Insight: Problematic Sexual Behaviour

In conversation with Carl Mojta, we aim to explore the key insights of working with problematic sexual behaviour by integrating Internal Family Systems (IFS) with the Out of Control Sexual Behaviour (OCSB) pathway model. Carl Mojta and Peg Hurley Dawson have contributed a chapter titled “Treating Problematic Sexual Behaviour with Internal Family Systems Viewed Through a Polyvagal Lens” in the upcoming publication of The Routledge International Handbook of Sexual Compulsivity and Clinical Sexology.

Carl is Registered Member of COSRT and an Accredited member of the BACP as well as a U.S. licensed marriage and family therapist, an American Association of Sexuality Educators, Counselors and Therapists (AASECT) Certified Sex Therapist and Supervisor and a Certified Internal Family Systems (IFS) Therapist and Approved Clinical Consultant. For almost a decade, he worked at the

U.S. Department of Veterans Affairs where he held leadership positions and provided clinical care to military veterans and their families, focusing on treating PTSD. He currently runs a private online psychotherapy practice in the Washington, DC area, specializing in sexual health and also sees clients in the UK. He is pursuing a doctorate in counselor education and supervision at James Madison University, Virginia, USA.

COSRT: How did you come to combine Internal Family Systems (IFS) in your approach to treating Out of Control Sexual Behaviour (OCSB)?

CM: I have been Integrating IFS into my OCSB approach for the past nine years. I was first introduced to IFS when I was a graduate student and took my Level I IFS training in 2009. It was also during my graduate programme that

I became interested in learning more about sexual health, but I knew – almost intuitively - that my values and beliefs did not align with the sex addiction model, given that sexual health is not an underpinning of this approach. I had the privilege of meeting Doug Braun-Harvey, one of the co-authors of “Treating

Out of Control Sexual Behaviour: Rethinking Sex Addiction,” at an AASECT Conference in Puerto Rico in 2016 and this conversation sparked my curiosity to deepen my understanding of how to treat problematic sexual behaviour from a non-pathologizing, sexual health perspective. What felt like a whim, but was actually due to a lot of enthusiasm, I travelled to London in 2017 to attend my first formal OCSB workshop, sponsored by Pink Therapy, featuring Doug as the guest presenter. I have been consulting with him on a regular basis ever since our first meeting in 2016.

COSRT: Why do you think Internal Family Systems (IFS) and Out of Control Sexual Behaviour (OCSB) complement each other so well to treat problematic sexual behaviour?

CM: IFS melds two major concepts: multiplicity of parts (and we all have many parts), and systems thinking into a salutogenic approach that integrates mental, physical and spiritual health. In the U.S., IFS therapy is considered to be an evidence based model that is rated effective on the National Registry of Evidence-based Programs and Practices (NREPP) by the Substance

Abuse and Mental Health Administration (SAMHSA). Although there are several IFS therapists, e.g. Nancy Wonder and Lawrence Rosenberg, who have written on this topic of compulsive sexual behaviour and bring this into their sex therapy, IFS is not widely used as a way to treat sexual health concerns. OCSB, on the other hand, is a sexual health based clinical pathway model to provide psychotherapy treatment to address problematic sexual behaviour. Simply put, the OCSB model is a sexual health model that creates a balance between sexual safety and sexual pleasure while ensuring sexual rights. A key part of the initial assessment process includes a client being able to identify or notice that a client is feeling out of control rather than the clinician immediately imposing a clinical diagnosis. I think this is an incredibly important distinction, because both IFS and OCSB are nonpathologizing and provide safety for clients by not having a diagnosis driven (medical) model. I want to note that because there is not sufficient empirical evidence to support sex addition or porn addiction as a mental health disorder, neither the DSM-V nor the ICD-11 provide a sex/ porn addiction diagnosis category.

The most amazing part of this journey with Roger was helping him identify and unburden the exiled part that carried the belief that he was ‘unloveable.’

COSRT: How do you create a sense of safety within the therapeutic relationship, particularly with clients who are struggling with problematic sexual behaviour?

CM: I think the most important part to creating safety is to ensure that I am able to suspend my judgement and perhaps most importantly that I am able to be attuned to my clients’ sexual shame. Sexual shame is a universal phenomenon and pervasive across all cultures and societies. It takes a lot of courage for clients to make the first step to come and talk about a problem that has caused so much pain, resulting in a negative self-evaluation of sexual identity, thoughts, desires, expressions and behaviours. I try to hold an honoring space to witness the part that carries the belief around sexual shame with compassion and empathy as part of the unburdening and healing process. Once clients know that they are safe to talk about a painful behaviour without fear of judgment and further shaming, this is when a shift can begin to occur moving away from a problematic sexual behaviour to creating a sexual health vision.

COSRT: Regarding your book chapter which includes a case study of a 34 year old male client - how did an IFS informed OCSB approach help you client to address his problematic sexual behaviour?

CM: To ensure client confidentiality, ‘Roger’ is a composite of several clients who have sought OCSB treatment with me over the years. Working with problematic sexual behaviour means from an IFS approach that we are getting to know a client’s firefighter part, which is a protector part reacting to a feeling or thought, that tries to distract from a part (or parts) that have been wounded or exploited and carry shame, guilt and/or worthlessness. Clients often respond well when there is a separation between a perspective that this is not who I am, but rather this is just a part of me. I have also found that the term ‘firefighter’ is often a welcomed term by clients’ internal system as they start to notice that this is often a good descriptor for how it feels to douse the pain they are experiencing. Another important part of the OCSB protocol is to assess a client’s motivation for change, so assessing motivated parts is critical, while also knowing that there are polarized parts that may not be ready or willing to change the firefighter behaviour. In the case study,‘Roger’ was very motivated for change, given the external stressors he was experiencing, most noticeably the negative impact it was having on his intimate relationship.

I would add that having a Sexual Health Plan (SHP), which is a core feature of the OCSB model, is helpful for clients’ parts to feel accountable to their commitment to change. The SHP is comprised of three components:

Boundaries: behaviours that a client is ready to change; Ambivalence: behaviours that are not ready to be changed; and Health: client sexual and nonsexual behaviours that contribute to and support sexual health behaviour changes (Braun-Harvey & Vigorito, 2016). Once this plan is developed, this becomes the client’s roadmap for recovery and a new healthy vision for their life.

The most amazing part of this journey with Roger was helping him identify and unburden the exiled part that carried the belief that he was ‘unloveable.’ When this happened, the firefighter part was freed from its many years of service to distract and self-soothe Roger from this pain.

COSRT: What developments would you like to see in research or clinical practice regarding IFS and the treatment of OCSB?

CM: Because of my doctoral studies, I’m thinking a lot about research ideas and topics to advance the sexual health and counselling fields. One topic that immediately comes to my mind is to examine what and whether there are differences between Sex Addiction groups and OCSB groups on the reduction of problematic sexual behaviours. Another topic that I think would be incredibly interesting would be to explore the effect of different theoretical models, e.g. IFS, Narrative, CBT, etc. used in OCSB therapy and the influence on treatment outcomes. I would also be excited to see more multiculturally informed research conducted in general, but particularly regarding OCSB, especially from an international perspective, to understand the effectiveness of this treatment on a global scale.

What’s exciting is that there are an infinite number of research topics that could be explored on OCSB and IFS together or separately from a sexual health perspective. The ultimate question is which one to start with – and who wants to collaborate on this research? I hope that is an open ended invitation.

Braun-Harvey, D., & Vigorito, M. A. (2016). Treating out of control sexual behaviour: Rethinking sex addiction. Springer Publishing Company.

Schwartz, R. C., & Sweezy, M. (2020). Internal family systems therapy (2nd ed.). The Guilford Press.