The opening sentence from van der kolk, McFarlane and Weisaeth (2007) could be perceived as fatalistic, but unfortunately it is realistic, “experiencing trauma is an essential part of being human; history is written in blood” (p.3). It would be incorrect to assume that the primary vehicle of trauma is delivered solely by physical traumas such as combat, rape or car accidents. Trauma can also create deep psychological wounds through childhood emotional neglect, abandonment and/or abuse (van der Kolk et al., 2007).
Post-Traumatic Stress Disorder (PTSD)
PTSD is complicated and personal, it can impact the psyche and also manifest in powerful somatic symptoms (van der Kolk et al., 2007). It can damage functioning in social domains, as well as the biological, psychological and spiritual aspects of one’s personality (van der Kolk et al., 2007). It is not uncommon to see disassociation and depersonalization linked to trauma as well (van der Kolk et al., 2007).
PTSD can be complex or have its roots in just one traumatic situation (van der Kolk et al., 2007). Adsit (2007) states that intention and intensity seem to play a key role in whether or not one develops PTSD. If situation is intentional such as a date rape, it may be more likely to cause PTSD compared to a natural disaster like a hurricane (Adsit, 2007). And example of intensity can easily be given in the events that occurred on September 11th. Complex PTSD is when a series of traumatic events happen over an extended period of time, creating multiple negative and impactful overwhelming experiences in one’s life that can pile up one on top of the other (van der Kolk et al., 2007).
The primary components that warrant a diagnosis of PTSD include avoiding stimuli that can trigger the original trauma, numbing or constriction of emotions and feelings and intrusive thoughts or flashbacks which can include nightmares (van der Kol et al., 2007). A person suffering from PTSD can also become hypervigilant and/or also struggle to focus and concentrate (van der Kolk et al., 2007).
PTSD is caused by an actual or perceived threat to one’s life, it can also occur after witnessing a life-threating event (van der Kolk et al., 2007). Two other classic symptoms of PTSD are persistent and increasing negative affect and an inability to participate and enjoy activities that previously interested the individual (van der Kolk et al., 2007). Aggressive behavior, including self-harm, is also a feature of PTSD (van der Kolk et al., 2007).
A combination of these symptoms can form and be diagnosed as PTSD directly after the traumatic event or some time later (van der Kolk et al., 2007). If the client meets criteria over a sustained period of time (more than one month), it is officially PTSD (van der Kolk et al., 2007). It is important to note that experiencing or witnessing a traumatic event does not mean one will develop PTSD, in some instances trauma can be subjective and often the impact depends on a person’s history, resilience and vulnerability (van der Kolk et al., 2007). Adsit (2007) states that 75% of the population will or has experienced a traumatic event that could warrant development of a PTSD diagnosis. Of the 75% who experience a trauma, only 25% will go on to meet criteria for PTSD (Adsit, 2007).
Personal history, resilience and vulnerability play key, yet enigmatic roles in whether or not one develops PTSD. Aaron (2012) notes that many studies have shown the quality of a child’s home life can act as an inoculating factor against PTSD. If a child is raised in an emotionally supportive home and experiences a traumatic event, it can be more likely that he or she may not develop PTSD (Aaron, 2012). If a child experiences a trauma and the perpetrator is a significant attachment figure, and the child does not receive proper familial support, this sets the stage for a more likely case of PTSD (Aaron, 2012).
Sexual addiction, or compulsive sexual behavior, is not currently listed in the Diagnostic and Statistical Manual of Mental Disorders(DSM-5). With that being said, there are many respected professionals in the mental health field who have been researching, studying and treating clients with this unique set of symptomology. It is estimated that up to 17% of the population suffers from some type of compulsive sexual behavior and that of the 17%, 40 to 50% are women (McKeague, 2014).
Sexual addiction can be divided into two categories of abnormal sexual patterns of behavior (Smith, Potenza, Mazure, McKee, Park & Hoff, 2014). The first, paraphilic behavior, includes sadistic or masochistic acting out or acting out with underage children. The second, is called normaphilic behavior, includes intense sexual urges/craving and/or fantasies related to compulsive masturbation, pornography and/or sex (Smith et al., 2014).
When one develops an obsessive-compulsive relationship with pornography, cyber-sex, infidelity, prostitution or another similar sexual behavior, sexual addiction may be present (McPherson, Clayton, Wood, Hiskey & Andrews, 2013). It is postulated that compulsive sexual behavior echoes that of other addictions such as substance abuse and gambling in psychosocial history and etiology (McPherson et al., 2013). McKeague (2014) lists trauma along with shame, attachment and cultural influences as four main facets that contribute to the development of sexual addiction. There are disturbingly high rates of childhood trauma in the history of sex addicts, and it needs to be noted that at this time the rates and level of severity surpass that of men (McKeague, 2014)
If left untreated, compulsive sexual behavior, not unlike other recognized addictions, is believed to be a progressive disease that can destroy families, careers, physical and mental health (Howard, 2007; Smith, 2014). Understanding the damage that this addiction can cause, and the fact that many still cannot refrain from acting out despite the lethal consequences, is evidence that compulsive sexual behavior is a serious condition similar to drug and alcohol addiction (Howard, 2007). Howard (2007) mirrors many other sexual addiction professionals when he states that trauma treatment is an essential part of successful recovery.
Howard (2007) notes that sexual compulsive behavior has been show to be a common way to numb and avoid symptoms of unresolved PTSD. Sex is a powerful tool that can act as a drug to escape disturbing traumatic memories (Howard, 2007). It can turn into a self-medicating coping behavior used to cover up powerful negative emotions that are the result of past trauma (Howard, 2007). The double-bind for those suffering from sexual addiction and PTSD is that compulsive sexual behavior has been shown as a stumbling block to trauma treatment because it is a powerful avoidance mechanism (Smith et al., 2014).
Smith et al. (2014) states that a population of military veterans has been shown to engage in compulsive sexual behaviors as a means to cope with the trauma of war. Smith et al. (2014) noted that the military population has a higher rate of PTSD correlated with sexual addiction compared to the general population. In one study the correlation between PTSD, military veterans and sexual addiction was 97% (Smith et al., 2014). In this same study, the symptoms correlated with the PTSD and sexual addiction was re-experiencing (Smith et al., 2014). It is interesting to note that this study did not correlate any other of the symptoms in the PTSD cluster to compulsive sexual behavior (Smith et al., 2014).
Childhood sexual trauma was also linked to sexual addiction in this study and increased a veteran’s odds of struggling with sexual addiction by three times compared to those veterans who did not have a history of childhood sexual trauma (Smith et al., 2014). Turban, Potenza, Hoff, Martino and Kraus (2017) parallel this finding and add that the severity of childhood sexual trauma, young age, PTSD and online compulsive sexual behavior have been correlated in populations of veterans as well. Aaron (2012) stated that if penetration was in the history of childhood sexual abuse, and/or high rates of frequency, that it could be more likely PTSD and sexual addiction would develop later in life.
In Smith et al. (2007) study, the veterans were engaging in online social media to compulsively seek out partners who were willing to meet up and have casual sex (Turban, 2017). Another interesting aspect of the Turban et al. (2017) study is that a lack of correlation between sexual addiction and substance addiction was recorded; the author postulates this may be due to the veterans choosing to use sex as opposed to alcohol to cope. This author adds that this may be a subconscious negative coping mechanism developed to self-medicate the re-experiencing cluster, due to complex PTSD (the combination of the childhood sexual trauma and the military induced PTSD).
Another form of childhood trauma, emotional neglect, in some studies has a higher correlation with sexual addiction than does childhood sexual trauma (Aaron, 2012). Lack of secure attachment has also been linked to emotional neglect, trauma, sexual addiction and PTSD (McKeague, 2012). McKeague (2012) states that insecure attachment, along with dysfunctional family of origin relationships that lack boundaries, attunement and have unhealthy family rules creates the environment for a dysfunctional approach to interpersonal relationships, which can lead to the development of sexual addiction. From the birth of the sexual addiction, a destructive cycle of addiction and trauma begins.
Gender and Age Differences
Female sex addicts present their addiction and trauma in a slightly different way from men (McKeague, 2014). A girl who is sexually abused at a young age, especially before puberty, is more likely to develop compulsive sexual behaviors, but if she is older, she is more likely to develop sexual anorexia, or acting in, which is considered to be at the other end of the sexual addiction spectrum (Aaron, 2012). The shame attached to the older girl is postulated as the reason she more likely will retract her sexuality and avoid it, as opposed to act it out (Aaron, 2012). She is more likely to avoid and develop a fear or phobic position towards sex (Aaron, 2012).
For a woman who develops a sexually acting out pattern of addiction, she is likely to carry intense feelings of shame and unworthiness due to the trauma inflicted from a poor attachment to her mother (McKeague, 2012). For women it is postulated that the addiction is born out of an intense need for connection (McKeague, 2012). For men it is postulated that the trauma may come from a ruptured attachment and subsequent shame and unworthiness associated with the father (McKeague, 2012). This author postulates that it would be traumatic for a child to have a ruptured attachment from either parent, and that either male or female could then development a severe need for connection and seek out love in all the wrong places to vacillate between re-enactment, sensation seeking and numbing of traumatic pain.
For boys, compulsive sexual acting out is more often correlated with childhood sexual abuse (Aaron, 2012). If the sexual abuse for the boy includes penetration and physical force, this heightens the risk even more (Aaron, 2012). For an adult male sex addict who has severe childhood sexual trauma, it is likely the acting out patterns will be a replication of the early sexual trauma (Aaron, 2012). Men seem to have a re-enactment pattern in the form of compulsive sexual addiction as a way to try and shake off the sense of powerlessness and lack of control they felt while being victimized (Aaron, 2012).
It is still important to clearly state that childhood sexual trauma, regardless of gender and age, just like trauma in general, does not create PTSD in all victims (Aaron, 2012). Aaron (2012) states that healthy family functioning and emotional support plays a huge role in early recovery for young victims and a higher chance to avoid PTSD down the road. If a family has low internal conflict, high maternal support, low levels of enmeshment which means individuals in the family system are allowed to express healthy anger, sadness along with a full range of emotions, these child victims can be symptom-free in fives years post-disclosure (Aaron, 2012).
Trauma-focused Treatment for Sexual Addiction
Levine (2008) states that, “suffering can be transformed and healed” (p.4) and that once we identify the source of our trauma and suffering, we then must, “find an appropriate path” (p.4). Pain and suffering are part of the human experience, but there are many ways available to treat trauma (Levine, 2008). Because trauma is complex and personal, trauma recovery must be as well. Sexual addiction is seldom seen without a history of trauma and PTSD (Cox & Howard, 2007). Clinicians understand that to treat sexual addiction the underlying trauma and shame must be addressed (Cox & Howard, 2007).
One of the most popular and empirically researched trauma treatment methods is eye movement desensitization and reprocessing (EMDR) (Cox & Howard, 2007). EMDR can successfully treat PTSD and trauma in as few as two to five sessions (Cox & Howard, 2007). It has a 95% success rate and is recognized by most health insurance companies so it is a pretty accessible form of treatment (Cox & Howard, 2007).
Neurofeedback is another form of trauma and PTSD treatment that is being used in the military and in some private practices today (van der Kolk, 2014). It is a sophisticated technique that is new but is seeing extremely promising results (van der Kolk, 2014). Neurofeedback, like EMDR, has demonstrated the ability to rewire the brain after a traumatic event (van der Kolk, 2014).
Neurofeedback, as van der Kolk explains, “stabilizes the brain and increases resiliency” (p. 314). Once the brain is stabilized, this happens in the frontal lobes, it is no longer stuck in the flight, flight or freeze stress mode, and therefore it frees the individual to have more choices in how to respond to life (van der Kolk, 2014). It trains the brain to produce alpha waves, which are synonymous with a state of calm and relaxation (van der Kolk, 2014). It is especially helpful in cases where the traumatized victim cannot even communicate his or her experiences because they are too horrific (van der Kolk, 2014). It can be a starting point to then open up a client for psychotherapy, or it also has been used as an ending point, or last resort, for some sex addicts who have been resistant to all other forms of trauma treatment (van der Kolk, 2014).
The downside to neurofeedback is the cost, finding a trained professional and the time-commitment. EMDR boasts a mere two to five sessions; almost always covered by insurance meaning just a small co-pay is usually required, and many professionals are trained in this technique. Neurofeedback professionals recommend at least 20 consecutive sessions (van der Kolk, 2014). It is a promising new treatment but that means the insurance companies are awaiting a dearth of needed research to prove its success empirically before they agree to cover it. A session can range from $100 to $150, and start to finish it can take 6 months of weekly sessions (van der Kolk, 2014). It also is a new area and requires the use of specialized equipment and a trained professional, so it is harder to locate help.
Referred to as communal rituals – theater, music and yoga are three ancient practices that have proven successful in treating trauma (van der Kolk, 2014). Theater, music and yoga all help a traumatized client learn to reconnect with his or her body through movement, which addresses the dissociation and numbing that is one of the profoundly horrible symptoms of PTSD (van der Kolk, 2014). Theater can serve as a conduit to ignite and tolerate feeling deeply, and music can help one learn to pendulant and soothe strong emotional surges (van der Kolk, 2014). The benefit of doing these as group activities is collective bonding.
These communal rituals build and support attunement, connection, attachment and interpersonal relationship building which can target childhood traumas such as insecure attachment, isolation and intimacy issues due to emotional abandonment that are often present in the history of sex addicts (van der Kolk, 2014). Collective bonding rituals also foster trust building (van der Kolk, 2014), which often needs to be restored for those recovering from PTSD and sexual addiction. In these forms of communal rituals, “we are healing trauma without anyone ever mentioning the word” (van der Kolk, 2014, p. 341).
Spirituality and PTSD
“When we reclaim our enthusiasm for life, we are drawing closer to God” (Levine, 2008, p. 79). Levine (2008) states that in almost every spiritual tradition, from Christianity to Buddhism, suffering is taught as a precursor to awakening. Levine (2008) goes on to say that trauma is about a loss of connection, to others, to oneself and most of all, to God. Trauma and suffering have the power to catapult one through the recovery process where on the other side spiritual transformation awaits (Levine, 2008).
Spirituality and theology gives individuals a historical timeline of human suffering and our remarkable resilience and ability to transform pain into purpose (van der Kolk et al., 2007). Meditation, prayer, religious ritual and worship music all provide a framework that promotes endurance and inoculation against the hardship and reality of pain and suffering in this life (van der Kolk et al., 2007). Christianity in its purest, most ideal form, provides the space for individuals to identify and empathize with the trauma and suffering of their fellow human beings (van der Kolk et al., 2008). Treating trauma along with addiction is a time consuming process that takes a multi-model approach (Aaron, 2012) and includes commitment, self-compassion and a safe community of support, because some aspects of trauma and addiction recovery feel like they may never resolve or heal.
