Neuroscience and Psychotherapy in the Treatment of Sexual Addiction

1. Neuroscience and Psychotherapy in the Treatment of Sexual Addiction Presented by: Matthew Hedelius, Psy.D., LCSW, CSAT, Candidate Director The IRATAD and Paradise Creek Recovery Center

2. The Brain • The brain is the organ which controls all processes within the body. • Cortex – This is the outer part of the brain that is responsible for all executive functions. • It helps us to reason. • Think about consequences. • Make rational choices. • Helps us to be future oriented. • Helps us to problem solve.

3. The Brain • The limbic system – This part of the brain is known as the “emotional brain”. • Responsible for feeling all emotions. • Helps to regulate the needs of the body and to get those needs met. • Lets us know when we are hungry or thirsty. • The first “responder” to let us know when danger is near. • Responsible for the experience of all pleasure.

4. The Brain • Nucleus Acumbens- The specific part of the limbic system that is responsible for the experience of pleasure. • It is reinforced with neural-chemicals any time we engage in any life sustaining activities. • It is reinforced by and large by a chemical called Dopamine.

5. Brain plasticity is… • The ability to alter the structure of the brain for good or bad. • Trauma – Damages the structure and functioning of the brain and the tissue and cellular level. • Effective Intervention –Alters the structure and functioning of the brain by facilitating dendritic branching and growth that ultimately facilitates positive behavioral and life change. • This change is known as neural plasticity which can lead to neurogenesis.

6. Neural Plasticity is… • The ability to make long term emotional and behavioral changes. • The ability to transfer previous unconscious processes such as acting out as a result of stress into a conscious process of activating a new and healthier pathway in the brain when stress occurs. • This is a result of new neuronal connections in the brain that include the cortex which is the rational brain.

7. Sexual Behavior Innate drive. Although a lot of energy is often spent thinking about sex, it is a rather unconscious process. It will happen without us having to “make it happen”. In other words, sexual behavior is highly connected to the mid and hind brain, which function unconsciously.

8. The Sexual Template A Blue print of what we like and desire sexually. Highly influenced by early life experience. Can be altered by trauma. Is impacted by parental messages during childhood and adolescent development. Is also influenced by media messages, experiences with friends, childhood trauma, etc. Continues to be plastic into adulthood. Strongly influenced by early childhood and adolescent sexual experiences.

9. Sexual Template According to Dr. Patrick Carnes, the arousal template is “the total constellation of thoughts, images, behaviors, sounds, smells, sights, fantasies, and objects that arouse us sexually” (Carnes, 2010 pgs. 244-247).

10. Sexual Neural Pathways • Arousal – Function is to bring excitement and pleasure • Numbing – Function is to bring reduction to pain and anxiety. • Fantasy – Function is to escape and maintain the high that comes from anticipation. • Deprivation – Function is to help the addict cope with feelings of fear, shame and disgust about their sexuality. (Carnes, 2010)

11. The Changing Sexual Template As mentioned, the template can continue to be altered into adulthood. The release of dopamine and firing of neurons during intense stimulation can facilitate the altering of ones arousal template. Deviant pornography use over time, has been shown to alter the ones template. Can lead to an inability to complete ejaculation or even obtain an erection in the absence of pornography.

12. Arousal Template “the plastic influence of pornography on adults can also be profound, and those who use it have no sense of the extent to which their brains are reshaped by it.” (Doidge, 2007 p. 103).(Referring to hard core and deviant pornography). Other intense sexual experiences can have significant impact upon the template long after one has reached adulthood.

13. Development of Arousal Template

14. Development of the Arousal Template Primary Sexual Experiences Biological Influences Cultural, Social and Family Influences Trauma and Psychological Influences Media and Technology Reinforcement Arousal Template

15. Altered Template in Adulthood • Sexual Trauma in adulthood. • Experimentation of alternative sexual behaviors: • Swinging • Going to strip clubs • Incorporating pornography into primary relationship • Experimenting with cross dressing • Having an affair • Your Spouse having an affair • Mixing alcohol/drugs with sex • Degree of vulnerability greatly impacts the alterability of template.

16. The Altered Template • The degree to which a persons template can be altered is greatly influenced by the following: • The degree of novelty associated with the sexual behavior. • Consistency, Frequency, Duration • The degree of vulnerability one possesses at the time the sexual behavior is engaged in. • Depression • Shame • Anxiety • Stability of Primary Relationship • Recent losses

17. Technology as a Template Changer

18. Dopamine and Anticipation Research shows that the release of dopamine is higher during the anticipation of a pleasurable experience than during or after the actual experience itself (Sapolsky, 2007). The release of neuro chemicals is what locks in long term memories. The more dopamine that is released, the greater the memory markers are and hence, the more likely the template can be altered.

19. Neurotransmitters as Memory Makers • Acetylcholine – Arousal, Excitation, Muscle Contraction • Glutamate – Excitation, Long term learning and memory • Norepinephrine – Arousal, Excitation • Serotonin - Soother • Dopamine – Pleasure reinforcement

20. Trauma, Addiction and the HPA AXIS Hypothalamic-Pituitary-Adrenal AXIS A Process of events with the function of modulating the impact of stress and trauma. Fight or Flight Response.

21. Chaos and Addiction • “This kind of chaotic coping through addiction(with or without substances) seeks to influence the balance of neurotransmitters in the brain, altering function in the direction of feeling better. However, the substance or activity becomes the momentary salve that never actually soothes the underlying pain and fear.” (Badenoch, 2008 P. 149).

22. Acting Out and Neural Pathways • Can activate pathways that ultimately lead to over arousal or under arousal. • Influenced by early template creating experiences. • The intolerable state determines which pathway will be activated. • Sympathetic • Parasympathetic

23. Addiction Pathways • Stress pathways become connected to reward pathways. • Stress leads to the activation of the reward pathways in order to seek relief from the pain. • Addictions artificially activate the reward pathways and ultimately cause the brains natural reward systems to decrease in spontaneous activation. • A binge or “act out” is followed by a dramatic decrease in dopamine and serotonin (Koob & LeMoal, 2006). • Leads to decrease in activity in the orbitofrontal cortex due to dopamine bursts (Volkow, 2007).

24. Trauma and Sexual Template • Early trauma and exposure to intense situations can alter the “sexual template” and future development of the brain. (Schwartz, 2008)

25. The Altered Template Does Not Discriminate Against Gender

26. The Altered Template • Novelty releases high amounts of dopamine. • When an increased amount of dopamine is released greater learning and memory takes place. • When an individual participates in novel and high arousal experiences, the template is at risk for being altered. • High arousal experiences change the brains expectations. • The brain than keeps pursuing these high arousal experiences in order to get to the same level of “pay off”.

27. Psychotherapy and Healing • An emotional, psychological, physiological and spiritual process between a mental health professional and one or more patients that has the efficacy, and is greatly influenced by the relationship, to facilitate healing in the recipients from mal adaptive behaviors, traumas and other psychological ailments that interfere with living peacefully in the world.

28. Psychotherapy and Right Brain Connections • Occurs when the therapist/patient relationship follows a healthy developmental process of parent/child. • Empathic listening. • Appropriate and attuned voice fluctuations. • Eye movements and gaze. • Healthy self regulation (Therapist effectively managing own anxiety) • Therapist being able to stay present. • Therapist recognizing when ruptures occur and work towards repair.

29. Psychotherapy and Attunement • “Attunement can be seen as the heart of therapeutic change. In the moment, such resonant states feel good as we feel ‘felt’ by another, no longer alone but in connection. This is the heart of empathic relationships, as we sense a clear image of our mind in the mind of another …. Here we see the notion of embodied simulation of the mirror neuron system (Siegel, 2007).

30. Psychotherapy and Attunement • “…relationships of secure attachment between parent and child, and the effective therapeutic relationship between clinician and patient each promoted the growth of the fibers in this prefrontal area” (Siegel, 2007 p. 27).

31. Psychotherapy and Interpersonal Attunement • “… interpersonal patterns of communication that are integrative stimulate the activity and growth of integrative fibers in the brain. And it is the integrative fibers in the brain that enable self-regulation because they are the circuits responsible for coordinating and balancing the internal and interpersonal elements of the individual” (Siegel, 2012, p. 34-2).

32. Right Brain Psychotherapy • “… right hemisphere-based ways in which we connect with our patients…riding on the flow of an integrating brain, our tone of voice, our gestures of care, the rhythm of our breathing, the tenderness in our eyes, and the receptivity of our postures can help open the door to our patient’s implicit worlds (Badenoch, 2008 p. 157).

33. Right Brain to Right Brain Connection • The patients autobiography. • Empathy. • Appropriate therapeutic attention. • Therapist mindfulness and being present. • Appropriate clinical knowledge. • Therapeutic atmosphere. • Therapeutic posturing.

34. Patient Autobiography • 1st Assignment given in therapeutic process. • Provides opportunity for therapist/patient attunement. • Allows patient to reflect on past and to look inward. • May be the first time the patient has ever truly been listened to. • Allows patient vulnerability. • Accesses Multiple parts of patients brain. • Prefrontal Cortex • Motor Cortex • Limbic System • Broca’s Area • Wernicke’s Area

35. Healing Through Neural Plasticity • Neuroplasticity is the ability of the brain to change its structure in response to experience. Experience activates neurons, which then can turn on genes that enable structural changes to be made that strengthen the connections among activated neurons. Even the focus of attention is a form of experience that activates neurons, turns on genes, and makes structural changes to the connections among neurons. In this way, the mental process of focusing attention can change the physical structure of the brain. This is neuroplasticity (Siegel, 2012).

36. Neural Integration • Connecting of different groups of neurons within the brain as well as the different parts of the body. • Facilitates optimal self regulation. • Developed as a result of secure attachment, optimally during infancy. • Effective attunement in therapy can help to facilitate neural integration even after trauma and a history of pathology.

37. Factors Facilitating Neuroplasticity • Aerobic Exercise • Good Sleep • Good Nutrition • Relationships • Novelty • Paying Close Attention • Mindfulness (Siegel, 2012)

38. Neurogenesis • There is definitive proof human beings continue to create new neurons in the brain. (Eriksson et al., 1998). • The process of generating new and additional neurons that integrate with existing cellular circuits after early postnatal development has stopped. • Occurs in the dentate gyrus (hippocampus) and the olfactory bulb (Aimone et al., 2007)

39. Neurogenesis • Neurogenesis: • Must have support from nearby glial cells. • Must have nutrients from the blood. • Must be able to establish connections with already established neuronal networks. • This allows for continued nutritional support. • Neurogenesis appears to be regulated by exercise. (Pereira et al., 2006; Ratey, 2008)

40. Neurogenesis and Brain Plasticity • Neurogenesis may help heal structures in the limbic system, specifically the hippocampus. • Though addictive neural pathways cannot be pruned away, brain plasticity, aided by neurogenesis, allows the addicted individual to transfer a healthy way of coping into long term storage and therefore creates long term change.

41. Neurogenesis and Brain Plasticity • Conditions for healing are created and supported by the following principles: • Consistency • Frequency • Duration • The addiction pathways will not be destroyed but they can in time, become less dominant.

42. Integrative Scripting • Integrative scripting refers to the idea of mapping out an optimal outcome of an unhealthy process, specifically using the differing parts of the body including the prefrontal cortex, limbic system, brain stem and body proper. • Builds upon the principles of neural integration. • Takes a holistic approach to healing and recovery. • Facilitates the building of confidence and hope within the patient.

43. Integrative Scripting • Written in the first person, present tense. • Written as if it were happening right now. • About ½ to 2/3 of a page in length. • Concretely identifies the pathway into the problem, recognizing it, choosing to remove self from the high risk situation followed by the optimal outcome. • Specifically identifies processes of the brain and body in the overall outcome.

44. Brain Plasticity and the Firing of Neurons • The same mechanisms which can lead to addiction can also be used for healing. • “ Neurons that fire together wire together” (Carla Shatz as cited in Doidge, 2007).

45. Mindfulness and Psychotherapy • “ In mindfulness we direct our attention to our intention. Where attention goes, neurons fire, And where neurons fire, they can rewire.” (Siegel, 2007 pg. 291). • SNAG – Stimulate Neural Activation and Growth • Actively practicing healthy thought patterns and behaviors to help facilitate new neural pathways. • Using new words to describe feelings of being out of control sexually. • Mindfully choosing new driving routes so as to avoid high risk areas. • Journaling about sexually anorexic states for the purpose of attaching new meaning to the emotional states.

46. Consciously identify corrective psycho-emotional and behavioral pattern. Therapeutic attunement. Integrative Communication. Scripting. Incorporation of SNAG. Psychopathology (Unconscious) Exercise. Cognitive and behavioral rehearsal. Practicing the SNAG. Leads to consciousness and short term learning and memory. Internal Integration. Long term learning and memory. Long term storage. Synaptogenesis and neurogenesis. Continued exercise. Apply principles of: Consistency, Frequency, and Duration .

47. Mindfulness • What is going on in each of these pictures? • What is a ‘mind full’ like for you? • What is being ‘mindful’ like for you? • How can being ‘mindful’ be used to help us regulate our emotions in healthy ways?

48. Mindfulness Wise Mind Act purposefully Logical Mind EmotionalMind Think React

49. Mindfulness and Vertical Integration • Vertical Integration • Cognitively connecting the prefrontal area, limbic system, brain stem and the body so that they are working harmoniously with one another and aware of the others functions. • Practicing desired skills so the new neural pathways are developed and strengthened. • Reinforcing this process in patients by helping them become mindfully aware of the possibility. • Inspiring our patients and their loved ones that deep, long lasting psychological and physiological changes can occur.

50. Psychotherapy and Neuroscience Mild to moderate levels of stress facilitates neuronal growth hormones that in turn, facilitates new learning (Galea & Fuchs, 1997 as cited in Cozolino, 2010). Managed exposure of stress during psychotherapy facilitates new learning and neuronal integration.