the manual is to strongly encourage participants to attend individual therapy, when available and feasible. I believe that by attending both individual and group therapy clients will have a lower risk of relapse, more support, and more positive outcomes. Summary of Chapter One Anecdotal evidence suggests that many people in the North have a sex addiction, however, there are limited resources available. While there are few stats on sex addiction in Canada, sex addiction falls under the substance use umbrella in regards to treatment costs. In Canada, approximately 4.4% of Canadians have a substance use disorder (Statistics Canada, 20 12). According to the Canadian Center of Substance Abuse, a total cost of 40 billion dollars is attributed to addictions in Canada alone (Join Together, 2006). It is unfortunate that even with all that money being spent; the North still has few resources available for treating sex addiction. It is my hope that the psychoeducational group I have developed will prove to 10 be both successful and effective. It is probable that throughout their careers, most therapists will come across clients who have some sort of sexual concern. Therefore, being able to access a manual to inform and educate mental health workers will be helpful to those facilitating a sex addiction group, while providing those with a sex addiction with an effective form of treatment without having to leave the North. Chapter One has provided the rationale for my project. Chapter Two will review the research and other literature on sex addiction which has been described as an up and coming area of mental health. Finally, Chapter Three will describe the group manual, ethical considerations, and content. 11 Chapter Two Literature Review Chapter Two provides a detailed review of the literature on sex addiction which has aided in the development of this group. The chapter begins by exploring the history of sex addiction and the controversy around diagnosing it within the DSM-V. This will be followed by a discussion of CBT as a treatment option, the advantages and challenges of group therapy, and the sub-categories of sex addiction. Lastly, I will highlight the therapist's role in this work. Background/History Sex addiction is a fairly recent concept which still has not made its mark in the DSMV due to concerns that there was not enough scientific research to back up the idea that sex can be an addiction (Weiss, 2012). Before it had a better suited label, being hypersexual was considered by many as either a sin or a disease (Garcia & Thibaut, 2010). Historically, hypersexuality has been recognized since the late 19th century when it was labeled as satyriasis and moral insanity (Levine, 2010). Beginning in the 20th century, and up until recently, being hypersexual was labeled as Don Juanism for men and as Nymphomania in women (Leiblum, 2007). Later in the 20th century hypersexuality carried with it a variety of labels such as compulsive sexual behavior, hypersexual disorder, or simply out of control sexual behavior (Kaplan & Krueger, 2010). Until recently, the term addiction was only used to describe chemical addictions and the idea of becoming addicted to something you do, such as sex, was not possible (Hall, 20 13). Then, in the 1960s and 1970s forms of sexual behavior and exploration became acceptable (Reay, Attwood, & Gooder, 2012). The primary factors in this making were an addiction discourse to sexual matters; a combination of conservative 12 Christian and radical feminist social purity; and the initial impact of AIDS in the 1980s that so dramatically intensified such sexual apprehensions (Reay, Attwood, & Gooder, 2012). Finally, in the 1980s, the term sex addiction began appearing in literature. Its success as a concept lay with its medicalization, both as a self-help movement in terms of self-diagnosis, and as a rapidly growing industry of therapists available to deal with the disease (Reay, Attwood, & Gooder, 2012). In the 1990s the media began to play a part in this new term we call sex addiction. Television, the tabloids, and the case histories of claimed celebrity victims all helped to popularize this newly invented term (Reay, Attwood, & Gooder, 2012). Early on however, there was controversy about the label of sex addiction because some believed that it pathologized and stigmatized normative sexual behavior such as masturbation and the use of pornography (Woody, 2011). At this point in time, hypersexual disorder has been proposed as a new DSM-V classification for the Sexual and Gender Identity Disorders category (Woody, 2011). Unfortunately, this disorder is intended to recognize only normal sexual activities or fantasies that have become problematic, caused distress in an individual, and interrupted their pattern of functioning. As mentioned earlier, according to the DSM-V sex is not yet viewed as a substance or behavior one can develop an addiction to. The first conceptualization of excessive non paraphilic or paraphilia-related sexual behavior as an addiction was proposed by Orford, who defined it as a "maladaptive pattern of use and impaired control over a behavior with associated adverse consequences" (as cited in Garcia & Thibaut, 201 0). Of course, others have developed the sexual addiction concept but there is still a considerable amount of controversy around how it should be classified. In the DSM-IV there was a lack of empirical research and consensus that validated sexual behavior as an addiction so instead of terming it "non paraphilic sexual addiction" the term "sexual 13 disorder not otherwise specified" was reformulated (Garcia & Thibaut, 2010). The term sexual disorder not otherwise specified is defined as distress about a pattern of repeated sexual relationships involving a succession of lovers who are experienced by the individual only as things to be used (Garcia & Thibaut, 2010). It is crucial to mention, however, that there have been other concepts proposed based on models of obsessive compulsive disorder (OCD), which include impulse-control disorder, " out of control" excessive sexual behavior, and addictive disorder. The obsessive compulsive concept was first proposed by Coleman, Raymond, & McBean who stated that there was a link between the phenomenology of OCD and excessive non paraphilic sexual behavior. They first proposed the term "compulsive sexual behavior" which can be described as recurrent and intense normal or paraphilic sexually arousing fantasies, sexual urges, and behaviors that cause a significant amount of distress in social, occupational, or other important areas of functioning (Garcia & Thibaut, 2010). Like OCD, these sexual compulsions, though initially resisted, are acted out to decrease anxiety and often are followed by feelings of distress. The comorbidity rate between non paraphilic sexual behavior and OCD is generally 15%. There are some implications to consider with this hypothesis. For example, in contrast to obsessive thoughts, repetitive sexual thoughts and fantasies, which can be triggers for excessive sexual behaviour, may be viewed as exhilarating and positive rather than ego dystonic. Ego dystonic can be defined as pertaining to aspects of one's behavior or attitudes viewed as inconsistent with one's fundamental beliefs and personality (Ego dystonic, n .d.). Also, contrary to excessive non paraphilic sexual behavior, clients with OCD don ' t often engage in a behavior which genuinely reflects their 14 obsessional ideas (Garcia & Thibaut, 2010). It is suggested that more research needs to be conducted to support this theory further. A second concept proposed was that of impulse control disorder which can be defmed as the failure to resist impulse, temptation, or drive to engage in an act or behavior that is harmful to oneself or others. The idea behind this model is that clients with excessive non paraphilic sexual behavior may fail to resist a sexual activity due to impulse. This disorder is characterized by an increased sense of tension or arousal prior to the behavior, a sense of gratification or relief when the behavior is acted out, and feelings of guilt after the act is completed. One research article states that the comorbidity of impulse disorder and non paraphilic sexual behavior is about 4.9% (Garcia & Thibaut, 2010). The next concept, called the "dual control model" of sexual arousal, was put forward by Bancroft and Janssen (as cited in Garcia & Thibaut, 2010). The concept suggests that sexual arousal depends on a balance between sexual excitation and inhibition of sexual response. For the sexual behavior to be out of control, an increase of sexual interest should occur during periods of negative mood states and low levels of inhibition of sexual response in the individual. Bancroft and Janssen hoped to develop a better understanding of individual differences in sexual response, function, and behavior. Ultimately, it is suggested that more research needs to be done to confirm that out of control sexual behavior may result from these various mechanisms. The last idea discussed is the addictive component of excessive non paraphilic behavior. This concept was developed by Orford (as cited in Garcia & Thibaut, 201 0) who made a parallel between this disorder and substance addiction. He suggested that both a sexual addiction and a chemical addiction include an escalation of sexual activity as the 15 disorder progresses, withdrawal symptoms such as anxiety, depression, guilt, and rumination related to a decrease of sexual activities, as well as difficulties stopping or reducing the frequency of sexual activities. Also like individuals with chemical addictions, sex addicts often spend a lot of time seeking out material or potential partners needed to act out their addiction which can lead to the reduction of activities they once enjoyed, impairment within relationships, and many other consequences. All of these features fit within the framework of the diagnostic criteria for an addictive disorder. Lastly, sexual addiction shares some of the core elements of addiction. These core elements include a craving state prior to engaging in the behavior, impaired control over behavioral engagement, and continued behavioral engagement despite adverse consequences. In addition, the comorbidity rate between excessive non paraphilic sexual behavior and other addictions is approximately 71% which is quite high (Garcia & Thibaut, 2010). As mentioned earlier, sexual addiction is a fairly new label pertaining to an issue that has been affecting individuals for many years. Although the notion of sex as an addiction is a new one, it is increasingly becoming more and more recognized and, therefore, more research is being conducted which has led to more treatment options becoming available (Garcia & Thibaut, 2010). Treatment Objectives and Options The model adapted for this project is Hall ' s acrostic UR-CURED model which describes six treatment objectives for sex addiction (Hall, 2013). These treatment objectives are: understand sex addiction, reduce shame, commit to recovery, understand and personalize the cycle of addiction, resolve underlying issues, establish relapse prevention strategies, and develop a healthy lifestyle. 16 Firstly, it is important that clients are educated in what exactly sex addiction is. Research supports the idea that, until the client is aware that sex addiction is a genuine health condition rather than a poor excuse for self-control, infidelity, or a heightened sex drive, they will be prevented from being able to move on to the next stage of treatment (Hall, 2013). Secondly, it will be necessary to address feelings of shame within the group. If a client is stuck feeling shamed, recovery will be unattainable and relapse is most often the result. Clients' shame often stems from prioritizing their sexual encounters over and above their commitments to their families, partners, friends, work, fmances, health, and personal goals. It is the therapist' s role to ensure they use empathy and compassion when discussing feelings of shame, and accept clients' stories without judgment. With shame removed, there is then the freedom to either decide that the behavior is not the issue, or, by refrarning shame as guilt, they may be more empowered to make changes. Reducing shame is one of the most challenging parts in treating sex addiction and is often an ongoing process (Hall, 2013). The next objective is the commitment to recover. Looking at Prochaska and Di Clemente ' s (1982) stages of change model as cited in Hall (2013), once the client understands sex addiction and has begun to reduce shame, most will have completed the precontemplation and contemplation stages of change and be entering the preparation and action phase. For someone to make the commitment to change, it is essential that they know what their recovery will look like. The focus should not just be on what the clients want to give up, but what they want to gain (Hall, 2013). When clients attend the group, they should already be at a point where they are willing to at least contemplate committing to therapy. Everyone ' s addiction is unique and it is important that they understand and are able to personalize the particular elements that make up their own unique sex addiction cycle. So, 17 the next objective focuses on understanding one' s addiction including identifying triggers, recognizing any cognitive distortions they may have and understanding what works for them in regards to relapse prevention (Hall, 2013). Another important objective in treatment is to resolve any underlying issues. Until the underlying functions of the addiction are recognized and addressed, the client will continue to act out on their addiction. This stage of therapy may be the longest, slowest, and most painful as the underlying issues are exposed. Relapse prevention strategies may be helpful to temporarily stop the client from acting out, but until the deeper unmet needs and issues are addressed, recovery will be much more difficult (Hall, 2013). Because this can be a long and emotional process, the client will be encouraged to address their issues both in an individual and a group setting. Also, group participants will not necessarily be encouraged to address their particular issues within the group but rather they will be encouraged to process and explore what addressing their deeper issues will look like for them. The next objective is to establish relapse prevention strategies. It is important for the therapist to keep in mind that some of the group members may come into group already discontinuing their behaviors, while others are in still in the process. Especially for those clients who have stopped, learning relapse prevention strategies will be a priority to keep them on the path of recovery. Because relapse prevention stems from CBT, the relapse prevention work used in group not only needs to acknowledge the emotional and environmental triggers but also the automatic thought patterns that can lead to relapse (Hall, 2013). These strategies will be discussed in the group during the relapse prevention session. The last objective is to develop a healthy life. The group is not just about learning to manage addiction but learning to manage life. For most people with a sex addiction, their 18 addiction has become a large part of their daily routine and, therefore, recovering means changing their lifestyle (Hall, 2013). Clients should be encouraged to develop a positive outlook on their sexuality and a healthy way to express and enjoy their sex life. The treatment options that will be implemented within the group will come from the CBT model, Prochaska and DiClemente's stages of change model and Hall's (2013) cycle of sex addiction model. The majority of techniques and theories will stem from CBT; however, I plan on using some of the theoretical influences from the stages of change model throughout the group. In regards to treating excessive sexual behaviors, CBT has been the most recommended psychological treatment. CBT is the first form of therapy that has compiled a vast amount of scientific evidence supporting its effectiveness in helping some people change the way they operate (Sbraga & O'Donohue, 2003). In regards to sexual behaviors, research has shown that CBT treatments have helped some people to control themselves sexually (Sbraga & O' Donohue, 2003). Another research study suggested that CBT typically focuses on reducing the denial and cognitive distortions that many individuals use to justify their sexual behaviors. This same study also stated that CBT techniques are helpful in identifying and decreasing deviant sexual arousal and behavior (Walker, 2005). Cognitive behavioral therapy consists of a combination of cognitive and behavioral principles and methods that are often practiced in a short-term treatment approach (Corey, 2009). It is suggested that CBT helps decrease excessive sexual activity, improves self-esteem, and may also help decrease the high levels of anxiety that often co-exists with sex addiction (Garcia & Thibaut, 201 0). In clinical studies, CBT has been shown to be as effective as drug therapy in regards to controlling some sexual desires and actions, without the occasional nasty side effects that 19 drug treatments can have (Grossman, Martis, & Fichtner, 1999). Some behavioral programs also encourage abstinence from any sexual behavior especially during the first phase of treatment. Most programs suggest individuals be abstinent for at least 60-90 days (Garcia & Thibaut, 2010). There may be clients in the sex addiction group who may choose this path, in which case the facilitators are urged to be supportive. There is a lot of shame and guilt that comes from having a sexual addiction. Another suggestion the CBT model has is to decrease shame and to resolve any issues of trauma that are thought to underlie sexual addiction. There are shame reduction techniques used in CBT to help participants in making a conceptual separation between disease-type thinking and behavior, and one's core self(Klontz, Garos, & Klontz, 2005). Some ofthese techniques will be addressed and used in the sex addiction group. They focus on self-esteem and often require clients to be honest with themselves while recognizing that behaviors can be changed and do not necessarily defme them as people. Relapse prevention will be one of the techniques taught in the group. This approach is a cognitive behavioral approach originally developed to treat drug and alcohol addiction. The goal of relapse prevention is to teach clients, who are attempting to change their behavior, how to anticipate and cope with a potential relapse in their addiction. Relapse prevention uses a variety of techniques to help the client prepare for and cope with relapse. Some of the strategies taught are skills training, cognitive interventions, and lifestyle change to help the client alter cognitive distortions or faulty thinking, and cope with overwhelming and high risk situations that could trigger a relapse (Kaplan & Kreuger, 2010). It is only recently that relapse prevention been adapted to treat sexual addiction. However, relapse prevention is one of the most critical elements involved in maintaining one's sexual behavior goal whether 20 it is abstinence or harm reduction (Hayden, 2012). Working an individualized relapse prevention (RP) program is not part of treatment per se, but maintaining a RP program is probably the most critical element involved in staying sexually abstinent. Studies of modalities for sex offenders suggest that for issues of self-control of sexual behavior, CBT is very effective (Kaplan & Kreuger, 2010). It is important to understand that not everyone participating in the group has grasped onto the idea that they have a sex addiction. A tool that can be helpful for considering the possibility of the client having a sex addiction is the stages of change model. Prochaska and DiClemente's (1982) stages of change model consists of up to six stages which include precontemplation, contemplation, preparation, action, maintenance, and relapse. If the client is already in the maintenance or relapse stage, assessment of the client's progress will most likely be completed. It will be expected that during the initial assessment with the client, the therapist will be able to assess which stage the client may be in. This particular group will most likely only take clients who are at least at the contemplative stage of change to ensure clients have similar goals for group therapy. The stages of change model suggests that, for most people, a change in behavior will occur gradually. This model is designed to be appropriately tailored to each client to increase chances of success. What works for one client may not work for another and, therefore, it is important to adapt to the specific needs of each client. It also suggests that relapses are almost inevitable and become part of the process of working toward a life-long change. Because relapse is a common occurrence in any addiction, therapists are encouraged to provide a supportive approach to their client in need. For example, therapists can explain to clients that, through their relapse, they may have learned something new about themselves and about the process of changing their behavior (Zimmerman, Olsen, & Bosworth, 2000). In 21 this model, therapists act as an encouraging force - always meeting the client where they are at and shifting the focus from failure to encouragement. As mentioned earlier, part of treatment requires clients to understand the cycle of sex addiction. Hall ' s (20 13) model of the cycle of addiction is an ideal model for facilitators to follow because it discusses each stage in depth and recognizes that each stage will look different for each client. This model consists of six phases: dormant phase, trigger phase, preparation phase, acting out phase, regret phase, and reconstitution phase. The initial phase is the dormant phase. In this phase of the addiction cycle, the addiction may seem to be temporarily in remission and one' s life appears to have gone back to ' normal ' . However, ifthe person with the sex addiction has needs that are unmet, their core beliefs remain unchallenged, or any trauma or attachment issues are left unresolved, then the addictive behaviors are much more likely to be easily triggered (Hall, 2013). The trigger phase is likely to occur after the dormant phase. This is where recognizing triggers become crucial. Many people can recognize their own unique triggers, however many triggers are subtle and tend to quietly re-surface. It is at this stage of the cycle that learning to identify one ' s triggers is the primary step towards being able to manage or avoid those triggers and prevent a relapse (Hall, 2013 ). The trigger phase divides triggers into three types based on whether the addiction is opportunity-related, trauma-related, or attachmentrelated. For example, an opportunity-related trigger may be being at a night club among many attractive individuals, whereas a trauma-related trigger may be dealing with a stressful life event such as a divorce. These triggers prepare the person with the addiction to act out their addictive behaviors. 22 The next stage of the cycle is the preparation phase. It is during the preparation phase that negative thought patterns and distortions take over, and one ' s core beliefs and morals become obsolete. For instance, one may feel that they deserve to get an escort because their spouse is away and therefore they are not able to be sexually satisfied, or, they will only look at pornography for ten minutes because it' s better than doing it all night. One of the suggestions for managing this phase is to complete a behavior chain. A behavior chain allows the person with the sex addiction to write down a chain of events that lead up to the negative behavior (Hall, 2013). The purpose of this activity is for the individual to be able to recognize their patterns of behavior in hopes that they will be able to stop the behavior before it starts. If patterns of negative behavior are not recognized and therefore not stopped, then one will likely act out their behavior; this part of the cycle is called the acting out phase. It is during this phase that Hall (2013) suggests doing an activity where individuals list what is gained from acting out and the positive feelings that accompany the behavior. The purpose of this activity is to identify these feelings so that the individual can understand which deeper needs are being met by acting out, then find healthier alternatives to satisfy these needs. The next phase of the cycle is the regret phase. Both this phase and the reconstitution phase allow the individual the opportunity to truly see what their addiction has cost them in regards to relationships, money, etc .. Although this stage often brings up feelings of guilt and shame, it can also be an opportunity for the person with the addiction to process their thoughts and feelings regarding their addiction (Hall, 2013). This can allow for personal growth which is positive step towards recovery. 23 The last stage is the reconstitution phase. This stage, like the regret phase, initially focuses on acknowledging the feelings and thoughts associated with the addiction. Then the focus is redirected to making amends, alleviating guilt, and striving not to engage in the negative behaviors (Hall, 2013). After one can identify the costs of their behaviors, they are more inclined to change these behaviors and start the recovery process. The cycle of sex addiction designed by Hall (20 13) is a great guideline to educate individuals and help them comprehend the cycle of addiction. As mentioned previously, the cycle will look different for everyone and therefore, it is encouraged that each individual personalize it in the way that best fits their addiction cycle. The Benefits and Challenges of Group Therapy It is highly recommended that clients participate in both individual and group therapy for their sex addiction. Research has suggested that group therapy is a beneficial and costeffective approach. Some argue that group therapy is more cost-effective than individual therapy and just as effective (Corey, Corey & Corey, 2010). The benefit of individual therapy, however, is for the individual to receive direct support for their unique concerns. Individual therapy allows the therapist to work on isolated issues that cater to only one client (Cuizon, 2013). This could be an asset to the individuals attending the group because it allows them extra support and more time to reflect on what they are experiencing in the group. Because the group doesn ' t allow for much time for individuals to discuss their own experiences in detail, individual therapy may provide the extra support that allows them to reflect on their own personal growth. There are several benefits of using a group model to address this issue. Furthermore, I have chosen to implement a group because though there are few resources for individual therapy regarding sex addiction, there are even fewer resources 24 for group therapy addressing the issue. I will discuss the advantages of group therapy for sex addiction as well as any challenges. The type of group I will be implementing is a psychoeducational group. Unlike the well-known SAA, which is more of a support group, this group focuses on interpersonal process and problem-solving strategies that emphasize conscious thoughts, feelings, and behavior. Support is still a part of this type of group but it uses support and interactive feedback from others in a more here-and-now time frame. SAA was developed in 1977 by a group of men who wanted more anonymity when receiving support in a group setting (Wikipedia, 2013). One difference between psychoeducational groups and SAA groups is the spiritual component. One of the expectations of SAA is that the individual will confess their sins to God and admit that they are powerless in healing from their addiction on their own (National12 step Meetings, 2012). Though psychoeducational groups encourage using support from others to help heal, it is not common to strongly encourage the religious aspect in this type of group. There is also no specific form of treatment such as CBT used in SAA groups. They rely mostly on faith and courage to change their way of thinking and behaving (Sex Addicts Anonymous, 2013). Compared to process groups, psychoeducational groups focus more on safety and structure in regards to disclosures and triggers. In process groups, clients are often encouraged to openly discuss their thoughts and feeling about the group dynamics, conflict, and their personal experiences. In psychoeducational groups, although sharing is encouraged, it is structured and closely monitored by facilitators to ensure clients stay on topic and discussions remain relevant and purposeful to the group. Process groups stress interactive group process for clients who may be experiencing transitional life issues, have a risk of 25 developing interpersonal or personal concerns, or are just interested in obtaining or enhancing personal qualities. The group' s focus is most often determined by the group members but often places emphasis on developing inner resources of personal strength and dealing with the barriers that prevent progress and success constructively. Psychoeducational groups, on the other hand, have three main goals: to educate clients on how to develop a more positive attitude and stronger skills, to use the group process to facilitate a change in behavior, and to help clients to transfer the skills they learn in group to everyday life. Although the clients often direct the group, the therapist still has a major role in psychoeducational groups. The therapist is there to educate the clients, facilitate clients ' interactions and the work they are doing, provide information to help clients see alternatives to their modes of actions and behaviors, and to encourage clients to turn their insights and ideas into concrete action plans (Corey & Corey, 2010). In psychoeducational groups, clients learn more about themselves and their goals for success through selfreflection and other clients' experiences which are definite advantages of a group. Some of the challenges to this particular group are issues around confidentiality, accessibility, group dynamics, goals of treatment, and content. It is important to note that there are concerns with facilitating any type of group; the following section covers how these concerns will be addressed to ensure that the groups ' benefits outweigh the potential harms. Maintaining confidentiality, especially among the group ' s members, is a common challenge within most groups (Corey, Corey & Corey, 2010). Clients will be asked to sign a consent form regarding confidentiality but there is still no guarantee that it will be respected outside of group. Self-disclosure will be encouraged; however, guidelines will be put in place for the clients at the initial group meeting. These guidelines will highlight what is expected of 26 group members focusing on the necessary ideas to keep the group therapeutic and safe for those involved. Although self-disclosure and feedback is encouraged, sharing in a way that is helpful to the participants will be stressed. Keeping in mind that confidentiality cannot be guaranteed, participants will be encouraged to take care of themselves in the way they see fit. Accessibility to attend the group may be a barrier for some group members. Depending on the time, day, and location, some of the clients may find it difficult to attend all of the groups. It is imperative that all group members attend all or at least most group sessions as missing sessions may be detrimental to their success and to the safety of the group. The therapists must also take into account the location of the group in regards to safety and confidentiality. For example, holding a sex addiction group at a church may not be particularly welcomed, but having it a community hall or university may provide a more comfortable environment. Running a group in the evening is often a better idea than the day to make up for those who work in the day. This may be based on the needs of the group members. The more flexible the therapist is on day and time of group, the better the chance that attrition will decrease. Like any type of group there will be various personality types attending; because of this, there is a possibility of confrontation. The chance of one person being singled out as the scapegoat is also a possibility and needs to be addressed by the facilitators immediately. It is important for the facilitators to be clear on group expectations and norms at the first session and to implement these guidelines throughout the eight sessions. Animosity between group members can set a hostile atmosphere for all group members and may negatively impact clients' individual progress (Corey, Corey & Corey, 2010). Facilitators should address any confrontation between group members, and aim to explore the issue more deeply so it can be 27 resolved. Another solution is for facilitators to model positive behaviors to the group in hopes that this will demonstrate what is expected of the group members themselves. Another challenge is the potential that group members may have different goals than one another and thus, the group may not succeed at the same rate as a group with members who all have similar goals. While it is likely that clients' goals will differ, it is the degree of difference that has the potential to make or break a group. For example, if half the group members ' goals are to be abstinent and the other half are aiming for harm reduction, this could potentially raise some conflict. It will be expected that group members may experience various levels of success within the group; it just should not be highly influenced by their peers ' personal goals. For example, one member may find themselves distracted from obtaining their goal of abstinence because another group member is glamorizing sex with his partner- which is his idea of harm reduction. This is where having the group expectations accessible for all group members to view at every session will be important and necessary. It should be used as a reminder of what will be expected and what won ' t be tolerated within the group setting. There will be a screening tool used before the group commences that will help distinguish each client's goals in attending the group. The purpose of the screening tool is to see where the client is at in regards to progress, goals, and stage of change. This will help the therapist identify clients ' goals and screen out those who are not ready for group. The last concern is around content. Being a group for sex addictions, the content will obviously require the discussion of sexuality. Just like groups for other addictions such as drugs and alcohol, precautions will be taken to minimize glamorization of sex among participants. It will be addressed in the guidelines during the first session that discussing sex 28 in an inappropriate way that is not beneficial to the groups' recovery will not be tolerated. Again, facilitators are expected to enforce this guideline if needed. Sub-Categories of Sex Addiction It is a common misunderstanding that people who have a sex addiction are addicted strictly to sex, however this is not the case. Individuals who have a sex addiction are people who become dependent on any sexual behavior that eventually interferes with their ability to function (Hall, 2013). The actions themselves are not dangerous; it is the relationship to the specific action that is the issue. For instance, viewing pornography occasionally while masturbating is considered fairly normal, however if one needs to view pornography on a regular basis to reach orgasm and is failing to attend school or work due to their pornography use, this may be viewed as a potential problem. Ultimately, it is not the action itself one should be concerned about but how it affects one ' s life. Comorbidity exists when a person has more than one diagnosis. An example of comorbidity is a person with an alcohol addiction who also has depression and anxiety. There is strong evidence that comorbidity is common among sex addiction suffers (Carnes et al. as cited in Hall, 2013). In a survey completed by Hall (2013), she found that 36.3% of those with a sex addiction also had another addiction or compulsive behavior. It is important for facilitators to understand that, when another addiction or compulsion is present, the addictions may influence one another so they should be worked through simultaneously. Failure to do this could result in relapse or in other addictions being escalated. Sexual addiction can be classified into paraphilic and paraphilia related sexual addictions (also known as non-paraphilic disorders) . Paraphilic sexual addictions most often include fetishism, frotteurism, exhibitionism, pedophilia, sexual masochism, sexual sadism, 29 transvestic fetishism, and voyeurism and become problematic if they are compulsive or excessive to the point of interfering with the individual ' s daily functioning (Hook, Hook & Hines, 2008). It is important to note that, for this particular sex addiction group, we will focus primarily on paraphilia related sexual addictions rather than paraphilic sexual addictions and, therefore, I will not go into detail on the latter. There are several paraphilia-related disorders that could label someone as a potential risk to develop a sex addiction. The most common sub-categories are compulsive masturbation, protracted promiscuity, pornography dependence, telephone sex dependence, cyber-sex dependence, severe sexual desire incompatibility, and paraphilia-related disorder NOS . A brief explanation, definitions, and examples of each of the paraphilia-related disorders follows. Compulsive masturbation is when one masturbates frequently and is used as the person ' s primary outlet even when in an intimate relationship (Kafka, 2001). For example, a woman in a committed relationship would prefer to masturbate than to engage in sexual activity with her partner and this interferes with their relationship and causes marital distress which ultimately leads to divorce. The term protracted promiscuity refers to someone who demonstrates a frequent and repetitive pattern of sexual encounters that may include cruising for prostitutes, multiple affairs or one night stands, or serial polygamy (Kafka, 2001). An example of protracted promiscuity may be a young single man who spends the majority of his time and money on prostitutes which causes him to lose his job and home. Pornography dependence is defmed as a constant, repetitive pattern of dependence on pornographic materials such as magazines, videos, internet pornography, etc. (Kafka, 2001 ). 30 A person who misses work frequently to stay home and view internet pornography which eventually costs them their job is an example of pornography dependence. Telephone sex dependence is described as a persistent, repetitive, and time consuming dependence on telephone sex that, for example, could lead to phone blocks or the person going into significant debt due to the addiction (Kafka, 2001). Cyber-sex dependence is defmed as repetitive, time consuming use of the internet in association to chat rooms that often lead to the enactment or planned enactment of a sexual behavior (Kafka, 2001). For example, a young woman could be putting herself at great risk by talking to unknown men in chat rooms, then meeting up with them for sex. Severe sexual desire incompatibility is when, in an ongoing romantic relationship, the excessive sexual desire of one partner causes sexual demands on the other partner (who does not suffer from a sexual dysfunction) that interfere with the capacity to maintain that relationship (Kafka, 2001 ). An example of this would be if one partner forces the other partner to engage in sexual activities that are out of their comfort level to meet the needs of the enforcing partner even though it causes them distress. Lastly, a paraphilia-related disorder NOS includes particular examples of sex workers, attending strip clubs, sexual harassment, professional boundary violations, time consuming and distracting sexual fantasizing experienced as egodystonic but not always accompanied by explicit genitaVsexual behavior, (Kafka, 2001). As mentioned before, these behaviors are only seen as problematic or addictive when the act interferes with normal thought processes and daily functioning. Persons who were diagnosed with paraphilia-related disorder NOS often reported distress, a persistent urge to engage in the behavior, and that 31 their partners felt sexually exploited, demeaned, or angry due to their behaviors (Kafka, 2001). Paraphilia related disorders are seen as culturally adapted expressions of sexual behavior. They are associated with personal distress or a significant impairment in one ' s social role functioning. The major difference between paraphilic disorders and paraphilia related disorders is that paraphilic disorders are associated with being socially deviant whereas paraphilia related disorders usually consist of excessive or disinhibited expressions of culturally sanctioned heterosexual or homosexual arousal (Kafka, 2001 ). The specific paraphilia related disorders discussed in this section are what the therapist facilitating the sex addiction group will most likely encounter. Therapist's Role Research has proven that the strongest indicator of success in any type of therapy is the therapeutic relationship itself. Approximately 30% of a client's desire to change is influenced by the quality of the therapeutic relationship. Therefore, a positive working relationship between the clients and the facilitators is the best determinant of the counselling outcome. Some factors that influence the client-therapist relationship are having a safe environment to disclose, being genuinely understood, experiencing a meeting of minds, feeling encouraged by the therapist, and gaining a sense of coaching and teaching from the facilitators (Powell, 2006). If the client feels the therapist provides these factors, the client tends to feel more connected to both the therapist and the group. Other factors that determine a client' s outcome are extra-therapeutic factors such as clients ' readiness for change, hope, and expectations, and techniques (Powell, 2006). Out of these factors, the therapists only directly influence the therapeutic relationship and can 32 provide techniques. Therefore, it is important that the therapists facilitating this group can build a strong rapport and offer effective techniques. Building a positive relationship with the clients in the group will be the first and probably the most valuable piece of the therapist's role for this particular group. This group is structured around the practice of CBT and, therefore, many of the theories from CBT will be incorporated into the therapist's role. In CBT, the therapist's role is an active and directive one where the therapists will act as teachers to encourage clients to learn more appropriate thoughts and behaviors. Although the group will encourage client participation and input, the facilitators are there to provide structure and guidance. The therapist will help clients to identify any irrational beliefs and help them discover new ways of thinking and, therefore, new ways of behaving. The sex addiction group is an integrative program that borrows from some of Ellis' work in CBT. Ellis proposes that one's emotions derive mainly from one's beliefs, perceptions, interpretations, and evaluations of real life situations (Corey, 2009). The group reflects this hypothesis in many of the activities and homework given to clients. In CBT, the therapist encourages clients to gain insight into their issues, develop effective skills to change their thoughts and behaviors, and apply what they learn in group to life outside of group. There appears to be some debate on how intense the client-therapist relationship should be when practising from a CBT lens. Most rational emotive behavioral therapists insist that therapists develop an unconditional, non-judgmental approach to clients; however, Ellis believed that too much warmth and compassion can actually prove to be counterproductive (Corey, 2009). I would advise the facilitator for this particular group to use their own discretion and do what feels comfortable for them. In saying that, I would also 33 recommend that both facilitators be on the same page as being incongruent may impact the therapeutic relationship with the clients as well as the group as a whole. The group and its members may be negatively impacted if facilitators have different goals for the group or do not trust each other' s directions for the group (Corey et al., 201 0). Summary of Chapter Two This chapter described the relevant research on group therapy for sex addiction. It described important topics for group leaders such as history, treatment objectives and options, and the benefits of group therapy. Chapter Three will describe the group format, ethical considerations, and content areas. 34 Chapter Three Target Audience The group is designed to target individuals who feel that their sexual behaviors are having a negative impact on their daily functioning. Individuals can be self-referred, or referred by other sources such family, physician, psychiatrist etc. The group is designed for adults, both males and females, however, male and female groups will be run separately. The group will ideally be facilitated by two facilitators at least one of whom will be knowledgeable in the area of sex addiction. It will be highly recommended that participants have either been to or are currently seeing an individual therapist regarding their addiction. Group Goals The main objectives of the group are to manage one' s sex addiction or compulsion and to develop and maintain a healthy sexual lifestyle. The group supports both abstinence and harm reduction; however the common goal is to develop healthy sexual well-being. The group will discuss the definition of sex addiction, the etiology, and some treatment options. Clients will learn about the cycle of addiction, how cognitive processes impact their addiction, and how sex addiction impacts their relationships and their life. Lastly, they will learn about relapse prevention and understand what it means to lead a healthy sexual lifestyle. Cognitive Behavioral Therapy Cognitive behavioral therapy can be defmed as a therapy that includes both cognitive and behavioral ideas and methods and can be delivered in a short-term approach. Cognitive behavioral therapy is a well-respected form of therapy as it has generated more empirical research than any other form of psychotherapy. In addition, it has numerous positive 35 attributes that make it a successful and efficient type of therapy. For example, CBT emphasizes the importance of the client-therapist relationship, it suggests that distress is largely due to disruption in cognitive processes, its goal is to change these cognitions into more desirable thoughts which will lead to positive changes in affect and behavior, and it is a brief therapy that focuses on specific and structured issues (Corey, 2009). One of the techniques widely used when treating sex addiction is changing thought processes which stem from CBT. The cognitive behavioral approach suggests that reorganization of one's self-talk will result in the reorganization of one's behavior (Corey, 2009). Therefore, if changing cognitive processes to change ones behavior is one of the goals for treating those with sex addiction, it makes sense to use CBT as the main type of therapy within this particular group. Group Counselling Using a group format to treat people who have a sex addiction has been developed for numerous reasons. First off, individual counseling for sex addiction is much more available than group counseling in this area; to the best of my knowledge, this will be the only group of its kind offered in Northern British Columbia. Secondly, the type of group being implemented is a psychoeducational group. Psychoeducational groups are designed to educate group members and provide skills and support to help group members resolve a particular issue, in this case sexual compulsions. The goals of psychoeducational groups are to educate group members on how to develop healthier interpersonal skills and a more positive attitude, to use the group process to facilitate a change in behavior, and to encourage members to develop healthy coping skills within the group and incorporate them into their everyday lives (Corey et al., 2010). 36 Although in this type of group facilitators will provide some degree of support, their main objective is to teach new skills and also for members to learn from each other as they face a common challenge. Another reason for implementing a group is the amount of support members will receive from other group members who have similar struggles. Groups can provide members with a feeling of safety and support from other members in regards to their addictions (Powell, 2006). Groups also allow for members to observe other members ' healthy coping strategies and to gain confidence from demonstrating to the group their own accomplishments with their addiction. Another advantage to groups is having the extra support that two facilitators can provide. In addition to providing extra support to the group members, having two facilitators means there is less chance of the group being cancelled due to vacations or illness. Also, because no two people are alike, each facilitator will have a vast amount of unique knowledge on the subject and this will ultimately add depth to the process. Furthermore, when there are two group leaders, one can be available to address a member' s needs outside of the group, if a situation arises, without disrupting the group because the other leader will still be able to facilitate the material. Lastly, facilitators are able to support each other when challenges such as countertransference arise. The groups will consist of members of the same sex. At this point I have a designed the group for all men, and will eventually work on implementing a group dedicated to women with sex addiction. There are a number of reasons for designing the group this way. First, research shows that men develop trust with other men when there is activity sharing (Powell, 2006). Therefore, in a group where men have commonalities such as similar 37 struggles, they are more likely to bond and to develop trust amongst each other which will encourage self-disclosure. Self-disclosure is an important part of therapy and will most often positively affect the members' success in recovery. Having an all-male group also instills a sense of hope in the members through listening to the other men's stories (Powell, 2006). Seeing that others have coped in healthy ways or have been successful with their addiction will often empower the other members as they relate to and learn from each other. Ethical Considerations As in any type of group there are always potential risks involved however, potential risks may be minimized beginning with group screening and continuing with the use of group leadership skills throughout the life of the group. During screening, the idea will be introduced that a variety of topics will be discussed since people are at all different levels of the spectrum in terms of the impact this addiction has on their lives. Basic understanding and expectations for the group will also be shared at that time. It is the facilitators ' responsibility to guide the group and redirect it if necessary. Facilitators will facilitate group norms and will keep the group on task in line with the purpose of the group. Participants will be encouraged to be open and honest when participating in group discussions. There is a high possibility that clients will disclose personal and emotional experiences. These disclosures are meant to be seen as a sign of growth and should be helpful towards the clients ' success in the group. It is expected that facilitators will make themselves available to members if they feel triggered or are overwhelmed with group discussions or activities. There is also a list of resources such as contact numbers and community resources that is available for participants to access during the group. 38 As mentioned previously, group facilitators are expected to present and discuss a set of group norms to be followed throughout the duration of the group. Some of the norms include confidentiality, ways in which the time is used, and group expectations. The group norms are meant to encourage safety amongst participants so that they feel they are in a safe environment to learn new skills and meet others with similar goals. These norms should be put in a designated spot so that they can be viewed and discussed at any point during the eight weeks of group. Group Schedule and Topic List The group will take approximately eight sessions within eight weeks to complete. Prior to the first session, the facilitators will hold a screening interview for each participant. The group sessions will be once a week and the duration will be one and a half hours for each session. The hour and a half will include approximately 30 minutes of homework discussion and a discussion of the current week' s topic, 30 minutes in-class activity/discussion, and 15 minutes of review and discussion of the next homework assignment. This hour and a half will also include one 15 minute break. Some of the topics covered in group are goal planning, shame & guilt, the cycle of sex addiction, and relapse prevention. Session One: Exploring Sex Addiction Session One Objectives: • Introductions to the group and group members • Establish group expectations and norms • Defme sexual compulsion and addiction • Discuss commitment to recovery • Discuss the losses and repercussions of maintaining addiction 39 • Explore personal goals Session One Outline: Part I • Introduction • Check-in • Ice breaker • Overview of group norms • Self-evaluation part one Part II • Group discussion of session one (in booklet) Break • Group activity I • Group activity II Part III • Homework assignment • Closing/Questions • Check-out Materials Needed: • Session one booklet • Name tags • Pens • Ice breaker handouts • Self-Evaluation handout 40 • Group norms handout • Duo tangs/Binders for participants Session Two - Etiology, Treatment Options, and Goals for Recovery Session Two Objectives: • Discuss and review session one • Explore where sex addiction comes from • Discuss treatment options for sex addiction • Discuss participants' goals for recovery Session Outline: Part I • Check-in • Review of session one • Review of homework Part II • Group discussion of session two (in booklet) Break • Group activity I • Group activity II Part III • Homework assignment • Closing/Questions • Check-out 41 Materials Needed: • Booklet #2 • Pens Session Three - Shame, Guilt, and Cognitive Processes Session Three Objectives: • Discuss and review session two • Explore the emotions that arise with sex addiction • Discuss these emotions in a safe and non-judgmental environment • Understand how cognitive process impact addiction • Discuss cognitive distortions • Learn more helpful and healthy ways to process cognitively Part I • Check-in • Review of session two • Review of homework Part II • Group discussion of session three (in booklet) Break • Group activity I Part III • Homework assignment • Closing/Questions • Check-out 42 Materials Needed: • Booklet #3 • Pens • Poster board/White board • White board markers/ markers Session Four- Cycle of Addiction Session Four Objectives: • Discuss and review session three • Learn about the cycle of addiction • Understand the impact the cycle has on an individual with an addiction • Discuss the stages of change model • Learn about chain thoughts and behaviors Part I • Check-in • Review of session three • Review of homework Part II • Group discussion of session four (in booklet) Break • Group activity I Part III • Homework assignment • Closing/Questions 43 • Check-out Materials Needed: • Booklet #4 • Pens • Poster board/White board • White board markers/markers Session #5-Decision Making & Self Worth Session Five Objectives: • Discuss and review session four • Explore self-acceptance and self-worth • Learn about self-control • Discuss what self-control looks like for each participant • Discuss decision making and how decisions affect one's life • Talk about what role sex plays in one's life Part I • Check-in • Review of session four • Review of homework Part II • Group discussion of session five (in booklet) Break • Group activity I • Group activity II 44 Part III • Homework assignment • Closing/Questions • Check-out Materials Needed • Booklet #5 • Pens • Poster board/White board • White board markers/markers Session Six - Developing a Healthy Sexual Lifestyle Session Six Objectives: • Discuss and review session five • Explore the impact sex addiction has had on one's relationships • Discuss what it means to each participant to have and maintain a healthy sexual lifestyle • Discuss what it means to each participant to have and maintain healthy relationships • Learn the steps to develop and maintain a healthy sexual lifestyle • Learn the steps to develop and maintain healthy relationships Part I • Check-in • Review of session five • Review of homework 45 Part II • Group discussion of session six (in booklet) Break • Group activity I • Group activity II Part III • Homework assignment • Closing/Questions • Check-out Materials Needed: • Booklet #6 • Pens Session Seven - Relapse Prevention Session Seven Objectives: • Discuss and review session six • Learn about relapse prevention • Discuss triggers • Learn healthy ways to cope • Discuss each participants ideas on relapse prevention • Learn about options for when relapse does occur Session Outline: Part I 46 • Check-in • Review of session six • Review of homework Part II • Group discussion of session seven (in booklet) Break • Group activity I • Group activity II Part III • Closing/Questions • Check-out Materials Needed: • Booklet #7 • Pens • Poster board/White board • White board markers/markers Session Eight - Closing Session Eight Objectives: • Discuss and review session seven • Review what it means to lead a healthy sexual lifestyle • Discuss participants individual goals • Tie up any last minute material/wrap up • Complete the post-test/evaluation 47 Session Outline: Part! • Check-in • Review of session seven • Review of homework Part II • Group discussion of session eight (in booklet) Break • Group activity I • Group activity II Part III • Closing/Questions • Check-out Materials Needed: • Booklet #8 • Pens • Post-Test/Evaluation Summary of Chapter Three This chapter described the format of my group including the target audience, group goals, ethical considerations, and the intended schedule and topics. Finally, a detailed sample of each of the eight sessions of the group was outlined. 48 Chapter Four: The Facilitator's Manual Introduction This chapter will provide an outline of each session including objectives, materials needed, a detailed description, and a weekly booklet of activities. Each of the eight sessions will be divided into three parts. Part I will mostly cover check in and homework review. Part II will consist of a group discussion and group and/or individual activities. There will be a short 15 minute break at some point during the second part of each session. Lastly, Part III will consist of a discussion of the day's session and the homework assignment followed by closing questions. The outline is followed by a more detailed description of each activity. Screening Interview Overview: • It is highly recommended that a screening interview be conducted with individuals before the group. o The purpose of the screening interview is to meet with clients to ensure that they are suitable candidates for the group. o Some individuals may not be ready for group therapy or for this type of group for a variety of reasons. Conducting the screening interview may help distinguish which individuals are ideal for this particular group, and which ones may be better suited for other types of treatment. o It is important to discuss resources available with any individuals who you may feel are not suited for the group. If they are not ready for the group, they may still need other forms of support and treatment. 49 • The screening interview should take no longer than 30 minutes to complete with the individual. o An example of the screening interview is in Appendix A. o It is important to note that the screening interview form is to be used as a guideline and can be adapted if needed. o When conducting the interview, it should feel more like a conversation then an interview. o Even though the interview is an important tool, the facilitator should use this opportunity to begin building rapport with the participant. • Either one or both of the facilitators may conduct the interview o After the interview, facilitators should have a discussion on the eligibility of the individual interviewed. o If the facilitators feel the individual is an ideal candidate, they will contact the individual and inform them of any information regarding the group. o If the individual is not well-suited for the group at that time, facilitators still need to contact them to inform them of their decision. • At this point, the facilitator would offer any resources or referrals deemed appropriate for that individual. Session One: Exploring Sex Addiction Session Overview: • In session one, we will commence with introductions and a discussion of group expectations. The purpose of session one is to explore sex addiction, discuss commitment to recovery, and establish personal goals. 50 • Each participant will be given a booklet regarding the week's session at the beginning of group. o They have the option to keep their booklets in their binder/duo tangs so they can refer to them at any point throughout the group. Each booklet consists of: table of contents, a discussion on the week' s topic, the activities for the week, a homework assignment, and resources. The booklets are located at the end of each weekly section. For example, the session one booklet can be found on pages 62-71, following the session description. Session One Objectives: • Introductions to group and group members • Establish group expectations and norms • Defme sexual compulsion and addiction • Discuss commitment to recovery • Discuss the losses and repercussions of maintaining addiction • Explore personal goals Session One Outline: Part I • Introduction • Check-in • Ice breaker • Consent form • Overview of group norms 51 • Self-Evaluation Part 1 Part II • Group discussion of session one (in booklet) Break • Activity 1: My Commitment to Change • Activity 2: Loss Chart Part III • Homework: Dream List • Closing/Questions • Check-out Materials Needed: • Session one booklet • Name tags • Pens • Consent form • Self-Evaluation Part 1 handout • Group norms handout • Duo tangs/Binders for participants Session One Description: Part I Introduction 5 minutes • Facilitators hand out binders/duo tangs to each participant. • If desired, facilitators can ask participants to wear name tags for the first session. 52 • Facilitators and participants will begin by introducing themselves to one another and welcoming participants to the group. • Facilitators will briefly discuss the group's objective which is to manage sex addiction, learn coping strategies, and help participants learn the skills to develop and maintain a healthy sexual lifestyle. • Facilitators will explain some of the topics and content that will be discussed throughout the program. • o Briefly list the topics for each session. o Ask participants if they have any questions. Facilitators will summarize what each session will look like. For example: o We start with check-in to see where each participant is at • Discuss their mood using a Iikert scale • Discuss safety • Discuss goals from the week before • Discuss any highlights for the participant that week o Then we review the previous week's session and homework. o We will have a discussion regarding the week's topic. o We will have a 15 minute break. o We will do 1-2 activities depending on time. o We will discuss each of these activities as a group. o We will discuss this week's homework assignment. o Lastly we will do a check out to briefly discuss safety and goals. 53 • Again, participants will state their mood using the likert scale to compare how they are feeling now to how they were feeling earlier • Discuss any highlights from today's session • Discuss safety • Discuss goals Check-in • 5 minutes Facilitators will explain to participants what check-in is and the form from Appendix C should be handed out at this time. During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been an improvement in their mood or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Participants can discuss where they are at with their goals from the previous week. • This part will be omitted from the first session. o Lastly, participants can discuss something positive that has happened to them this week. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. 54 o Facilitators are expected to do check-in as well as it demonstrates equality among participants and facilitators. 5 minutes Ice breaker • Materials needed: Session one booklet • Choose one of the ice breakers from the booklet and follow the directions given. • o A Significant Year o Question Game o Birthday Game Allow 5-l 0 minutes to complete the ice breaker. Consent Forms • 5 minutes Materials needed: Consent form o Refer to Appendix C • Hand out the consent form and discuss it as a group. • Ask participants if they understand what the form entails. • Ask participants to sign the form if they agree and understand the terms of the consent form. • Facilitators will collect the forms after they are completed. Discussion of Group Norms • Materials needed: Group norms handout o • Refer to Appendix D Below are a few of the norms that will be addressed: 5 minutes 55 Confidentiality. • Convey to participants that everything discussed within the group is to remain confidential including participants' identity. • Explain to participants that any discussions held outside of group, even with fellow participants, compromises the confidentiality of other group members. o If participants have concerns regarding the group ask them to please either discuss it in group or with a facilitator. • Remind participants of the informed consent they filled out before group and its exceptions. Respect. • Discuss the importance of respecting each other's opinions and disclosures. Belittling or ridiculing fellow group members will not be allowed. • Discuss cross-talk. Cross-talk is when more than one person speaks at a time or there are more than one conversations going on at one time. It is important to give everyone in the group a chance to speak, but to also listen when others are speaking. • Remind the group that glamorization of sex or addiction is not permitted. It is one thing to discuss sex addiction; however, gloating about one ' s sexual experiences can have a negative impact on other group member's progress. • Remind the group that we are a group of adults and mature topics will be discussed; however, using language that is offensive or derogatory is not permitted. • Discuss the policy on food and drinks. Some facilitators may be okay with food and drinks and some may find it distracting. 56 Punctuality. • Discuss the importance of being on time for groups. Being late is distracting to other group members. It also means that you may miss out on important information. If possible, please inform the facilitators if you are expecting to be late. • Remind participants to please inform the facilitators as soon as possible if they know they will be missing classes so that missed materials can be assigned earlier or other arrangements can be made. • Explain to participants the importance of attending all classes. They should be told that if they miss more than two classes they may be asked to leave the group and to join at another time that is more convenient for them. Participant Rights. • Explain that every participant has the right to attend this group and to learn in the group. They also have the right to leave the group at any time. o We encourage participants to meet with a facilitator in regards to leaving the group to make future arrangements if needed. • State that some of the topics that will be discussed in the group are of mature content. This may cause some participants to feel uncomfortable. Participants are encouraged to discuss these discomforts with the group or privately with a facilitator, but also have the right not to participate in conversations if they feel uncomfortable. Express that clients ' safety, both physical and emotional, are not to be compromised. • Explain to participants that participation is strongly encouraged as it is a group setting. We also, however; respect each participant' s right to not engage in conversation. 57 • After the group norms are discussed, ask the participants if they would like to add any of their own norms. • Ask the group if they have any questions or concerns with the group norms. • If possible, hang up a poster somewhere in the room with all the group norms listed on it for every session. Self-Evaluation Part 1: • Materials Needed: Self-Evaluation Part 1 handout o • 5 minutes Refer to Appendix E Discuss with the group the purpose of the self-evaluation. The purpose is to measure the participant's progress. The self-evaluation is an important tool to see if participants demonstrate improvement or not from participating in the group. • Remind participants that this isn 't a test in regards to there being no right or wrong answers. • The self-evaluation forms will be collected by the facilitator and marked after session one comes to a close. They will be stored in a private area to protect client' s confidentiality. They will be pulled out and reviewed at the last session for both the facilitator and the participant to view. Part II Group Discussion of Session 1 Materials Needed: • Session one booklet • Pens 15 minutes 58 Discussion: Sex Addiction & Commitment to Recovery • Ask clients to refer to their session one booklet • Take the time to open the floor to discuss how the participants defme the terms: sex, addiction, and sex addiction. Allow the participants to express their versions of sex addiction. • Explore the definitions of sex addiction and apply the participant's answers to these definitions. • Discuss some of the consequences of sex addiction with the group. o What would their lives look like if they were at a good place with their addiction? • Discuss as a group what it means to commit to change. • Discuss as a group the pros and cons of making a commitment to change. o Is it worth it? 15 minutes Break Part II continued. Activity 1: My Commitment to Change 15 minutes Materials needed: • Session one booklet • Pen Activity 1 Overview • The purpose of this activity is for the participants to acknowledge why they are here and what it is they each are committing to in regards to their recovery. • Ask the participants to complete the activity alone before bringing it to the group. 59 • The first question focuses on their commitment to change. Explain to participants that this will look different for everyone. Some examples are committing to abstinence, decreasing behaviors, or managing a healthy sexual lifestyle. • The second question asks why they are making a commitment. This gives participants the opportunity to really think about why it is they want to change and what this commitment is worth. It also allows them to see it written right in front of them and therefore may encourage more motivation. • The third question helps participants keep track of their commitment. o Explain to the group that there will be times of struggle. For example, a question that might be asked is, "What coping skills do you have that will help keep you focused on your commitment?" • The last question will look at their support system. o Give them examples such as spouse, friends, sponsor, counsellor, pastor etc. Again this allows them to acknowledge those in their lives who will help support them with their commitment. • Discuss the activity as a group. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Activity 2: Loss Chart Materials Needed: • Session one booklet • Pens 10 minutes 60 Activity 2 Overview • The purpose of this activity is to not only see what participants have lost through their addiction, but what they can again have by seeking help with their addiction. • Ask the participants to think about all of the losses they have experienced because of their behaviors. • Ask participants to complete Activity 2 individually. • There is a section for work, money, relationships, health, time, and other. • Discuss the activity as a group. o End with a positive note by discussing how getting back on track may help them repair their relationships and gain back what they have lost. • Ask the participants to put this activity in their binder if they wish. Part III Homework assignment: Dream List 5 minutes Materials Needed: • Session one booklet Homework Overview • The purpose of this activity is for participants to think of things other than sex that are important to them. It also gives them goals to work towards. • Ask participants to complete this activity at home, and bring it in for next week's session for discussion. • The activity asks them to share the dreams they have or have had for themselves when they were a child, a teenager, and presently. 61 • Remind participants that this activity is not a reminder of what they don 't have but a way to open up to hope and new possibilities for themselves. • Ask participants if they have any questions about the assignment. Check-Out • 5 minutes Ask clients to pull out their Check-out handouts. o Refer to Appendix F • Ask for a volunteer to go first. • Go around the room and ask clients to answer: o What was their mood on a scale of 1-10. o What they liked most about today' s session. o How they plan to keep themselves safe this week. o • If they have any goals for this week. Ask if there are any more questions, and then close the group. 62 Session One Booklet: Exploring Sex Addiction 63 Table of Contents Discussion: Exploring Sex Addictions 64 Icebreakers 66 Activity 1: My Commitment to Change 68 Activity 2: Loss Chart 70 Homework: Dream List 71 Resources for Clients 72 64 Discussion: Exploring Sex Addiction What is Sex Addiction? The term sex addiction can be defmed in various ways. A simple and clear definition describes sex addiction as a uncontrollable pattern of sexual behavior that has negative repercussions in one's life (Hall, 2013). Additionally, if one continues this out of control behavior and becomes dependent on it, despite the problems it causes in one' s life, they are addicted. For example if a particular sexual behavior, such as viewing pornography, begins to have adverse effects on an individual's relationships, finances, occupation, health etc. When we become dependent on something and cannot stop doing it, despite all of the issues it causes in our lives, then we are addicted (Hall, 2013). Sex addiction is used as a coping mechanism for individuals; it is a way of managing life (Hall, 2013). Sex addicts use sex as a way to alleviate negative feelings and create positive ones. Some addicts describe their addiction to sex as a way of numbing emotions. Although sex is initially used to alleviate these negative emotions, eventually it is sex that begins to create the very problems you are trying to escape (Hall, 2013). Commitment to Recovery Sometimes the most difficult part of recovery is admitting you have the addiction. The next challenge is making the commitment to yourself to change. Committing to change involves identifying what your concerns are (eg. compulsive masturbation, sex with prostitutes) and understanding how these issues have affected your life. Once these issues have been addressed, you can look at treatment options, personal goals, and what a healthy sexual lifestyle will look like for you. 65 Icebreakers A Significant Year: Hand out one slip of paper to each participant. On each slip of paper there will be a year i.e. 1985, 2001 etc. Once all of the participants have their slip of paper, go around the room and ask them to think of something happy and significant that happened that year. Then they can share with the group if they wish. The event can be either personal or could have been part of history. Examples would be "the year my daughter was born", or "the year Forrest Gump the movie was released." Question Game: Divide the group into pairs and ask them to meet with their partner for 3 minutes. In those 3 minutes, they have to ask their partner at least 3-5 questions without using: What, who, why, or when at the beginning of the question. When they are done, each partner shares what they found out about their partner. Birthday Game: Each participant has to answer a question based on the month they were born in, their favorite color, and how many siblings they have. Birthday Game Example Birthdays: January: Favorite person? February: Favorite movie? March: Favorite hobby? April: Favorite band? May: Favorite food? June: Favorite sport? July: Favorite season? August: Favorite memory? 66 September: Favorite holiday? October: Favorite place to visit? November: Favorite book? December: Favorite TV show? Favorite Color: Red: What is your best accomplishment? Blue: What is something you 've always wanted to do? Green: N arne a long term goal you have Black: What is your happiest memory? Pink: What is your best trait? Purple: Who is your best friend? Orange: Who is your idol? Yellow: What is your best skill? #of Siblings: 0: Tell us one thing about yourself 1: Tell us one thing about your family 2: Tell us one thing about your hobbies 3: Tell us one thing you are passionate about 4: Tell us one thing about your friends 5+: Tell us one thing about your goals in life 67 Activity 1: My Commitment to Change Making a written commitment to do something can have a strong influence on whether or not you actually fulfill your commitment. Ultimately commitment leads to success. Answer the following questions as part of your written commitment to change. My commitment is (e.g. abstinence from sex, to avoid unsafe sexual behaviors, etc.): How I plan to keep my commitment is to (e.g. cope with my urges in a healthier way, attend counselling regularly, etc.): Who I have to support me with my commitment is (e.g. my partner, my sponsor, friends, etc.): 68 When I am struggling to keep my commitment, I plan to (e.g. call a friend, go to the gym, etc.): Money Can't pay bills, $600 phone bill Work Lost Job Wife left me. Relationships ----- Herpes, stressed out Health lives and the lives of those close to us. Below is an example to follow if needed. No time for kids Time Reputation is at stake Other addiction has affected the areas of your life. The purpose of this activity is to remind us of how much our addiction can impact our With addiction come losses. Addiction can affect our health, relationships, finances and much more. Think of how sex My Loss Chart Adapted from Sbraga & O'Donohue (2003). Activity 2: Loss Chart 69 70 Homework: Dream List Adapted from Sbraga & O'Donohue (2003). Other than sex, what else is important to you? Think about some things you have always wanted or wanted to do. Remember that you are writing about your dreams because you eventually want to free up your time, energy, and other resources to get back on track and begin fulfilling these dreams. Write down the dreams you have or have had for yourself at each of the points in your life listed below. My Dreams: As a child: As a teenager: Present Day: 71 Resources for Clients Addictions Hotline: Free Health Services Information. Phone: 1-800-565-8603. Benefits that one can obtain by participating in a group like Sex Addicts Anonymous. (2012). Retrieved from http://national12stepmeetings.com/benefits-that-one-can-obtain-byparticipating-in-a-group-like-sex -addicts-anonymous/ Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare Publications. Community Acute Stabilization Team-Adult Mental Health & Addictions: Northern Interior Health Unit-3rd Floor, 1444 Edmonton Street, Prince George, BC. Phone: 250-565-2666. Hall, P. (2013). Understanding and treating sex addiction. New York, NY: Routledge. Ley, D.M. (2012). The myth of sex addiction. Lanham, MD: Rowman & Littlefield. Sex Addicts Anonymous: https:/I saa-recovery. org/Meetings/Canada/meeting. php? state=BC. Zilbergeld, B. (1999). The new male sexuality. New York: Bantam Books. 72 Session Two: Etiology, Treatment Options, and Goals for Recovery Session Overview: • In session two, we will focus on exploring what sex addiction derives from, discuss treatment options, and address participants' goals on their path to recovery. Session Two Objectives: • To discuss and review session one • To explore where sex addiction comes from • To discuss treatment options for sex addiction • To discuss participants' goals for recovery Session Outline: Part I • Check-in • Review of session one • Review of homework Part II • Group discussion of session two Break • Activity 1: Pros & Cons of Treatment • Activity 2: My Short Term Goals Part III • Homework assignment • Closing/Questions • Check-out 73 Materials Needed: • Session two booklet • Pens Session Two Description: Part I Check-In 5 minutes • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. o Discuss something positive that has happened to them this week Homework Review/Discussion • Ask participants to pull out their homework from last week. 15 minutes 74 • Ask participants how they felt about session one and if they have any questions regarding session one. Ask participants if anything stood out for them in session one and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don' t have to share anything they don 't want to. • Discuss last week's homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Two 15 minutes Materials Needed: • Pens Discussion: Etiology, Treatment Options & Goals • 15 minutes Explain the three primary areas sex addiction starts. o Trauma-induced addiction • Experiencing any negative or life-altering event can induce trauma. • If this traumatic incident is not dealt with or is dealt with in an unhealthy manner, this can have a negative impact on one's mental well-being • May use sex as an outlet or a coping mechanism to deal with the trauma. o Attachment-induced addiction 75 • Even if a child has experienced trauma in their lives, if they have a secure parental-attachment they are more likely to cope with the trauma in a healthy manner. • If there are few or no secure attachments in one's life, this may result in them finding attachment through sex. o Opportunistic-induced addiction • Sometimes sex becomes an addiction just because it is always available to an individual. • Have a discussion around the three primary areas. • If participants are willing to share, have discussions about any treatment options they have tried and whether they worked or not. Ask them what sort of treatment they think would be most helpful for them. • It is important to note that this can be a sensitive topic so try to discuss this topic in a more general way rather than making it personal. 15 minutes Break Part II continued. Activity 1: Pros & Cons of Treatment 15 minutes Materials needed: • Session two booklet • Pen Activity 1 Overview • The purpose of this activity is to weigh out pros and cons of seeking treatment. This will look different for each participant. 76 • Discuss with the group some pros and cons of treatment and not doing treatment. • Allow the participants approximately ten minutes to complete the activity, and then allow five minutes to discuss the activity as a group. • After the activity, ask participants if they would like to share with the rest of the group. • Have a brief discussion of the activity if needed. • Ask the participants to put this handout in the front of their binder so that they can always refer to it if needed. Activity 2: Weekly Short-term Goals 15 minutes Materials Needed: • Session two booklet • Pens Activity 2 Overview • The purpose of this activity is for participants to set small, realistic, and attainable short-term goals for themselves. • This activity asks participants to list a short-term goal then list seven steps to help them attain this goal. They may choose to do more than one. • Ask participants to complete activity two individually. • Have a brief discussion of the activity. • Ask the participants to put this activity in their binder if they wish. Part III Homework: My Long-term Goals Materials Needed: 5 minutes 77 • Session two booklet Homework Overview • The purpose of this activity is for the participant to explore different goals they have for themselves. These goals do not have to be related to their sex addiction. • The activity asks participants to list as many goals as possible. Then there is a section that asks them to list which goals they wish to accomplish within one year and within five years. • Ask participants to complete this activity at home and bring it in for next week' s session for discussion. • Ask participants if they have any questions about the assignment. Check-Out 5 minutes • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: • o What was their mood on a scale of 1-10. o What they liked most about today' s session. o How they plan to keep themselves safe this week. o If they have any goals for this week. Ask if there are any more questions, and then close the group. 78 Session Two Booklet: Etiology, Treatment Options & Goals for Recovery 79 Table of Contents Activity 1: Pros & Cons of Treatment 80 Activity 2: My Short Term Goals 82 Homework: My Long Term Goals 83 80 Activity 1: Pros & Cons of Treatment It is important to consider all of your pros and cons for treatment. The purpose of this activity is to explore the costs and benefits of seeking treatment, and also the costs and benefits of not seeking treatment. Follow the example below if needed. Pros & Cons of Treatment Seeking Treatment Pros Cons -Relieve a lot of my stress -Have to give up my affair Not Seeking Treatment Pros Cons -Can still get my thrills -I will still be at risk of losing my family 81 Seeking Treatment Pros Not Seeking Treatment Pros 82 Activity 2: My Short-Term Goals Adapted from Sbraga & O ' Donohue, (2003) Think of some realistic and attainable goals you hope to accomplish soon. Choose goals that are related to your sexual behaviors and to leading a healthy lifestyle. Start by writing down a goal then underneath, list the steps you will take to achieve this goal. My Short-Term Goals ~ygoal: _____________________________________________________ ~y steps to achieve my goal: 1. 2. 3. 4. 5. ~ygoal: ---------------------------------------------------------~y steps to achieve my goal: 1. 2. 3. 4. 5. 83 Homework: My Long Term Goals Adapted from Sbraga & O' Donohue, (2003) Think about some of the accomplishments you hope to achieve in your lifetime. Setting goals for yourself is good motivation to accomplish those things you have always wanted to do. Write down some long-term goals you have for yourself that hope to achieve one year from now, and five years from now. My Long Term Goals One Year from Now 1. 2. 3. 4. 5. Five Years from Now 1. 2. 3. 4. 5. 84 Session Three: Shame, Guilt, and Cognitive Processes Session Overview: • In session three, we will explore the emotions that are associated with sex addiction, discuss cognitive distortions, and educate participants about healthy alternatives to negative thinking patterns. Session Three Objectives: • To discuss and review session two • To explore the emotions that arise with sex addiction • To discuss these emotions in a safe and non-judgmental environment • To understand how cognitive process impact addiction • To discuss cognitive distortions • To learn more helpful and healthy ways to process cognitively Session Outline: Part! • Check-in • Review of session two • Review of homework Part II • Group discussion of session three Break • Group Activity 1: Cognitive Distortions Part III • Homework: Finding Alternatives 85 • Closing/Questions • Check-out Materials Needed: • Session three booklet • Pens • Poster board/White board • White board markers/ markers Session Three Description: Part I Check-In 5 minutes • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. o Discuss something positive that has happened to them this week. 86 Homework Review/Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session two and if they have any questions regarding session two. Ask participants if anything stood out for them in session two and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don 't have to share anything they don't want to. • Discuss last week' s homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Three 15 minutes Materials Needed: • Session three booklet • Pens Discussion: Shame, Guilt, and Cognitive Processes • 25 minutes Discuss as a group what causes someone to feel shame or guilt. o Things such as keeping secrets, illegal activities, and going against ones morals may be some of the causes that may come up. • Discuss the difference between shame and guilt. o Shame is a negative emotion where we often see ourselves as a bad person, whereas guilt is a negative judgment about a behavior one has. • Discuss how one copes with these feelings of guilt and shame. 87 o Try to end this on a lighter note. For example, end with discussing possible solutions or positive coping mechanisms to these negative feelings for instance: o • Sharing their thoughts and feelings with a friend or counsellor. • Being open and honest with loved ones. • Creating goals and achieving these goals. • Forgiving yourself. Explain how shame can leave us feeling weak, helpless and unworthy of receiving support. o Also explain how reducing shame is one of the most challenging parts of recovery and often can take a lot of time. • Have a brief discussion on cognitive distortions o Discuss the definition of cognitive distortions. o Mention that the good news is that negative thinking can be corrected with new ways of thinking. Break 15 minutes Part II continued. Activity 1: Cognitive Distortions Materials needed: • Session three booklet • Pen • Poster board or white board • White board markers/markers 20 minutes 88 Activity 1 Overview • The purpose of this activity is to learn about negative thinking patterns so participants can recognize when they are experiencing a cognitive distortion and to learn healthier ways of thinking. • Discuss with the group the list of cognitive thinking errors. • On the board/ poster board, do a matching game where as a group they have to match the distortion with the example. • If there is time, ask the group to pick one of the distortions that they feel they do the most, and then discuss it with the rest of the group if they wish. • Have a brief discussion of the activity if needed. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Part III Homework assignment: Finding Alternatives 5 minutes Materials Needed: • Session three booklet Homework Overview • The purpose of this activity is for the participant to learn different alternatives of thinking; to tum negative thinking into more positive thinking. • The activity asks participants to list some of the cognitive distortions they often have. They then have to list beside each distortion a more positive alternative. • Encourage participants to think of at least 5-7 distortions and alternatives. • Give an example if needed. 89 • Ask participants if they have any questions about the assignment. Check-Out 5 minutes • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? o What they liked most about today's session. • o How they plan to keep themselves safe this week. o If they have any goals for this week. Ask if there are any more questions, and then close the group . 90 Session Three Booklet: Shame, Guilt, and Cognitive Processes 91 Table of Contents Activity 1: Cognitive Distortions 92 Matching Game Answer Key 95 Homework: Finding Alternatives 97 92 Activity 1: Cognitive Distortions Adapted from Sbraga & O' Donohue, (2003) Cognitive distortions are irrational thought patterns which we often find ways to convince ourselves are real. There are several types of cognitive distortions that we all have depended on at some point in our lives. Below are descriptions of eleven examples of common negative thinking errors. Cognitive Distortions 1. Black & White Thinking: This is when we view situations as one extreme or another; there is no gray area. For example, Rick thinks that anal sex with prostitutes is the only way he can get off so therefore he continues engaging in unhealthy sexual behaviors. 2. Entitlement: When you believe someone owes you, or you deserve something from the world. For example, Len's wife hasn't had sex with him in a month so he feels he is entitled to having an affair. 3. Emotional Reasoning: This occurs when an action or behavior is justified because the individual feels strongly about something. For example, Lisa continues to engage in unsafe sexual encounters because she insists that it boosts her self-esteem when, in fact, it makes her feel worse about herself. 4. Jumping to Conclusions: When an individual comes to a conclusion or makes quick decisions without any information to base them on. For example, Laurie feels that, because of her age, she will never find a husband but has never actually bothered to try having a meaningful relationship . Therefore, she continues to engage in strictly sexual relationships. 93 5. Justification: This is when individuals make excuses for their behavior. For example, Marie complains that if her partner worked less, then she wouldn't have to cruise for prostitutes. 6. Magnifying or Minimizing: This thinking error occurs when make a big deal out of small issues, or minimize important ones. An example of magnifying is: because John ' s ex-wife said he was bad in bed, he fixates on womanizing to prove to himself that he is not. An example of minimizing is Jazmine who cannot pay her bills because of her sex addiction but she tells herself it is no big deal because everybody has money troubles. 7. Mental Filter: This is when an individual focuses on one part of a situation but then ignores any other information that may contradict that small piece of information they focused in on. For example, Ron thinks that because the stripper is paying a lot of attention to him, that it is because she likes him when in fact it is because he is spending a lot of money on her. 8. Mislabeling: When you give a name to something and then act as if the label is true, even if it is not. For example, Dominic was tested for STis after his first sexual encounter with a prostitute and he was clean so, therefore, he feels that having sex with prostitutes is safe and he will not contract an STI. 9. Overgeneralization: This occurs when a situation is falsely judged based on a single past experience. For example, Joanne sought treatment in the past for her sex addiction and felt that it didn't help her, so now she is hesitant to seek further treatment. 94 10. Rationalization: When you make excuses for your actions. For example, Greg told his wife that he has to go to strip clubs because his boss wants to go and therefore he should go to keep his boss happy. 11. Should Statements: This thinking error occurs when you decide in advance what should happen in a given situation then don 't accept when the reality doesn' t match what you thought should have happened. For example, Paulo thinks that because a woman is having fun on their date that the date should end with them having sex. 95 Matching Game-Answer Key As a group, match the generalization to the example. Use a whiteboard to complete the activity. The answers to the activity are listed below: Black & White Thinking Joe thinks of all prostitutes as scum, but holds his wife on a pedestal. Entitlement Don ' s partner won't have oral sex with him, so he feels he deserves to get it from escorts. Emotional Reasoning Carl has always felt that prostitutes are there for men ' s convenience, so why not have sex with them? Jumping to Conclusions Rita feels that if she tells her husband about her addiction to sex, he will leave her so she keeps on hiding it from him. Justification Mark tells his spouse that he only goes to the strip club every night because he likes their veal cutlets. Magnifying Grace's boss tells her twenty good things about her work, and one negative thing. She focuses on the negative remark. Minimization Dana's partner leaves her because of her porn addiction, but tells herself it's not a big deal because they were having problems anyways. 96 Mental Filter Jonathan feels that the women he talks to on the 1-900 numbers he calls really like him, so it' s worth every penny. Mislabeling Kendra thinks her sponsor is a bitch because she told her she was concerned she may have a sex addiction, when in fact her sponsor was only concerned for Kendra' s well-being. Overgeneralization Phil ' s dad was treated for a sex addiction but still continued to engage in unsafe behaviors, therefore Phil feels treatment is a waste of time. Rationalization Fatima tells her husband that she only went for drinks with an old boyfriend because she felt sorry for him. Should Statements Louise felt like her co-worker should have sex with her because she is a woman and men can 't resist sex. 97 Homework: Finding Alternatives Adapted from Sbraga & O' Donohue, (2003) Now that you have been able to explore some of the cognitive distortions, think of some of the negative thinking errors you sometimes have. List the cognitive distortion you have below, then, list an alternative way of thinking. Use the example below as a guideline. Finding Alternatives Example: Cognitive Distortion: I deserve to hang out at strip clubs because it helps me relieve stress. Alternative: I can go play basketball with the guys in the evening to help relieve stress. Cognitive Distortion: Alternative: Cognitive Distortion: Alternative: 98 Cognitive Distortion: Alternative: Cognitive Distortion: Alternative: Cognitive Distortion: Alternative: 99 Session Four: Cycle of Addiction Session Overview: • In session four, the facilitators with dialogue with participants on the cycle of addiction, discuss the impacts their addiction has had on their lives, and explore healthy alternatives to their negative behaviors. Session Four Objectives: • To discuss and review session three • To learn about the cycle of addiction • To understand the impact the cycle has on an individual with an addiction • To discuss the phases of the sex addiction cycle • To learn about chain thoughts and behaviors Session Outline: Part I • Check-in • Review of session three • Review of homework Part II • Group discussion of session four Break • Activity 1: Chain Reactions Part III • Homework: What I Learned from Behavior Chains • Closing/Questions 100 • Check-out Materials Needed: • Session four booklet • Pens • Poster board/White board • White board markers/markers Part I Session Four Description: Check-In 5 minutes • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. o Discuss something positive that has happened to them this week. 101 Homework Review/Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session three and if they have any questions regarding session three. Ask participants if anything stood out for them in session three and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don't have to share anything they don't want to. • Discuss last week's homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. PART II Group Discussion of Session Four 25 minutes Materials Needed: • Six Phase Cycle of Addiction handout (see Appendix G)- optional • Pens Discussion: Cycle of Addiction • Facilitators may use whichever model they choose, but the Six Phase Cycle of Addiction model (Hall, 2013) is highly recommended. • Briefly discuss with participants each stage of the cycle. o First stage is the Dormant Phase: where addiction appears to be in remission and life looks like it's back to normal, however, if underlying issues haven ' t been properly dealt with, then the behaviors are likely to reoccur. 102 o Second stage is the Trigger Phase: it is important for each individual to fmd their unique triggers and to be able to recognize them before they occur. • Discuss how triggers may differ depending on whether their sex addiction is opportunity-related, attachment-related, or trauma-related. • Give examples of each. o Third stage is the Preparation Phase: making preparations to engage in undesirable behaviors. This is where cognitive distortions come into play i.e. my wife and I haven 't been intimate in a week, I deserve to look at porn. • You may wish to briefly review the list of cognitive distortions. o Fourth stage is the Acting Out Phase: when the behavior is acted out by the individual. o Fifth stage is the Regret Phase: when the true cost of the addiction is realized. • o Feelings of guilt and shame often arise. Sixth stage is the Reconstitution Phase: the individual wishes to redeem themselves. • The individual ' s goals at this stage are often to alleviate guilt, make amends, and attempt to not engage in the behavior again. • Have a discussion with participants. o Ask them if this cycle sounds like something they can relate to? o Ask participants which stage or stages they fmd most challenging? How have they dealt with this stage or stages? Would they like to deal with it differently? If so, how? 103 • The purpose of these questions is for participants to acknowledge their challenging phase and discuss as a group some positive solutions. Break 15 minutes Part II continued. Activity 1: Chain Reactions 20 minutes Materials needed: • Session four booklet • Pen • Poster board or white board • White-board markers/markers Activity 1 Overview • The purpose of this activity is for participants to recognize their own unique triggers and to learn how to recognize these triggers so they can prevent relapse. • Explain to the group what a behavior chain is. • As a group, give an example of a behavior chain. o Start with an example of a behavior i.e. looking at pornography, or having sex with prostitutes. o With the group, discuss and list your example behavior chain on the whiteboard. o Ask the group members to participate and help give you examples of events that could lead to the behavior. • Ask participants to individually complete the activity. 104 o Inform participants that if they wish, they can complete a chain for each behavior if they have more than one concerning behavior. • Have a brief discussion of the activity if needed. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Part III Homework assignment: What I learned from my Behavior Chain 5 minutes Materials Needed: • Session four booklet Homework Overview • The purpose of this activity is for the participant to breakdown the key elements they learned by doing a behavior chain. It will help them recognize particular patterns they have so they will more clearly be able to identify triggers in the future. • The activity asks participants to answer a few questions on what they have learned from their behavior chain. • Encourage participants to answer these questions for each behavior chain they have done. • Ask participants if they have any questions about the assignment. 5 minutes Check-Out • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? 105 o What they liked most about today' s session. o How they plan to keep themselves safe this week. 106 Chapter Four Booklet: Cycle of Addiction 107 Table of Contents Activity 1: Chain Reactions 108 Homework: What I Learned from Behavior Chains 111 108 Activity 1 :Chain Reactions Adapted from Sbraga & O'Donohue, (2003) Sometimes negative behaviors just seem to happen. If you break it down, however, you will notice that there is often a sequence of events that lead up to the behavior. Completing a behavior chain will help identify possible triggers that may result in acting out the behavior. Once these triggers are acknowledged, it is easier to prevent relapse. Start with a behavior you engage in and then, below, write down the steps you often take that lead you to carrying out the behavior. You may have more or less steps than given below. Follow the example below if needed. Chain Reactions Behavior Chain Example: Viewing pornography 1. Feeling stressed with work 2. Come home to an empty house 3. Bored because no one is home 4. Check my email in case I receive an email from work 5. I'm already on the computer so I go on Facebook 6. I see some profiles of my old girlfriends 7. I begin to feel aroused 8. I see an ad in the background for Naughty Housewives 9. I click on it to get rid of it 10. Ends up going to the site 11. I view just one porn site 12. Now I find myself viewing pornography for hours 109 Behavior Chain #1: -------------------------------------1. 2. 3. 4. 5. 6. 7. 8. 9. 10. _______________________________________________ 11. _______________________________________________ 12. ----------------------------------------------- Behavior Chain #2: -------------------------------------1. 2. 3. 4. 5. 6. 7. 8. 9. 110 10. 11. _ _ _ _ _ _ _ _ _ __ ~ ~ Ill Homework: What I learned from Behavior Chains Adapted from Sbraga & O'Donohue, (2003) By breaking down your behaviors in the last activity, you are more likely able to identify your patterns of behavior. Recognizing these patterns will help prevent relapse, but what else have you learned from completing your behavior chain? Complete the questions below for each of the behavior chains you listed in the last activity. What I learned from Behavior Chains Behavior Chain #1: ------------------------------------------------- 2. Which steps on your list would you say are the biggest triggers for you? Why? 3. What are some healthy ways to cope with these triggers? What other steps can you take instead? 112 Behavior Chain #2: ------------------------------------------------- 1. Which steps on your list would you say are the biggest triggers for you? Why? What are some healthy ways to cope with these triggers? What other steps can you take instead? 113 Session Five: Decision Making and Self-Worth Session Overview: • In session five, we will have a discussion regarding self-worth, contemplate the costs and benefits of their sexual behaviors, and explore healthy sexual outlets. Session Five Objectives: • To discuss and review session four • To explore self-acceptance and self-worth • To explore the costs and benefits of one's sexual behaviors • To discuss decision making and how decisions affect one's life • To talk about what role sex plays in one's life Session Outline: Part I • Check-in • Review of session four • Review of homework Part II • Group discussion of session five (in booklet) Break • Activity 1: Decision Matrix • Activity 2: I am a Valuable Person Part III • Homework: Fantasy vs. Reality • Closing/Questions 114 • Check-out Materials Needed: • Session five booklet • Pens • Poster board/White board • White board markers/markers Session Five Description: Part I Check-In 5 minutes • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. o Discuss something positive that has happened to them this week. 115 Homework Review/Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session four and if they have any questions regarding session four. Ask participants if anything stood out for them in session four and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don't have to share anything they don't want to. • Discuss last week's homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Five 15 minutes Materials Needed: • Session five booklet • Pens Discussion: Decision Making & Self-Worth • Discuss as a group the term self-worth. o Discuss what makes them feel worthy. • o Examples: their relationship with others, their job etc. Discuss what determines one's value. • Examples: their self-esteem, if they are a productive person to society, their negative thinking patterns • Have a discussion regarding the decision to engage in negative behaviors. 116 o Talk about how there are costs and benefits to either engaging in the behavior or not engaging in the behavior. • Ask participants if they ever weigh out the pros and cons of engaging in a behavior or not engaging in a behavior? If so, was it helpful? o This discussion will lead into the next activity. 15 minutes Break Part II continued. Activity 1: Decision Matrix 15 minutes Materials needed: • Session five booklet • Pen • Poster board or white board • White-board markers/markers Activity 1 Overview • The purpose of this activity is for participants to examine the costs and benefits of their decision whether to engage or not engage in a negative sexual behavior. • As a group, give an example of a decision matrix on the white board. o Ask the group members to participate and help give you examples of the costs and benefits to a particular behavior. • Then ask the group to come up with some costs and benefits of both losing control and partaking in the behavior, and not losing control and not engaging in the behavior. • Ask participants to individually complete activity. 117 Inform participants that, if they wish, they can complete a decision matrix for o each behavior if they have more than one concerning behavior. • Have a brief discussion of the activity if needed. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Activity 2: I am a Valuable Person 15 minutes Materials needed: • Session five booklet • Pen • Poster board or white board • White-board markers/markers Activity 2 Overview • The purpose of this activity is for participants to think of and write down all of the reasons they are worthy. This activity is designed to help participants recognize their value and see that, though they sometimes engage in negative behaviors, these behaviors are what they have done, not who they are. • Discuss with the group the idea that their behaviors are something they have done, and do not necessarily define them as a person. o Explain how everyone is entitled to self-worth. o A fun way to demonstrate self-worth is by using a twenty dollar bill for example. • Ask for a volunteer to come up and hold the twenty dollar bill. First ask the group what this dollar bill is worth. They will say "twenty 118 dollars." Then get the volunteer to crinkle it. Then ask the group if the bill is still worth twenty dollars. They will most likely to respond with "yes." Then ask the volunteer to throw the twenty dollar bill on the floor and step on it. Lastly you will ask the group if this bill is still worth twenty dollars. They will most likely answer "yes." • Explain to the group that the purpose of this activity was to demonstrate that no matter what condition you are in, no matter what you have been through, everyone is entitled to being worthy and your worth never changes. • Ask participants to individually complete the activity. • Have a brief discussion of the activity if needed. o If there is time, go around in a circle and ask each participant if they are willing to share one thing that makes them valuable. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Part III Homework: Fantasy vs. Reality 5 minutes Materials Needed: • Session five booklet Homework Overview • The purpose of this activity is for the participant to breakdown the costs of their fantasy. By understanding the true costs of their behaviors, it provides them with the 119 reality of just what they have to lose by engaging in the behaviors. It will also allow participants to explore new healthy alternatives to their fantasies. • The activity asks participants to list all of the costs of their fantasy, as well as some healthy alternatives to their fantasy. o Discuss an example if needed. • Ask participants if they have any questions about the assignment. Check-Out 5 minutes • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? o What they liked most about today' s session. o How they plan to keep themselves safe this week. 120 Session Five Booklet: Decision Making and Self Worth 121 Table of Contents Activity 1: Decision Matrix 122 Activity 2: I am a Valuable Person 124 Homework: Fantasy vs. Reality 125 ~ -I might not know how to distract myself -I may have to wait to feel sexually satisfied -I can start doing the things I used to love doing -Spend more time with my family Not Losing Control - -May contract an STI - My spouse may find out -Not paying bills -Having an orgasm -Relieving stress Losing Control -Have more self-respect -Have more kids -I don 't have to change -I will still be able to get off the way I like to Benefits Benefits Costs Long Term Short Term Example: Having sex with escorts My Decision Matrix control, and costs and benefits. Use the example below as a guideline. -Might be boring -Lose my family -Lose my house because I can 't pay bills Costs completing your decision matrix, there are three areas to consider: Short-term goals vs. long-term goals, losing control vs. not losing Creating a decision matrix allows you to determine the short-term and long-term costs and benefits of a behavior. When Adapted from Sbraga & O'Donohue, (2003) Activity 1: Decision Matrix ~ Not Losing Control Losing Control Benefits Benefits Costs Long Term Short Term My B e h a v i o r : - - - - - - - - - - - - - - - - - - My Decision Matrix Costs ~ 124 Activity 2: I am a Valuable Person Adapted from Sbraga & O' Donohue, (2003) Taking control of your sexual behaviors is a huge step toward feeling good about yourself. No matter what you do or have done, you are still deserving of self-worth. There is more to you than your sex life. List the reasons why you are valuable, and answer the questions below regarding your self-worth. I am a Valuable Person Why I am Valuable: 1. 2. 3. 4. 5. Something I am good at is: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Something I enjoy doing is: _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ Three positive qualities I have are: 1. 2. 3. 125 Homework: Fantasy vs. Reality Adapted from Sbraga & O' Donohue, (2003) This activity involves naming a fantasy you have and writing down the costs of acting out the fantasy. Then you will list healthy alternatives to your fantasy. What is a safe way to carry out your wants and desires? Use the example below as a guideline. Fantasy vs. Reality Example: My Fantasy is: To have sex with a teenage girl Alternatives Costs • • - it is illegal • - it goes against my morals has legal age women dressed as • - my wife would leave me if she found teenagers out • watch pornography with my spouse that ask my wife to dress like a teenager My Fantasy is: ___________________________________________________ Alternatives - ---, l I 126 My Fantasy is: Costs l -Alternative_! r I I l 1 J - - 127 Session Six: Developing a Healthy Lifestyle Session Overview: • In session six, we will discuss the impact that sexual addiction has had on participants' relationships and life, explore what it means to lead a healthy lifestyle, and educate participants on some of the myths around sex addiction. Session Six Objectives: • To discuss and review session five • To explore the impact sex addiction has had on one's relationships • To discuss what it means to each participant to have and maintain a healthy sexual lifestyle • To discuss what it means to each participant to have and maintain healthy relationships • To learn the steps to develop and maintain a healthy sexual lifestyle • To learn the steps to develop and maintain healthy relationships Session Outline: Part I • Check-in • Review of session five • Review of homework Part II • Group discussion of session six Break • Activity 1: The Impact on my Relationships 128 • Activity 2: Sexual Myths Part III • Homework: Positive Sex Practices • Closing/Questions • Check-out Materials Needed: • Session six booklet • Pens Session Six Description: Part! 5 minutes Check-In • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. 129 o Discuss something positive that has happened to them this week. Homework Review/Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session five and if they have any questions regarding session five. Ask participants if anything stood out for them in session five and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don't have to share anything they don't want to. • Discuss last week's homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Six 15 minutes Materials Needed: • Pens Discussion: Developing a Healthy Sexual Lifestyle • As a group, discuss what a healthy lifestyle looks like. Some possible questions to discuss are: o What will you be doing differently than you are now? o What will your relationships look like? o What will you do that will keep you in this healthy lifestyle? Break Part II continued. 15 minutes 130 Activity 1: The Impact on my Relationships 15 minutes Materials needed: • Session six booklet • Pen • Poster board or white board • White-board markers/markers Activity 1 Overview • The purpose of this activity is for participants to discuss and list the effects the participants' behaviors have on their relationships. This will encourage them to see how their addiction affects others and not just themselves. • As a group, discuss examples of how negative sexual behaviors can have a negative effect on our loved ones. List them on the board if it is more helpful. • Ask participants to individually complete activity. • Have a brief discussion of the activity if needed. • If there is time, ask the participants if they would like to share their activity. • Ask the participants to put this handout in the front of their binder so that they can always refer to it if needed. Activity 2: Sexual Myths Materials needed: • Session six booklet • Pen Activity 2 Overview • The purpose of this activity is to educate participants on myths about sex. 15 minutes 131 • The activity consists of a true or false quiz although it is not actually worth any marks. • Ask participants to individually complete the activity. • Have a brief discussion of the activity. Some possible questions to discuss are: o Did any of the myths stick out to you? Why? o Were participants surprised by any of the answers? If so, which ones? Why? • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Part III Homework: Positive Sex Practices 5 minutes Materials Needed: • Session six booklet Homework Overview • The purpose of this activity is to provide the participants with a list of healthy sexual habits they themselves come up with. • The activity asks participants to come up with their own positive sex practices. o There will be examples listed at the beginning of their homework assignment • Ask participants if they have any questions about the assignment. Check-Out 5 minutes • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? 132 o What they liked most about today' s session. o How they plan to keep themselves safe this week. 133 Session Six Booklet: Developing a Healthy Lifestyle 134 Table of Contents Activity 1: The Impact on my Relationships 135 Activity 2: Sexual Myths 136 Sexual Myths Answer Key 137 Homework: Positive Sex Practices 138 135 Activity 1: The Impact on my Relationships Adapted from Sbraga & O' Donohue, (2003) Sex addiction impacts more than the person with the addiction. It can affect your relationships with those you love most. Others may be affected in ways you have never even thought about but there is often a trickle-down effect that reaches farther than you think. Use the example below as a guideline. The Impact on my Relationships In the spaces below, list five ways your sex addiction has negatively impacted others. Example: 1. I keep secrets from my family 2. I spend money on prostitutes that should go towards my and my spouse' s retirement 3. I spend less time with my kids so I can have my affair 4. I put less time in at work which has caused a decrease in sales for my boss and the company 5. I have lost a lot of my friends because I no longer have time for them Five ways my sex addiction has negatively impacted others: !. _________________________________________________ 2. _____________________________________________________ 3. ----------------------------------------------------- 4. ___________________________________________________ 5. _______________________________________________ 136 Activity 2: Sexual Myths Adapted from Sbraga & O'Donohue, (2003) There are several myths regarding sexual behaviors. Buying into these myths can do more harm than good so, it is important to receive accurate and factual information regarding sex. Sexual Myths Circle the answer to each of the following statements as either true or false. Choose true or false for each statement, even if you are not sure of your answer: 1. Men are always ready for sex T F 2. Sex has to be risky to be satisfying T F 3. Nobody would want me because of my past T F 4. Women secretly want to be dominated T F 5. Sex goes bad in long-term relationships T F 6. People say no to sex when they mean yes T F 7. Sex is the most important activity in life T F 8. The brain is the most vital sex organ T F 9. A balanced life usually includes sex T F 10. Anyone can refuse sex at any time T F 137 Sexual Myths-Answer Key The correct answers are highlighted in Red ink. All but the last three answers are False. I. Sex has to be risky to be satisfying T F 2. Nobody would want me because of my past T F 3. Women secretly want to be dominated T F 4. Sex goes bad in long-term relationships T F 5. People say no to sex when they mean yes T F 6. Sex is the most important activity in life T F 7. The brain is the most vital sex organ T F 8. A balanced life usually includes sex T F 9. Anyone can refuse sex at any time T F 138 Homework: Positive Sex Practices Adapted from Sbraga & O' Donohue, (2003) Becoming safely sexually aroused is important for good sex. There are many healthy and safe sexual practices, however, some may work better for you than others. Think of as many healthy sexual practices as you can, then circle the ones that best fit into your lifestyle. There are a few examples to get you started. Feel free to circle the examples and add to the list. Positive Sex Practices 1. Choose sexual partners you respect 2. Choose sexual encounters that don 't cause you to feel guilt or shame 3. Keep money out all of your sexual exchanges 4. Masturbating to fantasies of safe sexual activities 5. Decreasing porn use 6. 7. 8. 9. 10. _____________________________________________ 11. ___________________________________________ 12. ____________________________________________ 139 Session Seven: Relapse Prevention Session Overview: • In session seven, we will discuss triggers, educate participants on relapse prevention, distinguish the difference between a lapse and a relapse, and discuss healthy ways of coping with stress so relapse is less likely to occur. Session Seven Objectives: • To discuss and review session six • To learn about relapse prevention • To discuss triggers • To learn healthy ways to cope • To discuss each participant's ideas on relapse prevention • To learn about options for when relapse does occur Session Outline: Part I • Check-in • Review of session six • Review of homework Part II • Group discussion of session seven (in booklet) Break • Activity 1: Risk Factors • Activity 2: Lapses & Relapses 140 Part III • Closing/Questions • Check-out Materials Needed: • Session seven booklet • Pens • Poster board/White board • White board markers/markers Session Seven Description: Part I 5 minutes Check-In • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. 141 o Discuss something positive that has happened to them this week. Homework Review /Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session six and if they have any questions regarding session six. Ask participants if anything stood out for them in session six and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don 't have to share anything they don 't want to. • Discuss last week' s homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Seven 15 minutes Materials Needed: • Pens Discussion: Relapse Prevention • • As a group discuss what they know about relapse prevention o Discuss the definition o Why is it important? Discuss as a group what relapse prevention entails. o Identifying and managing triggers. • Remind the group of some of the triggers they addressed in session four 142 o Creating healthy relationships/support systems. • o Why is having a support system in place crucial? Positive sexual practices. • Remind the group of some of the healthy sex practices they came up with in the last session. • You may want to mention how sex can be a great and wonderful expenence. o Developing a healthy lifestyle. • What sorts of healthy lifestyle changes can one make to positively affect one's recovery? o Recognizing and overcoming hurdles to recovery. • Relapse isn't failure. • • If you have a relapse: o Forgive yourself/make amends. o Backtrack to see what you did wrong. o How can you do things differently next time? Discuss how commonly relapse occurs, and how not to let it affect one's path to recovery. Break 15 minutes Part II continued. Activity 1: Risk Factors Materials needed: • Session seven booklet 15 minutes 143 • Pen • Poster board or white board • White-board markers/markers Activity 1 Overview • The purpose of this activity is for participants to know which risk factors are most influential over them and to learn how to cope with these risk factors in a healthy manner. • As a group, discuss examples of risk factors. o Use whiteboard to display examples. • As a group, discuss some possible healthy coping. Some possible questions to discuss are: o How have group members coped positively before? o What are ways they hope to cope in the future? • With the group, discuss and demonstrate a grounding activity o The purpose of this is to help relieve anxiety when feeling triggered. o An example of a grounding exercise is the 5-4-3-2-1 exercise. • For this activity, you ask the participants to first visualize five different objects in the room they are currently in. For example, if they were at a restaurant they may list: chair, plate, glass, table, and waiter. • After they list the first five objects in the room, then ask them to visualize four more different objects they see in the room, then three more, then two more, then one more. 144 • This grounding technique works as a distraction and eventually decreases feelings of anxiety. • Ask participants to individually complete the activity. • Have a brief discussion of the activity if needed. • If there is time, ask the participants if they would like to share their activity. • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Activity 2: Lapses & Relapses 15 minutes Materials needed: • Session seven booklet • Pen • Poster board or white board • White-board markers/markers Activity 2 Overview • The purpose of this activity is to distinguish the difference between a lapse and a relapse. • Discuss as a group the differences between a lapse and a relapse. o Lapses: are temptations. • o Driving down a street populated with prostitutes. Relapse: is giving in to those temptations. • Picking up a prostitute to have sex with. • Ask participants to individually complete the activity. • Have a brief discussion of the activity. 145 • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Part III Homework assignment: Coping Cards 5 minutes Materials Needed: • Session seven booklet Homework Overview • The purpose of this activity is for the participants to create a concrete list of possible coping strategies to their high risk situations. • The activity asks participants to develop coping strategies they might use when they are in a risky situation. • Ask participants if they have any questions about the assignment. Check-Out 5 minutes • Ask clients to pull out their check-in/check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? o What they liked most about today's session. o How they plan to keep themselves safe this week. 146 Session Seven Booklet: Relapse Prevention 147 Table of Contents Activity 1: Risk Factors 148 Activity 2: Lapses & Relapses 150 Lapses and Relapses Answer Key 152 Homework: Coping Cards 153 148 Activity 1: Risk Factors Adapted from Sbraga & O 'Donohue, (2003) Risk factors are any thoughts, feelings, or situations that threaten your ability to control your sexual behaviors. It is important to learn how to recognize risk factors so that you can develop coping responses when they arise. Answer the following questions to the best of your ability. Risk Factors My high risk situations or triggers are: 1. 2. 3. 4. 5. 6. 7. 8. Some coping responses I can use are: 1. 2. 3. 4. 5. 6. 149 7. 8. 150 Activity 2: Lapses & Relapses Adapted from Sbraga & O'Donohue, (2003) Below are some examples of lapses and relapses. Circle whether you think the statement is a lapse or a relapse. Then in the space provided below, list some examples of lapses and relapses that attain to you. Lapses & Relapses Examples Lapse or Relapse? Going to a strip club Lapse Relapse Using the internet Lapse Relapse Sex with an escort Lapse Relapse Downloading pornography Lapse Relapse Giving a hitchhiker a ride Lapse Relapse Coffee with an ex-girlfriend Lapse Relapse Examples of Lapses and Relapses that I can relate to: Lapses: Relapses: 151 Lapses: Relapses: 152 Lapses & Relapses Answer Key Examples Lapse or Relapse? Going to a strip club Lapse Relapse Using the internet Lapse Relapse Sex with an escort Lapse Relapse Downloading pornography Lapse Relapse Giving a hitchhiker a ride Lapse Relapse Coffee with an ex-girlfriend Lapse Relapse 153 Homework: Coping Cards Adapted from Sbraga & O'Donohue, (2003) Throughout the group you have learned a variety of coping strategies to help prevent lapses or relapses. Developing coping cards is a quick way to provide you with instant access to coping strategies when you find yourself in a high risk situation. Fill in the coping cards below with coping strategies you fmd helpful. Cut out the coping cards and put them in a place you can access them easily. Use the example below as a guideline. Coping Cards Example: The Behavior: Having an Affair Coping Card 1. Spend time with family 2. Go for a walk 3. Delete person off of contacts 4. Remind yourself of the consequences 5. Talk to counsellor 154 The Behavior: Coping Card The Behavior: Coping Card 155 Session Eight: Closing Session Overview: • In session eight, we will review participants' goals, and what it means to lead a healthy lifestyle. We will discuss participant's thoughts on the group and what they found helpful and what they want to continue to work on. Session Eight Objectives: • To discuss and review session seven • To review what it means to lead a healthy sexual lifestyle • To discuss participant' s individual goals • To tie up any last minute material/wrap up • To complete the self-evaluation/evaluation Session Outline: Part I • Check-in • Review of session seven • Review of homework Part II • Group discussion of session eight Break • Activity I: Self Evaluation Part 2 • Activity 2: Evaluations Part III • Closing/Questions 156 • Check-out Materials Needed: • Session eight booklet • Pens • Self-Evaluation Part 2 (see Appendix H) • Evaluation (see Appendix I) Session Eight Description: Part I Check-In 5 minutes • The facilitator will ask participants to refer to their Check-in/Check-out handout. • The facilitator can ask if anyone from the group would like to go first. If no one volunteers, have a facilitator start. • During check in we do the following: o The participant will express how they are doing on a scale of 1 to 10. This will gauge their mood starting off the session. They will also be asked this at the end of session to see if there has been improvement or not. o The participant will state whether or not they have engaged in any unsafe behaviors i.e. prostitution, excessive porn use etc. The participant is not expected to go into detail nor list what excessive behavior they have participated in. o Discuss if they achieved their goals from last week. o Discuss something positive that has happened to them this week. 157 Homework Review/Discussion 15 minutes • Ask participants to pull out their homework from last week. • Ask participants how they felt about session seven and if they have any questions regarding session seven. Ask participants if anything stood out for them in session seven and, if so, ask if they would like to share with the rest of the group. • Remind participants that they don 't have to share anything they don 't want to. • Discuss last week' s homework assignment. Ask participants what they thought about the assignment. Was it challenging? Was it useful? • Ask participants if they have any further questions regarding the homework assignment. Part II Group Discussion of Session Eight 15 minutes Materials Needed: • Pens Discussion: Overview of Group • As a group discuss where they are at with their goals for group . Some possible questions to discuss are: o Did participants meet the goals they set for themselves? Are they still working on their goals? Did they change their goals? o • Is there a goal they have set for themselves for after group is done? Ask the group what their vision of a healthy lifestyle is. Some possible questions to discuss are: o Where are they at with achieving this lifestyle? 158 o What tools have they learned that will better prepare them with sustaining and maintaining a healthy lifestyle? o Discuss what their favorite part of group was? Least favorite? o Ask the group what would have they found more helpful? • Ask for any suggestions regarding the group. Some possible questions to discuss are: o Do we need more time to cover topics? o Should we add any topics? Take away topics? o Etc. o Discuss what their plans are for after group. Break 15 minutes Part II continued. Activity 1: Self-Evaluation Part 2 15 minutes Materials needed: • Self-Evaluation Part 2 (see Appendix H) • Pen • Envelope containing the Self-Evaluation Part 1 forms completed in session one Activity 1 Overview • The purpose of this activity is for participants to measure their individual progress over the course of the group. They will be able to compare their self-evaluation part 1 to their self-evaluation part 2 at the end of session. • Remind participants that recovery looks different for everyone. This is not a test but a measurement of where they are with their own journey to recovery. • Ask participants to individually complete the activity. 159 • After the post-test is completed, hand out the self-evaluations from session one for participants to view. • Have a brief discussion about how participants felt in regards to both tests. Ask the participants if there was anyone who was surprised by their results o • Ask the participants to put this handout in their binder so that they can always refer to it if needed. Activity 2: Evaluations 15 minutes Materials needed: • Pen • Evaluations (see Appendix I) Activity 2 Overview • The purpose of this activity is to give participants the opportunity to evaluate the group. o The evaluations are a valuable tool for facilitators to receive feedback regarding the group, the facilitators, and what changes could be proposed for future sessions. • The facilitators will ask for a volunteer from the group to collect the forms after and put them in the envelope to provide participants with anonymity. o Facilitators may choose to leave the room while the evaluations are being completed to provide more privacy if they wish. • Facilitators will discuss with participants the purpose of the evaluation. o Facilitators will explain that there are no right or wrong answers and should encourage participants to be honest with their answers. 160 o Facilitators will explain to participants that their evaluations will be helpful in improving the group for future sessions. o Participants will be reminded that, though completing the evaluation will be extremely helpful, it is completely voluntary. • Participants will be asked to complete the evaluations individually, and to have the volunteer collect it when they are done. • Ask participants to individually complete the activity. Part III 5 minutes Closing • Take this time to acknowledge the participants' hard work and dedication. • Use this as an opportunity to discuss, with participants, any highlights of the group. • Close with a positive note if possible. • Give participants the floor to express any thoughts or feelings about the group, their experiences or if they have any questions. Check-Out 5 minutes • Ask clients to pull out their check-out handout • Ask for a volunteer to go first • Go around the room and ask clients to answer: o What was their mood on a scale of 1-1 0? o What they liked most about today's session. o How they plan to keep themselves safe in the future. 161 References Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare. Corey, G. (2009). Theory and practice of counseling and psychotherapy. Belmont, CA: Brooks/Cole. Corey, M., Corey, G., & Corey, C. (2010). Groups: Process and practice. Belmont, CA: Brooks/Cole. Cuizon, G. (2013) . Individual vs. group counseling. Retrieved from http: //suite 10 1.cornla/individual-vs-group-counseling-a96995 Davis, S. (2012, April 16). Opportunities and challenges of co-facilitation [Web log comment]. Retrieved from http://facilitatoru.cornlblog/training/the-opportunities-andchallenges-of-co-facilitation/ Ego dystonic. (n.d.). The American Heritage® Stedman's Medical Dictionary. Retrieved from Dictionary.com website: http://dictionary.reference.com/browse/ego dystonic Garcia, F.D., & Thibaut, F. (2010). Sexual addictions. The American Journal ofDrug and Alcohol Abuse, 36, 254-260. doi: 10.3109/00952990.2010.503823 Grossman, L., Martis, B., & Fichtner, C. (1999). Are sex offenders treatable? A research overview. Psychiatric Services, 50, 349-361. 162 Hagedorn, W.B., & Hirshhom, M.A. (2009). When talking won't work: Implementing experiential group activities with addicted clients. The Journal for Specialists in Group Work, 34(1), 43-67. doi:10.1080/01933920802600832 Hall, P. (2013). Understanding and treating sex addiction. New York, NY: Routledge. Hayden, D. (January 24, 2012). Treatment of sex addiction: Relapse prevention [Web log comment]. Retrieved from http://voices.yahoo.com/treatment -sex-addiction-relapseprevention-! 0862001.html?cat=72 Herkov, M. (2006). About group therapy. Retrieved from http://psychcentral.com/lib/aboutgroup-therapy/000677 Hoffman, N. (2011 , November 30). Newsweek admits the obvious: America is in the grip of sex addiction. Life Site News. Retrieved from http://www.lifesitenews.com/news/newsweek-admits-the-obvious-america-is-in-thegrip-of-sex-addiction/ Hook, J.N., Hook, J.P., & Hines, S. (2008). Reach out or act out: Long-term group therapy for sexual addiction. Sexual Addiction & Compulsivity, 15, 217-232. doi: 10.1080110720160802288829 Join Together. (2006). Addiction costs Canada $40 billion annually. Retrieved from https://www .drugfree. org/j oin-together/ addiction/addiction-costs-canada-40 163 Kafka, M.P. (2001). The paraphilia-related disorders: A proposal for a unified classification ofnonparaphilic hypersexuality disorders. Sexual Addiction & Compulsivity, 8, 227239. doi: 10.1080/107201601753459937 Kaplan, M.S., & Kreuger, R.B. (2010). Diagnosis, assessment, and treatment of hypersexuality. Journal of Sex Research, 47(2-3), 181-198. doi: 10.1080/00224491003592863 Kleinplatz, P.J. (2012). New directions in sex therapy: Innovations and alternatives. New York, NY: Routledge. Klontz, B.T., Garos, S., & Klontz, P.T. (2005). The effectiveness ofbriefmultimodal experiential therapy in the treatment of sexual addiction. Sexual Addiction & Compulsivity, 12, 275-294. doi: 10.1080/ 10720160500362488 Kwee, A.W. (2007). Constructing addiction from experience and context: Peele and Brodsky's Love and Addiction revisited. Sexual Addiction & Compulsivity, 14, 221237. doi: 10.1080/ 10720160701480535 Leiblum, S.R. (2007). Principles and practice of sex therapy (4th Ed.). New York, NY: The Guilford Press. Levine, S.B. (2010). What is sexual addiction? Journal of Sex & Marital Therapy, 36, 261275. doi 10.1080/00926231003719681 McConaghy, N. (1993). Sexual behavior: Problems and management. New York, NY: Plenum. 164 National12 Step Meetings. (2012, Nov. 6). Benefits that one can obtain by participating in a group like Sex Addicts Anonymous [Web log comment]. Retrieved from http: //national12stepmeetings.com/benefits-that-one-can-obtain-by-participating-in-agroup-like-sex -addicts-anonymous/ Norcross, J.C., Krebs, P.M., & Prochaska, J.O. (2010). Stages of change. Journal of Clinical Psychology: In Session, 67(2), 143-154. doi: 10.1002/jclp.20758 Paraphilic disorder fact sheet. (2013). Retrieved September 24, 2013, from http://www. dsm5 .org/Documents/Paraphilic%20Disorders%20Fact%20Sheet. pdf Powell, D.J. (2006). Men in groups: Insights and interventions. Journal of Groups in Addiction & Recovery, 1(1), 95-116. doi: 10.1300/J384v01n01_06 Prochaska, J.O. & DiClemente, C.C. (1982). Transtheoretical therapy: Toward a more integrative model of change. Psychotherapy Theory, Research and Practice, 19, 276288. doi: 10.1037/h0088437 Sbraga, T.P., & O'Donohue, W.T. (2003). The sex addiction workbook: Proven strategies to help you regain control ofyour life. Oakland, CA: New Harbinger. Sex addiction treatment. (2011). Retrieved January 22, 2014, from http: //www.canadadrugrehab.ca/Sex-Addiction-Treatment.html Sex addicts anonymous: The twelve steps. (2013). Retrieved February 12, 2014, from http://saa-recovery.org/OurProgram/ 165 Sherry, P. & Hurley, J.R. (1976). Curative factors in psychotherapeutic and growth groups. Journal of Clinical Psychology, 32(4), 835-837. Smith, D.E. (2012). Editor' s note: The process addictions and the new ASAM definition of addiction. Journal of Psychoactive Drugs, 44(1 ), 1-4. doi: 10.1080/02791072.2012.662105 Statistics Canada (2012). Statistics on addiction in Canada. Retrieved November 23, 2013, from http://www.statcan.gc.ca/start-debut-eng.html The Ranch, (n.d.). Benefits of cognitive behavioural therapy in addiction treatment. Retrieved from http://www.recoveryranch.com/articles/recovery-at-theranch/cognitive-behavioral-therapy-addiction-treatment/ Walker, D.F., McGovern, S.K., Poey, E.L. , & Otis, K.E. (2005). Treatment effectiveness for male adolescent sexual offenders: A meta-analysis and review . Journal of Child Sexual Abuse, 13(3-4), 281-293 . Weeks, J. (2011). Th e languages of sexuality. Abingdon, Oxon: Routledge. Weiss, R. (2012, December 12). No sex please, we're psychiatrists (Web log comment). Retrieved from http: /lblogs.psychcentral.com/sex/2012/12/hypersexual-disordersdsm/ Wikipedia. (2013). Sex Addicts Anonymous. Retrieved from http: //en.wikipedia.org/wiki/Sex_Addicts_Anonymous 166 Wilson, G.T. (1978). Ethical and professional issues in sex therapy: Comments on Bailey's "psychotherapy or massage parlor technology?" Journal of Consulting and Clinical Psychology, 46( 6), 1510-1514. Woody, J.D. (2011). Sexual addiction/hypersexuality and the DSM: Update and practice guidance for social workers. Journal of Social Work Practice in the Addictions, 11, 301-320. doi: 10.1080/1533256X.2011.619926 Zimmerman, G.L. , Olsen, C.G., & Bosworth, M.F. (2000). A ' stages of change' approach to helping patients change behavior. American Family Physician Journal, 61(5): 14091416. 167 Appendix A Screening Interview 1. Who were you referred by? 2. What brings you here today? 3. Do you have a professional diagnosis of a sexual addiction or compulsion? a. If so when were you diagnosed? b. What was your official diagnosis? 4. If you answered no to question# 2, explain why you feel you may have a sexual addiction or compulsion? 5. What types of sexual behaviors are you engaging in that are causing you distress? 6. Has your addiction or compulsion with sex caused you distress in any of the following areas: relationships, fmances, work/school, emotional stress, health? 7. Do you find yourself engaging in these sexual behaviors frequently? 8. Do you experience difficulties abstaining from participating in these sexual behaviors? 9. What feelings do you associate with these sexual behaviors? 10. What sorts of treatments if any, have you seeked or are seeking now? 11. Where do you feel you are at in regards to your addiction/compulsion? I.e. ready to seek treatment, still feeling unsure of seeking treatment etc. 12. What do you know about this particular group? 13. What are your hopes and goals for yourself if you were to participate in the group? 14. Why do you think you would be a good fit for this particular group? 15. Do you feel ready to attend a group that is intended to help you on your path to recovery? 168 AppendixB Check-In 1. On a scale of 1-10 with 1 being horrible and 10 being awesome, how are you feeling? 2. Have you engaged in any unsafe behaviors this past week? 3. Did you achieve any of your goals from last week? 4. What was one positive thing that occurred this week? 169 Appendix C Informed Consent Welcome to the sex addiction group! We are happy to have you and look forward to supporting you on your journey. This group is a safe place for participants to discuss their experiences with their addiction as well as provide support and positive feedback to other members of the group. We understand this can be a difficult topic to discuss and, therefore, although participation is strongly encouraged, it is not mandatory. There may be some particular topics that trigger some group members and, therefore, we ask that all members be respectful and keep discussions within the group confidential. If it is suspected that a group member has compromised another member' s privacy, then the suspected member may be asked to leave the group. As a participant in the sex addiction group, it is expected that you, as a participant in this group, will respect other group member' s confidentiality. It is also our duty as facilitators to respect your confidentiality as a participant as well as the confidentiality of other participants in the group. As a facilitator, I am obliged to keep all matters discussed in group confidential with these few exceptions: 1. If a facilitator believes that you are likely to harm yourself and/or another person, he or she may take action necessary to protect you or others by contacting the appropriate agency. 2. If a facilitator has cause to believe that a child has been or may be abused or neglected, the clinician is required to make a report to the appropriate agency. 3. If a facilitator has cause to believe that an elderly or disabled person has been or may be abused, neglected, or subject to fmancial exploitation, the facilitator is obligated to make a report to the appropriate agency. 4. For the purpose of complying with legal obligations in the rare case in which your records are requested by a valid subpoena or court order. I understand this document and the legal obligations it entails. Participant Name:_ _ _ _ _ _ _ _ _ _ __ Participant Signature: Date:- - -- - - - - - - - - ------------------- Facilitator Signature: _ _ _ _ _ _ _ _ _ _ _ _ ___ Date: _ _ _ _ _ _ _ _ __ 170 Appendix D Group Norms 1. Confidentiality: a. Limitations of confidentiality b. Confidentiality within the group 2. Respect: a. Respect towards group members and their opinions b. Cross-talk c. Glamorization of sex/addiction d. Language e. Food & Drinks 3. Punctuality: a. Being on time b. Absences & Tardiness c. Attendance requirements 4. Participant's Rights: a. Right to learn b. Right to feel safe c. Right to participation 171 Appendix£ Self-Evaluation Part 1 Name:- - - - - - - Date: - - - - - Please complete the following questions as accurately as possible. 1. My sexual behaviors are currently having a negative effect on my life and/or my personal relationships 1 2 Not at all 3 4 Somewhat 5 Very much 2. I am sure I am on the right path to recovery 1 2 Not at all 3 4 Somewhat 5 Very much 3. I am engaging in these sexual behaviors more frequently than I would like to be 1 2 Not at all 3 4 Somewhat 5 Very much 4. I feel good about where I am at with my addiction/compulsion 1 2 Not at all 3 4 Somewhat 5 Very much 5. I am ready to explore options to get me on the path to recovery and a healthier sexual lifestyle 1 Not at all 2 3 Somewhat 4 5 Very much 172 Appendix F Check-Out 1. On a scale of 1-10 with 1 being horrible and 10 being awesome, how are you feeling? 2. What did you like most about today' s session? 3. How do you plan to keep yourself safe this week? 4. What goals if any, do you have for yourself this week? 173 Appendix G Hall's Six Phase Cycle of Addiction Adapted from Hall (2013) Hall ' s cycle of addiction model consists of six phases: Dormant phase, trigger phase, preparation phase, acting out phase, regret phase, reconstitution phase. Below is a diagram and a description of each of the phases of addiction. Six Phase Cycle of Addiction Diagram: 174 Six Phase Cycle of Addiction: 1. First stage is the Dormant Phase: where addiction appears to be in remission and life looks like it's back to normal, however, if underlying issues haven't been properly dealt with, then the behaviors are likely to reoccur. 2. Second stage is the Trigger Phase: it is important for each individual to find their unique triggers and to be able to recognize them before they occur. Listed below are examples of triggers. 3. Third stage is the Preparation Phase: making preparations to engage in undesirable behaviors. This is where cognitive distortions come into play e.g. my wife and I haven't been intimate in a week, I deserve to look at porn. 4. Fourth Stage is the Acting Out Phase: when the behavior is acted out by the individual. 5. Fifth Stage is the Regret Phase: when the true cost of the addiction is realized. Feelings of guilt and shame often arise in this stage. 6. Sixth Stage is the Reconstitution Phase: the individual wishes to redeem themselves. The individual's goals at this stage are often to alleviate guilt, make amends, and attempt to not engage in the behavior again. Triggers: Opportunity-related, attachment-related, and trauma-related addictions all have their own set of triggers. Below is a list of examples for each category. Opportunity-related Triggers: Environmental Emotional Being with certain people • • • • • Being in particular places • Feeling angry Seeing an attractive person • • • Empty house • • • • • • • Unprotected internet Too much time on your hands Too much money Using alcohol or drugs Feeling bored Feeling stressed Feeling entitled Feeling ashamed Feeling sorry for yourself Feeling sexually aroused Feeling unfulfilled 175 Attachment-related Triggers: • Getting into an argument with a loved one • Feeling rejected • Feeling overwhelmed by responsibility • Feeling unable to communicate needs • Feeling lonely • Feeling unvalued Trauma-related Triggers: • Felling powerless • When life feels stressful • When life feels out of control • When you feel vulnerable • Feeling empty or dead inside • Feeling depressed or anxious • When your body feels tense or numb 176 Appendix H Self-Evaluation Part 2 Name: - - - - - - - Date: - - - - - Please complete the following questions as accurately as possible. 1. My sexual behaviors are currently having a negative effect on my life and/or my personal relationships 1 2 3 4 Somewhat Not at all 5 Very much 2. I am sure if I am on the right path to recovery 1 2 3 4 Very much Somewhat Not at all 5 3. I am engaging in these sexual behaviors more frequently than I would like to be 1 2 3 4 Somewhat Not at all 5 Very much 4. I feel good at where I am at with my addiction/compulsion 1 2 Not at all 3 4 5 Very much Somewhat 5. I am ready to explore options to get me on the path to recovery and a healthier sexual lifestyle 1 Not at all 2 3 Somewhat 4 5 Very much 177 Appendix I Evaluation Part 1: Please complete the following questions as accurately as possible. 1. I gained many resources and tools from attending the group 1 2 Not at all 3 4 Somewhat 5 Very much 2. I found that my peers were helpful and supportive 1 2 Not at all 3 5 4 Very much Somewhat 3. I found my facilitators to be helpful and supportive 1 2 Not at all 3 5 4 Somewhat Very much 4. I found my facilitators to be knowledgeable in the area of sex addiction 1 2 Not at all 3 4 Somewhat 5 Very much 5. The material and homework discussed in the group were helpful 1 Nqt at all 2 3 Somewhat 4 5 Very much 178 6. The topics discussed in the group were relevant and helpful 1 3 2 4 Somewhat Not at all 5 Very much 7. I found the group to be a positive step towards my recovery and goals 1 2 Not at all 3 4 5 Very much Somewhat 8. Overall, I enjoyed attending the group 1 Not at all 2 3 4 Somewhat 5 Very much Part II: Please answer the following questions. This part is optional. 1. What I liked most about the group was: 2. What I would change about the group would be: 3. Other suggestions: _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ __ 179 Appendix J Resources for Facilitators American Association of Sex Educators Counselors and Therapists. Retrieved from http://www .AASECT.org/ Benefits that one can obtain by participating in a group like Sex Addicts Anonymous. (2012). Retrieved from http: //national12stepmeetings.cornlbenefits-that-one-can-obtain-byparticipating-in-a-group-like-sex-addicts-anonymous/ Carnes, P. (1983). Out of the shadows: Understanding sexual addiction. Minneapolis, MN: CompCare Publications. Corey, G. (2009). Theory and practice of counseling and psychotherapy. Belmont, CA: Brooks/Cole. Corey, M., Corey, G., & Corey, C. (2010). Groups: Process and practice. Belmont, CA: Brooks/Cole. Garcia, F.D., & Thibaut, F. (20 10). Sexual addictions. The American Journal of Drug and Alcohol Abuse, 36, 254-260. Hagedorn, W.B ., & Hirshhorn, M.A. (2009). When talking won't work: Implementing experiential group activities with addicted clients. The Journal for Specialists in Group Work, 34(1), 43-67. Hall, P. (2013). Understanding and treating sex addiction. New York, NY: Routledge. Herkov, M. (2006). About group therapy. Psych Central. Retrieved from http://psychcentral.com/lib/about-group-therapy/000677 Hook, J.N., Hook, J.P., & Hines, S. (2008). Reach out or act out: Long-term group therapy for sexual addiction. Sexual Addiction & Compulsivity. 15, 217-232. Kafka, M.P. (2001). The paraphilia-related disorders: A proposal for a unified classification of nonparaphilic hypersexuality disorders. Sexual Addiction & Compulsivity, 8, 227239. Kaplan, M.S. , & Kreuger, R.B. (2010). Diagnosis, assessment, and treatment of hypersexuality. Journal of Sex Research, 47(2-3), 181-198. Kleinplatz, P.J. (2012). New directions in sex therapy: Innovations and alternatives. New York, NY: Routledge. Klontz, B.T., Garos, S., & Klontz, P.T. (2005). The effectiveness ofbriefmultimodal experiential therapy in the treatment of sexual addiction. Sexual Addiction & Compulsivity, 12, 275-294.