By Robert Weiss, LCSW,CSAT-S

Flawed, Defective, Unworthy of Love and Happiness

It’s no great secret that most alcoholics, drug addicts, and behavioral addicts live with deeply felt feelings of shame.

In fact, shame is nearly always part of the underlying matrix of psychological conditions that can typically lead to addiction. Shame leads to extreme emotional discomfort and the gnawing belief that one is inherently flawed, defective, and unworthy of love. These feelings can in turn lead to depression, severe anxiety, and lifelong challenges with intimacy and relationships. And all of the above can create a powerful desire to escape and dissociate via the use of addictive substances and/or behaviors. Over time, a pattern of self-medicating life stressors and emotional discomfort can easily escalate to full-fledged addiction, with all of the usual negative life consequences.

Healthy Shame, Toxic Shame and Guilt

Over the past few decades, numerous clinical writers have developed the concepts of healthy shame — the feeling a person gets when he or she has done something that goes against his or her belief system — and toxic shame — the belief that one is inherently flawed, bad, and/or defective. More recently, Dr. Brené Brown has re-labeled what most therapists have been calling healthy shame as what it actually is, which is guilt, and toxic shame as just plain old shame. Guilt is useful motivation for positive behavior change, whereas as shame is self-defeating and depression/anxiety producing. I bring up this distinction now for two reasons:
I strongly prefer Dr. Brown’s newer and more descriptive terminology (much less shaming, is it not?)
I want to make it clear that when I use the term shame in this article, I am referring to what many readers may currently think of as toxic shame.

The Mystery of Sexual Shame

Most addiction treatment specialists are relatively in-tune with the general connection between shame and addiction. What often goes unrecognized, however, is the powerful role that sexual shame and adult romantic/sexual behaviors often play when it comes to addiction. For starters, sexual shame is among the most powerful and devastatingly painful forms of shame. As Patrick Carnes has often said, “sexual secrets are often the cause of our greatest emotional shame, yet they are the secrets we are least likely to reveal.”
Sexual shame often forms in childhood, most often as the result of early sexual trauma (overt, covert, or even societal) coupled with emotional abuse/neglect. Many sexually shamed children begin to self-medicate these painful feelings relatively early in life, usually during adolescence and sometimes even before. (Body image issues, shame about being looked at and/or touched inappropriately, and feeling icky about too much trust and affection can all begin very early in childhood.) 
For the luckless kids in these and similar family-attachment situations, the process of self-medicating typically involves alcohol and/or either prescription or illicit drugs. That said, many such children also learn that they can self-soothe with sexual behaviors (including sexual fantasy and masturbation), usually by eroticizing and reenacting their sexual shame — which, unfortunately, exacerbates their preexisting sexual shame, creating an even deeper sense of emotional discomfort and a more powerful need/desire to escape and dissociate.
Sadly, the early childhood survival practice of using drugs and/or sexual arousal to self-soothe the pain of early-life sexual trauma typically carries forward into adulthood, making long-term sobriety incredibly difficult. 
At Elements Behavioral Health facilities, especially in the multiple programs I’ve created with an emphasis on bringing intimacy and sexuality into the addiction treatment conversation, we see this all the time. In these programs, shame-based adult clients typically enter treatment for substance abuse or a behavioral addiction with an extensive history of relapse that is directly tied to their hidden unaddressed sexual shame. Very often, these clients are actively engaging in adult sexual behaviors that either mirror their early-life sexual trauma or violate their moral code. When this occurs, of course, their preexisting sexual shame grows worse, new sexual shame forms, and the desire for self-medication increases.
For some sexually shamed addicts, substance abuse and adult sexual behaviors can fuse into a single co-occurring addiction. In such cases, substance addiction and sexual behaviors continually reinforce one another, creating over time a surefire paired trigger for relapse. Usually in these cases the primary substance of abuse is a stimulant like cocaine or crystal meth, as these drugs allow users to simultaneously stay high and be sexual for hours or even days at a time. Men with this dual issue may also abuse Viagra, Cialis, Levitra, and other erection-enhancing drugs for rather obvious reasons. And both genders can abuse benzodiazepines and similar “downers” as a way to relax and get some sleep when the party finally ends. Once again, when this behavior occurs the client’s preexisting sexual shame grows worse, new sexual shame forms, and the desire for self-medication increases.

Effectively Addressing Sex, Sexual Shame, and Addiction

It has become increasingly clear to me over the years, as I work to evolve both substance abuse and intimacy disorders treatment, that past/current/future challenges with sexual shame, emotional intimacy, and adult sexuality must often be treated in concert with addiction — rather than just assuming that the establishment of chemical sobriety will also clear up a client’s shame-related devastation. This means that in order to achieve lasting sobriety when sexual shame is driving and/or triggering the addiction, adult sexual behavior patterns (addictive or not) must be dealt with concurrently and in an integrated manner. Without treatment for both the addiction and the sexual shame/behaviors, many people may not heal from either issue.
In a way, this is a novel approach to addiction treatment. In fact, very few substance abuse or behavioral addiction treatment centers are currently equipped for this duality of work, notable exceptions being the Substance Abuse and Intimacy Disorders Program at Promises, Malibu (for men) and The Center for Relationship and Sexual Recovery at The Ranch in Tennessee (for women). The clients being treated at these facilities often report histories of isolation and broken relationships in addition to the usual health and life-productivity losses that naturally occur with all forms of addiction. Mostly, though, they report lengthy histories of relapse, with those relapses nearly always tied to their unaddressed sexual shame.
For the most part, effective treatment of men and women whose substance and/or behavioral addictions are deeply integrated with sexual shame (and shame-based adult sexual behaviors) parallels that of effective addiction treatment in general – primarily cognitive behavioral therapy coupled with group therapy, social learning, and 12-step work – but with the added element of a deeper than usual examination of the individual’s sexual shame, sexual history, and current-day sex and relationship patterns. I cannot stress strongly enough the need for sexual shame and sexual secrets to be discovered and addressed as quickly as possible, as talking about sexual shame is the key to defeating it. In addition, effective treatment includes education about the ways in which sexually shamed clients might be able to be sexual in the future without reinforcing preexisting sexual shame or creating new sexual shame. In fact, the concept of healthy sex in sobriety should always be an integral portion of relapse prevention work with sexually shamed addicts.
In sum, the key to lasting sobriety for many addicts is recognizing the role that sexual shame plays in the formation and maintenance of their additions. As such, when sexual shame is uncovered it must be dealt with quickly and effectively, usually by sharing about sexually shaming events with an empathetic and supportive therapist and/or a similarly traumatized therapy group. Simply put, when sexually shamed addicts share about their pasts – the experiences that cause them to feel defective, unworthy, and unlovable right now – even long after their sexually shaming events occurred, their stress levels decrease and their overall mental and physical health improves, greatly increasing their odds of lasting sobriety (no matter their primary addiction).
Robert Weiss LCSW, CSAT-S is Senior Vice President of Clinical Development with Elements Behavioral Health. A licensed UCLA MSW graduate and personal trainee of Dr. Patrick Carnes, he founded The Sexual Recovery Institute in Los Angeles in 1995. He is author ofCruise Control: Understanding Sex Addiction in Gay Men and Sex Addiction 101: A Basic Guide to Healing from Sex, Porn, and Love Addiction, and co-author with Dr. Jennifer Schneider of bothUntangling the Web: Sex, Porn, and Fantasy Obsession in the Internet Age and the upcoming 2013 release, Closer Together, Further Apart: The Effect of Technology and the Internet on Parenting, Work, and Relationships, along with numerous peer-reviewed articles and chapters.