Depression and Sex Addiction: The Moment Between the Trapezes

"I choose my behavior; the world chooses my consequences" is a phrase that any recovering sex addict would do well to hold in vivid consciousness. When the awareness of a pattern of sexual addiction starts to become clear, a trail of consequences is likely to follow close behind. Rather than attempt to manage or minimize the consequences, the sex addict is advised to curtail sexual acting out and embrace a quality recovery program taught and modeled by other recovering addicts.

Despite the conviction to move toward the rigorous honesty of recovery, the addict is likely to experience the cold sweat of repercussions of previous behavior. The secret life is unveiled revealing affairs, exhibitionism, voyeurism, or other behaviors comprising a particular sex addict's modus operandi of acting out. Like the trapeze artist in the circus, the addict encounters the moment between letting go of one trapeze and catching the other. Such a crisis will make one exquisitely aware of hopelessness and depression. Hopefully, it will also dawn on the addict that he/she is powerless and that a Higher Power alone can and will be there in that moment.

Six classes of depressive types expressed in sex addicts

The mental health practitioner who treats sex addiction is called upon to diagnoses and treat the depression that is likely to be present before, during, and after the between-trapeze experience. This depression may present in several different forms, which can be summarized in the following classes:

1. Most commonly, a chronic, low grade depression or dysthymia in a shame-based person who has low self esteem and relatively undeveloped social skills. This dysthymic disorder may be punctuated with major depression especially likely at the time of significant relationship losses or at the time of exposure of the pattern of sex addiction. Shame, loneliness, and awareness of lost time spent in active addiction may haunt the addict. When shame rolls in, depression follows the flood. This type tends to have a strong superego and be at risk for self-punitive suicidal thoughts and behavior.

2. A seeming lack of depression in a perfectionistic, shameless-acting high achiever. Despite not having a history of previous clinical depression, this person may experience an overwhelming major depression as perfectionism and narcissism no longer stem the tide of mounting negative consequences of sexual behavior. Since this person may have a lofty professional and occupational position, the sexual acting out may involve level III abuse of a power position with employees, clients, or patients. If professional consequences (e.g. loss of license, termination of employment) lead to a further and more devastating breakdown in personal relationships (e.g. divorce, marital separation), the person's shame can be catastrophic and overwhelming, making suicide a real and pressing danger. This person may even need to be hospitalized against his or her will until adequate defenses can be reestablished and a recovery process begun.

3. The depleted workaholic whose life is without joy, and who has no balance in social or recreational spheres. This sex addict is likely to find someone or a series of subjects at work to groom as he/she presents as a martyr-like victim slaving to support a family yet deserving of a sexual release. When depression finally breaks through clinically, after the pattern of sexual behavior is exposed, it is likely to be massive because this addict has little to fall back on when the merry-go-round of work stops. The workaholic pattern becomes a central treatment issue with both sex addiction and depression seen as outgrowths of the long term lack of self-care. If a workaholic pattern recurs after treatment, relapse into sex addiction is almost certain, whether it be in the behavior or thoughts of the addict. Therefore, a goal in treatment and after for this person is to halt the pattern of self-abandonment expressed previously through workaholism, sex addiction, and martyrdom.

4. Psychotic depression in a person who may be older (45-60 or above) and who has a pre-morbid obsessive-compulsive style and a suspicious temperament. This person may have practiced a type of sex addiction that included perpetrating children or teenagers, but kept it concealed for years. When the addiction progresses and the behavior is discovered, the public outcry and shame may be processed by the addict via psychotic defenses of massive denial and projection. The addict may sink into a stuporous depression with psychotic features including frank paranoid thoughts of feeling acted upon by outside forces and profound social withdrawal. The reality of the perpetrating behavior is alien to the denying lifestyle the person has practiced for years. The recovery from psychosis is gradual and in-depth work on recovery from the addictive sexual cycle must be put off until aggressive pharmacological treatment takes effect.

5.Bipolar depression in a person who may or may not be a true sex addict. Since the manic phase and mixed manic/depressive phases of bipolar disorder are often accompanied by hyper-sexuality with heightened sex drive and increased sexual behaviors of boundary-less type, the clinician, in attempting to make an accurate diagnosis, should be mindful to search for a true pattern of sex addiction behavior which transcends the mood swings of bipolar disorder. A bipolar patient may also be a sex addict, but a significant subset of bipolars show hyper-sexuality during mania that is not part of a pattern of sex addiction. The bipolar group as a whole is at significant risk for suicide (the lifetime suicide rate for untreated bipolars is 15%) and risk can do nothing but rise for the portion who are both bipolar and sex addicts. The dual bipolar/sex addict patient may actually complain of two types of depression; one that is without a particular stimulus (the bipolar depression that comes on suddenly like a black cloud overhead), and another depression which mounts slowly and is accompanied by shame and the emptiness of active addiction much like the dysthymia of Class #1.

6. A sociopath who may feel pain from consequences of addiction or perpetration, but lacks true remorse and may feign a victim stance for secondary gain from significant others and legal authorities. The dramatic victim behavior may mimic depression, but usually lacks the classic vegetative signs (sleep, appetite, energy, and interest disorders) of true major depression. If a person with antisocial personality disorder threatens suicide or acts on suicidal thoughts, it is usually in retaliation toward authority figures, related to substance abuse, or associated with additional accompanying character pathology (e.g. borderline personality).The sociopathic pattern should eventually be evident by the triad of lack of remorse for perpetrator behavior, failure to learn from past mistakes, and projection onto others of blame (lack of accountability). Such a person may have been through multiple previous treatments accompanied by a professed wish to work a strong recovery program yet, in reality, followed by failure to "walk the talk."

The six classes of depressive types show that the entire array of depressive disorders is expressed in sex addicts. As a practical help to the mental health therapist, it might be useful to codify some of the clinical tools to employ in assessing and treating the depressed, suicidal sex addict. First, the practitioner will want to be able to distinguish the type, depth, and severity of the depression. Second, the therapist should as accurately as possible know what to consider in terms of risk of suicide.

Steps for determining the severity of depression

Determining the severity of depression combines a play-it-by-the-book (DSM IV) approach to asking about each possible depressive symptom with an intuitive awareness of what could happen (call it clinical "thinking dirty") as the sex addict in treatment relates to mounting consequences. These steps are suggested:

1. Take no shortcuts in the intake process. Get a broad anthropological/cultural view of the person while conducting a careful search for symptoms and signs of depression and/or suicidal ideation and plans. The cultural context and support system have a telling influence on suicidal potential.

2. Withhold too early conclusions about character pathology. "Hip-shooting" labeling (e.g. borderline, narcissistic, antisocial) only closes off possibilities in the clinician's mind and prevents the therapist from seeing the patient in all his/her potential for resilient recovery or calamities such as suicide.

3. Request psychological testing to back up interview data and clinical observations. Something may surface that was not considered earlier (e.g. schizotypal thinking or a low-grade thought disorder.

4. Search out nooks and crannies in relation to suicidal and homicidal thoughts. For example, if a person denies active suicidal thoughts, he/she may still wish that a semi-truck would meet them head-on. Likewise, even though a patient is a mother of children and says she would never kill herself because her children need her, has she recently bought life insurance or given away belongings?

5. Review any past history of suicidal ideation or attempts. What are the similarities and differences (e.g. strength or lack of strength of support network) to the present situation? Has the person ever faced anything as humiliating as the exposure of sex addict behavior?

6. Consider, "How deep is this person's shame?" Will the person consider suicide to be the only "viable" way out of a lifelong shame-existence bind?

7. Inquire about how the person has taken out anger in the past. Toward self? Toward others? He/she is likely to follow the same pattern again.

8. Determine the dynamic significance of the type of sexual acting out practiced by the patient (e.g. the exhibitionist who could never get his mother's attention). Has that meaning been processed with the patient and the power taken out of the pattern, or does shame still envelop the patient and fuel suicidal/homicidal thoughts?

9. Measure whether the patient's medication for severe depression is at a therapeutic level. Smoldering along with depression that is only partially treated can heighten the patient's hopelessness and could lead to suicide (e.g. Is this as good as it gets?).

10. Assess medication compliance. What has been the response of the depression to medication? Does the patient understand the importance of taking medication as prescribed, and for as long as prescribed? Are any side effects intolerable to the patient (e.g. decreased sex drive, anorgasmia, or impotence)?

11. Examine any progress made in treatment in processing anger, shame, and other overwhelming emotions. Have the circumstances of the person's life changed for the better? For the worse? Remember, if nothing changes, nothing changes.

12. Gauge employment and economic prospects. Has sex-addict behavior led to consequences at work? Will there be further repercussions and consequences?

13. Ask the patient what he or she sees for the future. Hope or hopelessness?

14. Practice appropriate boundary setting with the patient as he/she relates to co-workers and people outside the circle of recovering sex addicts. To whom will the person claim sex addiction, and with whom will anonymity and strict boundaries be maintained? Role play some of these scenarios. Would the person rather die than face so-and-so?

15. Concretize aftercare plans. Who will see the patient for outpatient treatment? Is that therapist knowledgeable about sex addiction treatment and recovery? Will the therapist refer the patient if suicidality becomes prominent again? Is extended care needed? How many and what type of Twelve Step meetings will the person attend? Will the person get a sponsor and work Steps, or will he/she remain a "movie critic" at meetings as in the past? Will the person "put your whole self in" to recovery, as the song says?

16. Bring to light the person's growth or lack thereof of a concept of a Higher Power. Does the person think his/her preciousness is a reality? Would a Higher Power really care? Is there still a false Higher Power operating (e.g. money, power, self, another addiction, or a partner)?

In summary . . .

The sex addict is really hurting. It is the clinician's task to assess where the pain could lead while providing a safe, healing, holding environment.

Depression present at the start of treatment often deepens as shame crashes down upon the addict whose acting out pattern is revealed. Suicidal ideation at the "between trapeze" moment is a likely probability. The educated clinician's index of suspicion will help to anticipate the presence and depth of depression, and the existence of self-destructive thoughts or plans. Caring and professional assessment and treatment will allow the sex addict to survive the shock of discovery and move toward the daily rewards of a healthy and spiritual recovery.

Stephen S. Brockway, M.D., Dr. Brockway has been in private practice since 1979, specializing in in-patient psychiatry and addiction medicine.