Sex and Pornography Addiction: CBT Tools for Recovery

Welcome to today's presentation. We're going to be going over the brief introduction to sex addiction treatment. Now, there's a lot more to sex addiction treatment, obviously, than we can go over in an hour, but it's important to hit the highlights in some cases to understand the differences between straight up substance abuse addiction treatment and sex addiction treatment, because there are caveats like there are with gambling addiction and eating disorders and other things like that that we have to attend to in order to make sure our clients are achieving their highest level of recovery and success. So over the next hour, we're going to define sex addiction, discuss similarities and differences between drug addiction and sex addiction, and explore some interventions that might be used with clients who are talking about either sex or pornography addiction issues. So just like any other addiction, sex addiction would be an activity used to escape from negative feelings, whether it's physical pain, emotional pain, boredom, despite experiencing negative consequences. And that's the caveat there. People continue doing this behavior, whatever it is, despite experiencing negative consequences. And when we talk about sex addiction or pornography viewing or, you know, anything like that, just about anything that we talk about, there's a range of normality. And, you know, some people engage in behaviors that are more or less right or left of center, and that's okay if it is between consenting adults and it is something that is not causing them negative consequences as far as an addiction definition is concerned. So similar to other addictions, sex addiction and pornography watching causes a dopamine surge, which leads people to experience a rush or a high of certain magnitudes, cravings. The person will start having cravings for that dopamine rush. We talk about people with sex addiction or pornography viewing, and we can talk about people who are having to engage in sexual behaviors or masturbation or multiple times a day, like seven, eight, nine times a day, because their cravings become so strong. It's similar to those cravings that people have for cocaine, methamphetamine, et cetera, because they're changing the neurochemical balance in their brain, and their brain is adapting to that higher level of dopamine. So when they don't have that higher level of dopamine, they're feeling less than happy, they're feeling less than what we would call normal for them. Triggers and condition stimuli are also there for people with sex addiction. And I've noticed over the past, you know, 20 some odd years, what we see on TV has gotten progressively explicit. So just watching TV in the evening can create triggers for people. Certain smells, sights, sounds, music. There Are a variety of things as well as emotional states that can trigger someone to want to engage in sexual behavior, Whether it's because they're wanting to engage in sexual behavior, or it's because they're wanting to feel better. Brain changes that occur with sex addiction, and especially pornography Tend to be worse if the pornography viewing, if these addictive behaviors start at a younger age. They found that the adolescent brain Just is not designed to handle Internet porn because there are varying levels of explicitness, Varying levels of shock value in the Internet porn. And you can keep hitting the enter key, and it's never ending novelty. It's not like, you know, back in the olden days when dad had a playboy or a penthouse or something and there was one centerfold. People can literally spend hours or days Going through the amount of Internet porn that's there and never see the same image twice, which means they become desensitized to some of the more routine sexual behaviors, and they start looking for more extreme types of behaviors, Whatever it is that does it for them. And, you know, that depends on the person, which direction they go. But eventually we find that a lot of people who engage in Internet porn or sex addiction Tend to expand past their comfort zone and start looking at things that are more extreme, more challenging, in order to get that rush. Because the sex itself is not providing the rush anymore, the orgasm itself is not providing the rush anymore. So they're looking for another way to increase that rush. Kind of like when people start combining drugs in order to chase that high. These brain changes can, you know, be undone or rewired or rerouted. But it does take time. And there's a whole website called yourbrainonporn.com and I believe it's in the resources for this class that has some videos that explain the neurobiology of what may be going on. And it also explains explores some of the side effects of sex and pornography addiction, including things like erectile dysfunction. Because the range of normal behaviors or average routine behaviors, Whatever word you want to use, that occurs in face to face meetings Is very small Compared to the range of what someone can see online. So eventually, the novelty in having a face to face partner multiple times wears off. The novelty of doing the same thing with a face to face partner multiple times wears off. So you can see how the brain kind of gets spoiled, if you will, into expecting new partners and new experiences with every single click of a button. This can lead to a lot of problems. I mean, financial problems is just only part of it. You know, there's A lot of free porn online, but there are a lot of people who end up getting fired from their job or end up going to jail in the case of child pornography and some other things because of porn. But there's also emotional problems. You can actually have too much sex. Yes, you can. Believe it or not, when the body has basically exhausted that reward system, there is nothing left to give. And so that rush of dopamine just doesn't mean anything anymore, even if there is dopamine left to put into the synapses. The nice thing is, again, the body can recover once it says, okay, the flood's over. We're going to go back to this normal, steady state of occasional trickles of dopamine instead of tidal waves that takes anywhere from, you know, three months to a year for most people. Sex addiction, experimental sex behaviors, and pornography viewing may start as recreational, just like gambling does, just like drinking alcohol does, Smoking cigarettes, some recreational drug use. You know, there are a lot of things that people become addicted to that start out as recreational. They don't start out as, oh, I need to numb the pain. But then the person has a really exciting experience from it. So when they're feeling down, when they're feeling blue, they want that reward. They want to feel that excitation again. So they go back. It's kind of like, oh, I know how to feel better. Let me go back and do this again. Sex addiction differs from other addictions partly because it's a biologically driven urge. We are designed to procreate. If we don't procreate, our species doesn't survive. So one of the interesting things is that there's something called the coolidge effect where. And it's not just men, it's men and women get bored with the same partner after a period of time. Now, does that mean that we are doomed to be in. Not to be in monogamous relationships? No, it just means you have to be aware of the fact and kind of try to keep it interesting. But the coolidge effect basically says that the. And they talk about it on the website. Your brain on porn. In terms of lab rats. After a while, a lab rat will get bored with its partner, and it'll want to go engage in sexual activity with other partners. In order to diversify the genetic pool. Most people can't abstain forever. So taking someone who's a sex addict and saying. Or a pornography addict and saying, you can't masturbate anymore or you can't have sex anymore is, like, way more than they can Handle and likely not even healthy. So what do we do? One of the things that we talk about, and we're going to talk about it in interventions is telling people that, okay, maybe masturbation is not something that you want to engage in all the time, eight, nine, ten times a day. Let's restrict it to if you feel like you can do it with your current human partner in a monogamous relationship. So put some restrictions on when and where it can be done initially. Most people who have been who either have sex addiction or pornography addiction may not be able to get aroused in that sort of situation. After a period of time and therapy and recovery and yada, yada, yada, and that's the stuff that we don't have the time to go into right now, they will find that they are able to have a fulfilling sexual life without the addiction part. The other unique thing about sex addiction is sex is socially sanctioned. And even to some extent pornography is socially sanctioned, or we wouldn't have Playboys, Penthouses, and you know, goodness knows, I think Hustler was one other. I don't know if it even still exists. You know, I'm aging myself now, but those were the things that, you know, my father and his father probably had. It's somewhat socially sanctioned as a rite of passage in some cultures for young men especially to view pornography. We do find in certain studies that men tend to be more visually engaged than women do. Men tend to want to view things more often than women do. Women are more about experiencing, feeling, talking, that sort of stuff. Many women are not as enthralled by simple two dimensional, two dimensional pictures. You know, I mean, you can appreciate what's there, but it's not going to do a whole lot for you one way or another. So it's a matter of what your preferences are. But understanding that our society has really expanded its horizons and made things a lot more explicit and, and children are being exposed to this a lot sooner. So what are some symptoms needing more of the same substance or activity to get the same high. The dopamine system, like I talked about earlier, is self regulating. When you flood it, it's going to shut down some of those floodgates so your body doesn't get overstimulated until it realizes or is confident that it's not going to be flooded anymore. Those floodgates are going to stay closed. The brain is protecting itself is really cool, but it really sucks during the early recovery period before the brain goes, oh, we're not doing that anymore, okay, so we need to rebalance our neurotransmitters. The other thing to consider, and I've just talked about dopamine, but there are a lot of other chemicals that are involved in the reward process and it's a balance. They regulate one another. Serotonin, gaba, norepinephrine, dopamine, acetylcholine. Understanding how all of those interplay with one another and some of them bolster the other ones. Other ones they act kind of antagonistically. So it balances it out. It's important to understand that it's not always about more, more, more. In response to worsening problems in the person's life, they also may seek out the porn or the sex more often because they just need to escape. So the sex and the porn is not providing as much of a rush. So they're chasing the high, just like we see with other addictions. But things like with other addictions, things outside of that one behavior are probably continuing to fester and maybe actually worsened significantly by the revelation that the person has an addiction, either sex addiction or pornography. So this causes the desire for engaging in the behavior more, using more or for longer period than intended. Online porn sites and dating apps, there's a bunch of stuff out there that has never ending novelty you can go through and watch, like I said, different types of porn, different genres of porn, different whatever. It's a really, really financially beneficial market if you're into that. So knowing that it's out there and knowing how to access it, One of my friends texted me the other day, he was out in the field and one of his friends had sent him a link to something that was on Reddit and I don't even remember what it was. And he just texted me, he's like, have you ever been on Reddit? No. He's like, oh my gosh, there is so much porn. And for him that's a huge trigger because, you know, pornography is one of his fallback coping skills or whatever. So anytime it's around and available, it sort of sucks him in. So understanding that people can get sucked in and they may intend to spend 30 minutes looking at it and, and spend three hours unsuccessful efforts to cut down the biologically driven urge for stimulation as well as procreation, but also that need to feel okay because you're not getting without artificially raising your reward levels, your happy chemicals, your happy chemical level is going to be low. And really understanding how that regulatory process works is key to understanding any addiction and understanding the cravings in any addiction, once people really start to use and their brain adapts, then they have to continue to use to feel normal. Their baseline is raised. So if they don't give it that extra dopamine, if they don't give it that extra cocaine in order to get the dopamine, they're not going to feel like the rest of us feel. Spending significant time and or resources like money thinking about preparing for, acquiring, using or recovering from use. Like I said, it's a multi billion dollar industry. So people spend a lot of money on toys, sex toys, apps, dating things in order to engage with people who have similar sexual desires and preferences and all that kind of stuff. People can spend an inordinate amount of money or time because it's something you know, and at this point it's often the only thing that really provides them that sense of escape and euphoria. I don't want to say joy because joy has more to it than that and continued use despite consequences in one or more areas of life due to the addiction, relationship issues. Now, sex addiction, a lot of people is like a no brainer. You can understand where if your partner is having relations with other people on multiple occasions, how that can be hurtful. But with pornography addiction, it is similarly damaging to the relationship. And it's important not to minimize that. When you're talking with the significant other of the addict, it's important to understand what it means to him or her that the significant other was engaging in lots and lots of pornography usage. And that's a whole other class. Again, some of the key features are rejection, the unknown, fear that the person's going to leave, fear of not being good enough kind of goes back to rejection, betrayal, basic things that you could think about if you put yourself in that person's place and you found out that your significant other was spending lots and lots of time viewing porn. Financially, like I said, it's a multibillion dollar industry, so it can cause financial problems. If you get fired from your job because you're downloading porn, that's going to cause financial problems, work problems just covered that. Anxiety, motivation and depression. Motivation. Motivation is that desire, that urge to do something. Dopamine is our motivating chemical. If you're out of dopamine, you're out of motivation. There's very little motivation to get up and do the next thing, especially if it's not nearly as rewarding and as what you've been doing. So going to work starts to lose its appeal. Going to class starts to lose its appeal. Helplessness and hopelessness when nothing Seems to do it for you anymore. When there's no motivation, people start feeling helpless, hopeless. Blue, gray. I find it interesting how we use different colors. But anyway, I digress. Which can also lead to a certain level of anxiety. If once people start seeing how much problem that the pornography or sex addiction has caused and, or, you know, if they're engaging in sexual behaviors with other people and using risky sexual practices, there can be a lot of anxiety about health problems, anxiety about other people finding out what would they say if they knew. Those are all things that the person with sex or pornography addiction has to deal with. So just bearing in mind that it's not a simple thing to issue, to deal with in therapy, this is something that is actually more pathologized by society in many ways than alcoholism. So it's important to kind of wrap our heads around that. And what does it mean when Jim Bob's pastor or Jim Bob's boss or Jim Bob's mother finds out about this? Addiction is driven by survival mechanisms. Now I say addiction, sex addiction, gambling addiction, everything is driven by the body's last ditch effort to survive, to reduce pain, emotional and physical. People don't wake up in the morning and go, hey, I want to really screw up my life today. They wake up and they're like, I can't go another day feeling this bad. I need something to make the pain stop. And that's when they fall back sometimes to things in the past, other behaviors they've tried in the past which have made them feel better. Whether it's drugs, sex, gambling, exercise, food. Another safety mechanism or survival mechanism is the elimination of threats. If they are withdrawing into themselves, if they are isolating, then they don't have to worry about rejection. They don't have to worry about counting on somebody and being disappointed because their addiction is always there for them. It's them and their addiction and that's all they need. And survival mechanisms like food and water, we have to have those. You know, people are not going to forego water or at least fluid. You know, some people don't drink enough water. But we find when people get into an addictive mindset, they may not be eating healthfully and taking care of themselves because they are so driven. And you know, we've all heard of the rat studies with cocaine where they've stimulated the pleasure centers of the brain and the rat has continued pushing that lever to get another hit until it died of starvation. You know, poor rat. But it's important to recognize that there are certain things that will override Certain desires that will override others. So what do we do? Well, one of the things that we can do is have people, what we call reboot. They need to give their brain a rest from the rush. Stepping back and let's see, Terry Crews. There were some articles that came out about a month ago. C R E W S was a football player and he's an actor, but he came out as somebody who's dealing with sex addiction. And he had talked about. He didn't use the word reboot, but taking a sex timeout. And he and his wife agreed to abstain from sexual relations for a certain period of time. That's not for everybody to go extended periods of time, but it is important when people come in to help them understand that their brain is used to going 1000 miles an hour and it can't do that anymore. It's burned out. It's not able to keep that pace up. So it needs to rest. You need to let the engine block cool off. So how can we make that work for you? Helping them understand that it's the brain's normal protective reaction. If they're having erectile dysfunction or sexual dysfunction, these urges, etc. Help them understand the function of those so they can understand, okay, my neurochemicals are out of whack. My brain wants them to be in balance. And in order for them to be in balance, right now, the only way to do that is through these dysfunctional behaviors. So how do I get it reregulated? So my brain is operating at what it used to operate at. And I try to stay away from the word normal as much as possible, but it's baseline is usually a better word. So what do we do during this period? Encourage the person to be kind to themselves. They need to take care of themselves so their brain can recover, get adequate sleep, which may be really hard in early recovery, just like from any other addiction. While the brain is recovering, the person may feel very edgy, the cravings may be very strong. So it may be worth having them talk with their primary care or their psychiatrist about pharmacological interventions. One interesting thing is that certain serotonin reuptake inhibitors, your typical SSRIs, some of them are more well known for their sexual side effects of reducing libido and they found in patients with sex addiction during the early recovery process. Sometimes it's helpful to deal not only with the depression, but also to reduce their libido so they can get more sleep and help their body and brain recover faster. Not everybody wants to Take a pill. Totally get that. But that is one option that's available to people. Adequate nutrition. The body needs the building blocks to make the chemicals to rebuild. You know, all this stuff. Exercise. Exercise is a good way to not only get a natural endorphin rush, but also to shake out some of the tension, some of the anxiety, and help people get rid of all that nervous energy so they can sleep. And when I say exercise, I'm not talking about an aerobics class or boot camp or anything like that. For some people, that means walking the dog. And if that's what it means, great. For others, they can turn on the music at home and they can rock out in the living room. Great. Whatever it is, that's exercise for them. Something to get their blood moving, finding activities to occupy their time. Boredom is devastating in early recovery for anybody. For anybody. Whether it's from addiction, anxiety, depression. When the person gets bored, they have time to sit and really analyze all the things that are wrong or all the things that they want or the fact that they're edgy. So encouraging people to keep a list, things that they can do to prevent boredom. That's part and parcel of your early relapse prevention plan. Having an emergency plan. When you feel triggered, what are you going to do? Also, when you feel. When you're, you know, going through your day, if you start to feel bored, what can you do? Identify and eliminate or recondition things, pardon me, that trigger your cravings, people, places, things including TV shows, emotions, and times of day. Those are going to be important to consider when working on a relapse prevention plan. Certain people are going to bring out the more animalistic behaviors in you. Certain places may remind you of it. Driving home from work, if you've got to drive past the strip club or just being on the computer. One of the things that I find frustrating or interesting or I don't even know how I find it, but there are a lot of online support groups for people with pornography addiction. And my first thought is the last place this person needs to be right now is online. So it's important to understand that. And then there are also certain times of day when hormones naturally ebb and flow, helping the person understand that and how to deal with it. Their emergency plan, when they feel triggered, who can they call? What can they do? They need to keep it either in their wallet, in their purse, on their smartphone, somewhere where it's always with them. Encourage them to engage in competing behaviors. What does that mean? That means when they feel triggered, they need to do something where they can't engage in the target behavior. So when we're talking about sex addiction, when they feel triggered, they need to go out and do something where they can't engage in masturbation or sex. Walk in the park. You know, sometimes you would say go to the gym. But seeing people run around in scantily clad outfits may not be the thing for your client. They need to identify things that they can do. Walk the dog, go play with their kids. You know, there are things that can be libido crushers, Figuring out what those are. They're good to have in your back pocket. Identify the function of this behavior and develop alternatives. One of the things that they talk about in a lot of the sex addiction recovery workbooks is the fact, and it's the same basic issue that people with a variety of addictions deal with, that negative self talk. And one of the books I read, they called it hecklers in the gallery. It's like you're performing, and every time you say something, every time you do something, somebody heckles you. Well, these hecklers are the old tapes that you've got from the past that you're replaying. So silencing those hecklers is going to be one of the first things that you need to do. The other thing that patients need to do early on is to play the tape all the way through. For example, yes, it would be great if you could go to a bar, hook up with somebody, and have an hour of passion. Okay, fine, whatever. However you want to put it, the tape doesn't stop there. What are the ramifications once you do that? How do you feel? What are the consequences? Yada, yada, yada. So have them play the tape out in its entirety. We do the same thing with people who have addiction to alcohol. One drink sounds like a grand thing, but ultimately we know it's not going to be one drink. One drink is never enough. So it's going to be 3, 4, 5. Then somebody's going to have to call you a cab. Then your spouse is going to find out that you were drinking again, and that's going to cause an argument and play it all the way out. By the time you finish playing the tape out, 99% of the time, the person realizes, yeah, this is not something I really want to do. Another part of rewiring is only to allow themselves to experience sexual pleasure with a single other person in a monogamous relationship. Now, that's the ideal that we're going to set up here. Each person is Going to have their own ideas about what healthy sexuality looks like. So I don't want to be culturally insensitive, but for the most part, this is what we're going to be looking at. Trying to encourage people to restrict their activities to humans. And in a monogamous relationship, I'm not necessarily saying married. You know, that's a personal decision people have to make. But not just going to a bar and hooking up with any human that will hook up with them. Understanding that during the rewire, there may be a period when the person can't get aroused. This is important to help the person understand as well as their partner. Because we don't want their partner. If their partner finds out they've been watching hours and hours of porn and then they're together physically and the addict can't get aroused, the partner may feel rejected and the addict may feel inadequate. And then we've just kind of complicated the situation. Is it really, really important that both parties understand what's going on? This arousal thing, it's going to take a little while to come back because the brain circuitry is broken. And I try not to get too into neurochemicals unless they really want to go there. But understanding it's not about desire necessarily or mental connection. It's about how the brain's working and the physiological ability to get aroused. Procreation is genetically programmed. Once your brain recovers, arousal will be possible again. It's not gone forever. Your brain's gonna eventually come back around, but it's important to understand. On that note, it's also important to help clients understand if they do start taking medication, and there are other medications, not just SSRIs, that have libido bashing qualities. But if they start taking a medication and they find that their libido is not coming back up where they think it should be, they need to talk to their doctor. There could be something a little bit wonky or there could be other medications that would achieve the same goal that wouldn't have those side effects. There are antidepressants people can take now that don't have the sexual side effects that, you know, some of your older ones do. Person has low dopamine, they're depressed, they're exhausted, they're frustrated, they feel helpless and hopeless. How do we address motivation? Well, goal setting, it's my favorite part. Now we want to get them excited about something. We want them to see that recovery is possible. So we need to focus on small goals. And we need to focus when they come in for that assessment, not for session one or session three. For the assessment, they need to walk out with some tool, some something that is going to help them start getting on their way to recovery, even if it's just keeping a baseline log of when they feel their urges to use and what they do. So goal setting, where do you want to be? And at the end of the month, where do you want to be in three months, six months and a year? So we want to look at that. The other thing you can do is look at asking the miracle question. If you woke up tomorrow and you didn't have the compulsion to engage in this behavior anymore, what would be different? Another way to ask the question, before this problem started and you were happy, what was different? The key to that is you were happy. Because the problem, the addiction, the use is merely the tip of the iceberg. The problem started before that and the use ended up coming in to finally go, I can't take it anymore. So we need to go all the way back to when the person was happy. What was different? What, what can you know, what needs to change? What needs to stay the same? Decisional balance exercises. And we go through this in every class, but they're important. It's important to understand the benefits and the drawbacks to the addiction. What are the benefits to watching porn eight hours a day? What are the drawbacks? Yeah, we're going to talk about the benefits. What does it do for you? Because we have to figure out another way to meet those needs. What it does is rewarding enough that the person is willing to sacrifice just about everything else in their life for whatever that reward is. So we need to know what it does for them. Then we also need to look at the benefits of recovery and the drawbacks to recovery. Recovery can be hard. It can suck at times. So we need to figure out how to minimize the suckiness. For lack of a better clinical term, make recovery rewarding. Make it more rewarding than the addictive behavior. And it takes time to figure out what that is for that person. Because a lot of times they've become so detached from themselves, they quit feeling so long ago that they don't even know what their triggers are anymore. It's just like, I just don't. I don't feel anything. And we need to put in rewards. What is it that would make you feel like you accomplished something this week? And what can you do to celebrate? What are the rewards? You know, and self satisfaction sounds great, but that is not reward enough. I am sorry. It just isn't what do you really enjoy doing and what rewards can be kind of there? Sometimes it can be going out to a movie, sometimes it can be going out on a date with their significant other. There's a whole host of different things, but we need to make recovery rewarding and we need to make recovery fun. So, yeah, at the end of the week, if you've made it and you haven't used, you haven't slipped, and you want to go to a roller coaster park, that sounds great. And you're scratching your head going, but our clients are adults. And my response is, yes, they are. And they've forgotten how to tap into that little kid inside, which is why life wasn't fun anymore. They need to learn how to have fun without sex. Novel concept. Clients need to learn to be mindful. And we teach mindlessness from the time kids are knee high to a grasshopper. We don't teach them to be mindful of when they eat, when they need to do anything, except when we're potty training and we're really big on mindfulness. But other times, do we really focus on teaching kids, are you hungry? Or do we teach kids, it's dinner time, sit down and eat. And obviously food is different than sex. But mindfulness is important to understand how you're feeling because we tend to develop a habitual pattern, acting or reacting, if you will, to certain emotions. Each individual person has a way of reacting when they're bored, when they're stressed, when they're angry. Any emotion, understanding how you do it and what would be good for you or how it would be better to do it is important. Living in the present instead of the past or in the future. In 12 step circles, we say, if you've got one foot in the past and one foot on the future, you're squatting on the present. Many of our clients are so filled with anxiety and resentment that they are not focusing on what's right in front of their eyes. So encouraging them in session when they start talking about the past or the future, bring it back to now. How is this impacting you now? Why is this an issue for you now and what can we do about it? Because this thing that happened back when you were 12. Yeah, you can't change that. That's in the past. It's done. But this resentment you're holding onto is eating away at you. Now that you are 22 instead of 12, you have different skills, different needs, you're more independent. What can you do to deal with that resentment so you can better use your energy for something that makes you happy instead of just staying mad. We need to teach clients observation and awareness skills, external skills, be aware of the triggers in the environment. If they were neglected or abused or exposed to trauma as children, there may be some triggers in the environment that are really anxiety provoking. There may be triggers in the environment. We all have that song that we listen to and it reminds us of our first love or something that makes us really sad. Having people be aware of those and figure out how to deal with them. But also the good things. We don't want to just focus on all the bad triggers. What are the good triggers? Because if you're surrounding yourself with good triggers, then there's less room for the bad triggers. So what things do you like to be surrounded by? What things make you happy? You know, I like critters. So being surrounded by pictures of little animals and memes with little animals and anything that's cute, anything that's nature oriented, that makes me happy. It doesn't necessarily make my son happy. He'd rather be surrounded by images of F14 fighter jets and stuff. But, you know, whatever it takes. Knowing what makes you happy and calm, knowing your own vulnerabilities and assets. What do I mean by that? Vulnerabilities are those things that happen that make you more vulnerable to relapse from addiction, relapse into depression, relapse into anxiety, anger management issues. Some of those are sickness, tiredness, low blood sugar, poor nutrition, dehydration. We all have things that we know make us cranky. And sometimes it's just getting up on the wrong stinking side of the bed that's a vulnerability. But if you're observant and aware, you can say, you know what, I got up on the wrong side of the bed today. So everybody just give me a wide berth for about 30 minutes until I get my head together. But we also have assets. What things can you do that make you less vulnerable? For me, it's exercise. If I go to the gym in the morning, it helps me get my blood flowing, clears out the cobwebs. I'm great for the day and that helps a lot. Eating regularly, that helps me a lot. One of my vulnerabilities, I am really sensitive to lack of sleep. So I know if I don't sleep well, it's going to be a long day. And I know to plan for that and not put too much pressure on myself in order for me to get. Now I can't even talk. In order to set up the situation where I would get frustrated. We want people to learn how to describe what's going on. Once they are observant and aware, then they need to start using descriptive words. How does it feel? What does it look like? What is it reminiscent of? Help them accept without judgment how they feel. You feel how you feel. It is what it is. It doesn't mean you have to act on it, and it doesn't mean any more or less about you as a human being. It just means, but what does it mean? And then you can decide how to deal with that. Once a person observes, they become aware. They can describe what's going on and accept it without having to just immediately react. Then they can act with awareness. They can make a reasonable decision about is this worth my energy or is this getting me closer to my goal, or is this going to set me back? Which is purposeful action, acting with the purpose of getting, moving forward in life instead of being stuck, staying backwards, or just getting lost along the way. Clients need to learn distress tolerance, how to cope with crisis situations and urges in healthier, less destructive ways. So when you feel those urges, what can you do? Urge surfing is one helping clients learn that urges, cravings, thoughts, panic attacks, all those things tend to crest within about 15 minutes and then start to dissipate. So what can you do for that 15 minutes? Have them identify alternate activities that are less problematic for those 15 minutes. When I work with people who are engaged in self mutilation, self harming behaviors instead of cutting, holding ice cubes in both hands is extremely painful, but it doesn't permanently hurt them and it doesn't even temporarily hurt them. What does it do? It gives them a pain to focus on that's not inside their head, but it's in their hands. It's a pain that they've learned how to control. Now is this how I want them to cope for the rest of their life? No, but it is certainly better than cutting, shooting up, going out and getting drunk, whatever the options are. Active distraction for that 15 minutes. Do 15. And doing 15 is just choosing something. Going out on a walk, taking a bath, playing with the dog, cooking dinner, whatever it is for that person that can help distract them for 15 minutes. And then after 15 minutes, if that urge is still there, then they need to take more aggressive steps. Most of the time the urge will have crested and be long gone by the time they're finished. These are things we can give clients in the assessment before they walk out. After that assessment, we can say, okay, I hear you're telling me you're masturbating eight times a day, and you're spending inordinate amounts of time watching Internet porn. So let's identify three things you can do when you get the desire to watch porn. And let's identify three things you can do to make your home safer so you don't have access to that porn. And that includes mobile devices. And let's identify three things, because I like threes. Three things you can do that you're going to enjoy. You know, part of recovery is learning to love life and learning to enjoy life again, not just stop doing whatever you're doing. So what are you going to do instead? If you're not watching porn? What are some things that you would like to do? What's on that bucket list that you haven't gotten to? That gives clients something to focus on. And that active engagement helps sort of propel them toward doing something positive in and of itself. It has some intrinsic rewards, and it'll often help get them through the first couple of weeks with a few slips here and there sometimes. Emotion regulation. Helping clients manage and tolerate their emotions is crucial. One of the reasons people use, or one of the results of people using and getting their neurotransmitters all wonky is that emotions seem just unbearably huge. There's no glad, there's no irritable, it's euphoric or rageful. There's no middle ground. Helping clients learn to tolerate their emotions, learn that they don't have to respond to every fight or flight reaction. Matter of fact, it's better not to. It's better to do that. 15 minutes, get an awareness of what's going on and then decide how to handle the situation most of the time, except that sometimes you can't change or reduce the intensity of the feeling. If you find out something devastating, you're going to feel devastated. And yeah, that is an intense emotion. And you may not. It may not be something you're going to make less devastating. So how do you deal with it? Besides getting drunk or watching porn or going out and hooking up with somebody? How do you deal with it? It's not going to make it go away right now. And those are the skills that clients will learn throughout treatment. Skills and tools that they've used in the past to deal with emotions. And we're just going to sharpen those a little bit and maybe add a couple new ones. They need to identify what makes their negative emotions worse. So when you're already angry, what tends to stoke that fire? And let's stay away from that. But likewise, when you're angry, what starts to diffuse it? How can you diffuse it? For me, petting my dog. My dog has the cutest little wrinkly face and it's hard to stay mad even at him when I'm petting his silly little wrinkly face. That just kind of takes the wind out of my sails. So understanding what does it for you? Sometimes having comedians memes on your smartphone, something that'll make you laugh because you can't laugh and be angry at the same time. It's just not possible. Encouraging people to have things available that they find funny encourage people to get support and see the obnoxious silver lining. And I usually put it to them exactly that way at first. When you're angry, the last thing you want to do is start looking for the silver lining in things. As you move through recovery, you'll realize how much less energy you spend if you're willing to look at the silver lining. And they need to learn interpersonal effectiveness so they can maintain healthy relationships. Act assertively, take good care of themselves. And remember, karma, if somebody is negative, nasty and hateful and angry, from a therapist standpoint, I'm saying, okay, that person is really afraid and really unhappy and feeling really anxious. And they're trying to keep everyone away either to avoid having, avoid feeling out of control or to avoid being judged or something. Anger pushes people away. Anger, Anger is a power, power move. But when you're angry all the time, you're either surrounded by other angry people or you're surrounded by no one. When you're anxious all the time, there's so much energy tied up in being anxious. If you've spent time around somebody who tends to be anxious or you know, has some other high drive tendencies as a friend, you know how exhausting that can be over time. And if you're around somebody who has these negative traits, you either end up taking them on or you have to back away. So karma, when I'm talking about it here is the fact that like begets like. So if you're kind of negative and nasty, you're probably going to be surrounding yourself with negative and nasty. When you start to feel better about yourself and about other people, you're going to be surrounded by people who tend to be more positive and empowering. So sex addiction has similarities and differences with drug addictions. The biggest difference is the fact that, you know, most people would say that it's unhealthy to permanently abstain from sex and sexual activities. That is a choice your client can make. Obviously, the younger the brain changes occur, the greater the possibility for actual brain damage, rewiring or short circuiting or whatever you want to call it. The awesome thing is, over time the brain can find workarounds or fix itself. So it's not hopeless. But if somebody starts viewing porn at 8 and they come and see you when they're 28, the time for their recovery is going to be longer than someone who started using or viewing Internet porn at 20 and came to see you at 40. Because there's just so much more brain development going on at 8. Antidepressants can be helpful in the short term. Any of your dialectical behavior therapy interventions can also be extremely helpful. We talked about those with the stress tolerance and mindfulness. As with any addiction, the reason someone started and continues to use needs to be addressed. The use is the coping skill. It's a dysfunctional one, but it's a coping skill. So what is maintaining that use besides the physical physiological effects of the substance? Once we remove those, what's maintaining the addiction? We need to deal with that and help people figure out that they are strong enough and they are good enough and they are worthy of living a happy, healthy lifestyle.