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Assessment and Treatment of Addictive Sexual Disorders:
Relevance for Chemical Dependency Relapse
by Jennifer P. Schneider, M.D. and Richard R. Irons, M.D.
Substance Use & Misuse 36(13), 1795-1820, 2001.
Abstract
Despite some skepticism about the existence of sexual addiction, the addiction
model has proven very useful for treating compulsive sexual behaviors. Addictive
sexual disorders often coexist with chemical dependency and are a frequently
unrecognized cause of chemical dependency relapse. Sex addiction also contributes
significantly to the spread of HIV disease. This paper reviews the differential
diagnosis of addictive sexual disorders, their assessment, their treatment, and
their interaction with chemical dependency, and provides information about
12-step (mutual-help) resources.

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Disclosure of Extramarital Sexual Activities by Persons with Addictive or
Compulsive Sexual Disorders: Results of a Study and Implications for Therapists
by Jennifer P. Schneider, and M. Deborah Corley
In The Clinical Management of Sex Addiction
Patrick Carnes and Ken Adams (Eds). Brunner-Routledge Publishers, 2002
Abstract
Despite religious and cultural precepts that forbid sexual activities outside marital
relationships, such behaviors have continued in most societies and are common in the
United States. Fifty years ago, Kinsey and associates found that one in two husbands
(Kinsey, Pomeroy, & Martin, 1948) and one in four wives (Kinsey, Pomeroy, Martin &
Gebhard,1953) had engaged in extramarital sex. During the peak of the "sexual revolution"
20 years later, the reported numbers of unfaithful women increased (Tavris & Sadd, 1975),
and categories of affairs were defined on the basis of approval or disapproval and
knowledge or lack of knowledge by the spouses about the affair (O'Neill & O'Neill, 1976;
Rubin & Adams, 1986). In surveys published in the United States in the past two decades,
more than 50% of men and women admitted they had engaged in marital infidelity at some
time in their marriage (Glass & Wright, 1992; Hatcher, et al, 1990; Thompson, 1983).

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Guidelines for Therapists Working with Sex Addicts and Co-addicts
By M. Deborah Corley and Jennifer P. Schneider
Sexual Addiction & Compulsivity 9:43-67, 2002.
Abstract
Therapists who treat clients with addictive or compulsive sexual behaviors are often faced
with the dilemma of whether a person should disclose to others secrets about the sexual
behaviors. If a disclosure is determined, then when, what and how to disclose are issues
clients must face. This article discusses issues related to the therapist including
transference and counter-transference, disclosure of therapist's personal history and the
therapist's values regarding keeping secrets from one member of a couple. Practice
guidelines outlined for clinicians include obtaining and gathering history, the importance
of establishing goals with clients, timing of disclosure, how much to disclose and how to
disclose. Other ethical situations and steps to rebuild relationships are discussed.

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A Qualitative study of Cybersex Participants: Gender Differences, Recovery Issues, and Implications for Therapists
by Jennifer P. Schneider
Arizona Community Physicians, Tucson, AZ
Published in Sexual Addiction & Compulsivity 7:249-278, 2000
Abstract
In a companion study to one previously published on the effects of cybersex addiction
on the family, a new, brief online survey was completed by 45 men and 10 women, aged
18-64 (mean, 38.7) who self-identified as cybersex participants who had experienced
adverse consequences from their online sexual activities. Nearly all the respondents
(92% of the men and 90% of the women) self-identified as current and/or former sex addicts.

Significantly more men than women reported downloading pornography as a preferred activity.
As in previous studies on gender differences in sexual activities, the women tended to prefer
sex within the context of a relationship or at least e-mail or chat room interactions rather
than accessing images. However, in the present small sample, several women were visually-oriented
consumers of pornography. Two women with no prior history of interest in sadomasochistic sex
discovered this type of behavior online and came to prefer it. Although a similar proportion
of men (27%) and women (30%) engaged in real-time online sex with another person,
significantly more women than men (80% versus 33.3%) stated that their online sexual
activities had led to real-life sexual encounters.

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Effects of cybersex addiction on the family: Results of a survey
by Jennifer P. Schneider
Sexual Addiction and Compulsivity 7: 31-58, 2000
Abstract
A brief survey was completed by 91 women and 3 men, aged 24-57, who had experienced serious
adverse consequences of their partner's cybersex involvement. In 60.6% of cases the sexual
activities were limited to cybersex and did not include offline sex. Although not specifically
asked about this, 31% of partners volunteered that the cybersex activities were a continuation
of pre-existing compulsive sexual behaviors.

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Compulsive and Addictive Sexual Disorders and the Family
By Jennifer P. Schneider, M.D., Ph.D.
Published in "CNS Spectrums," Vol. 5(10), October, 2000:53-62
Abstract
In the treatment of sexual addiction and compulsivity, the family unit is often neglected.
Yet this disorder has a major impact not only on the identified patient, but also on the
spouse or partner (the coaddict) and on the family as a whole. Moreover, the family unit
is the context in which the sexual addict continues to live, and the mental health of the
partner has a significant impact on the sexual addict's recovery. Increasing evidence points
to a family history of addiction or dysfunction as a primary contributor to both sexual
addiction and coaddiction in adulthood. When compulsive sexual behaviors are present within
a family, treatment of both members of the couple improves the couples' relationship as well
as the mental health of each partner. In addition, treatment of children in such a family
can help break the cycle of sexual addiction and prevent its perpetuation into the next
generation.

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When is Domestic Violence a Hidden Face of Addiction?
by Richard Irons, M.D., FASAM*, and Jennifer P. Schneider, M.D., Ph.D.**
Journal of Psychoactive Drugs, Vol 29, pages 337-344, 1997.
Abstract
This article reviews studies pertaining to comorbidity of domestic violence, addictive
disorders, and sexual abuse, and presents a model in which domestic violence parallels
the chief features of chemical dependency. Domestic violence and addictive disorders have
a number of common characteristics, including loss of control, continuation of behavior
despite adverse consequences, preoccupation or obsession, development of tolerance, and
family involvement. Domestic violence predisposes the next generation to both domestic
violence and addictive disorders. Sexual abuse within the family of origin and/or the couple
relationship are common features of both domestic violence and addictive disorders, and
predispose to both in the next generation. Clinicians encountering patients who are
perpetrators or victims of domestic violence or sexual trauma, or have addictive disorders,
must assess for the presence of either of the other problems.

"I first experienced the effects of alcohol at age four. My father came home from work late
one night, staggering and intoxicated. He and my mother got into a terrible fight. They were
hitting each other. My mother drew a kitchen knife out of a drawer and held it up to defend
herself. She asked me to go across the street to my grandmother's house to get her. She was
the only person who could control my father once he had begun drinking."
-- Comments at an AA meeting

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Addictive Sexual Disorders: Differential Diagnosis And Treatment
by Jennifer P. Schneider, M.D., Ph.D. and Richard Irons, M.D.
Published in Primary Psychiatry, April, 1998
Abstract
Patients who present with excessive and/or unusual sexual urges or behaviors are often a
source of confusion to clinicians. In some cases the diagnosis appears clear-cut: The young
man who has a history of arrests for exposing his genitals to unsuspecting strangers has a
paraphilia, exhibitionism (DSM-IV diagnosis 302.4); a young woman's obsessive, intrusive,
and very disturbing sexual thoughts may be one aspect of her obsessive-compulsive disorder
(300.3); the 70-year old nursing home patient who gropes any female staff member who gets
within touching distance may be exhibiting a loss of judgment secondary to his Alzheimer's
disease (290.1) ; another hypersexual patient exhibits pressured speech and grandiosity
typical of the manic phase of bipolar type I or II psychosis (296). In each of these cases,
the appropriate treatment is guided by the diagnosis.

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How to recognize the signs of sexual addiction
Asking the right questions may uncover serious problems
Jennifer P. Schneider, MD, PhD
VOL 90/N0 6/NOVEMBER 1, 1991/POSTGRADUATE MEDICINE - SEXUAL ADDICTION
Abstract
Addiction to sexual activities can be just as destructive as addiction to chemical substances.
Addicts may jeopardize their marriage and family relationships, allow their job performance
to deteriorate, and endanger themselves and their partner through multiple sexual exposures.
Even though they realize the consequences, they cannot control their compulsions without
appropriate treatment. The author explains how to spot addicts and coaddicts among your
patients. For most people, sex enhances the quality of life. However, about 3% to 6% of
Americans have sexual addiction(1). Through their addiction, they may injure themselves
physically, experience psychological distress, lose their livelihood, and ruin meaningful
relationships. Sexual addiction often coexists with chemical dependency, and untreated sexual
addiction contributes to relapse to chemical use. These patients not only endanger themselves
but also put their loved ones at risk for AIDS and other sexually transmitted diseases.
Physicians can help by learning about this phenomenon, which is gaining increasing attention
in behavioral medicine, and then educating these patients and their families.

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"Couple Recovery from Sexual Addiction/Coaddiction: Results
of a Survey of 88 Marriages."
by Jennifer P. Schneider, M.D. and Burton H. Schneider, M.A., M. Ed.
Sexual Addiction & Compulsivity 3:111-126, 1996.
Abstract
To obtain information on how couples recovering in 12-step programs from sexual addiction
and coaddiction were actually dealing with their problems, the authors anonymously surveyed
142 persons representing 88 marriages. Additional information was obtained over a 7-year
period through facilitating 12-step couples' retreats attended by approximately 100 couples.

The most common problems identified by couples were rebuilding trust, learning intimacy,
establishing boundaries, developing a healthy sexual relationship, and forgiving. Most
couples also reported great difficulty in conflict resolution. The factors which appeared
most helpful to couples in rebuilding and improving their relationship were individual
involvement in 12-step meetings and therapy, and joint counseling and attendance at couples'
mutual help and/or therapy groups. Coaddicts typically required over a year to forgive and
become willing to trust the addict again. New sexual problems were common in the early
recovery period, and tended to gradually improve. Eighteen percent of male addicts had
engaged in same sex activities. Despite enormous past hurts and significant relational,
financial, legal, and health problems faced by many of the couples, most were actively
working on their marriages and were committed to a future together.

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"Differential Diagnosis of Addictive Sexual Disorders Using the DSM-IV"
Sexual Addiction & Compulsivity 1996, Volume 3, pp 7-21, 1996.
by Richard Irons, M. D. and Jennifer P. Schneider, M.D., Ph.D.
Abstract
The current Diagnostic and Statistical Manual of Mental Disorders (DSM-IV) describes
certain sexual disorders which are characterized by, or include among their features,
excessive and/or unusual sexual urges or behaviors. Common disorders in the differential
diagnosis include paraphilias, impulse disorder not otherwise specified (NOS), sexual
disorder NOS, bipolar affective disorder, cyclothymic disorder, post-traumatic stress
disorder, and adjustment disorder. Infrequent disorders in the differential diagnosis
consist of substance-induced anxiety disorder, substance-induced mood disorder,
dissociative disorder, delusional disorder (erotomania), obsessive-compulsive disorder,
gender identity disorder, and delirium, dementia, or other cognitive disorder. Addictive
sexual disorders which do not fit into standard DSM-IV categories can best be diagnosed
using an adaptation of the DSM-IV criteria for substance dependence.

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Seekingsafety רתאמ םייעוצקמ םירמאמ
A Psychotherapy for PTSD and Substance Abuse
(םישדח םירמאמ ועיפוה םא םעפ ידמ קודבל יאדכ)
Najavits L.M. Seeking Safety: A new psychotherapy for posttraumatic stress disorder
and substance use disorder. In: Trauma and Substance Abuse: Causes, Consequences, and
Treatment of Comorbid Disorders (P. Ouimette & P. Brown, Eds.).
Washington, DC: American Psychological Association Press, in press.

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Outcome of a new cognitive-behavioral psychotherapy
for women with posttraumatic stress disorder and substance dependence.
Najavits, L.M., Weiss, R.D., Shaw, S.R. (1998)
Journal of Traumatic Stress. 11:437-456.
Abstract
Women with current posttraumatic stress disorder (PTSD) comprise 33-59% of substance abuse
treatment samples and show a more severe course than women with either disorder alone. As
yet, no effective treatment for this population has been identified. Therefore, a new
24-session cognitive behavioral group therapy was designed to address their treatment needs.
This paper reports outcome results on 17 women who completed the protocol treatment, based
on assessments at pre-treatment, during treatment, post-treatment, and at 3-month follow-up.
Results showed significant improvements in substance use, trauma-related symptoms, suicide
risk, suicidal thoughts, social adjustment, family functioning, problem solving, depression,
cognitions about substance use, and didactic knowledge related to the treatment. Patients'
treatment attendance, alliance, and satisfaction were also very strong. Treatment completers
were more impaired than dropouts yet more engaged in the treatment. Overall, our data suggest
that women with PTSD and substance abuse can be helped when provided with a treatment adapted
to them. All results are clearly tentative, however, due to the lack of a control group,
multiple comparisons, and the absence of assessment of dropouts.

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Training clinicians to conduct the Seeking Safety treatment for PTSD and substance abuse
Najavits, L.M. (2000) Alcoholism Treatment Quarterly. 18:83-98.
Abstract
This paper provides suggestions for training clinicians in the Seeking Safety psychotherapy
for patients with posttraumatic stress disorder and substance abuse. The treatment is a
manual-based 25-session cognitive-behavioral therapy for integrated treatment of both
disorders. Training guidelines include: procedures for clinician selection and training,
supervisory principles, and typical problems. Emphasis is placed on procedures that allow
observation of the clinician "in action" rather than through verbal report (e.g., taped
sessions) and on intensive training experiences (e.g., watching videotapes of good versus
poor sessions, rehearsal of "tough case" scenarios, peer supervision, identifying key themes,
and think-aloud modeling). Supervisory principles include, for example: Encourage clinicians
to use the coping skills in their own lives; Elicit patient feedback; and Listen to behavior
more than words. These methods are "best guesses" based on experience with clinicians over
several years; further empirical testing will be needed to determine which training
strategies are most effective.

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Implementing Seeking Safety therapy for PTSD and substance abuse: Clinical guidelines.
Najavits, L.M. (2002).
Behavioral Health Recovery Management Project.

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Suggested protocol for selecting and training clinicians in Seeking Safety.
Najavits, L.M. (2002).
Unpublished manuscript, McLean Hospital, Belmont MA.

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Cocaine dependence with and without PTSD among subjects in the
National Institute on Drug Abuse Collaborative Cocaine Treatment Study.
Najavits, L,M.. Gastfriend, D.R., Barber, J.P. Reif, S. Muenz, L., Blaine, J.,
Frank, A., Crits-Christoph, P., Thase, M., Weiss, R.D. (1998).
American Journal of Psychiatry. 155: 214-219
Abstract
This study (1) examines the prevalence of lifetime traumatic events and current posttraumatic
stress disorder (PTSD) symptoms among treatment-seeking cocaine-dependent outpatients, and
(2) compares patients with and without PTSD in current substance use, psychopathology, and
sociodemographic characteristics. Method. Subjects were 122 adult cocaine-dependent outpatients
who were participating in a treatment outcome study of psychosocial therapy. In addition to
standard self-report and interview measures of psychopathology and substance use, subjects
completed a Trauma History Questionnaire and PTSD Checklist prior to entry into treatment.
Results. Lifetime trauma events were high in this cohort (mean = 5.7), and were gender-related,
with men having more general disaster and crime-related traumas and women more physical and
sexual abuse. Twenty percent of the cohort met DSM-III-R criteria for current PTSD diagnosis
based on self-report measures (with a rate of 30% among women and 15% among men). Patients
with PTSD, in comparison to non-PTSD patients, evidenced significantly higher rates of
co-occurring Axis I and II disorders, interpersonal problems, medical problems, resistance
to treatment, and psychopathology symptoms (with the latter the most consistent area of
difference between the two groups, as well as providing the best praddiction of PTSD status
in a logistic regression). However, the groups did not differ significantly in current
substance use or sociodemographic characteristics. Conclusions. Findings underscore the value
of screening substance abusers for PTSD since a small but significant number potentially
requiring additional treatment are apt to be identified. Further studies of the relationship
between PTSD and substance abuse appear warranted.

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A clinical profile of women with PTSD and substance dependence.
Najavits, L.M., Weiss, R.D., Shaw, S.R. (1999)
Psychology of Addictive Behaviors. 13:98-104.
Abstract
To assess the clinical characteristics of women with posttraumatic stress disorder (PTSD)
and substance dependence, we compared 28 women with both disorders to 29 women with PTSD-alone
on a wide battery of lifetime and current clinical measures. The dual diagnosis women consistently
had a more severe clinical profile, including worse life conditions (e.g., physical appearance,
opportunities in life), both as children and as adults; greater criminal behavior; a higher
number of lifetime suicide attempts; a greater number having a sibling with a drug problem;
and fewer outpatient psychiatric treatments. One discrepant finding, however, was their lower
rate of major depression. Interestingly, the two groups did not differ in number or type of
lifetime traumas, PTSD onset or severity, family history of substance use; coping style,
functioning level, psychiatric symptoms, or sociodemographic characteristics. Treatment
implications and methodological limitations are discussed.

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The Addiction Severity Index as a screen for trauma and posttraumatic stress disorder.
Najavits, L,M.. Weiss, R.D., Reif, S., Gastfriend, D.R., Siqueland, L., Barber, J.P,
Butler, S., Thase, M., Blaine, J., (1998)
Journal of Studies on Alcohol. 59: 56-62.
Abstract
Objective. The Addiction Severity Index (ASI) includes items to assess patients' history
of trauma (physical or sexual). The goal of this study was to assess the sensitivity and
specificity of those questions in relation to a more thorough measure of lifetime trauma
(the Trauma History Questionnaire; THQ) and, in addition, to an actual posttraumatic
stress disorder (PTSD) diagnosis. Method. 110 cocaine dependent outpatients were assessed
at the start of treatment on the ASI, the THQ, and a PTSD symptom checklist as part of
a multisite clinical trial. Results. Specificity of the ASI questions was higher than
sensitivity for both physical and sexual trauma, while for PTSD the sensitivity of the
ASI was higher than its specificity. Other findings indicated that patients were more
likely to report trauma on the THQ than on the ASI (which may be due to the self-report format
of the THQ); that the ASI was better at assessing sexual than physical trauma; and that the higher
the number of ASI trauma items endorsed, the more likely was the PTSD diagnosis. Finally, patients
with PTSD had greater severity than non-PTSD on other ASI items (e.g., psychological
severity, need for treatment). Conclusions. The ASI trauma questions show stronger
utility as a screen for PTSD than for trauma. Results of the study are discussed in
light of ways to modify the ASI to screen more accurately for trauma, clinical
implications, and limitations of the study method.

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Helping "difficult" patients.
Najavits, L.M. (2001). Psychotherapy Research. 11:131-152.

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Psychotherapists' implicit theories of psychotherapy.
Najavits, L.M. (1997) Journal of Psychotherapy Integration. 7:1-16.
Abstract
The concept of an "implicit theory" is raised to describe the private beliefs that a
therapist holds about therapy, aside from those provided by an explicit theoretical
orientation (e.g., behavioral, psychodynamic). It is suggested that the combination
of an explicit theory and an implicit theory will account for more variance than an
explicit theory alone when studying psychotherapy process and outcome. Examples of
implicit theories include "principles of practice", "role definition", "professional
dilemmas", and "images". The assessment of implicit theories is described; and the
application of implicit theories to psychotherapy research is illustrated in relation
to three topics: the identification of expert therapists, improving training in
manualized treatments, and understanding negative patient outcomes.

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Clinicians' impact on the quality of substance use disorder treatment.
Najavits, L.M., Crits-Christoph, P., Dierberger, A. (2000)
Substance Use & Misuse; 35: 2161-2190.
Reprinted in: Research on Alcoholism Treatment, volume XVI of the series
Recent Developments in Alcoholism (M. Galanter, Ed.), 2003; pages 55-68. New York: Plenum.
Abstract
Clinicians' impact on substance use disorder treatment has been much less studied than
therapy and patient variables. Yet, in this selective review of literature, a growing
body of empirical work on clinicians' impact highlights several key issues that have
relevance both to clinical practice and future research. These issues include clinicians'
effect on treatment retention and outcome, professional characteristics, recovery status,
adherence to protocols, countertransference, alliance, personality, beliefs about
treatment, and professional practice issues. Specific recommendations are offered to
help improve the quality of care clinicians provide. In particular, it is suggested
that greater accountability for clinicians' performance be balanced with increased
support for their very difficult role. Methodological issues in studying clinicians'
are also addressed.

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Variations in therapist effectiveness in the treatment of patients
with substance use disorders: An empirical review.
Najavits, L.M., Weiss, R.D. (1994) Addiction. 89: 679-688.
Abstract
Despite the widespread use of psychotherapy for patients with substance use disorders,
the effectiveness of psychotherapists conducting such treatment has received little
research attention. In this paper, empirical studies of therapists' differences in
patient outcome and dropout rates are comprehensively reviewed. The main conclusions
are that therapists show diverse rates of effectiveness, and that such differences appear
independent of both therapists' professional background and of patient factors at the
start of therapy. The primary therapist characteristic thus far associated with higher
effectiveness is the possession of strong interpersonal skills. Guidelines for research
on therapist effectiveness are presented.

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