Review, Treating Pornography Addiction, by Dr. Kevin Skinner (GrowthClimate, Inc., 2005)
Dr. Kevin Skinner is a licensed marriage and family therapist who specializes in helping people who are struggling with pornography-related problems. His work, Treating Pornography Addiction (GrowthClimate, Inc, 2005) is a summary of the treatment approach he has found most effective. Although he does not mention cognitive-behavioral therapy by name, his approach is clearly informed by this tradition, and is a welcome and much needed application of it.
Am I Addicted?
It is common for people to wonder whether they have an addiction or simply a bad habit. Addiction is defined most simply as any costly behavior repeated due to cravings. More serious addictions have greater costs, more frequent repetition, and stronger cravings.
In the case of pornography, more severe addictions are marked by greater lengths of time more frequently spent viewing more explicit materials, with more time spent fantasizing between viewings, and consequently with greater costs to one’s relationships, work, finances, and so on. Severe addictions also involve greater difficulty in stopping due to less sense of control, and worse withdrawal symptoms when abstinent. If one factors in the moral cost of pornography use, which is always significant and cannot be outweighed by any moral benefit, it becomes clear that any repeated viewing of pornography that is due to cravings would constitute an addiction.
Understanding the Reaction Sequence
Cognitive-behavioral therapy has always assisted patients in understanding the relationship between triggering events and the automatic response in one’s thoughts, emotions, and behaviors. The nature of the automatic response can be healthy or unhealthy. For instance, if one were walking in a corridor at work and a friend passed by without saying hello (a triggering event), one could have the automatic thought: “He must be really busy.” One may feel concerned or curious (emotion), and make a note to ask him later how his work is coming along (behavior). This would be a healthy reaction, and would likely serve to strengthen the friendship, as the behavioral response would favor engaging the friend later.
One could also have the automatic thought, “He didn’t even make eye contact, he must think I’m not worth addressing,” feel sad, and withdraw from attempting to engage this friend in the future.
These are not equal, alternate responses; one response involves an interpretation that is likely more accurate, and leads to positive, goal-oriented behaviors, while the other involves a likely misinterpretation and leads to self-defeating behaviors. Since we do not have direct control over our emotional response, cognitive-behavioral therapy focuses on correcting the automatic cognitive distortions and interrupting the automated behavioral responses.
The same model is easily applied to addictions, and to pornography addiction in particular: one helps the individual to identify and minimize triggers, to refute the distorted thoughts that give permission, and to interrupt the automated behavioral sequence that leads to viewing pornography.
Although people may have a hard time identifying them at first, there is always some trigger preceding pornography use. Triggers can include situations, such as finding oneself alone with access to pornographic materials; or events, such as coming in contact with sensual materials inadvertently; or emotions, such as feeling anxious, bored or lonely.
Triggers are called such because they induce permissive thoughts and cravings. When cravings occur a person experiences a cognitive effect in which his attention constricts onto the object of his cravings, a physiological effect in which his muscles may tense, palms become sweaty, eyes dilate, heart rate increases, etc., and a behavioral effect in which he acts to satisfy the cravings. This cognitive-physiological-behavioral state is called a reaction sequence.
Each person’s reaction sequence is fairly consistent. Indeed, the routine of it can be particularly discouraging, as the same triggers lead to the same responses, and one ends up making exactly the same mistakes.
As a person recovers from an addiction, the main change is not that they are no longer tempted to view pornography, or that they no longer have any cravings. Triggers will still be triggers, even after much work. The difference is that one grows in the ability to deactivate the reaction sequence before automated behaviors take over. As one progresses, triggers that are experienced but not acted upon gradually lose their strength; what once predicted almost 100% that pornography will be used now only predicts the occurrence of some manageable cravings and permissive thoughts.
To make this progress, Skinner advises one to begin by specifying as precisely as possible the behavior one would like to change — for example, “I want to stop viewing all immodest pictures of women.” This specificity helps one to avoid falling into the trap of “settling” for lesser exposures or quibbling with oneself about whether certain materials, such as swimsuit ads, are pornographic.
With the goal clearly set, the next steps are to understand one’s reaction sequence, and then to make a game plan for deescalating it when it next occurs. He suggests the following exercise:
- List common triggers
- List all the thoughts one have that give permission to view pornography
- Describe how the reaction sequence feels, physically and emotionally
Each of these three lists needs to be addressed in turn. See the appendix for forms specific for each list.
Triggers need to be prevented or minimized. This step is crucial in overcoming addictions, and it requires a great deal of determination. If triggers are predictable, one needs to learn to prevent them from occurring. If they are not predictable or if one’s prevention attempts fail, then one needs to practice interrupting the reaction sequence they’ve triggered.
Preventing triggers means having clear boundaries and rules. For instance, if a person knows that having unrestricted access to the Internet in a secluded location is a trigger, then one can prevent the trigger by keeping one’s door open and having the computer screen be visible to all who walk by.
If one knows that having large amounts of free time is a trigger, one may need to take a quick look at one’s schedule each morning to spot where the difficulties will likely arise, and then make plans for how to make the best use of time.
If coming in contact with sensual images inadvertently is a trigger, one can use TiVo to bypass commercials, use screenit.com to vet movies before watching them, use an email service that does a better job filtered out porn-spam (Gmail is much better than Yahoo!), and install a filter on one’s computer to prevent missteps.
Filters provide real help to the addicted by preventing inadvertent exposure to sensual materials. They have an important role to play, but this role is quite limited: they are an unable to thwart deliberate attempts at viewing pornography, and in some cases their prohibitions act as triggers for an automated response in which a person tries to get around them just to see if he can.
Filters are most useful in less severe cases, and almost useless in severe ones. In some cases they may help prevent problems from starting or intensifying; in others they may be less helpful, providing a false sense of security and fostering an excessive focus on controlling external factors rather than developing internal strengths.
The more one works at knowing triggers and foreseeing them, the more one can practice ways of preventing and minimizing them. Writing out each trigger on a list, and adding to the list after any lapse, helps to ensure that one concretely addresses ways of preventing it and of managing it should it still occur. If one cannot think of a specific trigger, one should write down the situation one was in when one first became aware of having cravings and permissive thoughts.
Permissive thoughts occur automatically after exposure to a trigger. Skinner emphasizes the role these thoughts play, and highlights the opportunity they provide for effectively interrupting the sequence. He provides the following example:
“One more time won’t hurt.”
“I have been saying this for many years now and it is never just one more time. What are the outcomes of telling myself that one more time won’t hurt? I give in and feel bad. Then, because I have given in again, I binge for a few days and feel like all is helpless. … The truth is, one more time will hurt and I will have to start the recovery process over if I allow this thought to stay in my mind.” (p. 62)
The power of permissive thoughts to direct behavior is derived from how certain they appear. Just after experiencing a trigger, the thought, “One more time won’t hurt anyone” may appear to be completely true. If one had been tracking this thought for an interval before the trigger, however, one may see that it hadn’t appeared true at all. This change in belief is referred to as a thought “getting activated,” and it is accompanied by a swing in emotions – in this case, an upsurge in desires. If one works on these thoughts beforehand by writing out all the evidence in support of a rational, alternate response, one minimizes this activation, “anchoring” the permissive thoughts in the deactivated position.
Cognitive therapists have found that people being vaguely aware of distorted or permissive thoughts and their refutations is not as helpful as having people actively practice – best, in writing – the formulation of the permissive thoughts and their convincing refutation. Making a list of these thoughts and their responses is a good start. It may also be helpful to have each thought written on a notecard, with its refutation on the back; then, if one foresees a time when these beliefs may activate, one forestalls them by practicing their refutations in advance.
The Reaction Sequence in the Body
The third list one should make concerns how the reaction sequence feels as one experiences it. The list should include both physical sensations (e.g., increased heart rate, sweaty palms, other signs of arousal) and emotions (e.g., curiosity, excitement, despair).
One needs to become expert in detecting and interrupting the reaction sequence. By learning to judge where they are in the reaction sequence, people learn to judge for themselves what level of response is needed to counteract it. When the sequence has just begun, milder forms of distraction may suffice to turn it off: putting oneself into one’s work, a brief moment of prayer, reviewing the refutation of permissive thoughts, and so on. As it advances, more engaging efforts are needed. An excellent guide to these advanced strategies is Arthur Horvath’s book Sex, Drugs, Gambling & Chocolate, in the chapters where he discusses coping with cravings.
Overcoming Automated Behaviors
The concept of the self-intensifying reaction sequence helps to highlight that, as a result of repetition, actions surrounding pornography use become increasingly automated. Faced with this automation people can lose their sense of freedom and feel that they are at the mercy of their triggers.
The passivity of automation is like a plane being on autopilot. After experiencing a trigger and the consequent physiologic changes, the person “ends up” in a secluded place, then “ends up” getting on the computer, and then gets on the Internet, and then – predictably – “ends up” viewing pornography. Throughout the whole sequence he can feel that he never made a deliberate choice to view pornography, but that it “just happened.” As it keeps “just happening,” the frustration and discouragement intensify.
When people addicted to pornography seek support from others, much of this passivity still remains. They may hold themselves accountable and describe what “happened,” and express shame and regret. This accountability may have some benefits, but in order for it to be effective it has to address the passivity that lies at the core of the automated behaviors.
More than accountability, what is needed is active foresight – the prudence needed to foresee upcoming triggers and likely responses, and develop ways of breaking the patterns. Lapses reveal gaps in one’s preparation, and foresight makes use of this information to actively prepare for the next struggle.
One of the most advanced uses of foresight is to perform what Skinner calls “fire drills.” The drills consist of rehearsing predictable situations in one’s imagination, making use of knowledge of likely triggers, permissive thoughts and the stages of the reaction sequence to come up with alternate responses. One works out how one will interrupt the reaction sequence should certain triggers occur, and also how to answer the permissive thoughts that will likely come to mind.
Rehearsing conditions automated responses, a fact that can work for or against people struggling with pornography addiction. If they allow themselves to fantasize about getting on the Internet when alone later in the evening, they have unwittingly rehearsed the event, facilitating the automatic response that will occur later when they are alone in the evening. Conversely, when they foresee difficulties and come up with ways of interrupting the reaction sequence in advance, they facilitate the prudent response. In effect, foresight provides an alternate repertoire of automated responses.
An example of such a game plan would be:
THOUGHTS JUST STARTED (EARLY IN REACTION SEQUENCE)
Put myself in presence of God, ask for help, and then try to make my time as productive as I can; set demanding goals to work faster (e.g. read twenty pages in next ten minutes)
(Prayer & productivity)
THOUGHTS MORE PERSISTENT, MORE INTERFERING (MIDDLE OF REACTION SEQUENCE)
Read reasons to NOT give in (written beforehand)
Make a phone call.
Change locations to one more public, or open office door.
THOUGHTS VERY PERSISTENT, GETTING TUNNEL VISION, DECISION WAVERING (ADVANCED REACTION)
Stop working completely.
Go for an intense walk or run.
Take cold shower.
(More engrossing distractions)
Skinner provides a sample dialogue from a therapy session to show how one can use these sessions to do a fire drill (see Appendix A). What is important, whether or not one has a therapist, is to learn: 1) to foresee predictable triggers, and then minimize them; 2) to foresee predictable permissive thoughts, and practice refuting them; and 3) to foresee how the reaction sequence would progress, and decide on a game plan for interrupting it.
By minimizing triggers, refuting permissive thoughts and learning to interrupt the reaction sequence, one can effectively gain mastery over what had seemed an insoluble problem. Should any lapses occur, one should strive to learn as much as possible from them. The following list of questions are worth examining carefully:
- What was the trigger?
- How predictable was it?
- How can I prevent it in the future?
- What can I do if it occurs again?
- What new permissive thoughts did I have?
- How can I practice more effective refutations?
- When was the earliest time the reaction sequence was detectible?
- What can I do in the future to interrupt it at the earliest moment?
- What symptoms of the sequence can I use as markers to step up my planned response?
Other general questions
- Was I becoming more secretive before the lapse? How?
- Have I been isolating myself from others?
- Are there any conflicts with others that I am not addressing squarely?
- Are there any emotions or emotional issues I have been avoiding?
- Am I living with the purpose of experiencing thrills?
- Did I make a real effort to prepare myself for future challenges before this lapse occurred?
- Had I been experiencing any symptoms of withdrawal?
This last question may be especially helpful. The word “addiction” is not used lightly when dealing with chronic impulsive pornography use. In all of its psychological aspects, pornography addiction functions in an individual’s life in exactly the same way as a drug addiction. When one is making progress and is refraining from viewing pornography, one will likely experience some symptoms of withdrawal. These common, but commonly overlooked, symptoms include depression, anxiety, insomnia, restlessness, fatigue, dizziness, body aches, headaches, and irritability.
How quickly the withdrawal reaction sets in, and how long it lasts, will vary from person to person. As a general rule, Skinner suggests these symptoms may be present from two weeks to two months from the time they began.
Although they are signs of progress, withdrawal symptoms are, by their very nature, also triggers for relapse, and so should be dealt with in the same way as all unpreventable triggers: they should be minimized as much as possible. Most of the symptoms can be managed with increased cardiovascular exercise (daily, if possible), proper diet (minimizing alcohol and caffeine), and regularly getting seven to eight hours of sleep. Fortunately all withdrawal symptoms eventually go away, and in the majority of cases they are noticeable but mild.
Overall, the book Treating Pornography Addiction provides excellent guidelines for helping people to stop viewing pornography. The author relies upon a proven theoretical framework, and presents the ideas clearly and briefly. The text is not altogether free of trite phrases and clichés, but these need not derail one.
One of the most helpful reviews of this book on Amazon is by a therapist named Lew Mills, who takes Skinner to task for his “moralistic tone.” Mills writes,
“There is not an acknowledgement of an appropriate role for erotica or sexual fantasy in a person’s life. Sexual fantasy itself seems to be on trial, from a moralist’s vantage point. One of the criticisms of pornography is that it erodes the spiritual life. Although that perspective could be important for many people, some will find that less relevant or even an obstacle. Another common problem caused by pornography addiction is the shame that usually accompanies it. But this book does nothing to address the negative attitudes about healthy sexuality that fuel that shame. In fact it could indirectly support those negative attitudes.”
Many therapists no doubt would echo Mills’ concerns. But for other therapists, these complaints are an accolade for Treating Pornography Addiction. Skinner does not think erotica has a healthy place in anyone’s life? He does not think that sexual fantasizing does one any good, and even suggests it does harm? He even suggests the same about other solitary sexual acts? If these questions are shocking to anyone, it is only because they underestimate the moral cost of these behaviors, a cost so high that even were the benefits real, they would never outweigh it.
Those who appreciate the costs of these behaviors – morally, financially, emotionally, functionally, etc. – will have no hesitation in recommending this text to those caught in pornography addiction.
Developing Foresight in Therapy
In the chapter, “Changing for Good,” Skinner provides a dialogue between a therapist and client in which the therapist helps the client develop foresight:
Under what circumstances are you most likely to view pornography?
I generally view pornography late at night when everyone else is asleep. I am tired and am just aimlessly surfing the web.
If you are going to look at pornography, is that the way it is most likely to occur? Could you give me a percentage?
I would say that this is the scenario seventy-five percent of the time.
So if we were to change this pattern do you think you would find more success in not viewing pornography? Or do you think you would find other times to view it?
I think it would reduce how much I look at pornography. I think it would help a lot.
Okay then, let’s put you in that very same circumstance right now. When does the first idea of looking at pornography come into your mind?
If I am honest with myself it starts when I am watching television. It often starts by seeing a commercial or something else that is sexual in nature.
So would you say this is the stimulus that gets you started?
Okay, what happens next?
I get pretty excited thinking about viewing pornography so I go up to my room under the guise that I am going to check my email. If no one else is around or I think that I can find something without anyone knowing, I will quickly check my email and then start looking for something pornographic in nature. …
I want you to imagine that you are up watching television. Across the screen comes a sexual scene. The thought comes to you to go and find something pornographic on your computer. The feeling is extremely powerful and you start to feel the chemical rush because you haven’t viewed pornography for two weeks. What will you do?
Under this circumstance I must first recognize that I am being challenged. I need to admit to myself that I am feeling like viewing pornography. Next I need to either go and talk with someone else, which is part of my game plan, or I need to think through what the outcome would be if I give in and look at pornography.
What would keep you from taking these steps?
When I relapse it is because I don’t think of these things until I am on my computer.
So let’s suppose you ignore the early signs… You have just checked your email and now you catch yourself at Yahoo. What will you do?
This is harder because I am already feeling the chemical rush. Under these circumstances I have realized that I have to turn off the computer. Next, I have agreed to call someone else because I know I cannot fight it alone when the chemicals are that strong inside of me. If I cannot call because it is too late, I am going to sit down and write in my journal about what I am feeling. I will write until I have come up with a solution other than viewing pornography (pp. 87-89).