Complex Trauma in Women with Compulsive and Addictive Sexual Behaviour Often compulsive and addictive behaviour is thought of as a male problem, however, more and more women are coming forward struggling with the behaviour.

2. COMPLEX TRAUMA IN WOMEN
WITH COMPULSIVE AND
ADDICTIVE SEXUAL BEHAVIOR
Dr. Stefanie Carnes, PhD, CSAT-S
Clinical Sexologist

3. FULL DISCLOSURE
 Dr. Stefanie Carnes is a Senior Fellow at
the Meadows Behavioral Health and the
President of the International Institute for
Trauma and Addiction Professionals.

4. AGENDA
Sex and Love Addiction in Women
Case Example with Video
C-PTSD
C-PSTD in FSLAs
Treatment of FSLA with Complex trauma

5. WHAT’S IN A NAME?
Women seeking treatment for sex and love addiction may be best described
by any number of labels depending on their specific presenting symptoms:
 Sex Addiction
 Sex & Love Addiction
 Love Addiction
 Relationship Addiction
 Porn Addiction
 Traumatic Bonding
 Sexual Anorexia/ Aversion
 Intimacy Disorder
 Insecure Attachment
 Complex / Developmental Trauma

6. WOMEN SEX & PORN ADDICTION
Not all women seeking treatment problematic sexual behavior
will manifest as love and relationship addictions.
The proportion of women accessing online pornography is
significantly on the rise and more women and girls are reporting
problems with porn.

7. TRENDING SEARCH TERMS:
PORN FOR WOMEN

8. 2017 RISE FEMALE PORN VIEWERS

9. CASE EXAMPLE

10. CASE STUDY
Demographic Data (Changed for purposes of
confidentiality)
• 21 year old Caucasian female.
• Lives Washington DC.
• Works in a sales position

11. CASE STUDY
Chief Complaint
• Sex addiction
• Watched online web cams of people having sex.
• Phone sex and masturbation at least 3 times a day.
• Used Tinder and Instagram for sexual hookups.
• Began having casual sex with men/women every night.
• Choking, punching and hitting became part of sexual acting out.

12. CASE STUDY
Chief Complaint
• Sex addiction
• Recognized that she had symptoms of sexual compulsivity.
• Involved in infidelity in all of her relationships.
• Relapsed with alcohol and sexual acting out increased.
• She felt hopeless, believed she was a failure and had a plan to commit suicide.

13. CASE STUDY
Co-Morbidity
• Depression:
• Depressive thoughts started around age 8.
• Diagnosed in high school but didn’t receive adequate treatment.
• Symptoms worsened during relapses and sexual addictive behaviors.
• Suicidal plans but denied history of suicide attempts.
• Prior to admit, considered taking pills and self-harming with a knife.

14. CASE STUDY
Co-Morbidity
PTSD: Sexually abused as a child. Emotionally and physically abused by mother.
• Disordered Eating: medicated with high-sugar foods.
• Past History:
• Self-harm
• ADHD
• Anxiety/Panic
• OCD

15. CASE STUDY
Childhood Trauma and Abuse
• Sexually abused by her Uncle at 8 years old.
• Mom physically abused her when mother was angry.
• Raped at age 16 years old.

16. CASE STUDY
Substance Abuse History
• Alcohol: began drinking at age 14. Abused alcohol regularly her junior year of college. Currently
1 to 3 times a week. On weekends she drinks up to five beverages. She drinks alcohol before
her home to help her “hookup and have sex”. Minimizes her alcohol use.
• Marijuana: She uses marijuana about 4 times a week at night to relax. One bowl helps her with her
nightmares and sleep. She does not believe she has a dependency to Marijuana.
• Cocaine: Tried it on New Year’s Eve.
• MDMA: uses on special occasions.

17. CASE STUDY
Patient Quotes
• “I have recurring nightmares of being molested or raped by my
immediate family”.
• “I have had sex with 93 people. Some of whom I don’t remember”.
• “I find it difficult to be sexually satisfied by sex that doesn’t involve
violence”.
• “For the past year I have secretly struggled with my gender and
identity”.
• “I have seen my birth as a mistake or a cruel joke by the universe”.

18. CASE STUDY
Family of Origin History
• Father: He is a cardiologist. He does not have a history of mental illness. However, his family has a history of anxiety
depression. She described him as sweet and loving. He is supportive of her and they have a close relationship.
• Mother: Her mother is an physical therapist. Her mother’s family has a history of Borderline PD, drug addiction and
alcohol addiction. She describes her mother as having a “bad drinking problem”. Her mother angered easily and was
“awful and abusive”. She currently has a close relationship with her now as she chose to forgive her mother.
• Home Life: parents frequently fought. They temporarily separated when she was in middle school. Fighting revolved
around her mother’s drug and alcohol use. CPS became involved and parents attended counseling and discovered the
Catholic Religion.

19. SAST Core = 18

33. COMPLEX TRAUMA (DEVELOPMENTAL TRAUMA)
 Trauma is extremely threatening and prolonged
 Generally refers to stressors that are interpersonal,
that is they are premeditated, planned, and caused by
other humans
 Most often involves exploitation and maltreatment
including neglect and abandonment or antipathy by
caregivers
 Often occurs at developmentally vulnerable times in
the victim’s life, especially in childhood and
adolescents but can also occur in later life
 E.g. disability, age, infirmity, dependency,
disempowerment, captivity
 Escape is difficult
 Reaction is more severe than when trauma is
impersonal (such as natural disaster, car accident)
 C. Coutois (2015) Understanding complex trauma, complex
reactions & Treatment Approaches

34. 34
IDC – 11
6B41 Complex post traumatic stress
disorder
Exclusions
•Post traumatic stress disorder (6B40)
Description
Complex post-traumatic stress disorder (Complex PTSD) is a disorder that
may develop following exposure to an event or series of events of an
extremely threatening or horrific nature, most commonly prolonged or
repetitive events from which escape is difficult or impossible (e.g., torture,
slavery, genocide campaigns, prolonged domestic violence, repeated
childhood sexual or physical abuse). The disorder is characterized by the
core symptoms of PTSD; that is, all diagnostic requirements for PTSD have
been met at some point during the course of the disorder. In addition,
Complex PTSD is characterized by 1) severe and pervasive problems in
affect regulation; 2) persistent beliefs about oneself as diminished, defeated
or worthless, accompanied by deep and pervasive feelings of shame, guilt or
failure related to the traumatic event; and 3) persistent difficulties in
sustaining relationships and in feeling close to others. The disturbance
causes significant impairment in personal, family, social, educational,
occupational or other important areas of functioning.

35. 35
ICD – 11 6B41 Complex Post Traumatic Stress
Disorder
PTSD Symptoms
Re-experiencing
Trauma
in Here and Now
Avoidance of
Reminders
Persistent Sense
of Current Threat
CPTSD Symptoms
Affect
Dysregulation
Negative Self
Concept
Relationship
Disturbance

37. CORE CHARACTERICTICS OF
C-PTSD
#1 - Relationship Disturbance

38. INSECURE ATTACHMENT STYLES
57 36 21
SECURE
10 26 36
PREOCCUPIED
18 13 8
DISMISSIVE
Controls
Male Sex Addicts
Female Sex Addicts
15 25 35
FEARFUL-AVOIDANT
Bartholomew & Horowitz (1991); Jore (2015); Jore (2015)

39. Anxious
Avoidant

40. CORE BELIEF: OTHERS CANNOT BE RELIED
UPON
Intimacy creates
intolerable
anxiety
Crave
connection and
attachement

41. CHALLENGES IN TREATMENT OF C-
PTSD
 Our clients’ most frequent presenting problems are not the many symptoms of
PTSD, but rather their failed or failing relationships. They want to love and be loved
by someone, and it is not going well. Our clients often enter our offices with a
sense of hope and dread. Therapy evokes the most challenging dilemmas for
survivors of betrayal trauma. Turner, McFarlane, and Van der Kolk (1996) write: “The
process of entering and maintaining a treatment relationship is always extremely
complex. However, it becomes even more so when a patient has been humiliated,
hurt, and betrayed, often by people whom the patient counted on to provide
safety and protection” (p. 541). Many survivors of betrayal trauma come to therapy
with the belief that abuse is “a dreaded but unavoidable fate and is acceptable as
the inevitable price of relationship”
 Kahn, L. (2006). The understanding and treatment of betrayal trauma as a
traumatic experience of love. Journal of Trauma Practice, 5(3), 57-72.

42. C-PTSD
VICTIMS ARE
AT
SIGNIFICANT
RISK OF RE-
VICTIMIZATION
Traumatic repetition of the trauma
High risk behaviors
Self-destructive behaviors
Substance abuse
Exploitive and abusive relationships

43. VAN DER KOLK, B. A. (1989). "THE COMPULSION TO REPEAT THE TRAUMA. RE-ENACTMENT,
REVICTIMIZATION, AND MASOCHISM". THE PSYCHIATRIC CLINICS OF NORTH AMERICA 12 (2): 389–
411. PMID 2664732. EDIT
 Anger directed against the self or others is always a central problem in
the lives of people who have been violated and this is itself a repetitive
re-enactment of real events from the past. Compulsive repetition of
the trauma usually is an unconscious process that, although it may
provide a temporary sense of mastery or even pleasure, ultimately
perpetuates chronic feelings of helplessness and a subjective sense of
being bad and out of control. Gaining control over one's current life,
rather than repeating trauma in action, mood, or somatic states, is the
goal of healing.

44. TRAUMATIC BONDING
 Trauma bonds are generally defined as an
attachment to another person that is not
healthy and sometimes dangerous, because
the attachment is based upon some form of
shame, exploitation, danger, threat, or a
combination of these things.
• Individuals who experience Traumatic Bonding, are bonded to
the other person based upon the type of bonding they
experienced growing up.
• It is not uncommon for people who have experienced
abusive relationships, especially when they occurred or were
formed in childhood, to repeat the cycle of abusive
relationships well into their future, even though it is
recognized as bad or destructive.

46. 46
VAN DER KOLK, B. A. (1989). "THE COMPULSION TO REPEAT THE TRAUMA. RE-ENACTMENT, REVICTIMIZATION, AND MASOCHISM". THE
PSYCHIATRIC CLINICS OF NORTH AMERICA 12 (2): 389–411. PMID 2664732.
Van Der Kolk on Intrafamilial Abuse…
“People seek increased
attachment in the face of
danger.”
“When the traumatic event is the result of an
attack by a family member on whom victims
also depend for economic or other forms of
security, as occurs in victims of intrafamilial
abuse, victims are prone to respond to assaults
with increased dependence and with a paralysis
in their decision making processes.”

47. “Like a lot of other girls, she
chose a husband like her father.
I think I understand it. They
start connecting love with pain.
They begin searching out men
who will hurt them, thinking they are
searching for love.
~ Prince of Tides ~

48. CORE CHARACTERICTICS OF
C-PTSD
#2 – Negative Self Concept

49. CORE BELIEF: I’M NOT GOOD ENOUGH
 Toxic Shame
 Negative self attribution
 Self-destructive thoughts and behaviors
 Impaired relationship with the self
 Inability to come to one’s own assistance
 Disbelief in self

52. Managing Toxic
Shame
Shameless
Better than
Perfect
Control
Blame
Righteous
Criticism
Shameful
Less than
Failure
Don’t Care
Rage
Excess

55. CULTURAL CONSIDERATIONS
Kelly McDaniel explored the impact of cultural
expectations of women to distinguish the
unique experiences of female sex and love
addicts from their male counterparts.

56. CULTURAL BELIEFS FOR WOMEN

57. CORE CHARACTERICTICS OF
C-PTSD
#3 - Affect Dysregulation

58. CORE BELIEF: I CAN’T DEAL WITH MY
LIFE (I CAN’T HANDLE MY FEELINGS)
 Self Medicating
 Numbing
 Risk Taking
 Control (restricting, avoidance, perfectionism)
 Distracting/ Avoiding Intimacy
 Compartmentalizing
 Overwhelming resentment

64. COMPARTMENTALIZATION
 Having different parts of self, secret or double life
 Can split off parts of self to avoid feelings

67. THE GRIEVANCE STORY IS…
A narrative of repeated
injustices
A focus for our anger,
reason for grief, answers to
feelings of unworthiness
A way to disown
responsibility for causing or
adding to our pain
A path to entitlement
A deeply held reason to
stay stuck

68. “He was singled out, shamed for his
differences, abandoned and hurt by those
he trusted and loved. He withdrew and
became obsessed with those whose
thoughtlessness hurt him so deeply. His
lifestyle and all that he did was organized
around this original plan. Vengeance was
the logical conclusion of his obsession.
This wonderful holiday tale holds a deeper
truth: our grievances feed obsession,
especially addictive…obsession.”
Carnes, Recovery Zone1 p 113

69. AFFECT REGULATION
 Dan Siegel- Window of Tolerance
 Personal change, both in therapy and in life, often
depends on widening what I call a “window of
tolerance.” When that window is widened, we can
maintain equilibrium in the face of stresses that
would once have thrown us off kilter.
 Think of the window as the band of arousal (of any
kind) within which an individual can function well.
This band can be narrow or wide. If an experience
pushes us outside our window of tolerance, we may
fall into rigidity and depression on the one hand, or
into chaos on the other. A narrow window of
tolerance can constrict our lives.

70. Window of Tolerance
Trigge
r
Tools to
Regulate
Hyper-
Arousal
Hypo-
Arousal
Regulation
Tools:
• Seeking support
from group or
supportive friends
• Mindfulness
• Yoga
• Exercise
• Shame reductions
strategies
• CBT/ DBT
• Self-Expression
(art, music)

71. 71
Treatment
&
Healing

72. Judith Herman on healing C-PTSD:
• Recovery can only occur within a healing relationship
• Survivor must be empowered in that relationship
• Can include therapeutic relationship
Judith L. Herman (30 May 1997).Trauma and Recovery: The Aftermath of Violence--From Domestic Abuse to Political Terror. Basic
Books. ISBN 978-0-465-08730-3. Retrieved29 October 2012.

73. 73
The underlying assumption is
that the therapeutic relationship
provides an opportunity to
rework attachment difficulties
Treatment involves the
development of a secure
therapeutic relationship
(therapist must be capable of
secure attachment)
Therapist must provide safety to
process the trauma and navigate
life’s struggles
Therapeutic Alliance is Key!

74.  Schore, J. R., & Schore, A. N. (2008). Modern attachment theory: The central
role of affect regulation in development and treatment. Clinical Social Work
Journal, 36(1), 9-20.
“Therapists know that, like the
securely attached child who
can look around herself, the
securely attached client who
feels safe in the therapist’s
presence can look inside to
investigate her inner world.”
Allen Schore on the Therapeutic Alliance….

75. 75
Focus on safety & stabilization
Establish framework for therapy and therapeutic alliance
Skill building:
• Strategies to contain trauma
symptoms
• Attention to wellness
• Stress management
• Support for medical/ somatic
concerns
• Healthy boundaries
• Safety planning
• Assertiveness training
• Self-nurturing/ Self Soothing
• Emotional modulation
Courtois: Early Stages of Treatment

76. 76
• Revisiting and reworking the trauma
• “Careful processing to integrate traumatic material along
with it’s associated but often avoided emotion”
• Expression of pain and grief (with witness and support)
• Maintenance of stability and safety
Courtois: Middle Stage of Treatment

77. TREATMENT: LATE STAGE
(COURTOIS 2015)
• Identity and self-esteem development
• Improving relational skills and relationships
• Intimacy issues, sexuality
• Understanding the meaning of trauma and
losses
Courtois: Late Stage of Treatment

78. EMDR
Somatic Experiencing
Biofeedback
Internal Family Systems
Art therapy
Sensorimotor psychotherapy
Psychodrama
Post induction model
Mindfulness
Cognitive Behavioral
Comprehensive Resource Model
(Not an exhaustive list!)
Provide treatment for the trauma response for partners and
children! So many options…..

79. THREE CIRCLE SOBRIETY DEFINITION

80. PERSONAL CHAOS INDEX

81. TREATMENT – AFFECT REGULATION

82. TREATMENT –
AFFECT
REGULATION
Regulate Affect & Treat Underlying Trauma:
CBT, DBT, somatic & mindfulness-based interventions for mood
& anxiety disorders.
Regulate nervous system. Improve distress tolerance.
Begin to treat underlying trauma and shame. Consider how
past traumatic experiences impact present relationships.
Restructure a self-compassionate relationship with the self (ego
states, functional re-parenting, wise mind, observer self).

84. LOVE ADDICTION CYCLE

85. TRAUMA EGG

86. RECOVERY START KIT AND 30 TASK MODEL
• Some female clients may
respond better to more
experiential or relational
processing of Trauma & Parts
of Self Tasks.
Consider addressing task work using experiential interventions such
as:
• Group therapy,
• Art therapy,
• Psychodrama
• Internal Family Systems

87. TREATMENT – INTIMACY
DISORDER
Promote Healthy Attachment Relationships:
 Interpersonal connections are key to
recovery (therapist, 12-step group,
partner/family, higher power)
 Deepen trust and combat shame with
rigorous honesty & vulnerability.
 Support effective co-regulation and safe
attachments with therapists, 12-step
community and other women

88. CASE EXAMPLE
Sabrina Stoorman - Primary Therapist
Irene Jacobs – Clinical Director
Crystal Nesfield – Trauma Therapist

89. Case Presentation
 31 year old marred female
 Chief Complaint – “I need to work on
my sex and love addiction which makes
me abuse other things”
 Patient came into inpatient treatment for
female SLA and trauma resolution
 Has had numerous previous treatment
experiences
 Met her husband at the Meadows during
a previous treatment stay (He got
administratively discharged for sex with
a different patient) She contacted him
after he discharged and they have been
together ever since
 Both are chemically dependent

90. KEY PRESENTING
PROBLEMS
 Volatile marital relationship with husband
who is also alcoholic
 Chemical dependency – Alcohol,
cocaine, Marijuana, Benzodiazapines,
was prescribed adderal for ADHD but
reports she has never abused it.
 Depression – Grieving over recent death
of her mom
 Bipolar symptoms – very impulsive,
mood unstable
 Self harm – has cut forearms on 10
occasions
 ADHD
 Generalized Anxiety Disorder

91. SEXUAL
BEHAVIORS
 Compulsive masturbation
 Porn Addiction
 Online sex chatrooms and webcamming
 Began masturbating age 4
 First internet chatroom age 12
 Arousal template
 Rape fantasy
 Power differential fantasy
 “I want people to lust after me”
 On numerous occasions patient has
raped her husband, he would say no and
when he got an erection she would jump
on top of him

92. SOCIAL HISTORY
 Parents relationship was conflictual
 Sexually abused by father
 Father is a possible sociopath and she no
longer has relationship with him
 Mother passed away recently from
alcoholism, cancer and anorexia
 Has identical twin sister – was always
compared to her. Sister was the
“beautiful/ sexy one” and patient was the
“cute one”
 She and her sister regularly mutually
pleasured each other until age 12

93. ASSESSMENT AND
TESTING

99. ART THERAPY

102. PERFORMABLES

110. QUESTIONS?

111. RESOURCES FOR CLIENTS

112. RESOURCES FOR CLINICIANS

113. Thank you!
Stefanie@iitap.com