COMBINING OUTDOOR EXPERIENTIAL THERAPY WITH CBT FOR THE NON-RESIDENTIAL TREATMENT OF YOUNG MALE INTERNET PORN ADDICTION
A Dissertation Proposal
Presented to the Faculty of
The Chicago School of Professional Psychology
In Partial Fulfillment
Of the requirement for the Degree
Doctor of Psychology
CGI-TCS Reader or External Reader:
TABLE OF CONTENTS
LIST OF TABLES………………………………………………………….
LIST OF FIGURES…………………………………………………………
1 NATURE OF THE STUDY
Background to the Problem………………………………………………………4
Problem Statement ……………………………………………………………….7
Application of Results…………………………………………………………….9
Outline of Remaining Chapters…………………………………………………15
2 REVIEW OF THE LITERATURE
Pornography and Sexuality on Internet……………………….…………………18
Types of Pornographic Material…………………………………………………18
Non-violent or degrading pornography..……………………………….21
Violent pornographic materials…..……………………………………..22
Positive Sides of Pornography…………..……………………………………..23
Review of Current Research Literature..………………………………………29
Online Sexual Behavior………………………………………………………..29
Sexual Behavior of Young Males.……………………………………………..35
Sexual Compulsive Behavior………………………………………………….37
Internet Pornographic Addiction…………………….………………………….37
Treatment of Sex Addiction Behavior…………………………………………39
Therapist and Clinicians……………………………………….………………40
Cognitive Behavioral Therapy………………………………………….47
Outdoor Behavioral Healthcare programs………………………….……49
Evaluation of Research Literature……………………………………………….50
3 RESEARCH DESIGN AND METHOD
Hypothesis and Their Relations…………………………………………….……54
Pilot Studies ……………………………………………………………….…….57
Proposed Treatment Plan……………………………………..………………….61
APPENDIX A QUESTIONNAIRES …………………………………….
APPENDIX B CONSENT LETTER…………………………………………………..
LIST OF FIGURES
1 Theoretical Framework …………………………………………….14
2 Sexual Behavior Sequence………………………………………….35
3 The Addictive System ……………..……………………………….38
LIST OF TABLES
1 Treatment Plan Grid…………………………………………….57
NATURE OF THE STUDY
Background to the Problem
When Tim Berners-Lee invented the web (www) in 1989, he would not have thought of as many applications of internet as it is today. The use of internet has grown enormously in the last two decades. Internet is used by different individuals and professional with a variety of purposes. The initial use of internet was limited to the academic purposes and research. However it evolved as an effective mode of communication for millions of internet users across the globe. Internet users are using internet for a range of online activities such as e-learning, online banking, online shopping, games, social networking websites, sharing of knowledge and information, sharing of music and videos and entertainment activities. This has increased the role of internet technology in the life of an average user. There are various studies that indicate that users are dependent on internet so much that it impacts their professional and personal lives. It is a well known fact that internet is one of the widely used tools for the transfer of pornographic and erotic materials from one part of the world to the other. There are abundant pornographic materials available on various websites.
According to Cooper (2002) the emerging phenomenon of availability and use of online pornographic materials has become one of the major areas of concerns for the behavioral and psychological health clinicians. Terms like Internet-enabled sexual behavior (IESB referred by Greenfield, 2000 as cited by Cooper, 2002) and online sexual activity have become one of the most interesting areas of studies. In the recent past the addiction of online activities has been described for those who have limited ability to control themselves for the over use of internet for any activity. The online addiction can be of online gaming, chatting or online sexual activities. This study is focusing on one of the areas of problems of this technology-driven addiction, which is known as online pornographic addiction or cybersex addiction.
There is an ongoing debate in the field of research and psychology on the existence of internet pornography addiction. There have been extensive concerns among the medical establishment, psychologists, Congress and The Supreme Court about the possible harms of youth being exposed to online pornography.
Brain research shows that sexual excitement occurs after viewing an image. This is due the releases of epinephrine into the bloodstream by adrenal glands. The chemical then travels to the brain and locks in the image. The mind can then recall the image at any time, and trigger the same feelings of arousal. Other biochemicals such as serotonin, endorphins, adrenaline, and dopamine are also released. These contribute to euphoric emotions, causing the person to want to experience the feeling again and again (Schneider, 1991). Accessibility and anonymity make it virtually impossible for a teenager to resist going back for more (Rambaree, 2004; Tareen, Nilsen and Stigum, 2006; Young, 2009).
There are various uses of online pornography. It can be used for helping individuals and couples dealing with problems of intimacy and are willing to improve their sex life. Yet these couples sometimes may have a narrow view of sexuality. They can be stripped of the context of true intimacy, closeness, health and well being of oneself and partner. Ross, Rosser, Mccurdy, & Feldman (2007) argue as a primary source of sex education, it is inaccurate and incomplete, creates feelings of confusion, anxiety, shame and guilt. As the compulsive behavior escalates, individuals become increasingly withdrawn and isolated (Ross, Rosser, Mccurdy and Feldman, 2007 ). The internet acts as a drug of choice. It does not require him to leave the room, spend money, or communicate with another human in order to maintain a constant supply (Hill & Beamish, 2007; Goldberg, Peterson, Rosen, & Sara, 2008).
Despite the rapidly increasing number of families seeking help for their teenage sons struggling with compulsive internet porn use, there are only two residential treatment centers in the United States specifically established and designed for the treatment of male, teenage internet pornography addiction. It is also a growing problem in adult young males.
There have been various studies on the Internet-enabled sexual behavior (IESB). Orzack, Voluse, Wolf and Hennen (2006) revealed that the IESB had negative impact on the social relations of the individual, productivity at the workplace and academic success. This study was conducted among the middle aged men with problematic IESB. The therapy used in this study was combined therapy with CBT and Motivational Interventions (MI). This study revealed that the problem of IESB requires more studies and interventions (Orzack et al, 2006).
Young (2007) studied the performance of Cognitive Behavioral Therapy among the clients suffering from internet addiction. The findings of this study revealed that significant improvements were recorded in terms of motivation, time management for online uses and overall social relationships of the client (Young, 2007).
Both Oxbow Academy and Pine Creek Ranch have achieved 80-90% success rates using a holistic approach designed to help students recognize and deal with behavioral, emotional, and social problems that contribute to their sexual issues, using a combination of CBT along with an experiential model that is strength-based and emphasizes honesty, accountability, empathy and family re-unification.
Experiential therapy includes various types of experience programs that can be based on equine therapy, dance, music, art and activities that can add on to the real life experience. Experiential therapy can be divided into two main categories: outdoor experiential therapy and indoor experiential therapy. Outdoor experiential therapy (OET) or Wilderness Therapy utilizes nature to help residents work through their problems and free themselves from dependency through the physical challenges offered in nature. There are various types of outdoor therapies used by different organizations for different problems. The theoretical aspect of any OET or wilderness therapy program consists of the perspectives like the perception of client by the program, theoretical setting of the program and approaches of the therapist for the program.. The two identified types of OET are expedition and base camp programs (Russell, Hendee and Phillips-Miller, 2000).
According to Russell et al (2000) wilderness therapy consists of three main phases of cleansing, personal and social responsibility, transition and aftercare phase. The cleansing phase is based on the fact that a client should be replaced from his/her destructive environment to a healthy environment with focus on physical and mental health. This step is based on natural consequences to change an individual and his behavior. A slow start of this phase followed by the personal and social responsibility phase depends on natural consequences. A peer interaction helps individuals to learn their personal and social responsibilities. A natural setting of environment, variations in the environmental conditions and natural aspects of lifestyle help individual at various levels. Natural consequences for the real life of the individuals participating lead them to understand their responsibility for themselves and towards others.
Russell et al (2000) focused on the approaches used by primary care staff in a wilderness therapy. Russell et al concluded that these staff members have empathetic view for the clients. They nurture them and care about their clients in the camp and build a relationship of trust and friendship. This way they help them in dealing with their resistance and anger. However the role of staff had been questionable due to the deaths of teens during 1990s in some of the Wilderness camps.
The experience of being out in the world reconnects an individual to his world. This helps him reconnect with the people in his life. Outdoor activities like living in camps with nature and expedition programs showed significant improvements in social relationship. Research supports the use of experiential therapy for motivation and increased ability for social integration. Teens are typically less resistant to experiential therapy. This therapy could involve them in different activities instead of giving the sense of being treated. Staff members are trained to process with each student. In this way they help students to understand the value of what is happening and helping them see parallels in their own lives. Experiential therapy is relationship based therapy in which bonds between the student and his therapist is developed over a period of time. This enables a student to experience safe, healthy, supportive behavior within a family-styled structure. Various activities help students discover new interests to compete with their old patterns of sexual dependency. This helps in developing confidence and determination to overcome different challenges experienced by the students. Therapists are involved in thinking, emotions and senses of the student to help them internalize what they learn through their experience. Empirical studies show that experiential methods help clients to achieve dramatic results in the areas of psychological symptom reduction.
There are plenty of organizations that are providing experiential therapies for the teen age students. Oxbow Academy in Central Utah provides treatment to boys of age 13-17 through experiential therapy. It has six primary treatment objectives. These objectives are disruption of negative behavior patterns, honesty and accountability, healthy perception of self and thinking, loving and validating relationships, skills for life, including social competency and personal integrity or relapse prevention. However the number of organization providing similar facilities for the adolescents and young individuals of 16-26 years of age are limited.
In many cases, therapists have provided combination of CBT and experiential methods to facilitate recovery of distress, compulsive thoughts, impulses and actions, fewer feelings of inadequacy and inferiority, fewer symptoms of depression, anxiety, fear and anger, a greater orientation to the present, a tendency to be more independent and self-supportive, increased flexibility and sensitivity to their own needs and feelings, a greater likelihood to express feelings and be themselves, an improved capacity to develop meaningful and warm interpersonal relationships with others (Weiner et al, 2003).
Are there any potential benefits of combining weekly CBT with experiential therapy for the treatment of young male internet porn addicted in a non-residential setting?
1. How therapists for young adult males (18-26 years) both healthy and unhealthy perceive a treatment plan combining CBT with Outdoor Experiential therapy as compared to the treatment through CBT in an office setting?
2. What are the attitudes of therapists of young adult males for their supportiveness for combining CBT with Experiential therapy in an outdoor setting, than a group of young adult males of CBT in an office setting?
3. To what extent do the therapists believe that young adult males will report a more favorable perception of their therapists consistency in a combining CBT with Experiential therapy in an outdoor setting, than a CBT in an office setting?
4. How important therapist for young males in CBT with Experiential therapy in an outdoor setting, than CBT in an office setting?
5. To what extent qualitative results of the use of CBT and Outdoor Experiential therapy support the quantitative outcomes of positive change in the behavior of clients?
6. What are the patterns of long term impacts of the CBT and Experiential therapy treatment offered to the individuals with the addiction to online pornographic material?
Application of Results
The results can be applicable in integrating a CBT and an experiential therapy to get better and sustaining results for treating clients with internet pornography addiction problems. These results may help them in developing an effective treatment plan. The survey responses from the people with online addiction programs will help in determining effectiveness of the programs. A thorough comparison of data will clarify if the proposed treatment plan would be effective or not.
Experiential therapy combined with CBT in an outdoor environment will facilitate willingness and readiness for change the typical adolescent resistive behavior. This study would provide the therapist perspectives of an overall treatment process in CBT in an non residential setting and experiential outdoor therapy. This will help in understanding how therapists perceive the combination of these two methods in order to helping the internet pornographic addicts. Therapists are the people working at the grassroots level of the problem. They are involved in the development of treatment plans and work with the patients on one to one basis. They have experience and skills to deal with such problem at practical level. Getting their perspective will help in understanding if the desired level of results will be achieved to help clients suffering from internet pornography addiction.
This theoretical framework is a guiding tool for the content of literature review. This provides a synthesis of different subtopics of the literature review for the greater understanding of the topic of the study. Online pornographic addiction leads to various problems of social relationship, physical, psychological, productivity and performance problems. These act as origin of behavior related problems such as failed social relations, lesser engagement in offline activities, failure in online time management, and poor levels of motivation, productivity of the individual, depression and anxiety.
The treatments offered to the online pornography addiction programs are similar to that of any other addictions. In most of the treatments, a therapist or group of therapists work closely with the subject and help him developing an addiction free behavior. The treatment plan is developed on the basis of severity of the problem. Cognitive behavior therapies are widely used for treatment of wide range of behavioral health problems. Outdoor experiential therapy is used widely for the treatment of various addictions and addiction led compulsive behavior treatments. These programs are based on series of activities with different nature of difficulties and challenges for the subject. Individuals try to deal with these challenges in a group environment and with the consistent support of staffs working with them. The open communication between staff and subjects allow them to share and develop better understanding of their challenges. The self evaluation can be based on open communication or maintaining a journal or diary to write about their experiences. Most of the wilderness programs use nature as major source for healing for the subjects. These programs help students gaining their confidence and motivation. This leads to gaining self reliance and control back which results in greater self respect for oneself. An online addict requires change in behavioral level to develop healthy behavior. Confidence and self-reliance will help in improving his productivity. All these help an individual to develop and live healthy lifestyle.
Figure 1: Theoretical Framework
Source: Developed on the basis of available literature
“Compulsive, uncontrollable dependence on a substance, habit, or practice to such a degree that cessation causes severe emotional, mental, or physiological reactions”. Addiction is studied with models like disease models, genetic model, moral model and cultural model. Disease model has biological, psychological, social and spiritual dimensions (Rotgers, Morgenstern and Walters, 2006).
Cognitive Behavioral Therapies (CBT)
“Cognitive Behavioral Therapy (CBT) is the term used for a group of psychological treatments that are based on scientific evidences. These treatments have been proven to be effective in treating many psychological disorders.” (Association of Behavioral and Cognitive Therapies, 2010)
According to Fisher and O’Donohue (2006) there are more than 70 behavioral health problems that can be treated with CBT. O’Donohue and Fisher (2008) state that cognitive behavioral therapy is empirically found very effective in the treatment of high incidence psychological problems like depression and anxiety disorders. It is brief, cost effective and can be delivered in group as compared to other therapies. This has clear goals and straight in implementation. This allows combination of individual techniques according to the individual client and severity of a problem (O’Donohue and Fisher, 2008).
Cyber sex / Online Sex
Cybersex allows users to get involved in pleasurable and exciting sexual activities through the web navigation. The only purpose for cybersex activity is sexual stimulation through visuals, audio or reading erotic content. Online sex activities can be done with variety of purpose like improving sex life, entertainment, curiosity and compulsive activity. High involvement in online sex can impact on various spheres of life of an individual from social to individual aspects of their life.
Experiential Outdoor Therapy
This therapy is based on the experience and challenges that an individual can find in nature which can help them grow and bring changes in their life. These therapies can be living in camp with nature.
The Rogers Memorial Hospital explains Experiential Therapy as “Experiential therapy helps patients identify social, coping and life skills through a variety of guided tasks and activities. Once patients identify these behaviors, they build their ability to shift old patterns to new, self-supporting ways of thinking. ”
There are list of activities that can be included in the experiential therapy like art, music, fitness, recreational activities and adventure and outdoor activities. Experiential outdoor therapies include trips, equine based therapies, sensory walks, rock climbing, biking, mountaineering, canoeing, caving and others.
There is no definition given for internet addiction. Young (2009) has compared internet addiction to any other addiction. This can be explained as an uncontrollable dependence on internet browsing for various purposes i.e. gaming, online surfing or cybersex that can cause severe emotional, mental and physiological problems.
These programs are reported to have started from 1959 in Utah. These programs allow individuals to “remain in their homes and receive counseling, education, employment, diagnostic, and casework services. A counselor gives innovative and intensive support to help the youth remain at home. Family therapy, educational tutoring, and job placement may all be part of the program” (Siegel and Welsh, 2008)
According to the Standford Encyclopedia of Philosophy, “Pornography is any material (either pictures or words) that is sexually explicit.”
There is no unanimous definition for the pornography. The Oxford Dictionary defines pornography as “books, videos etc. that describe or show naked people and sexual acts in order to make people sexually excited, especially in a way that many people find offensive.”
Sigel (2002 as reviewed by Cocks, 2003) elaborates “The word pornography, used to define forms of purely sexual representation, was coined in the 1860s, and represented a significant shift in the nature of sexual imagery and in the place of sexuality within modern culture. Lynn Hunt has argued that until the late eighteenth century, sexual imagery was rarely isolated from other forms of address”. In the present scenario, pornography has been considered “characteristics creations of modernity” (Sigel, 2002 in Cocks, 2003).
Online Sexual Activity (OSA)
“Online Sexual Activity (OSA) is defined as use of the Internet (including text, audio, graphic files) for any activity that involves sexuality, whether for purposes of recreation, entertainment, exploration, support, education, commerce, or finding and/or meeting sexual or romantic partners. OSA includes cyber sex (i.e., sexual activity via the net), Online Sexual Problems (OSP) (i.e., OSA has lead to difficulties, usually feeling out-of-control and/or having others complain about the activity), and Online Sexual Compulsivity (OCS) (i.e., an ongoing, out-of-control engagement with OSA).” (Cooper and Griffin-Shelley, 2001)
Sexual addiction is related with the obsessive sexual activities that are related to loss of control and escalation, inability to stop, social, emotional, physical and legal consequences. This can lead to irritability, extreme defensiveness and anger in the individual (Weiss, 2008).
This is an indexical term which depends on the culture and society it is applied. In some cultures showing any part of female body can count as sexually explicit i.e. Afghanistan and other Muslim dominated countries where modesty is determined with clothing and behavior. At the same time in some parts of the world sexually explicit material can be only the materials showing sexual acts and exposed sexual organs and related body parts. (The Stanford Encyclopedia for Philosophy, 2004)
‘Victorian Effect’ is a term used for a phenomenon where hiding leads to increasing curiosity for a particular thing or activity. D’Amato (2006) explains, “The more that people covered up their bodies with clothes in those days (Victorian Era), the greater the mystery of what they looked like in the nude. The sight of a woman’s ankle was considered shocking and erotic.”
Outline of Remaining Chapters
Chapter 2 Review of the Literature
This chapter provides review of literature that covers the previous studies on internet pornography and sexuality on internet, psychological theories of sex addiction, internet pornography and compulsive behavior in men, healthy and unhealthy sexual habits and therapies used for the treatment of internet pornographic addiction. This chapter provides theoretical understanding of the topic of the study.
Chapter 3 Research Design and Methodology
This chapter provides the details on different aspects of research design and methodology such as research methods available and used, research instrument, target respondents and limitations of research.
REVIEW OF THE LITERATURE
The chapter consists of the internet pornographic addiction concept through literature on 1) Pornography and sexuality on internet, 2) Psychological theories of sex addiction, 3) Internet pornography and compulsive behavior in men, 4) Healthy and unhealthy sexual behavior and 5) Therapies used for the treatment of internet pornographic addiction. The theoretical background covers the etiology of online pornographic materials. The current literature has focus in the direction of theoretical description online sexual behavior and male compulsive behavior, internet pornographic addiction and treatments from addictive behavior.
Pornography and Sexuality on Internet
According to Kendall (2007) pornography can be regarded as one of the oldest professions of the world. The term ‘porno’ is derived from the Greek term for a prostitute that is ‘pórni’. There is an ongoing debate over the positive and negative impact of pornography in our society. Feminists have condemned pornography time to time for degrading women presentation and contributing to the crime. Liberals wants to have empirical support or evidence before declaring it harmful. Some researchers have argued on the significant link between pornography with crime (Dworkin, 1993) whereas some others find the relationship of pornography and criminal activities to be casual (Marquit, 2010). Marquit (2010) argues that the behavior of criminal is similar to those who had spent years in religiously restricted environment for pornography. There are various advantages of pornography particularly for the couples who already have a sexual experience and look for improving their sex life (Klein, 2002). These couples can learn new positions, get better sharing opportunity watching pornographic material, get opportunity to express their sexual preferences and fill the communication gap by communicating about their sexual preferences and dislikes (Klein, 1998; 2006). Watching other couple making love can release hormones for excitement and sexual arousal. This can lead to intense orgasm for them and improve their relationship. Sex is a highly private affair of two individuals. Pornographic materials help in understanding the performative norms and sexual meanings of various aspects of the sexuality of other individual (Attwood, 2002). Zillmann (2000) had emphasized on the need for a “re-conceptualization of harm from exposure to erotica.” According to ˇ Stulhofer, Busko and Landrepet (2010) sexually explicit materials (SEM) can contribute to the sexual well being of young men.
Rambaree (2004) advocates role of Internet to be important in every walk of one’s life in the present scenario that allows us doing range of activities online from communication to online shopping. There are various studies conducted over a decade period that identified use of internet as a medium for sharing pornographic material. Internet led sexual acts based on online chatting and live chat through video has increased. According to Goldberg, Peterson, Rosen & Sara (2008); Nua Internet Surveys of 2001 indicated that sex is one of the most popular search terms over the internet.
“No truly random study has been conducted to determine the number of people accessing sexual Internet sites, some estimate that 31% of people online visit sites with sexual content, and of those, 5.5% of individuals exhibited compulsive behaviors and an additional 17% are “at risk” of becoming sexually addicted (Cooper, Delmonico, & Burg, 2000). Based on these estimates, as many as 69.7 million people are using the Internet for sexual purposes (cybersex), and as many as 11.8 million may be experiencing problems controlling their behaviors with cybersex.”
Cooper et al. (2000) argued that internet is playing important role in changing the traditional mode of sexuality. According to Cooper et al (2000), “Sexuality is one aspect of human social behavior that is being dramatically impacted by the Internet” (as cited by Rambaree, 2004). Sherman (2003) listed the reasons of the growing sexuality over the internet. These reasons are possibility of fast distribution of material over the internet, possibility to reach larger user base with pornographic contents, quick downloads, easily access and high storage capacity allows them to access, store and view various pornographic media files (Kendall, 2007). Electronic gadgets like personal computers, laptops, iPod and mobiles have added to convenience of users for storing and sharing pornographic materials and media files. Internet technology is advancing demand for pornography contents. In the modern society and culture, online pornography has created its place (Wondracek, Holz , Platzer, Kirda and Kruegel, 2010).. Online sexual content and materials are sold and shared by huge community of people. This is a highly profitable and advanced business in the present scenario (Wondracek et al, 2010).
Pornographic materials available online can be accessed by variety of users. Some users are those who want to improve their sex life and enhance the joy of regular sexual activities. This also includes individuals willing to utilize this platform for sexual fantasies’ and desires. Rambaree (2004) explains that people coming and joining the chat rooms for interaction, enjoyment and exploring each others’ sexual properties. The anonymity and interactivity allows individuals to communicate fearlessly and second thought about their image and reputation (Rambaree, 2004).
Types of Pornographic Material
In the present scenario, internet has facilitated an access to unlimited pornographic materials, still images and audio/video materials to millions of users in. These materials can be classified on the basis of the nature of material like image, literotica (erotic literature), erotic images and erotic videos. In terms of type of content, it is classified as erotica, degrading and violent pornography.
Erotica generally carry sexual or erotic materials that can be art form, literature, sculpture etc. Erotica is justified as an art form that depicts arousal or love making. Erotica usually provides positive, loving human sexual interaction between willing individuals (Glascock, 2005). This can be used for the people suffering with sex related problems wherein they can understand and explore different perspectives of sexual pleasures and try with their partners. Erotica is free from any degrading and violent type of pornographic contents and sexual activities.
Non-violent or degrading pornography
Non violent pornography is different from erotica type of pornography materials. It may contain verbal abuse and degrading language and presentation of a human being. This can contain visuals and contents that objectify an individual for the pleasure of other. However it does not contain any type of physical violence. Non violent pornographic materials generally consist of man dominating over women and women representation in such content is objectified as a plaything responding to male sexual needs immediately (Glascock, 2005).
Violent pornographic materials
This kind of materials includes pain and physically forced sexual activities i.e. rape, bondage, discipline, bestiality, sadism and other forms of paraphilic linked sexual activities (Glascock, 2005). These materials are degrading and present violent sexual encounters. Dominant-submissive behavior can be seen between male to male, male to female, female to male or female to female or in groups.
There are various positive and negative aspects of online pornography. This area has attracted attention of feminists, social study researchers, psychologists and economics researchers. There are two philosophical approaches for viewing pornography i.e. liberal and feminists. Feminists on one hand stress on the link between criminal activities based on sex and pornography where as liberals argue that there is no significant evidence that can prove this link. Most of the studies related to cybersex have been in the areas of understanding negative consequences of cybersex. Some researchers have argued on the positive implications of cybersex on specific group of people. These include committed couples looking for expanding their sexual experiences, gay adolescents, people with difficulty in finding partners like physically or mentally challenged, unattractive and shy, women seeking to rejuvenating sexual knowledge with limited opportunity to do otherwise and others (Waskul, 2004 as cited by Philaretou, Mahfouz & Allen, 2005)
There are very limited studies conducted on the positive aspects or advantages of pornography. Even though it is identified as a tool for improving sexuality and pleasures with sexual acts among individuals and couples with the sexual behavioral problems, studies on the positive aspects are much lower than those of the negative aspects. Stone (2006) supports use of young adult literature to help adolescents and young people understanding the physical and emotional aspects of sexual behavior. Pornographic and erotic materials can help them to understand acceptable and non-acceptable behavior in sexual encounter. Therefore pornographic material can offer a great tool for educating adolescent and allow them to understand role of respect, dignity and pleasure through sex.
Positive Sides of Pornography
There have been long debates over the positive and negative aspects of pornography. Pornography affects individuals, society and different sexual behaviors. There are more arguments available to justify the negative impacts of pornography than its positive usage. Pornographic materials can help healing damaged male psyches (Therapist Terry A. Kupers in Slade, 2001, p 966). Pornography helps men and women to understand sexuality and explore their sexual desires with the response of audio-visual stimulation (Slade, 2001, p 967). This is particular helpful for the individuals who are hesitant or shy to share their sexual desires with their partners. Ellen Willis (as cited in Slade, 2001, p973), pointed out that sex itself is much politicized and complex within the blurring dimensions of authentic sexual impulses that makes pornography an unacceptable thing to vast majority of the society.
According to Baroni (as cited by Slade, 2001) pornography helps men to control their sexual urges and experience sex in the absence of partner. These can be single males. This helps them to be better lovers eventually. This is also suggested that pornography helps males to understand their own capacity for sexual arousal and deal with their problems of erotic and wet dreams. It allows an option of ‘safe sex’ as it is virtual experience. Any sexual experience through it is free from the risk of sexually transmitted disease or any physical harm.
According to Dr. Marty Klein (Slade, 2001, p 974) “One hallmark of healthy adult sexuality is the ability to choose to lose yourself in a sexual situation under the appropriate circumstances, and it is that experiences that most of pornography depicts.”
Pornography helps in dealing with the problems of erotic anxieties and sexual ignorance. In a correlational study by McKee, Albury and Lumby (2008) compared and concluded pornography and religion against women and stated,
Pornography doesn’t cause negative attitude towards women. But religion does, Atheists had significantly better ‘Attitudes towards women’ scores [27.3] than Protestant Christians [24.2]. Catholics are in the middle which is surprising given the question about abortion [25.4]. Buddhists are almost as positive as atheists [27.1].
In order to understand the consumers’ experience of pornography 1023 consumers were surveyed and only one percent respondents felt that pornography has large negative effect on their attitudes towards sexuality. “6 percent thought it had small negative effect whereas 35 percent thought it had no effect; 31 percent thought it had a small positive effect and 26 per cent thought it had a large positive effect” (McKee, Albury and Lumby, 2008, p 83).
There were nearly 93 per cent consumers with the feeling that they did not experience any negative effects of pornography. This is a high percent to justify the positive use of pornography in the society. Pornography has been criticized for increasing the sexually violent behavior and motivating factors for rape and other incidences. This study contradicted the efforts of The Nixon and Reagan Commissions in which pornographic materials’ exposure was linked with the violence in the society. This was an assumption by the commission, which was proved baseless by the studies of D’Amato (2006). In the paper ‘Porn Up, Rape Down’ by D’Amato (2006) showed that access of pornography was easily available in the US society to teens and adults. This availability of pornographic material had increased over the past 25 years. This trend was growing with the growth of internet. The Official figures according to D’Amato (2006) indicated that the reported sexual cases of violence had reduced in last 25 years in the US. There was 85% of reduction in reported number of rapes per capita since 1970s. In the same study Professor D’Amato also showed that the variations of the changes of the rape incidences with the household internet access across four US states. The higher was the internet access, the lowest were the rape incidents (27 per cent decrease in the incidences) between the duration of 1980 to 2004. At the same time with low internet access states have reported highest increase in the rape incidents (53 per cent increase). D’ Amato argued that easily availability of the internet pornographic material helped in de-mystifying sex and reducing “Victorian effect” in the society.
Lehman (2006) argues, “Pornography also depicts a world in which desire can be satisfied, because the typical obstacles of the real world are missing. There are no constraints of time, privacy, fatigue or health…..And there are no (arbitrary) limits set by partners, who might be self-conscious, self-critical, anxious or inhibited. When men watch porn, they’re able to imagine “yes, that’s how I would be without the obstacles I normally face” (p 251).
According to Klein (as cited in Lehman, 2006) the fundamental views of sex, gender relations and role of sexuality is being challenged with pornography. It is culturally shocking to admit interest of man in desire, lust or erotic relationships. Pornography offers human experience for sex and helps validating life erotically (Lehman, 2006).
“Controlling our sexuality can be painful, not because we lack self-control or will power, but because sexual energy is powerful and demands expression. The primitive, infantile forces behind those demands often make sexuality feel like a matter of life and death–which, in the unconscious, it is” (Klein, 1998).
The inappropriate use of porn is regarded similar to the use other things in life that can lead to self destruction e.g. money, car or even food that can lead to different social and psychological problems. Sex is an important aspect of the modern society and should be accepted in order to prevent its misuse (Lehman, 2006). The said negative implications of pornography in society are result of multiple reasons than pornography alone.
Review of Current Research Literature
There are various approaches towards sexuality. Traditionally sex has been considered as very private affair and was less talked about publicly. In the recent part the trends have been changed. Sex as one of the basic needs of human being is talked and discussed at various levels and introduced at the educational institutions in the form of sex education.
Sexuality is regarded as integral part of human and worthy of dignity and respect (SIECUS, 2010). Facilitating development of healthy sexuality is considered an integral aspect of sex education. This kind of sexuality based on respect and equality would help developing healthy sexual behavior. At the same time some authors suggested development of the positive image based websites for the online pornography viewers where pleasure with sexuality, dignity and respect and help viewers realize the true pleasure related to sex rather than commercialized and fabricated experience.
Klein (2000) lists the condition for enjoyable sex that includes oneself who needs to be clean and has no chores pending, has an environment that ensures the privacy and someone to be enthusiastic and romantic. However it depends on person to person how they enjoy sex. Some people can be more excited with the high heels of female partners whereas others would be aroused by something else. The overall idea of sexual pleasure between two people depends on the extent they can enjoy their sexual desire with each other (Klein, 2002, 2005, 2006). Klein advocates that sex normality models should be part of cultural discourse. The sex normality model is constructed with self help movement in the current scenario.
Online Sexual Behavior
Online sexual behavior is one of the most recent researched areas for the psychologists and sexologists. Goldberg et al, (2008) identified exponential growth of the adaptive and pathological use of sexual component over the internet. Philaretou, Mahfouz & Allen (2005) have studied different forms of cybersex behavior. There are various aspects of online sexual behavior that includes wide range of online behaviors. Cooper (2002) listed various online sexual activities like “answering sexual personal ads; chat rooms/message boards; webcam sites; private member chat rooms; adult online sex shops and catalogs; e-mails; flirting and sexual innuendo; actual overt sex talk with the goal of arousal/orgasm; telephone sex; and actual, real time sexual encounters.”
Cooper (2002) has identified three subcategories of the online sexual behavior of various individuals. These are “cybersex and its own subcategory of cybering, online sexual problems (OSPs) and online sexual compulsivity”.
Cybersex. Cybersex as cybering consists of the behaviors that gratify sexual behavior through various tools of pornography, chatting, erotic mails and live video chats through online camera and sharing same sexual fantasy. According to Delmonico (1997) cybersex has three basic forms i.e. online pornography exchange, real time sexual exchange and use of multimedia software for sexual fantasies. Cybersex can be explained through isolation, fantasy, anonymity and the low cost mode of entertainment (Delmonico, 1997). Bostwick and Bucci (2008) related internet sex with the brain malfunctioning and described the source of motivation to be the basic need of have sex. They studied the neurotransmitter Dopamine with relation to the addiction behavior and offered use of naltrexone as suppressing the addiction for internet pornography.
Online Sexual Problems. Online sexual problems consist of the problems people face or might face by using internet medium for their sexual desires. These problems can be individual, social or financial. Individual problems consist of guilt, shame, breach of trust, broken relationship, loss of respect, financial loss and others. Loss of family and friends, divorce and criminal charges for illegal activities can be other problems people might face.
Online sexual compulsivity: Online sexual compulsivity is part of online sexual problems but signifies a state where an individual completely looses his control over daily activities and is dominated by the compulsion of online pornographic activities.
Sexual Behavior of Young Males: It is evident from the previous studies that people come across with the pornographic material as early as the age of 11 years. The exposure turns to curiosity to know more. This is added to the physical and psychological changes these young people are undergoing. There are various implications of early exposure of pornographic and sexually explicit material among the teens and young adults listed by the magazine The Sex Educator. First of such implications is development of unrealistic image for genital organs among the young adults and teenagers (Des Deserts, 2002 as cited in The Sex Educator, 2007). This helps in normalizing of all types of sexual activities i.e. oral, vaginal and anal relations (Dagenais, 2005 as cited in The Sex Educator, 2007). According to Robert (2005 as cited in The Sex Educator, 2007) young minds tend to believe that every kind of sexual activity is possible, desirable and will be accepted which prepare them to try anything (Wold, 2003 as cited in The Sex Educator, 2007). The early age sexual exposure encourages them to involve in sexual acts in an early age (Dionne, 2005 as cited in The Sex Educator, 2007). Development of compulsive behaviors and unsafe sexual behaviors are some of the highest risk points (The Sex Educator, 2007).
Sˇtulhofer, Busˇko and Landrepet (2008) studied the behavior of young males (18-25 years) for understanding the effect of sexually explicit material on them. This study indicated that early exposure of SEM to young males can lead to affect their sexual satisfaction and level of intimacy with partner adversely.
According to SIECUS (2010) there are limited data available to determine adolescent sexual behavior. The information available from different sources revealed that the average age for first intercourse among the youth was 17 years for males and 17.4 years for the females. Other sexual activities in which young people can be engaged are oral sex, kissing, fondling with genital and specific body parts, mutual masturbation and anal intercourse. Most of the time, involvement in any sexual activity is born with a natural curiosity among the youth.
Adolescents face various challenges due to their physical and physiological changes. The changing balance of hormones within their body results in mood swings and deviation of behavior between adult and child like behaviors. Sexually they become more independent from their parents and require lesser protection. Till this age, individuals get involved in self stimulation processes for sexual pleasure. This can be masturbation or fondling with their private parts. Level of curiosity to know more makes them explore new sources for information on sexual acts. Adolescents are divided in early, middle and late adolescence ages. The late adolescents are most independent and in various occasion their behavior and outlook would be similar to an adult. They develop their sexual identity by this stage and look for intimate relationships to satisfy their physical and emotional needs and probably get establish in their career and start their families.
Recently, Lynch (2009) studied the various sources of exposure to sex related information to the adolescents that revealed that media has been the primary source of information for more than two third of the total respondents studied (SIECUS, as cited by Lynch, 2009). Pattee (2006) has suggested that young adult literature should be added in sex education programs of the schools in order to give them realistic and needed information on different aspects of sex and sexual acts. Lynch (2009) points out a need for a private and safe place to try on new feelings of sexual desire as SEM are less risky than the sexual contact itself.
Fisher and Barak (2001) have explained the Sexual Behavior Sequence for individuals coming with contact of erotic content or material. This sequence starts with the contact with erotic stimuli that leads to physiological arousal. Individuals are more likely to involve in overt sexual behavior by looking for partners, opportunity to masturbate or online chat rooms. This stage is called preparatory sexual behavior. This stage leads to the actual sexual behavior (Fisher and Barak, 2001).
Figure 2: Sexual Behavior Sequence
Source: Developed on the basis of Fisher and Barak (2001)
Klein (1998) argues various aspects of sexuality and sex addiction and explains the entire concept of ‘sex addiction’ as a concept relying on the negative assumption regarding sex. Klein regarded this assumption with the term ‘sex negative heritage’ where from the past one has been taught to view sex as something dangerous. These are Devil’s tool for temptation. This includes pornography, masturbation and extramarital affair. However it is not true scientifically. Masturbation is a way of releasing sexual energy. This helps individuals to balance their sexual urges. Klein (2002) argues that assumptions for the Sex addiction model are based on unhealthy presumptions that lead to strengthening the negative views regarding sex and related activities. Some of the assumptions mentioned by Klein (2002) are, “Sex & sexual desire are dangerous. There’s one “best” way to express your sexuality. Relationship sex that enhances “intimacy” is best. Imagination has no healthy role in sexuality. People need to be told what kinds of sex are wrong/bad. If you feel out of control you are out of control. Laws & norms define sexual health”
Klein (2002) questions the entire concept of sex addiction. He argues that the history of sexological diseases includes libertine, masturbator, nymphomaniac, birth control advocate, frigid, homosexual and sex addicts. There is no definition of the sexual health model which is the need of the hour. Klein questions on the background, understanding and knowledge of porn’s critics regarding porn and human sexuality. Klein (2005) argues over the approaches of people on the perceived harms of pornography on society. He suggests that government should listen to the pornography consumers regarding their use and positive and negative impact of pornography on them. Any conclusion should be derived on the basis of the views of pornography users and sex expert for social or individual effects of pornography. Pornography represents adult entertainment and should be regarded as the same.
However much of the studies have been conducted to study the online addiction and in the recent past some studies have focused on the online sex addiction problems. Goldberg et al (2008) used the term ‘cybersex addiction’ to cover pathological and compulsive behaviors with negative impact on the user and his surroundings. Addiction or compulsion of cybersex is related to uncontrolled use of internet for sexual desires and impulsive control (Goldberg et al, 2008). There have been various studies were in different symptoms of changes in behavior has been reported with cybersex addiction such as lack of sleep, isolation, loss of productivity, loss of interest in other relationships, loss of interest in normal sex and fading sense of responsibilities (Schneider; 1991; Young, 1999; Boies, Cooper and Osborne, 2004; Goldberg et al, 2008). Indirect victims of the cybersex are primarily spouses, who feel betrayal, rejection and other negative implications that might lead to ending up or distorting a healthy relationship. Children, family members and other social relations also suffer in such cases.
Sex addicts can exhibit ten types of sexual behavior (Carnes, 1991 as cited by Carnes and Adams, 2002). These are “fantasy sex, seductive role sex, and voyeuristic sex, exhibitionistic sex, paying for sex, trading sex, intrusive sex, anonymous sex, pain exchange sex and exploitive sex”. These sexual behaviors are encouraged and aroused online (Carnes and Adams, 2002).
According to Carnes (2001) Sexual addiction cycle consists of four-steps of “preoccupation”, “ ritualization”, “compulsive sexual behavior” and “despair”. Preoccupation is the stage of sexual stimulation resulted from the thoughts of sex. This is followed by ritualization where addict seeks more arousal and excitement. Third stage is when individual loses his control to stop his obsessive behavior. Last stage of despair is helplessness and powerlessness. Carnes (2001) further explains,
“The addictive system starts with a belief system containing faulty assumptions, myths, and values that support impaired thinking. The resulting delusional thought processes insulate the addiction cycle from reality….All the other support systems, including relationship, work, finance, and health become unmanageable.”(p 25)
Figure 2: The Addictive System (Carnes, 2001 )
Weiss (2008) identified various areas of sexual addiction similar to those of other addictions. These are:
Loss of control and escalation in frequency of the sexual activity and/or content; Inability to stop the behavior despite previous agreements with self or others; Consequences directly related to the sexual behavior in areas such as social functioning, relationships, parenting, financial, career, emotional / physical health and legal; Significant loss of time and focus to the pursuit of or engagement in sexual activity to the detriment of other life goals or priorities.; Irritability, extreme defensiveness or anger when having to address, change or stop a particular sexual behavior.
Sexual addiction behavior falls in four categories of shameful, secret, abusive and void of relatedness (Carnes, 1978 as cited by Weiss, 2008).
Psychological symptoms Physical symptoms
(a) Experiencing a sense of well-being or euphoria while online,
(b) Feeling unable or unwilling to stop online surfing,
(c) Increasingly desiring and spending more and more time online,
(d) Neglecting interpersonal relationships with intimate partners, friends, and family,
(e) Experiencing feelings of emptiness, distress, and irritability when prevented from pursuing online activities,
(f) Lying to employers and family to cover up extent of online activities, and
(g) Experiencing general problems with school or work responsibilities (a) Carpal tunnel syndrome,
(b) Dry eyes,
(c) Migraine headaches,
(d) Back aches,
(e) Eating irregularities,
(f) Neglect of personal hygiene, and
(g) Sleep disturbances due to change in sleep patterns
Source: Developed on the basis of Orzack (2004 as cited by (Philaretou, Mahfouz & Allen, 2005).
Klein (2002) explains the professional needs to have a clinical model to address any sexual-behavioral problem such as clinical professionals, marriage counselors, sex therapists, social workers, nurses and others. This clinical model should consider “phenomenological context, clinical sophistication along with differential diagnosis, personal agency and responsibility, cross cultural insights, minimize self-diagnosis and political and public policy utility.” (Klein, 2002)
Sexual Compulsive Behavior
Sexual compulsion is a stage of “uncontrollable urge to perform an irrational sexual act” with or without complete knowledge of negative consequences (Cooper 1998 as cited by Philaretou, Mahfouz & Allen 2005). Factors that can determine the compulsiveness of online pornographic addiction are frequency of sexual activities online, time spent on cybersex and its relation with the negative consequences of their lives, feeling of guilt and depression and obsession for particular pornographic material (Philaretou, Mahfouz & Allen, 2005).
Internet Pornographic Addiction
According to Cooper et al (2002) cybersex addicts are those individuals who spend more than eleven hours in a week in computer sex. This leads to shortage of time for other important aspects of life like family, children, work and social circles. These individuals tend to avoid time needed for other things for cyber sex fun, prolonged hours of sitting in front of system and screen has negative implications on their physical and mental health and leads to isolation. Coombs (2004) argues that this heavy involvement affects the sexual activities with the primary partners. “Male sex addicts may be physically unable to have more sex after a session on the computer. A survey of partners of cybersex addicts found that among 68% of the couples, one or both had lost interest in relational sex; 51% of addicts had decreased interest in sex with their spouse as did 34% of partners”.
Weiss (2004) lists impacts of cybersex affair on relationship of a couple and argues that the emotional impacts are similar to the offline affair that can result in damaging self-esteem, hurting the partner,
“Betrayal, abandonment, loneliness, shame, isolation, jealousy and unrealistic comparison of partner’s psychical and traits and sexual performances to the fantasy partners, loss of interest in intimacy and mutual sexuality.”
Coombs (2004) argues that these addicts tend to normalize the illegal or deviant sexual activities like bondage and submission, sex with minors, forced sex, fetish and various unimaginable sexual activities which are possible in the normal life. Cyber sex addicts tend to be using their nights without sleeps and diverted mind. As a result their productivity goes down and their professional lives get adversely affected. There has been increase in number of arrests for the illegal online sexual activities particularly for stalking, contacting or alluring minors for online sex.
Treatment of Sex Addictive Behavior
The sex addiction, particularly the cyber sex addiction is comparatively new disorder. This is the reason that this particular problem borrows treatment approaches of various other addiction treatments. In last one decade, it has been identified as a growing concern with different individual, social and psychological implications. 12-Step Programs (i.e. Sexaholics Anonymous), Cognitive-behavior Therapy (CBT), Interpersonal Therapy, Group Therapy and Medication are some of common treatments offered to sex addicted (Herkov, 2006). According to Taintor (2005) addiction to online pornography needs to be treated like any other addiction. There are various ways clinicians and therapists can provide treatment such as online, face to face, medication, individual psychotherapy, group psychotherapy, self help groups, reimbursement and others.
Weiss (2004) focuses on the tools and principle for appropriate assessment of the addiction and mental health state of the client. This assessment should be used as the basic information for determining the overall approach of treatment. This can be cognitive-behavioral approach or integration of different therapies like Psychodrama, Art Therapy and EMDR. CBT and 12-step social support has been most effective and proven strategy to help addicts to develop healthy habits and cope up with the problems of sexual addictions (Weiss, 2004). Psychodrama, Art Therapy and EMDR help in stabilizing the sober behavior.
“These therapies can help elicit subconscious motivations and concerns, often uncovering blocks to therapy and recovery.” (Weiss, 2004)
Carnes and Adams (2002) listed objectives of successful therapy. This consists of:
Establishing relationship of trust and empathy, promoting an understanding of the difference between emotion, feeling and affect; increasing awareness regarding impairments in attachment and bonding; facilitating awareness regarding impairments in attachment and bonding; facilitating awareness regarding the relationship between disrupted bonding and the inability to develop strategies to regulate affect, increasing skills helpful in the recognition, identification and modulation of affect; increasing awareness of environmental, emotional and situational stressors associated with dysregulated affect. (Carnes and Adams, 2002, p 85)
The treatment is individual approach for the client, based on individual characteristics and severity of his problem (Goldberg et al, 2008). There is no single therapy that is developed for the treatment of the online pornographic addicted patients. The therapies used in the present scenario are modified therapies used for other addiction treatments like alcoholism, eating disorders and others (Goldberg, 2004; Goldberg, et al, 2008).
Therapist and Clinicians
Most of the studies are focused on the sex addicted clients, social and psychological implications and others. There are limited studies that have covered issues of therapists and clinicians while dealing with internet pornography addicted clients. One of the initial studies in this area has been conducted by Young (1999) and covered incident rates, complaints at the primary level, psychiatric problems along with the addictions, attitude of therapists and their backgrounds. Young (1999) provided the therapists view of the internet addiction in overall and internet pornography was one part of this study. Therapists explained deceptive and illegal behavior of their patients like forced sex, bondage fantasies and others (Goldberg, Peterson, Rosen, & Sara, 2008).
Clinicians face various challenges when it comes to the dealing with sexually addicted clients such as preventing clients from sexually acting, fantasizing about clinicians, using sexually explicit language, creating physical proximity with the clinicians and try to develop sexual relationship with the clinicians. It is very challenging for the clinicians to handle their own biases. The boundary between appropriate and inappropriate can get easily blurred in lack of clear sense of therapeutic boundaries.
However, there are very limited studies conducted in the area of understanding uniformity of etiology of online pornographic addiction among the therapists and clinicians (Young, 1999; Goldberg, 2004, Goldberg, Peterson, Rosen, & Sara, 2008).
According to Weiss (2004),
“Working with sexual addicts requires a new skill set- one that combines the empathy, insight and relational abilities of a good psychotherapist with the limited setting, confrontation and cognitive-behavioral strategies of an addiction specialist.” (p 234)
There are various aspects of challenges working with online pornography addicted clients for the health professionals. There were very limited studies conducted in this aspect till late 1990s. Young (1999) covered some aspects of the therapist perspectives in the internet addiction studies with one subset of cybersex. However, last one decade attracted attention of young researchers towards this aspect of the online pornography addiction therapies (Erickson, 2002; Goldberg, 2004; Weiss, 2004; Chiou, 2006; Goldberg et al, 2008).
Many chemical dependency counselors and mental health professionals, while expressing interest in furthering their understanding of such work, are under –standably anxious and uncomfortable at the thought of actually working with client issues such as compulsive masturbation, exhibitionism, anonymous sex, and the frequenting of strip clubs. (Weiss, 2004)
According to Cooper & Griffin-Shelley (2002) the knowledge of Triple-A-Engine helps clinicians to familiarize with different aspects of the sexual compulsive tendencies. Cooper and Griffin-Shelley (2002) argue that exposure of internet can disturb sexual life of people without any sexual problems and risks of developing range of sexual problems.
Therapists would be wise to stay current in this rapidly developing area through readings, workshops, and discussion and consultation with colleagues. Treatment for Online Sexual Problems and Online Sexual Compulsivity can include cognitive and behavioral interventions, individual, group, and couples therapies, medication, Twelve Step and online support groups and residential care. (Cooper, McCloughlin as cited by Cooper and Griffin-Shelley, 2002).
Weiss (2008) provides some insights on the client concerns regarding their treatment. This list was prepared on the basis of survey with the clients who took professional helps to deal with their sexual addiction problems. The problem issues identified by various respondents were lack of understanding of the power or intensity of the compulsion act by their therapist, lack of knowledge of online and offline sexual activities, under-informed, lack of decision making, failure of insisting on eliminating self destructive sexual behavior, lack of understanding of the impact on the spouse or partner of the addict, adopting wrong approach to deal with spouse or include spouse in the treatment process and others. Weiss (2008) recommended that the therapists should be provided special training and awareness of the online sexual addiction and compulsive behavior in order to access and manage the challenges of addict successfully.
12 – Steps Program
There are three ingredients such as knows the ways, goes the way and shows the way. These ingredients are important to recognize a person to help with the intimidating task of recovery from a co-occurring mental health and substance use problem. “Sane is an excellent bridge to the remarkable and miraculous transformation that can take place through the fellowship and wisdom of the twelve step program of recovery” (Hornbacher, 2010).
According to Hornbacher (2010) these steps help people with co-occurring disorders, making people understandable. Hornbacher (2010) explains recovery terminology with mental health problems. There are many reasons for mental problems. The mental problems can be due to symptoms of avoidance, isolation, withdrawal, and negativity that can forestall action.
Rotgers, Morgenstern and Walters (2006) “12 –steps treatment refers to certain core concepts, implicit assumptions, informal hypothesis and explicit ideas that constitute one recognizable approach to addictions treatment and recovery.”
Twelve-step recovery group is not open for people who have severe mental health issues. Other clients with mental problems can be recovered by their social support, family support. The aim of the program is to create group that is comprehensive and accepting. That group should not be exclusive and judgmental. Most peer recovery support meetings need to keep the ambiance of acceptance and patience. The primary purpose is to help people. The first step of the twelve step process is to understand the mental health issue. Addicts usually develop excellent skills for hiding their things and habits from their families, relatives, friends, employers and anyone. They believe that no one can see or find out about what they are doing. This also helps them in hiding their actual conditions from many. In their minds they feel ashamed of and hide their illness from that judging world, from their friends, their family members and even themselves. This disorder completely takes over the individual taking control over all the activities of the life of an individual.
The is followed by the stages with the identification of people who have this mental illness are living under many coating of shame, cheating, refutation, and fear. These people generally prefer to be isolated. They join company according to their choice with similar bent of minds. This creates imbalance in their lives. The twelve steps process helps such individuals to develop better way to live their lives. The addicts and mentally ill people are made realized about the problem that can arise due to their addiction. They are taught that it is a right time to go back and set a new way for them.
The next steps deal with human brain and mental illness. It is very difficult to understand human brain. During any addiction or mental illness, it is much complicated and painful. Initially individuals do not feel comfortable with these steps. People who suffer from mental illness and addiction are physically different from those without these problems. “The bodies of addicted person respond to certain substances and behaviors differently than do healthy, non-addicted bodies” (Hornbacher, 2010). People receiving treatment for the addiction are also fall in the category of the mental illness of addiction in the fourth step. This is the reason dual diagnosis is performed at this stage. Addicts feel powerlessness and loss of control for their lives initially. “This is a simple fact that by using drugs and alcohol makes mental illness worse and prevent their medication from having the necessary effects” (Hornbacher, 2010).
12-step process is found helpful in treatment of the addicts in different empirical studies.
Cognitive Behavioral Therapy
Cognitive behavioral therapy is one of the widely used therapies for the treatments of mental health problems. There are various studies conducted to understand the process of cognitive behavior therapy. However each treatment with CBT is totally based on the individual patient and his requirements. According to Ronen (2002),
The behaviorist approach in psychology emerged in the 1920s when Watson (1970) brought together concepts and methods of conditioning research method in Russia. Psychologists attempted to contest psychiatrists’ medical intervention model by proposing a scientific theoretical foundation for human disorders rooted in behavioral principles. The theoretical base for behavioral therapy has since undergone a continuous process of change as new knowledge enabled new explanations of human behavior and later, as behavioral theory was emerged into cognitive theory. (p 165)
There have been notable developments in the theories since 1920s. The learning process studies were divided in three branches of studies. The first was classical modeling in which Pavlov provided notable study of thon the dog with respect to the food and behavioral response which was generated though ringing the bell every time while giving the food. This resulted in the condition where even if dogs were not given food, if they are hungry and bell was ringed, the response in terms of salivating was resulted. The second modeling is operational and the third modeling is social learning modeling.
According to Ronen (2002) “clinical implications of cognitive theory includes identification of thoughts, awareness of emotions elicited following thoughts, the link between thoughts and emotions’ and the view of behavior as the outcome of a process combining thoughts and emotions.” (p. 166)
Seven basic features as identified by Rosenbaum and Ronen (1998 as cited in Thorne, 2002) considered it as a “meaning making process” directed to “define the problematic areas”. This was regarded a systematic therapy in which goals are very clear. This requires collaboration between the client and therapists. The overall focus is on client and than to the problem faced by client. Therapist facilitates the change in the client by empowering and developing ‘independent functioning’ of the client. This makes it more than just a ‘talk therapy’.
Ronen (2002) states “clinical implications of the identification of thoughts, awareness of emotions elicited following those thoughts, the link between thoughts and emotions and the view of behavior as the outcome of a process combining thoughts and emotions” (p 166)
Outdoor Behavioral Healthcare programs
These behavioral healthcare programs are comparatively new and found effective in reducing behavioral and emotional symptoms of young clients particularly in the cases of substance abuse. There are limited studies that have covered to study the effectiveness of this approach. Russell (2005) listed various studies that covered outcomes associated with OBH programs, treatment approaches, reduction of symptoms of problems and others.
OBH is also known as Wilderness therapy. Russell (2001) lists various terms used for this therapy such as “challenge courses,” “adventure– based therapy,” or “wilderness experience programs MEPs) or “wilderness therapy” and “boot camp”. Boot camp is the term giving negative impression of overall therapy. This portrays it as a cruel process (Russell, 2006). Russell (2003) identified OBH as one of the widely accepted program for the individuals with mental health needs. OBH programs are run by licensed agencies who utilize services of licensed and non-licensed clinicians. Duration of OBH program varies from individual to individual. Individuals with similar needs can be grouped together (Russell, 2003). The natural elements of the wilderness creates essential environment for the change in mental and psychological level. Personal learning and growth through the activities in the natural environment leads an individual to the third aspect of socialization (Russell, 2006).
Source: Russell, Hendee and Phillips-Miller, 2000 p211)
There are six components of any OBH program i.e. wilderness, eclectic therapeutic model that combines family systems theory, CBT, and experiential process, alone time, communication skills training, Native American reference and continuum of care (Russell, Hendee, & Phillips-Miller 2002; p. 211).
Evaluation of Research Literature
It is evident from the literature reviewed that internet provided an easy access to all kind of pornographic materials to the users that can be useful under very special circumstances but in most of the cases the overuse and dependence on these materials lead to addiction among the users. Addiction of internet pornography leads to the compulsive behavior among the users that can have serious psychological and physiological health implications. An individual suffering with online pornography addiction requires help to get back to a healthy routine of life. There are various therapies used for treatment of internet pornography addicts. These therapies are similar to the one used for the treatment of other addictions, with some modifications. The most common treatment approaches for the treatment of addiction as identified in literature are 12-step programs, CBT and OBH.
There has been gap in therapists’ understanding the etiology of internet pornography addiction, different aspects of client assessment and evaluation and therapists’ perspectives of online pornography addiction. CBT and OBH are growing in acceptance due to effectiveness.
This chapter covered various aspects of pornography and sexuality on internet wherein researcher explored different streams of thoughts in favor or against pornography and sexually explicit materials. Cooper et al (2002) found that sexuality has been one of the most impacted aspects of human social behavior over the internet. Kendall (2007) supported this by the fact that internet has allowed faster distribution and easy storage options for such material. Rambaree (2004) explained the real time impact of the online sexual behavior that allows people sharing their fantasies and desires at the same time with someone else who can be a stranger as well. The anonymity allows individuals to reach to the extremes of their virtual fantasies. There are various types of pornographic materials available on the internet that can be simple straight to extremes like snuff and rape. There are many arguments on the negative social impacts of pornography. However there are number of psychologists, sexologists and therapists who believe that pornography is not responsible for what people are doing, rather people are responsible how they are using it. According to Klein (2005) use of porn is like use of money, car or house, it depends on user and an inappropriate use can lead to similar problems which one can feel with inappropriate use of other things in their lives.
However in various studies on sexual addiction has been regarded as similar to any other addiction of eating disorder, substance abuse or alcoholism and has been treated with therapies and treatment plans used for sex addicts. There is lack of any sexual model or treatment plan that deals with the problems of online pornography addicts exclusively. Klein has questioned on the negative perception of pornography as well as the treatment provided for the porn addicts. He argues that sex is a part of healthy behavior and human needs to release their sexual energies. The treatment plans are based on certain aspects that strengthen the inherited and traditional view of pornography where anything related to it is regarded dangerous thing. There is no right kind of sex. It depends on individual to individual. However excess of anything is harmful, including pornography. This does not make pornography a bad thing.
It is evident that there have been limited efforts to identify the origin of sexual addition over internet, identifying the patterns of internet pornographic sexual addiction and effectiveness of treatments with respect to time taken to treat clients and their social and demographic backgrounds and history of repeated cybersex addiction problems.
RESEARCH DESIGN AND METHOD
This chapter provides detailed information on the procedures adopted for fulfill the objectives of this study to develop an appropriate treatment program for the online pornography addicted young males. Research design consists of research approach, methods used, and variables, types of measurements, instrument, and validity of research methods, data collection process and other aspects of the study.
Are there any potential benefits of combining weekly CBT with experiential therapy for the treatment of young male internet porn addicted in a non-residential setting?
To evaluate the role of therapists in providing appropriate treatment to the clients with online pornographic addiction problems.
To understand perception and attitude of therapists towards any treatment have important role in making it success or failure.
To study the CBT approach for providing treatment to the young males suffering from the online pornography addiction problem.
To understand effectiveness of outdoor experiential therapy for providing treatment to the young males suffering from the online pornography addiction problem.
To understand the perception and attitude of therapists for the use of combined CBT with Outdoor experiential therapy to provide a better approach for the treatment to the young males suffering from the online pornography addiction problem.
To evaluate the quantitative and qualitative outcomes of use of CBT and Outdoor experiential therapy support each other.
The research design for this research is based on applied social research methods. The study aims at exploring experiences of the therapist in order to understand the essence of the treatment program outcomes for the OPA among the young males and effectiveness of the combination of modalities of two therapies in the treatment of online pornography addiction. The research paradigm is based on ‘pragmatism’ whereas the consequences of action will are explored in the real world practices for the treatment of OPA. The research methods used for this study are based on the mixed method approach.
The focus of this study will be to understand the core of the treatment methods used by the therapists and its implications on the clients from their perspectives. Data will be collected on the basis of long interviews. Respondents would be asked set of open ended questions related to online pornography addiction treatment programs for young males.
This will be based on survey where in prospective respondents will be requested for their voluntary participation in an online survey. This survey will provide the attitude and perception of therapists who work with addicts of pornography, online pornography or online activities and belong to young male respondent groups. The questions would be directed to understand various treatment programs and therapists roles. This will be based on structured questionnaires with the set of bipolar, scale based questions and open ended question for particular issue.
The questionnaire will be tested for its effectiveness and identifying any practical problem in language, sequence and understanding of questions. The sample size for pilot study will be thirty and the participants participating in pilot studies will be excluded from the presentations of the final findings.
Therapists and staff working with clients suffering with online addiction, sexual addiction and cybersex addiction are the primary respondents for the interview purpose. This will help in understanding the overall phenomenon of online pornographic addiction, factors impacting it and the therapist perspectives for the same. The sample size for the interviews will be n=10.
Quantitative data will be collected from the therapists who have work with addicts under different addiction treatment program. This will help in determining the programs that have been effective for the addicts, their perception and attitude regarding the therapists helping them dealing with their addiction. The sample size n=100.
The instrument for the interviews will be questionnaire with open ended questions allowing participants to the freedom of sharing their experiences. Researcher will use probes pertaining to every question so that more inputs can be collected.
The survey will be based on structured questionnaire. The questions will be closed ended where in each respondent will have choices available to select the most appropriate response (see appendix A and B).
Researcher intends to use the instrument used by Widyanto and McMurran (2004) for the study of “The Psychometric Properties of the Internet Addiction” with some modifications according to the present study.
All the respondents will be informed regarding the purpose of the research. Researcher will not use any identifier for the respondents. Due to the sensitivity and vulnerability of the information related to sexual behavior, the consent of each respondent participating would be taken.
All the respondents will be clearly informed that they have right to retract their participation at any point of time of in filing the survey form.
Proposed Treatment Plan
The proposed treatment plan consists of a clinical setting the combined efforts of CBT and Outdoor Therapy to treat internet pornography compulsive behavior in young men.
This Treatment Plan will look at major aspects of CBT (traditional) and Outdoor Therapy (non-traditional) detailing how in steps that researcher aims to apply this combination of two modalities.
Table 1: Treatment Plan Grid
Steps Activity Expected Outcome
Diagnostic Assessments of the Subjects Diagnosis will help in understanding the severity and chronicity of the disorders (Anthony and Barlow, 2010) Identifying the problem areas for the patient
Assessing functional impairment and quality of life in social relations, family relations, work and productivity, recreation and health (Anthony and Barlow, 2010).
To identify target behavior to change and method for treating that behavior To identify the target behaviors for change Anxiety, depression, low level of motivation, failed social relations and lack of engagement in offline activities
Use of CBT to treat Anxiety and depression
Use of Outdoor Therapy to increase the level of motivation, improved social relations and engage in offline activities
Applying Combined Therapy Application and Process of Therapy for identified behavioral problems and their treatment Application of the treatment plan according to the individual problems
Re-evaluation of the Patient after completion of Treatment To determine the possibility of recurrence of addiction problem and determine the healthy sexual behavior for the individual Ensuring that the individual is free from addiction and has a healthy lifestyle including healthy sexual life
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Appendix A Qualitative Research Questions
Job Related Information:
How long you have been working in the current position?
How long you have been working with online pornography addicts?
Are you clinically licensed to work with addicts?
Do you receive any clinical supervision?
Is your clinical supervisor is clinically licensed?
Which of the therapy programs best describes your work environment?
How many and what kind of clients do you deal with at a given point of time?
What kind of challenges you face while working with online pornography addicts?
How you measure the severity of addiction for online pornography addicts? Is it same as the measures of other addiction problems?
Based on your experience, what do you think is best for the treatment of online pornography addicts?
How you would rate the success of treatment programs for the online pornography addicts?
Do you feel there is any better way to provide treatment to online pornography addicts?
What do you think about the combination of Cognitive behavior therapy (CBT) and Outdoor Behavioral programs (Wilderness therapy) for the online pornography addicts? Kindly explain.
Probes for question 5
Wilderness Therapy-Base camp
Wilderness Therapy- Expedition
Both a and b
12 Step Program
Cognitive Behavioral therapy
Appendix B Quantitative Survey Questionnaire
Hi, I am ………………conducting a study on the title “combining outdoor experiential therapy with CBT for the non-residential treatment of young male internet porn addiction”.
Kindly fill the following survey form. All the information and identity related information will be treated as confidential. There is no identifier used for any survey feedback questionnaire in order to maintain the anonymity of the participant. Your information would be valuable for this study.
26 to 35 years
36 to 45 years
45 years and above
Kindly chose the most appropriate. You are:
White Non Hispanic
Black non Hispanic
How many students on an average you work in six months with for the treatment of online pornography addiction problem?
Less than 2
Three to five
Six to Ten
Eleven to twenty five
More than twenty six
What do you feel are main factors for the online pornography addicts that led them to addiction problem?
Lack of social relations
Curiosity led addiction
Lack of interest in other activities
Lack of time management skills
Lack of proper support system and guidance
Problems having normal social relations
Individual problems like shyness, hesitant behavior
Any other (please specify)……………..
Kindly select from the available options (1 for least applicable, 5 for most applicable):
Questions 1 2 3 4 5
Addicts used to spend more time virtually than spending that time with others in reality.
Addicts used to feel bad when they were able to do any online activity any day.
Addicts could not imagine my life without internet.
Addicts used to visit pornographic websites everyday.
Addicts used to download pornographic materials everyday.
Addicts usually forgot everything when they were on pornographic websites.
I agree that addicts used to think about pornographic contents even when they were not in front of the system.
Addicts used to feel bad about their online sexual activity every time.
Addicts used to find themselves helpless to deal with that situation.
The family members and friends of addicts used to complain about their more involvement online.
Addicts used to find internet more exciting that their real partner for sexual activities.
Addicts’ performance in class/workplace suffered due to this habit.
Addicts experience in the treatment process was good.
Addicts treatment was well designed and suited to deal with their problems
You work on which of the following treatment programs
Cognitive therapy based
Outdoor therapy based
I do not know.
Do you think this treatment program can be better?
Can you please elaborate on your response to the previous question?
Do you agree if the young adult males with online pornography addiction are provided treatment plan combining CBT and Experiential Outdoor Therapy would be more effective that treatment through CBT in an office setting?
Can not say
How supportive do you think young adult males with online pornography addiction would be with the combined CBT and experiential therapy in an outdoor setting than a group of young adult males of CBT in an office setting?
Not at all supportive
Do you think young adult males will report a more favorable perception of their therapists consistency in a combining CBT with Experiential therapy in an outdoor setting, than a CBT in an office setting?
Can not say
What do you think about the role of therapists are more important for the treatment process of the CBT and Experiential therapy in an outdoor setting, than in CBT in an office setting?
Can not say
What do you think are the chances for individuals treated with combination of CBT and OET to get addicted to the online pornography again in their future?
Very High possibility
Kindly elaborate your response for the previous question with at least one reason for that.
Thank you for your participation.
Appendix 2 Consent Letter
CONSENT TO PARTICIPATE IN RESESARCH
Description of Study:
I hereby authorize Full name of student researcher a doctoral candidate at California Graduate Institute of the Chicago School of Professional Psychology (CGI-TCS), to include me in a research study titled: “COMBINING OUTDOOR EXPERIENTIAL THERAPY WITH CBT FOR THE NON-RESIDENTIAL TREATMENT OF YOUNG MALE INTERNET PORN ADDICTION”
I have been told that the research project is designed to study the online pornography addiction and development of treatment plan for the same. I understand that I am being asked to participate in this project because I am a therapist for individuals with online pornography addiction problems and have given treatment for pornographic/online activities addiction problems to addicts
I understand that I will be answering questionnaires, and that, altogether, this will take approximately 10-15 minutes of my time. I understand that the question are about the patients of online internet pornography addiction problems and does not require any individual or confidential information regarding individual patients.
I understand that my name will not appear on any of the measures used and that only an identification number will link my answers to this consent form. I understand that all consent forms will be kept in a locked file as part of the project records, in the researcher’s control. I understand that research findings will be reported only for groups of participants, and that my answers shall never be separately identified and reported as mine. My answers will always be protected by confidentiality.
I also understand that I will be informed if the design of this study or the use of its findings is changed, and I will be asked to sign a revised consent form.
Risks and Benefits:
I understand that there are no known discomforts or risks involved in my participation. I understand that I will receive no direct benefit from participating in the study. The published findings of this study, however, may be useful to develop the treatment plan for the individuals with the online pornography addiction, therapists and other professionals.
There are possible risks of responding to certain question regarding treatment of the online pornography addiction behavior. I am informed that I will not be paid anything for my participation in the research. This is a complete voluntary and non paid form of participation.
I understand that I may refuse to participate in, or may choose to withdraw from, this research at any time. I also understand that the researcher may stop my participation before I am finished.
I have been told that this study’s design, instruments (including this form), research steps, and other necessary elements have been evaluated and approved by the researcher’s dissertation committee as well as by CGI-TCS’s Research Review Committee. I understand that these committees are comprised of professionals who are experienced in research. I understand that the committee approvals, however, do not change the fact that the final decision to participate in this study belongs to me, and that I may stop my part in it at any time.
Answers to Questions or Concerns:
I understand that if I have any questions or concerns about the study or my part in it, I may write or call the researcher:
Full Name of Student Researcher
Phone number at which researcher can be reached
I also understand that I can write or call the chairperson of the researcher’s dissertation committee:
Committee Chairperson’s First & Last Name, Degree
CGI-TCS Phone Number
Signing to Participate
I have been told that signing this form means that I have read this form, understand that it means, have had a chance to ask questions, have had these questions answered to my satisfaction, and agree or consent to participate in this research project. Finally, my signature also means that I have been given a signed copy of this consent form.
Therapist’s Informed Consent
Therapist’s Full Name (print):________________________________________
This agreement and consent is for (initial one of the following):
_______ only my participation