Originally posted February 25, 2013
Patrick Carnes: Evolution of Revolution, Understanding Sex Addiction
It was a cold late fall evening, and I was about to give my first address to the medical staff of Golden Valley Health Center. This facility was an 850-bed hospital located in suburban Minneapolis. It had a long and respected tradition as a psychiatric facility that also treated substance abuse. The year was 1984 and Out of the Shadows had appeared in January. While the reception that year certainly started controversies, there was also real and substantive support in both the professional and the recovering communities. The very first inpatient program for sex addiction was set to open in January 1985.
My job that night was to be the keynote speaker for the annual medical staff dinner for close to 300 doctors, clinicians and their spouses. My purpose was to underline the importance of this new sex addiction program. I was nervous, but I strategized that what had worked best for me was to use compelling cases to paint a picture of real need. One example was that I had a letter from the wife of a physician who had joined Sex Addicts Anonymous (SAA) and received treatment. It was a moving tribute to the power of treatment and her gratitude for the help received. Also I knew I had spouses in the audience as well as doctors, so it was a way for all to identify. And the author had kindly given me permission to share her sentiments anonymously. So I was ready.
Yet I was totally unprepared for what happened. After the lovely supper had been served and eaten, the hospital administrator went to the podium and started his introduction for my talk. It was a cue for a staged walkout. Suddenly about half of the audience simply got up and left. They were led by the most significant psychiatric group on the medical staff. Even more stunning was that key members of the administration staff joined the exodus in protest to the hospital opening a sex addiction program.
Over my career I have had critics, hecklers and reluctant staff members. But that moment was a defining moment in which I and what I represented were clearly not welcome. I remember the spotlights being on me, and everyone waiting for what I would say. I stood there, notes and letter in hand, transfixed with the fear that I had no right to be there. I wondered if I should walk away, but then I looked at that letter and knew I needed to speak the truth I knew. So I stepped forward and with a somewhat halting voice thanked those who had stayed and told them why I was there.
At the time Golden Valley was owned by Compcare Corporation and its president was Dr. Richard Santoni. He and I had spent afternoons together reviewing data and cases about sex addiction. His resolve pushed all of us to opening that program on time. Once open, a transformation occurred. The patients were profoundly grateful to have a place that understood their problem. Compared to most patients in the facility, they were not only hurting but also motivated. Soon the Sexual Dependency Units became the place where everyone wanted to work. Even the physicians who had walked out during my address changed their minds. When the patients came, the legitimacy of the problem was clearly established. The reputation for breaking new ground and being of genuine help compared to the revolving psychiatric doors characteristic of the day was more than attractive. Plus in 1985, physicians would be paid by patient as a separate bill. With $265 a day at stake, those who walked out the night of my talk now demanded to be put on the rotation list.
Then new institutional battle lines were drawn. The word spread that these were interesting, motivated patients who could afford to pay. Doctors wanted to be these new patients’ doctors but did not have time to go through the training to understand what the staff was asking of the patients in the program. Thus you had doctors giving well-meaning but ill-informed advice that was contrary to the precepts of the program. Clearly, a training program was necessary. Similarly, referents were asking for help because now that there was help, others followed locally from 12-step groups. Clinicians also saw the progress made in the hospital but questioned how to maintain momentum when the patient returned to the real world.
Other questions arose. With so many patients coming to the clinic, could they be put into groups? What was the criteria for inpatients other than desperation? Did treatment work for offenders? Were offenders part of a continuum, a separate problem or was there an overlap with sex addiction?
Leading the requests to join the new program were various directors of physician health programs. Most notable among those was Dr. Richard Irons, who eventually joined the staff at Golden Valley, and Dr. David Dodd from the Tennessee Medical Foundation, who worked hard to open the doors to understanding for those who treated physicians with addictions. Both of these men rose to the challenge of leadership and contributed dramatically to the knowledge and acceptance of sex addiction as a problem. Now physicians were joining in the fight and advocating for further knowledge.
The problem then was how to acquire that knowledge. I remember sitting at lunch with colleagues from Golden Valley in May of 1985.
We were celebrating all the progress being made and a recent television show with Oprah Winfrey, which brought over 11,000 calls to the hospital seeking help. We were talking of the new training necessary. Suddenly I experienced a deep fear within myself and I tuned my colleagues out. I realized we were celebrating the opening of the hospital program as an end goal that would solve the problem. Yet it was but a waypoint. All these unanswered questions existed. How would we find the answers and pay for the research? We had worked so hard just to get to the point where we had a facility. So many prejudices and professional barriers had to be overcome. We had just begun. When I tuned back to my friends, the tone of the lunch changed when I shared what I was thinking.
Still, throughout this whole journey people were ready to help. Money was found. A team of eight researchers, including myself, started to gather data. Hundreds of therapists opened their practices to this work. And just short of 1,000 sex addicts and many of their partners joined in the effort. The pooling of the efforts of all of us helped us to fashion training as a collecting point for the story of recovery that was emerging. It was the beginning of the Certified Sex Addiction Therapist program whose participants today we call CSATs. The resistance to our work did not stop, since there frequently were obstacles such as “that may work in the city but will not in the country” or even, “that will never work in my country.” Plus the process of discovery led to more questions and complications. Yet we persisted in pooling our knowledge.
What we have experienced is now a global phenomenon. For example, a young woman who just started working on her CSAT returned to a very rural part of Canada. She was told such clinical interventions would never work there and certainly not with families. But with the backing of her hospital she now directs a thriving sex addiction program with heavy family involvement. In Slovenia, a country of only two million, a family physician supports the beginning of a 12-step program for sex addicts. Today she has left family practice behind and devotes herself to helping families of sex addicts. In South Africa, I attended an SAA meeting of about 125. I was struck by the level of knowledge and good recovery in the room. I asked how this happened. It was business leaders who knew something had to be done who had bought materials and distributed them for free. And then they subsidized interested therapists who sought training.
One of the more interesting stories internationally is what the Norlien Foundation in Alberta, Canada, has been able to achieve. Once they became clear about the problem of addiction, they focused first on prevention. They created an initiative for early childhood education and family wellness that leveraged foundation and provincial funds into an amazing resource for Canadian families. Then they brought the very best science experts in addiction together for a series of conferences involving policymakers, government officials and healthcare professionals. They completely revamped the approach to talking about sex addiction by focusing on brain development and trauma. Then they ramped up the discussion into understanding addiction as a brain problem–of which sex was one of the options. They created an initiative to educate providers and physicians. They invited an American think tank called Frameworks to help with a cultural intervention.
(see Figures 1 and 2)
Their first effort was to show that a consensus existed amongst all the various professions involved. Amongst the average citizen, however, there were all kinds of perceptions, far from those of the research consensus, and few areas of agreement. Figure 1 graphically summarizes where the discontinuities were. The second initiative was a massive education effort of the public, which showed an astounding shift in understanding. Figure 2 lists what emerged in a survey of 4,000 citizens. Sexual compulsivity was at the top of the list. (For more information, please go to their website norlien.org. It is an open source treasure trove of useful information.
Clearly the time has come for a global conversation. Hosted by Caron and U.S. Journal Training, but supported by key professional associations and treatment facilities, the 1st International Conference on Sex & Love Addiction will be held April 4–6. A planning group was formed with clinicians and physicians from around the world. The conference is being held in Brooklyn, New York, an international city with easy access. The goal is to again share what we know across disciplines and countries.
Sex addiction does have uniqueness. It requires clinicians who understand addiction, sex therapy, family therapy, trauma, sex offending and brain science. Physicians need to step past traditional psychopathology and recognize process addictions. Cultural differences are a factor. We, for example, are the world leaders of pornography, producing over 400 million pages last year alone (the closest other country is Germany with 10 million pages). Yet the irony is that terrorists, including Osama bin Laden, were consumers of porn. In putting together this conference we were not surprised to learn that the pornography consumption among United States military personnel emerged as a significant issue and the United States military is not the only military struggling with this concern.
Sex addiction is most difficult to treat because of the intimacy and centrality of sex to being human. At a recent conference, an elderly clinician from China leaned over and whispered to me, “You do know this is the most important global issue we probably have. It is a huge problem in our country. But no one wants to talk about it.” She looked at me with tears in her eyes as she left. She did not even hear my whispered, “I know” as she now was already focused on her labored walking.
My seatmate on the plane was a professional man. After talking with him for a few minutes I was aware that the language he used was 12-step based. I asked if he was in the program and he said yes, that he had been in AA for four years. We talked some about it. Then he leaned over and asked me if I knew anything about sex addiction. I said that I had been in a program of sex addiction recovery for some time. He then said, “I have three sponsees who are struggling because they have not surrendered to their sex addiction. I finally said to one of them that I could not help him any longer if he did not do what his sex addiction treatment asked him to do, because he would die.” He then leaned over and asked me if that happens often. I nodded my assent. He leaned back and said, “We have to wake up.” I said, “I know.”
So consider this issue of Counselor a wake-up call. Sex addiction is not just a collateral problem to be referred on. We have invited some of the best providers in the country to share with you here some of the latest knowledge and tools. Rob Weiss is amazing at his ability to track how digitalization is transforming the key variable in addiction acquisition: availability. Suzanne O’Connor and Stefanie Carnes review some of the latest instrumentation available. Three private practitioners talk about what it has been like to build their practice around sex addiction. Two inpatient providers talk of revising their programs in light of evidence-based practice. Caron Foundation staff share what they learned when they systematically assessed clients for sex addiction. The Pine Grove staff at Gentle Path share their realization of how differentiated their patient population was when they simply tracked the patients as they withdrew from the program. As you read you will also learn how 12-step programs have provided so many good options across the world.
The professionals writing here are both evolutionary and revolutionary, doing what good medicine and science has always done. We make things better by pooling what we know and helping each other. Now our network will extend across the world. In the words of a song from the sixties, “There’s something happening here. . .”
I sold an old farm that my wife and I had while she was alive. In it all the research records were stored that we started collecting in 1985. Among them were all the stories of the 1,000 addicts and their partners. The average transcript was about 80 to a 100 pages long, single spaced. These stories were in addition to all the data collection we did, which took hours to fill out and seven years to collect and analyze. In moving my records, I sat on the floor, opened the boxes and was flooded by memories of all the people who had shared their pain, struggles and success. I heard their voices and wept. I whispered out loud, “I know.” And I think many more will know now too. Thank you.