Process Addictions

Articles

Treating the Sexually Addicted Client:
Establishing a Need for Increased
Counselor Awareness

W. Bryce Hagedorn
Gerald A. ]uhnke

Seventeen to 37 million Americans struggle with sexual addictions (P. Carnes,
1994b; A. Cooper, D. L. Delmonico, & R. Burg, 2000; B. Morris, 1999; J. L.
Wolf, 2000), yet traditionally trained addictions and offender counselors
often find themselves unprepared to assist clients who are sexually ad-
dicted. This article provides a general overview of the disorder, explores the
ongoing definition debate, and offers clinically proven treatment protocols.

The suggested prevalence of sexual addiction is staggering. An estimated 17 to
37 million Americans struggle with this addictive disorder (Carnes, 1994b; Cooper,
Delmonico, & Burg, 2000; Morris, 1999; Wolfe, 2000).These figures are greater
than the combined number of Americans who are addicted to gambling or have
eating disorders (National Center on Addiction and Substance Abuse at Colum-
bia University, 2003; Potenza, Fiellin, Heninger, Rounsaville, & Mazure, 2002;
Shaffer & Korn, 2002; Tenore, 2001). In addition to the prevalence, the incidence
of sexual addiction is rising, due in part to the affordability, accessibility, and
anonymity of sexually explicit material available on the Internet (Cooper et al.,
2000). The prevalence of sexual addiction is predicted, based on current trends,
to continue rising at a rapid rate (Cooper, 2004).

Because of the lack of qualified counselors, many addicted individuals turn to
self-help groups, all of which are administered by nonprofessionals without for-
mal education and training in treating sexual addiction (Haugh, 1999; Myers, 1995;
Wolfe, 2000). Of the 73 nationally known 12-step, self-help support groups, 8 distinct
groups are dedicated to individuals seeking assistance in managing their sexu-
ally addictive behaviors. This number of sexual addiction support groups is more
than any other 12-step group addressing an addictive disorder and may reflect
the large number of individuals who are sexually addicted. Despite steadily in-

W. Bryce Hagedorn, Department of Educational and Psychological Studies, Florida Interna-
tional University: Gerald A. Juhnke, Department of Counseling and Educational Development,
University of North Carolina at Greensboro. Gerald A. Juhnke is now in the Department of
Counseling, Educational , Adult and Higher Education, The University of Texas at
San Antonio. Correspondence concerning this article should be addressed to W. Bryce Hagedorn,
Department of Educational and Psychological Studies, ZEB 239A, Florida International Uni-
versity, Miami, FL 33199 (e-mail: [email protected]).

66 Journal of Addictions & Offender Counseling ‘ A p r i l 2005 “Volume 25

Is

creasing self-referral and participation in 12-step, self-help groups such as
Sexaholics Anonymous, Sex and Love Addicts Anonymous, Sex Addicts Anony-
mous, Sexual Compulsives Anonymous, and Sexual Recovery Anonymous, the
treatment community lacks the resources and funding to address this growing
population (National Council on Sexual Addiction and Compulsivity, 2000).

Although the increase in the number of 12-step groups specific to the treatment
of sexual addiction is a commendable step, there is a growing need for addictions
and offender counselors to respond to the needs of the population of clients who
are sexually addicted. Although a very limited number of articles related to sexual
addiction have been published, these articles have typically been published in journals
specific to other clinician groups. For example, Carnes (1990) presented his early
findings in the American Journal of Preventive Psychiatry &: Neurology, Goodman
(1993) offered a definition and some treatment suggestions in the Journal of Sex
and Marital Therapy, and Myers (1995) explored the impact of addictive sexual
behavior in the American Journal of Psychotherapy. A specific journal. Sexual Ad-
diction Se Compulsivity, was created in 1993 to provide a forum for authors and re-

. searchers to provide information regarding sexual addiction (e.g., Delmonico & Griffin,
1997; Goodman, 2001; Manley & Koehler, 2001; Ragan & Martin, 2000). Whereas
this demonstrates the importance and timeliness of information pertinent to treating
clients who are sexually addicted, this information has been disseminated to most
clinician groups, with the exception of addictions and offender counselors. Psy-
chiatrists, sex and marital therapists, psychotherapists, even those working spe-
cifically with sexual addicts, all have the necessary scholarly resources at their
disposal to aid in their work with this client population. As of yet, no meta-analysis
defining sexual addiction and outlining the recommended treatment protocols has
been published for addictions and offender counselor generalists who are not spe-
cialists working exclusively with couples or persons who are sexually addicted.
Concomitantly, no meta-analysis defining sexual addiction has been pubUshed in
the Journal of Addictions & Offender Counseling. Therefore, the intent of this ar-
ticle is to (a) define this disorder according to the existing literature; (b) establish the
need for professionals working in the addictions and criminal justice fields to know
about sexual addiction; and (c) offer clinically proven treatment protocols to assist
with the assessment, diagnosis, and treatment of clients who are sexually addicted.

Defining Sexual Addiction

Patrick Carnes (1994b), a pioneer in the sexual addiction field since 1976, noted
that compulsive sexual behaviors resembled the progressive and chronic com-
pulsive behaviors commonly found with other addictions. For this reason, Carnes
chose to use the term sexual addiction to describe a set of maladaptive behav-
iors that were uncontrollable, that brought negative consequences upon the
addicted individual, and that harmfully affected those involved with the ad-
dicted individual. He further noted that, similar to the early days when public
education on alcoholism spurred both ignorance and prejudice, controversy about
the use of the term sexual addiction was to be expected.

]ournal of Addictions b Offender Counseling ‘ A p r i l 2005 •Volume 25 67

Controversy has indeed ensued. Terminology and diagnostic criteria for sexual
addiction have undergone considerable scrutiny and debate (Apt & Hulbert,
1995; Coleman, 1990; Goodman, 2001; Schneider & Irons, 1996). Although
scholarly debate can be an impetus for improved training and treatment regi-
mens, it can also impede the delivery of necessary resources to individuals in
crisis: This has occurred in the debate over sexual addiction. The resources
and energy needed for training new counselors, conducting empirical research,
and creating new treatment protocols and facilities have been stymied over
the legitimization of the disorder (Goodman, 2001; Manley & Koehler, 2001;
Wolfe, 2000).

Before treatment protocols are explored, the continuing debate must be addressed
to help validate our suggestions. Therefore, we explore (a) the addictive disorder;
(b) criteria development for the designation of an addictive disorder; and (c) the
literature-based debate over the use of the term addiction to describe maladaptive,
compulsive-like sexual behaviors.

The Addictive Disorder

The model on which this article is based is that of the addictive disorder (Carnes
1994b; Goodman, 2001). This model assumes that compulsive-like behavioral mani-
festations that meet criteria similar to those for chemical dependency are in fact
addictive behaviors. Researchers (Goodman, 1998; Griffin-Shelley, Sandier, & Lees,
1992; Raviv, 1993) have stressed the importance of understanding addiction in a
broader context than that of strictly chemical dependency. Although some researchers
and counselors in the addictions field (Apt & Hulbert, 1995; Barth & Kinder, 1987;
Levine & Troiden, 1988; Rachlin, 1990) believe that the term addiction should be
applied only to circumstances that involve chemical substances, similar diagnostic
criteria have been applied to a number of problem behaviors, often called “process
addictions.” These addictions include those related to sex (Abouesh & Clayton,
1999; Carnes, 1992,1994a, 1994b; Fischer, Williams, Byington, & Lonsdale, 1996;
Goodman, 1993,1998,2001; Levin, 1999), gambling (Buchta, 1995; Griffiths, 1992),
eating (Baker, 1995; Sheppard, 1995), work (Robinson, 1998, 2000), television
(Mcllwraith, 1998), shopping (Lee, Lennon, & Rudd, 2000), exercise (Cockerill &
Riddington, 1996), the Internet (Armstrong, Phillips, & Saling, 2000; Young, 1999),
and video games (Griffiths, 1991,1997).

Diagnostic criteria for addiction are often applied to provide a framework for
treatment because clients seldom present with a singular addictive disorder (Das,
1990; Merta, 2001; Rowan & Galasso, 2000). It seems prudent, as well as cost-
effective, to treat multiple addictions simultaneously so as not to repeat therapeu-
tic interventions for each disorder (Juhnke, 2002). Because the same interventions
used with chemical dependency have proven effective in treating other addictive
disorders (Griffin-Shelley et al., 1992), and given that many who are chemically
addicted also meet sexual addiction criteria (Black, Kehrberg, Flumerfelt, &
Schlosser, 1997; Carnes, 1992; Delmonico & Griffin, 1997), it follows that those
trained to treat chemical dependency should also be trained to treat the com-
monly comorbid sexual addiction.

68 Journal of Addictions & Offender Counseling •April 2005 ‘ V o l u m e 25

Criteria Development for the Addictive Disorder

In working toward defining the addictive disorder, Carnes (1992), Goodman (1998,
2001), Levin (1999), and Young (1999) suggested that one begin by identifying
the key elements used to identify chemical dependency. The fact that neither tol-
erance nor withdrawal is necessary for designating a behavior or substance as
addictive (American Psychiatric Association [APA], 2000; O’Brien, 1996; Potenza
et al., 2002) is an issue that we address in more detail later in this article. There-
fore, we begin with the conditions that are both necessary and sufficient for the
diagnosis of a dependence/addictive disorder.

Goodman (2001) suggested that the two criteria necessary and sufficient for the
designation of drug addiction are ” (1) recurrent failure to control the use of one
or more drugs, and (2) continuation of drug use despite substantial harmful con-
sequences” (p. 195). To arrive at a concise definition of an addictive disorder,
Goodman (a) substituted the word behavior ior drug in the above conditions and
(b) added key elements from those arguments asserting that addictive behaviors
are better defined within the context of a compulsion or an impulse control dis-
order. An addictive disorder can therefore be defined as

A behavior that can function both to produce pleasure and to reduce painful affects is
employed in a pattern that is characterized by two key features: (1) recurrent failure to
control the behavior, and (2) continuation of the behavior despite substantial harmful
consequences, (p. 195)

Similar definitions have been applied to designate gambling (Blaszcynski, Buhrich,
McConaghy, 1985; Buchta, 1995; Griffiths, 1992; Potenza et al., 2002), the Internet
(Armstrong et al., 2000; Young, 1999; Young, Pistner, O’ Mara, & Buchanan, 1999),
and eating disorders (Baker, 1995; Flood, 1989; Sheppard, 1995) as addiaive disorders.

If one accepts the merits of this definition for an addictive disorder, the next
step is to specify diagnostic criteria. In developing such criteria, Goodman (1993),
Levin (1999), and Young (1999) began with comparing the criteria for compul-
sive gambling with the criteria established for substance dependence as found in
the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text
revision {DSM-IV-TR; APA, 2000). In addition to the diagnostic criteria noted
by each of these authors, they also noted three additional elements of sexual
addiction, namely, the factor of secrecy, the use of sex as an escape from dyspho-
ric mood states, and the likelihood of engagement in illegal activities in pursuit
of one’s addiction. Goodman (2001) then combined the criteria and substituted
the term behavior for the terms substance and substance use found in the sub-
stance dependence criteria. In addition, “characteristic withdrawal syndrome for
the substance” (APA, 2000, p. 197) was replaced with a more universal definition
for withdrawal that applied to all addictive behaviors.

We therefore suggest that the following set of criteria be accepted as clinically
relevant for diagnosing an addictive disorder:

A maladaptive pattern of behavior, leading to clinically significant impairment or dis-
tress, as manifested by three (or more) of the following, occurring at any time in the
same 12-month period;

Journal of Addictions & Offender Counseling ‘ A p r i l 2005 •Volume 25 69

1. tolerance, as defined by either of the following:
a. a need for markedly increased amount or intensity of the behavior to achieve the

desired effect
b. markedly diminished effect with continued involvement in the behavior at the same

level or intensity
2. withdrawal, as manifested by either of the following:

a. characteristic psychophysiological withdrawal syndrome of physiologically described
changes and/or psychologically described changes upon discontinuation of the behavior

b. the same {or a closely related) behavior is engaged in to relieve or avoid withdrawal
symptoms

3. the behavior is often engaged in over a longer period, in greater quantity, or at a higher
intensity than was intended

4. there is a persistent desire or unsuccessful efforts to cut down or control the behavior
5. a great deal of time spent in activities necessary to prepare for the behavior, to engage in

the behavior, or to recover from its effects
6. important sodal, occupational, or reaeational activities are given up or reduced because of the behavior
7. the behavior continues despite knowledge of having a persistent or recurrent physical or

psychological problem that is likely to have been caused or exacerbated by the behavior
(Goodman, 2001, pp. 195-196)

To conclude, the establishment of diagnostic criteria appears to have several
merits including, but not limited to, the creation of common clinical language,
a legitimization of the disorder for the purposes of third-party reimbursement,
and a step toward a standardized treatment protocol.

The Addictive Disorder Debate

To address the validity of using the addictive disorder model for this article, it
is necessary to address the literature that discounts, as well as affirms, sexual
behavior as addictive. Whereas there is a plethora of literature that debates the
merits of designating these addictive behaviors as compulsions (e.g., Abouesh
& Clayton, 1999), impulses (e.g., Hollander & Rosen, 2000), or paraphilias (e.g.,
Kafka, 1997), the arguments addressed herein involve issues of dependence
(e.g., physical withdrawal and tolerance) and recovery.

In arguing against acknowledging sex as addictive, many authors address the
physical dependence criteria often found with addictive substances. Apt and
Hulbert (1995) asserted that “A true addiction involves a physiological depen-
dence on a particular substance that results from the habitual use of that sub-
stance. Sex is a form of interaction, not a substance on which the body comes to
depend” (p. 104). Levine and Troiden (1988) made similar claims in advocat-
ing for the retention of the term addiction for chemical substances when they
added, “Although sexual experiences may be ‘mood altering,’ abrupt withdrawal
from sexual behavior does not lead to forms of physiological distress such as
diarrhea, delirium, convulsions, or death” (p. 357). Finally, Barth and Kinder
(1987) declared that any similarities between sexual and chemical addiction

do not overrule the original definition of addiction as a physiological dependence on a
foreign substance, evidenced by the removal of that substance producing a physiological
withdrawal state. Sexual impulsivity involves no foreign substances or withdrawal states,
and as such should not be labeled as an addiction, (p. 21)

70 journal of Addictions 6- Offender Counseling ‘ A p r i l 2005 ‘ V o l u m e 25

The main argument made by these authors is that for a behavior/substance to be
addictive, it must meet criteria for physical dependence, criteria exhibited by
tolerance and withdrawal.

Although these arguments may have had merit in the past, current research re-
futes such assertions. O’Brien (1996) stated that “Modern concepts of addictive
disorders emphasize the compulsive and relapsing drug-taking behaviors rather
than tolerance and physical dependence” (p. 677). Potenza et al. (2002), through
a comprehensive study discussing the merits of designating gambling as an ad-
dictive disorder rather than as an impulse control disorder, found that behav-
ioral addictions can be “considered an addiction without exogenous substance
use” (p. 722).

The DSM-IV-TR (APA, 2000) lists substances such as cannabis, cocaine, and
hallucinogens, all of which have dependence criteria. It is interesting that none of
these substances cause physiological dependence but that all are considered “ad-
dictive” substances based on psychological dependence. Because maladaptive pat-
terns of chemical use must meet 3 of 7 criteria to be designated as a dependence
(versus abuse), it is likely that an individual can experience dependence without
undergoing tolerance and withdrawal. In fact, according to the DSM-IV-TR,
“Neither tolerance nor withdrawal is necessary or sufficient for a diagnosis of
Substance Dependence” (APA, 2000, p. 194).

Typical withdrawal symptoms from such substances as caffeine, cocaine, and
marijuana include the following: anxiety; depression; suicidal ideations; dysphoric
mood states; irritability; changes in appetite; sleep disturbance; fatigue or drowsi-
ness; cravings; and significant distress or impairment in social, occupational,
or other important areas of functioning (APA, 2000). These same withdrawal
symptoms are seen in those who cease sexually addictive behavioral patterns
(Carnes, 1994b; Goodman, 1998; Levin, 1999). Even opponents Levine and
Troiden (1988) noted the high levels of anxiety experienced by sexual addicts
in withdrawal. Although sexual addiction does not involve the ingestion of a
foreign substance, the behavior patterns noted by Carnes (1992, 1994b),
Goodman (1993,2001), and others appear to meet the criteria necessary for psy-
chological dependence and withdrawal as noted by the DSM-IV-TR (APA, 2000).

The other primary argument against classifying problematic, compulsive-like
sexual behaviors as addictive concerns the issue of recovery from this disorder
(Apt & Hulbert, 1995; Barth & Kinder, 1987; Levine & Troiden, 1988). The ma-
jority of treatments for addictive disorders call for lifetime abstinence from all
addictive substances, but individuals who are sexually addicted are not expected
to abstain from having sex (Barth & Kinder, 1987; Goodman, 2001; Willenbring,
2000). Apt and Hulbert (1995) claimed,

A person with a sexual addiction is seldom urged to forgo sex entirely. Instead, he or she
is usually encouraged to find other, more appropriate forms of sexual expression. A
person with a drug addiction is cured when he or she gives up the substance; a person
with an addiction to sex is cured when he or she confines his or her sexual activities to
a culturally sanctioned pattern, such as a long-term relationship in which there is emotional
intimacy and sexual reciprocity, (p. 104)

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Apt and Hulbert further contended that the only path to recovery for sexual ad-
diction, similar to chemical addiction, is through total abstinence. Because this
goal is not often the focus of treatment for sexual addiction (Carnes, 1992), op-
ponents to the addictive disorder model discount the addictive nature of sex.

In response to the need for total abstinence as defined by the previously reviewed
research, Goodman (2001) and Willenbring (2000) suggested a closer examina-
tion of the definition and goal of abstinence. Although many of the 12-step fellow-
ships call for total abstinence from all mood-altering drugs, the reality is that many
individuals in recovery routinely ingest substances either for pleasure (e.g., caf-
feine and nicotine) or for mental health purposes (e.g., Prozac for depression).
Goodman (2001) recommended investigating what “functional qualities of unac-
ceptable drugs make them unacceptable” (p. 202). An “unacceptable” drug for a
given individual would therefore be defined by that individual’s propensity to use
that drug addictively (as defined by a failure to control the use of the drug and
continued use despite negative and harmful consequences). Therefore, Goodman’s
(2001) recommended definition for drug abstinence would be “Abstaining from
(not using) any drug that would be likely to be engaged in addictively” (p. 202).
When defined in this manner, abstinence from sexual addiction would involve ab-
staining from any sexual behavior that results in (a) a failure to control that behav-
ior or (b) the continuation of the behavior despite negative consequences. When
abstinence from addictive behavior is understood in this context, lifetime absti-
nence from sexual addiction is more easily understood and attainable.

To conclude the discussion of the addictive disorder, we want to emphasize that not
all compulsive-like sexual behaviors are best explained as addictions. Whereas similar
behaviors can be part of ongoing personality disorders, obsessive/compulsive dis-
orders, sexual paraphilias, or other disorders, the lack of a separate diagnosis for
an addictive disorder (with accompanying criteria) leaves counselors without
relevant and appropriate diagnostic and treatment options.

A Fundamental Understanding of Sexual Addiction

It is imperative that addictions and offender counselors have a fundamental
understanding of sexual addiction. This is especially true for counselors working
with chemically addicted and court-referred clients. First, given that addicted
persons often exchange one addiction for another, and because of the high
comorbidity between chemical and sexual addictions, counselors must be able
to recognize the presence of addictive behaviors (e.g., sexual) and intervene
efficiently. Addictions professionals stand the risk of misdiagnosing clients when
they assume chemical dependency independent of other addictive behaviors
(Manhal-Baugus, 1996). In reality, there may be underlying sexual compul-
sions driving the overt and readily identifiable secondary, chemical addictions
(Peck, 1993). Clients often first acknowledge these secondary, chemical ad-
dictions because such addictions are more socially acceptable than sexual ad-
dictions. Additional reasons for increased professional awareness of sexual
addiction include the comorbidity between psychiatric disorders and sexual

72 Journal of Addictions & Offender Counseling ‘ A p r i l 2005 •Volume 25

addiction and the efficacy of using a sexual addiction recovery model with
incarcerated individuals.

The Relationship Between Chemical and Process Addictions

Several studies have demonstrated the clear relationship between chemical and
process addictions. Das (1990) demonstrated the connection between excessive
drinking, overeating, and compulsive gambling. Merta (2001) noted the
comorbidity of chemical dependency and such behaviors as compulsive eating,
gambling, and compulsive shopping. Rowan and Galasso (2000) showed the con-
nection between gambling and alcoholism, as did Ledgerwood and Downey (2002)
and Potenza et al. (2002). Other studies have discussed cross-addiction in even
greater detail (see Buck & Sales, 2000; O’Brien, 1996; Raviv, 1993).

Griffin-Shelley et al. (1992) studied chemically dependent adolescents admit-
ted to a dual diagnosis inpatient psychiatric hospital. Of the adolescents who
participated in the study, 91 % reported being drug dependent. Of these partici-
pants, 100% reported concurrent nicotine addiction, 87% reported concurrent
relationship dependency, 82% reported concurrent alcohol dependency, 74%
reported concurrent compulsive sexual behaviors, 6 1 % reported concurrent eat-
ing disorders, and 18% reported concurrent compulsive gambling. Although there
are many additional studies that confirm the connection between chemical and
process addictions, the comorbidity of chemical and sexual addiction is of par-
ticular interest in this article.

Carnes (1992) conducted a comprehensive study of individuals who were sexu-
ally addicted and found high rates of comorbidity between sexual addiction and
other addictions. Carnes found in his participant sample that 42% of individuals
who were sexually addicted were also chemically dependent, 38% had a comorbid
eating disorder, 28% had issues with compulsive working, 26% were compulsive
spenders, and 5% were compulsive gamblers. Delmonico and Griffin (1997) iden-
tified comorbid addictions to drugs, spending, eating, and gambling among the
sexually addicted sex offenders whom they studied. Young et al. (1999) surveyed
therapists who had treated clients who had addictive cyber-related disorders and
validated the connection between chemical and sexual addiction by highlighting
the similar statistics, behaviors, and interventions used for both types of addiction.

In a related study. Black et al. (1997) described the sociodemographic, phe-
nomenology, and psychiatric comorbidity of individuals responding to an
advertisement for persons suffering from problems with compulsive sexual
behavior. They found that a high number of participants also had chemical
addictions. These authors also justified the use of the term sexual addiction
and alluded to the complications involved with the psychiatric comorbidity with
this type of addiction.

If one accepts that during their career counselors are likely to encounter a client
struggling with substance abuse, compulsive gambling, or an eating disorder, it
seems practical to equip them with the knowledge and skills necessary to treat these
disorders concurrently. Given that sexual addiction is often comorbid with these
and other addictive disorders, it is not sensible for counselors to be adept at assess-

]ournal of Addictions e, Offender Counseling •April 2005 •Volume 25 73

ing and treating one disorder (e.g., chemical dependency) without understanding
the impact of comorbid disorders. Raviv (1993) concluded that “Psychotherapists
need also to be aware of the phenomenon of multiple addictions and of the fact that
many of their addicted patients are simultaneously addicted to more than one type
of substance and/or dysfunctional behavior pattern” (p. 28).

The Relationship Between Psychiatric Disorders
and Sexual Addiction

In addition to comorbid addictive disorders, sexual addiction is often found in con-
junction with common psychiatric disorders. Many authors (Carnes, 1994a; Manley
& Koehler, 2001; Ragan & Martin, 2000) describe the complications in assessing the
presence of sexual addiction because it is often hidden, intentionally or not, behind
other presenting issues, such as depression, suicide attempts, or anxiety.

Ragan and Martin (2000), in describing the psychobiology of sexual addiction,
noted the psychiatric comorbidity between sexual addiction and disorders such
as depression and anxiety. Delmonico and Griffin (1997) identified feelings of
hopelessness, helplessness, despair, and shame among studied individuals. In
comparing three groups (i.e., sexual addicts, pathological gamblers, and
nonaddicts), Raviv (1993) found that not only were sexual addicts significantly
more anxious, depressed, and obsessive-compulsive than the nonaddict control
group, but they were also significantly more depressed than the pathological
gamblers. Finally, Carnes (1994a) found that sexual addiction often accompa-
nies such disorders as paranoia, depression, suicidal ideations, mania, anxiety,
and obsessive-compulsiveness.

Additional studies that demonstrate common comorbid disorders with sexual
addiction have been mentioned throughout this article. The purpose of highlighting
these connections is the following: If counselors are exposed to these disorders in
their formal graduate training and are not prepared for the possibility of an un-
derlying, exacerbating, or comorbid sexual addiction, treatment outcomes will
likely be affected.

Working With Incarcerated Individuals

Educating counselors about sexual addiction will also assist those who work with
incarcerated individuals, particularly sexual offenders. Several studies (Tays, Earle,
Wells, Murray, & Garrett, 1999) have demonstrated the efficacy of using a sexual
addiction recovery model with sexual offenders. Fischer et al. (1996) conducted
a program evaluation using a pre- and posttest design for counselors who worked
primarily with clients referred from the judicial system. The goals of the pro-
gram were to increase the understanding of the process of sexual addiction, to
differentiate between sexual addicts and sexual offenders, and to describe the
recovery process. The differences in pre- and posttest scores showed a consistent
positive …