Clinical Management of Sex Addiction Eds. Patrick J.Carnes, Ph.D.& Kenneth M.Adams, Ph.D., Brunner & Routledge, 2002. Reviewed by Doug Greenlee Read the review...
Attachment and Family Systems: Conceptual, Empirical, and Therapeutic Relatedness Erdman, P. & Caffery, T.(Eds.)(2003). New York: Brunner & Routledge, 273 pp. Reviewed by Doug Greenlee Read the review...
Clinical Management of Sex Addiction Eds. Patrick J.Carnes, Ph.D. & Kenneth M.Adams, Ph.D., Brunner & Routledge, 2002. Reviewed by Doug Greenlee
Pat Carnes,a primary sex addiction researcher, therapist and speaker, once observed that sex addiction has something to offend everyone! I m inclined to agree with him! Once a month, I present this topic as part of the overall education-lecture rotation of our CD treatment program, and I have experienced every conceivable reaction: clients intrigue, trauma responses and tears, nervous laughter and silly jokes, self-righteous indignation and moralistic preaching, disgust and anger, and walk outs — all because I am attempting to talk about problematic sexual behaviors. Yet, sex addiction as an issue for recovering clients is treated as if it were the proverbial elephant in the room that no one acknowledges. Carnes & Adams text provides for the CD and family therapist a useful collection of applied research articles with a systemic focus that addresses assessment and treatment issues for individuals, couples, families and a variety of special populations.
I often encounter clients with cybersex issues — that is,clients accessing internet pornography sites about which they express concerns regarding their emotional conflict between their intrigue and guilt/shame. In the chapter, “Sex on the Superhighway: Understanding and Treating Cybersex Addiction, ”David Delmonico provides the reader with a useful description of the allure of internet porn as “intoxicating, isolating, interactive, inexpensive, imposing and integral.”(p.243) He also differentiates between recreational users (appropriate users such as adults and inappropriate users such as children)and problematic users (discovery group, predisposed group and life long sexually compulsive group). Delmonico references the Internet Sex Screening Test as a clinically useful self-report tool as part of the therapeutic assessment of the clients behavior.
I also work with couples who have fear and betrayal is- sues because one partner is accessing porn sites, chat rooms, etc. Mark Laaser's chapter on "Recovery for Couples" addresses the sex addict and partner's struggles to re-establish "an intimate relationship with a committed partner." (p.125) He suggests that the primary core issues are the addict's sense of shame, worthlessness, social isolation, and sex as the primary need in relation to his/her partner who has complimentary co-dependent issues in addition to disapproval and fear of losing partner. Laaser recommends that the therapist use a modified version of the 12 step model in which the Step 7 'defects of character' such as sexual behavior, communication, recreation, money, roles and trust become the therapeutic focus for couples in recovery.
In her chapter on “Strategies for Assessment and Early Treatment with Sexually Addicted Families,” Judith Mathany discusses the importance of family therapy that focuses upon restoring the emotional wellbeing of family members and reducing the risk of generational transmission of behaviors and/or eliminating the potential for sexual perpetration within the family. She suggests a two stage process whereby the therapist focuses upon the parents re-establishing relational intimacy and personal self-care. During the second stage, Mathany suggests that the therapist focuses upon the children in which they are encouraged to share their feelings and to learn more about healthy boundaries and sexuality.
Finally, Carnes and Adams provide applied research articles that highlight a variety of special population issues within the sex addiction field such as clergy abuse, women sex addicts, borderline personality disorder sexual acting out, adolescent sexual behavior - to name a few. However, they don't reference the in/outpatient programs that provide treatment services for sexually addicted clients.This is an unfortunate and curious exclusion in light of Carnes and Adams' very thorough overview of related issues.
Attachment and Family Systems: Conceptual, Empirical,and Therapeutic Relatedness Erdman, P. & Caffery, T.(Eds.)(2003). New York: Brunner & Routledge, 273 pp. Reviewed by Doug Greenlee
In his "Forward" to Erdman and Caffery's text, Jon Carlson clearly states what most family-focused clinicians already know: "Those of us who work in daily clinical practice find no mystery in the merging of attachment and family systems theories ... attachment theory appears to be at the root of all relationships... [and] family systems theory... describes the structures in which we live." (xi)Carlson's observation sets the stage for Erdman & Caffery's collection of clinically focused research and practice articles that demonstrates an integration of attachment and systemic perspectives, ranging from the theoretical implications of an integrated model to its therapeutic applications for life cycle transitions and trauma related clinical issues.
In general, Erdman and Caffery have carefully structured the content of their text to reflect their anticipated questions from a clinically-focused audience, such as: What is the concept? Why should it command the clinicians attention? What level of investment must be made by the clinician to understand it and to apply it in daily practice? How do clinicians apply it to specific populations, and is it more appropriate for some clinical populations as opposed to others? How effective is it, and how is its effectiveness measured? In response to fundamental questions such as these, Erdman and Caffery introduce their audience to the theoretical aspects of the integrative model by way of Robert Marvin's introductory chapter, "Implications of Attachment Research for the Field of Family Therapy." Marvin deftly demonstrates his ability to delineate and re-integrate the attachment and systems models in a clear and direct manner. Erdman and Caffery, then, devote a chapter to the topic of internalized relational representations, with the remainder of their text focusing upon attachment and systemic dynamics for child, adolescent and adult life transitions and related clinical issues associated with familial violence patterns and trauma experiences.
More speciffcally, Robert Marvin effectively summarizes the similarities and differences between attachment and systems theory. He discusses the interrelationship between the systemic model as a system consisting of interdependent and bidirectional subsystems that are self-regulating and evolving and the attachment model as an individual's interactive 'dance' among sociable, exploratory and fear-wary systems as the individual experientially develops his or her attachment style over time. Marvin suggests that the common element between the two models is the “notion of a bond, which itself conceptually demands the interactions of at least two partners...[who] activate and terminate each other in an intricate dance on a minute-to-minute basis over the course of a day,and how this dance changes and adapts over time .” (p.8) In other words, Marvin is describing the manner in which an individual is ingluenced by and simultaneously influences others as he or she interacts and develops relational bonds with others over time. Finally, Marvin discusses the implications of this bond because it functions as a basis for diagnostic assessments as he combines attachment style and the related family systems in the following manner: 1) secure-autonomous bond and adaptive family system, 2) avoidant-dismissing bond and disengaged family system and 3) ambivalent-preoccupied bond and enmeshed family system. He illustrates these distinctions by providing relevant clinical examples and useful interventions for each type.
If Marvins chapter represents the theoretical aspects of the integrative model, then Susan Mackeys chapter on “Adolescence and Attachment from Theory to Treatment Implications," is one of several identified examples of the clinical application of the model as it relates to the developmental/life cycle section of the text. She notes that "the most diffcult cases that a therapist faces with adolescent families are those in which the problems did not begin with the transition to adolescence but much earlier." (p.79) Mackey identifies the importance of the child's secure attachment to parent(s) as instrumental for the child/adolescent's differentiation, autonomy and goal-focused relational developmental tasks. She also discusses the implications of an adolescent who experiences an ambivalent or avoidant parental attachment, respectively characterizing the behavioral traits of the ambivalent adolescent as "anxious, ruminative,and needy... alternating between being needy and being demanding in an angry way" and the avoidant adolescent as "...having 'written off' their needs for connection with their parents and present themselves as invulnerable." (pp.82-3) Moreover, she highlights the importance of life experiences that may influence the development of anxious and avoidant adolescents, such as early parent-child separation, lack of fit between parent and child, the temperamentally diffcult child, poverty effects, parental abuse, narcissistic parents and dysfunctional family of origin systemic patterns. Finally, Mackey recommends that the therapist conduct a detailed developmental history not only of the child but also of the parents. She further recommends that the therapist and the client(s) develop mutually identified goals for their treatment plan that includes a strategy for addressing the parental subsystem relational issues,as well as interventions that support the adolescent fs ability to enhance his or her self-awareness, self-in relation awareness, setting personal goals, body care, self-soothing and nurturance skills. Mackey illustrates her recommendations via her case illustration.
Finally, an example of the integrative model as it has been applied to related client trauma issues is Sylvia Marotta's chapter on the "Integrative Systemic Approaches to Attachment-related Trauma." In her chapter, she discusses the individual's attachment processes in adaptive, disengaged and chaotic family systems and the implications for an individual who has experienced childhood sexual abuse.Marotta discusses her assessment process which includes but is not limited to the clients environment, such as its potential deficits, lack of information and/or potential conflicts within the environment (e.g. insuffcient social support, mental health services, etc.). In addition,she focuses upon the psychodynamics associated with the client's ability to examine "...material from past experiences that is disturbing or that impedes function in such a way that new meanings are created for use in the future." (p.233) Marotta also demonstrates the therapeutic importance for the preoccupied, avoidant and disorganized client-types to participate in individual resilience building strategies. Finally, she emphasizes the therapeutic necessity for the client to actively manage his or her anxiety and to participate in ongoing psychoeducation and relevant skills training to reduce problematic coping methods associated with each of the client types.
In closing,Erdman and Caffery's collection includes other important clinical topics where attachment and systems issues intertwine, such as work, love and family issues,couples dynamics and the use of emotion-focused therapy to assess and to address attachment styles and related issues. These chapters notably reflect the ongoing influence of attachment-systemic styles. Also,as third party payers continue to limit clinician-client contact time, it appears that the integration of the attachment and systems models may enhance the clinician's potential effciency and effectiveness in working with these complicated client issues. Yet, regardless of the current economic climate there may also be clinicians who resist integrating the attachment and systems models because of their emotional, intellectual, financial and social investment in maintaining the differentiation and status of one model over the other. It seems as if the editors do not adequately address this issue, which could result in maintaining fractious relations between attachment and systems-trained clinicians rather than encouraging these clinicians to explore the potential opportunities associated with an integrative model. Nevertheless, as a clinician who works with individual, couples and families who struggle with substance abuse, mental health and trauma related issues, I have found Erdman and Caffery's collection immensely useful for enhancing my clinical understanding of the attachment and systemic dynamics. It has enabled me to codify the inter-relationship among types of individual attachment bonds and related systemic dynamics within families saving time and assisting my treatment planning effectiveness. I suspect that most clinicians who read Erdman and Caffery's text and begin applying the information contained therein to their case loads will reach a similar conclusion.
