An Integrated Approach to the Treatment of Sex Addiction
June 3, 2016
Understand Porn Addiction for the Addict and His Spouse
June 4, 2016

Pornography Addiction: A Case Study


A new sexual revolution, tantamount to the one in the 1970’s has been underway since the Internet became part of our lifestyles a mere 20 years ago. Contemporary clinicians need to have a working knowledge about the impact of Internet sexuality on their work with clients and families.  Pornography addiction already reflects issues around sexual issues that are pervasive throughout our culture.  Armed with knowledge, clinicians can be proactive in shaping the future of the new sexual revolution.

Since it’s beginning, the Internet has been interwoven with sexuality, each contributing to the transformation of the new sexuality.  Eighteen million people in the United States accessed pornography sites in the year 2000, a figure that is three times higher than for 1999.

Computers speed things up. Regarding sexuality, the increase in speed can evoke intense emotional reactions.  The changes in speed and intensity of online sexual encounters is unprecedented. Three central components that have given rise to the speed and power of pornography addiction are:

  • Access

The Internet has become available, convenient and easily accessed by increasingly larger number of people worldwide.  This accessibility has contributed to sex being one of the most commonly search topics on the Internet.  People now do not have to delay sexual gratification as the Web is available 24/7 to satisfy any sexual desire or fantasy they may have without the need to delay gratification.

  • Affordable

With improvements in search engines, the Internet serves as a clearinghouse that keeps time and costs in check.  Consumers who know their way around the Net can easily find free sexuality-related items and services.  In addiction, the declining costs of server space and increased revenue from banner and link advertising helps keep user fees low.

  • Anonymity

Thinking that one’s identity is concealed online has a powerful effect on individual sexual expression.  For example, those who may hesitant to purchase sexually explicit materials or products in a one-to-one encounter are usually more comfortable when protected by the anonymity they feel online.

Cooper, A. (1998b).  Sexually compulsive behavior.  Contemporary Sexuality, 32, 1-3


More Than Just Pornography

Today, digital sexual activity extends well beyond the bounds of pornography.  It is possible

  • to meet a potential sex partner using a smartphone hookup app, to flirt via texts and sexts,
  • to be sexual via webcams and then to brag about the encounter on some form of social media.
  • People join sexual membership communities that address various sexual interests.
  • Individuals view and download porn photos or videos from other people,
  • commercial porn sites, newsgroups or file transfer protocol (FTP) sites;
  • use prostitute, escort and sexual massage websites and apps;
  • engage in mutual sexual activity in private chat rooms
  • write back and forth while masturbating,
  • masturbating in video chat;
  • viewing, via webcam,
  • staged sexual acts in real time;
  • using apps to find anonymous sexual hookups;
  • searching social media to view intimate photos or locate potential sexual partners;
  • sending sexual texts and images via smartphones just for the sexual thrill of it;
  • playing virtual sex games to create customized fantasy avatars that participate in interactive online sexcapades.

Given the amount and variety of currently available digital sexual activities, it is easy to see why sex addiction is on the rise.

What Makes for a Pornography Addiction?”

Most casual users of digital sexnology are people who find sexual virtual experiences fascinating and fun.  They have involvement in these pleasurable distractions but not to extremes. They find these activities to be an enjoyable distraction that is ultimately not as satisfying as more intimate connections.

Cybersex addicts, however, compulsively use digital technology to use sexual fantasy and behaviors to cover underlying issues of low self-esteem, shame, anxiety, depression and low self-worth.  Sexuality is used to temporarily fill an inner emotional void.  They are, however, unable to stop these behaviors on their own, even when they experience negative consequences  or have a desire to change.

People who become addicted to the intensity of cybersex for emotional numbing and self-soothing are, in essence, drug addicts.  Instead of using something external to themselves to produce a high, they exploit their own neurochemistry.  The self-induced neurochemical stimulation provided by hours of engaging in digital sex becomes their “drug of choice.”.  Over time, their priorities shift from family, spouse, work, recreation to the pursuit of stimulation via sexual content and behavior.

Pornography addiction individuals continue their behaviors despite feeling shame about their activities and damaging life goals and personal relationships.

Case Study

When Steve arrived to his first session with me, he was markedly unkempt and underweight.  With head held down, he didn’t make eye contact with me and, once sitting in the chair, was inward and lacking anything much to say.

After a few sessions, he did communicate that he had received a demotion on his job and that his wife had filed for divorce.  He seemed to be in a severe depression around these losses.

Steve reported that he once over-indulged in alcohol and drugs but that because of a serious accident on the job, he quit using substances.  However, over the next several months, he found that his urges to masturbate increased.  He found that if he did not act on these urges, he would remain “horny” all day and would be unable to focus on his work or pay attention to his wife when she spoke to him.  He was constantly preoccupied with his sexual fantasies.

Steven felt lifeless and empty, devoid of energy, interest, or capacity of enjoyment.  The only thing that gave him a sense of aliveness was a sexual encounter.  For months after his wife declared that she was leaving, he found that his sexual fantasies and urges to masturbate were becoming more and more imperious.  He realized that if he did not masturbate, he would remain “horny” all day which would make him feel restless, irritable and discontent.

Beyond Fantasies

Steve began to see that pornography was not enough to sexually excite him.  His use of digital devises to achieve sexual stimulation escalated.  He found that being locked into the fantasies and rituals that preceded the sexual acting out were just as compelling as the actual sex act, perhaps even more so.  His emotionally charged neurochemical high was maintained by the ongoing dopamine-enhanced searching, downloading, chatting, texting, sexting and other sexual-based behaviors.  Every new video, picture, game, or person released more dopamine, aiding him to maintain lengthy periods of excitement through all of his looking, searching, fantasizing and anticipating.

Steve reported that he could spend endless hours feeling intense arousal without becoming physically aroused or coming to orgasm.  His search for the perfect video, image or partner kept him disengaged and distracted from life’s priorities, relationship and life commitment as effectively as heroin, cocaine, or any other mood-changing substance.  Cybersex was, indeed, his “drug of choice.”

After a year in treatment, Steve agreed to go to a meeting of Sex Addicts Anonymous (SSA).  He found comfort there, knowing that he was not the only person in the world who engaged in such sexual behaviors.  He felt supported and valued in a way he never had been before in his life.  For the first time, he felt he belonged somewhere.  He began to feel that he could talk to people and that people could share with him.  Most importantly, he reported, he was learning how to be himself and to be comfortable with himself in social situations.

Of course, this effected his treatment.  We began to do a cost/benefit analysis of his sexual behavior.  The benefit was the intense sexual pleasure and the escape from unwanted inner experiences.

At this time, Steve made a major breakthrough.  His denial broken, he saw clearly the damage he had done to himself and to those close to him.  These included:

  • Isolation from friends and family
  • Reduced intimacy with one’s committed partner
  • Broken trust in one’s relationships
  • Increased stress from living a duplicitous life
  • Loss of income from demotion at work and possible loss of job
  • Partners losing self-esteem and self-worth by failing to ‘live up” to fantasy porn images
  • Emotionally neglecting children
  • Sexual dysfunction (erectile dysfunction)
  • Loss of interest in hobbies and other healthy activities
  • Self-neglect due to lack of sleep and exercise

Life History

Steven was the first of three children, with two younger sisters.  Before he was born, his mother had a miscarriage at five months gestation.  Steve described his mother as “deceitful”, warm and inviting one moment and rejecting the next.  She idolized Steven.  He was the apple of his eye who could do no wrong.  However, she had exacting standards when he failed to meet those standards, and she would tell him with contempt that he was disgusting, noisy and boorish and would send him to his room for hours on end.

Steven recalled that his mother had “horrendous” attitudes toward men and would often complain that they were “beasts”: loud, rough, and only interested in sex.  She would often undress in front of Steve, and would leave the bedroom door open before she went to bed.  When he was afraid, he would often climb into bed with his parents.  This continued until his father left the family when he was 12 years old.  He recalled that he was lying in bed with her and she wore a flimsy nightgown.  Steve reported that he had always had sexual thoughts about this mother.

Steven’s father was a kind, sensitive and depressive man, when he was sober.  When he had been drinking, he was loud and aggressive.  By the time he was 3 years-old, his father was rarely sober.  Steven’s father was abusive to the whole family when he was drinking but he was particularly abusive to Steven.  From time to time, he would mention that when Steven was born, he was neither planned or wanted.  Steve observed that his father “always made sure that I knew what an asshole was.”

Steve’s father left the family when he was 9 years-old.  He felt abandoned and feared that he would never return.  At the same time he also feared that his father would come back and shoot them all.  He also felt responsible for the breakup of his parent’s marriage.

Clinical Procedure 

Steven’s core affective experience was intense, searing shame from which sexuality gave him his only relief.  He had failed to live up to to his parents’ expectations of him and failed to live up to his own.  Living in a family where he was either idolized or belittled, his shame had become internalized, that is, an essential part of his identity.

He had primary shame from living with his family and secondary shame from his addiction.  Every time he had an orgasm, he was left with shame and self-hatred.  It’s shameful not to be able to be in control of own’s own behavior despite one’s best effort.

Steve’s low self-esteem and his vacuous sense of self derived party from his sense that his father neither wanted nor valued him, partly from his mother’s erratic and narcissistic responsiveness to him and partly from his split and sometime amorphous sense of identity.  Harold’s mother complicated Steven’s task of developing a healthy make identity by devaluing his father, criticizing Steven when he acted like his father and devaluing men in general.

His experience with a 12-Step program helped lessen that shame and the empathy and understanding I offered him also helped to alleviate his shame.

Treatment was divided into “first order” change and “second order” change. “First order” change is designed to stabilize his behavior.  He was sent for a psychiatric assessment to rule out co-morbid psychiatric disorders.  The doctor put him on a low dose of Prosac, not for a mood disorder, but to help him manage his obsessive sexual urges.

We then embarked on a Cognitive-Behavioral regime to establish a Relapse Prevention program.  He wrote out a series of “triggers” – internal and external events that preceded his sexual acting out.  He learned to stay away from high-risk situations. Alternative coping strategies were then devised for each trigger.  Ways to manage cravings and urges were then discussed. He saw cravings and fantasies as signals of inner distress.  He could more readily observe and verbalize his inner states, rather than simply responding to them with physical action.  In addiction, how to handle lapses and relapses were dealt with.

Simple behavioral changes were put in place.  He exchanged his SmartPhone for a regular cell phone.  The computer was put in the family room.  A filter that eliminated erotic material was put on the computer.  He installed a family-oriented Internet service contract.  When he had to use the computer, he limited himself to specific times when he checked his emails and such.

Steve and I then discussed at length his relationship to his own emotions because negative emotions are often used as a fuel for acting out.  The treatment focused on learning to tolerate negative emotions without using sex to relieve them.  Knowing how to cope effectively with strong feelings is essential to sexual sex-control.  Coping with the issue of immediate gratification was discussed.

A critical part of a Relapse Prevention Plan is working on recognizing and disputing cognitive distortions.  Sex addicts have plenty of cognitive distortions about themselves, about women and about sex.  I asked Steve to write down what he thought his were and then to write down next to them an alternative, more realistic thought that he was to read a few times a week.

Because Steve had been isolated for so long, we worked on basic communication skills and he agreed to take a course in assertiveness.  Both of theses tasks made him feel more comfortable in the world with people.

Second-Order Changes

Second-order changes are the nuts-and-bolts of treatment.  They occur only after the patient is stable enough to handle the volatility of dealing with the more difficult aspects of treatment and tend to be psychodynamic and couples counselling.

Couples Counseling

One of the things that propelled Steve into treatment was his wife’s threat of divorce.  Although their relationship was in shambles after years of his addictive behaviors, he still loved her and very much wanted her to be in his life.

Sara, for her part, had become torn into pieces by Steven’s behavior.  Having spent such large amounts of time in the basement engaging in “deviant” sexual behavior made her feel lonely, ignored, unimportant and neglected.  Her self-esteem suffered, knowing that her husband preferred to spend his time in front of a computer screen in the company of a fantasy person with whom she could not compete.

She felt a deep sense of shame because of what was going on in the family, heightened by the fact that she was hesitant to speak to anyone about the situation or her feelings about it because she wanted to protect Steve from the humiliation of the situation.

The combination of devastation, hurt, betrayal, loss of self-esteem, betrayal and self-esteem set the stage for Sara to begin to have an affair with a neighboring man.  Her motives were both to shore up her sexual self-esteem and to wreck revenge on Steve for betraying her.  Sara didn’t continue in the affair from very longer, however, because she still felt devoted to Steve.

Steve’s acting out had a deleterious effect on the couple’s sex life.  Sara, feeling that she didn’t “measure up” to his fantasy women, worked to make herself especially attractive and initiated lovemaking much more often that she once did.  She wore sexy articles of clothing that she though Steve would like.  On some occasions, Sara performed sexual acts that she found repugnant because she thought it would please him.  She did everything she could to persuade him that he didn’t “need” to look at those “other women”.

What Sara didn’t understand was that no mortal human being could ever live up to the “erotic haze” – the dopamine enhanced highly aroused state that the sex addict entered into when he was acting out that really had little to do with sex with a real woman. A real-life person can never compete with a fantasy.  She also didn’t understand that she held NO responsibility for the situation; that Steve fabricated his condition as a result of childhood trauma and that he carried the emotional wounds with him well before he ever met Sara.

In sex addiction treatment, Sara relayed that it wasn’t the sexual behavior that hurt her as much as the lies and secrets that surrounded the behavior.  It was that that she didn’t know if she could forgive.  She doubted she could ever trust him again.

Sara, in counseling, need her feelings validated especially because for years Steven would tell her she was “crazy” when she’s suspect something.  She need to accept that she did not cause the problem and that she could not control it and the belief that if she had enough information she’s be able to control his behavior was an illusion.

For a number of years, Sara, like so many women before her, became obsessive about “spying” on her mate; repeatingly checking computer hard drives, smart phones, texts, videos, webcams, emails, etc. to see if he was acting out.  She said she felt crazy when she did this routine, but she actually felt so out of control, that she felt that if she had more information, she would feel less crazy, that things would make more sense and that she would, indeed, have more control over a situation over which she felt powerless.

Sara agreed to begin to attend S-anon, a 12-Step program for partners of sex addicts where she met women who were able to give her support and empathy.  At the same time she started treatment with a therapist I referred her to, while they both continued couples therapy.


One year after treatment began, Steve announced that he was terminating treatment.  I encourage him to talk about what had led him to this decision and our exploration revealed his fantasy that I would punish and humiliate him for having “failed” after having been so sure of himself.  Further work indicated relationships between this fantasy and (1) Steve’s shame about his fall from grandiosity and his need for help (2) his envy and resentment of me; and (3) a number of emotionally significant childhood experiences with both his parents.  Steve’s ability to discuss these things in a safe environment enabled him to see me as less as a bully and more as a stable and stabilizing mentor who might be able to help him out of the mess that he now knew to be his inner life and (4) the motivational dynamics and the fantasies that were associated with Steve’s sexual inclinations.

As treatment progressed, Steven began to realize that these fantasy-based transient sexual encounters were not what he was really looking for, since they would not satisfy him or meet his needs for intimate connection.

Treatment then took the turn of addressing the damage incurred from his relationships from his parents.  We looked squarely at the messages he internalized as a child that were effecting his well-being as an adult.  Some of these were:

  • He was not good enough, not lovable and he did not belong;
  • He experienced threats of abandonment, neglect and disinterest;
  • Parental perfectionism.

After we located the most important deficiency messages he received, he went through a grieving process in his life that resulted from these messages.  As an adult, he consciously challenged the messages with new messages that reflected his self-worth.  Most importantly, he returned his “borrowed shame”.  Both of his parents were wounded souls and had their own low self-esteem and sense of shame that they gave over to Steve.  Steve make a decision that the shame didn’t belong to him; it belonged to his parents and he gave it back to where it belonged – to his parents.

Steve grappled with the idea of forgiving his family.  He saw forgiveness as something he did for himself because living live in resentment was too painful.  This was demonstrated when he went to visit them.  The visits were shorter and his interactions with them were calmer and less angry.  He had accepted them as fallible human beings who did the best they could to parent him.

Three years after treatment had begun, Steve had made tremendous changes in his life.  He continued to come to therapy and he worked an active program in Sex Addicts Anonymous.  He had a network of supportive friends with whom he did enjoyable activities with.  He developed new hobbies.  He exercised regularly.  He and Sara were doing well.  They adhered to a “sobriety contract” which consisted of a list of behaviors that he would adhere to which, over time, showed her that he could once again, be trusted.

Steve did still experience cravings, but he had acquired skills with which to deal with them.  On a few occasions he lapsed.  However, because of the relapse prevention work we had done, he did have have to move into a full-blown relapse and he understood that a lapse meant that he had to make some changes in his relapse recovery plan.


Love and sex are part of the human condition and, as such, they are matters of concern for the clinical community.  It behooves those of us who work with the clinical population, especially young people, to have some familiarly of the effects that digital technology is having on human sexuality.

Excessive sexual compulsivity indicates a loss of control and a diminished capacity to regulate the activity to regulate the activities of daily living.  The Internet enables sexual pursuits to alter people to alter their consciousness or mood and interferes with major sphere of living, e.g. work, children, school, health, social and family relations.

Cybersex creates a virtual world in which participants can be whomever they wish, engage in a wide variety of erotic behaviors and live out fantasies that they could never before the realized.

Even for people who are not addicts, the rampant use of digital technology is having a dehumanizing effect on sexuality – it’s gradually separating love from sex.


Dorothy Hayden, LCSW has 20 years of experience treating sex and porn addicts, love addiction, codependency, fetishes, sadomasochism, "kink friendly", crossdressers and their wives, partners of sex addicts. She has been interviewed on "HBO", "20/20" and Anderson Cooper 360. Ms. Hayden has authored the book "Total Sex Addiction Recovery - A Guide to Therapy"

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