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Kenneth Rosenberg talks about the cultural determinants of behavioural addictions, the importance of ...
2020-03-02 09:00:00

Sex and Other Drugs
An Interview with Kenneth Rosenberg

“Embrace (Lovers II)”, Egon Schiele, 1917. From Österreichische Galerie Belvedere
Sex and Other Drugs
Sex and Other Drugs

What determines how good or bad, treatable or untreatable, a mental illness is, has a whole lot to do with the subculture in which you function – your family, your friends, your doctor. Marcin Moskalewicz talks with Kenneth Paul Rosenberg, a psychiatrist and documentarian.

Read in 17 minutes

Kenneth Rosenberg’s latest documentary, Bedlam: An Intimate Journey Into America’s Mental Health, premiered this year at Sundance Film Festival. It received a standing ovation. The story boggles the mind. The biggest ‘mental health institutions’ in the US are currently prisons. 40 million Americans experience mental illness each year. 15 million suffer its severe types, and over 300,000 are homeless. Rosenberg claims that the most visible symptoms of mental illness in the US are troubles with the law and lack of shelter. It is America’s greatest secret. The state is to blame, Rosenberg says, for throughout the last half-century, it has continuously withdrawn financial support from mental health services, investing instead in prisons. Rosenberg knows what he is talking about. He is a practicing psychiatrist.

Rosenberg specializes in behavioural addictions. These are, perhaps, as old as the hills, but only recently have received due attention. What once seemed an innocent search for pleasure or entrainment is now regarded as destructive. As the 2014 book, Behavioral Addictions: Criteria, Evidence, and Treatment (co-edited by Rosenberg) shows, one can get addicted not only to gambling, computer games and Facebook, but also to shopping or love. The most potent drug, however, is sex.  

In his Infidelity: Why Men and Women Cheat, published last year, Rosenberg argues that sex is a primordial and foundational addiction. It has a biological basis. The brains of those who compulsively search for sexual gratification require more dopamine than usual to reach the same pleasure effect. Should we then judge them differently for being unfaithful?

The average American teenager watches 50 porn clips a week, half of those in relationships and one in five marriages are adulterous. Men used to cheat more often, but now we have gender equality. In America, the land of excess consumption and a puritan lifestyle, sex is both a taboo and the most desired commodity.

Marcin Moskalewicz: Behavioural addictions are in fashion. All of a sudden, you can get addicted to anything: compulsive buying, tanning, Facebook, sex. How are these different from chemical dependencies?

Kenneth Rosenberg: Chemical addictions are addictions to substances. Behavioural addictions are addictions to behaviours. In the US, we call them process addictions. I was trained at Cornell Medical Center in New York by wonderful teachers on the faculty in the late 1980s. One was an addiction expert, Robert Millman, and the other was a sexual disorders person named Helen Singer Kaplan. One taught me about chemical addictions, the other taught me about sex. But they both had one thing in common – they both agreed that there was no such thing as sex addiction. For the longest time, professionals, as well as the public, felt that addiction to behaviours is nonsense. But I think it is nonsense that behaviours can’t be addictive.

So you can get addicted to gambling or sex. But the gap remains?

The recent changes in the lexicon of psychiatry helped to bridge the gap enormously. In the new diagnostic manual, DSM-5, the American Psychiatric Association (APA) decided that addictions were not based upon chemical dependency and chemical tolerance. When you, for example, drink six glasses of wine every evening, and you do that for six months and then stop immediately, you will develop withdrawal symptoms. Your brain will now become dependent. If you abuse alcohol, have anxiety and drink six glasses of wine every evening, after six months it won’t do anything for you because you have developed tolerance. What helped you six months ago is no longer helpful. These two things – addiction and tolerance – are pathognomonic, meaning characteristic and defining of chemical addictions. However, with DSM-5, this conception became a thing of the past.

We now define addiction by the fact that you have this irrational exuberance, which is doing you no good. It essentially hijacks your reward centres – the part of you that releases dopamine, your brain’s reward chemical, which makes you high – and it hijacks your frontal lobes (or your reasoning centre). It is a different kind of definition. Addiction is now defined by the process of how your brain functions, how your reward centres and reasoning centres were corrupted or hijacked. That opened the way to talk about behavioural addictions. You can now, using the nomenclature of psychiatry, say that a behaviour can be addictive. There is one behaviour that is not controversial in terms of addictive qualities whatsoever – that’s gambling. It’s part of the addictive disorders. Sex addiction was not chosen as an addiction, nor was internet addiction.

Is the APA’s official storyline about the lack of evidence and the difficulty in distinguishing high sex drive from pathological behaviours convincing? Or are there some other reasons?

Honestly, I think it was the right decision, even if many of my peers objected. You need a lot more data to call it an addiction. The workforce group didn’t look at it as an addiction disorder, they looked at it as a hypersexual disorder. When it comes to anything sexual, the APA has to be very careful, because they have made some egregious errors in the past. They called homosexuality a disease. So it is good to be circumspective. The consensus in psychiatry is scientific, but it is also very political and maybe can even be seen as economically driven. Often, there are a lot of social factors at play. More recently, the World Health Organization (WHO) put together a new classification system, the ICD-11, and they said sex could be addictive. Thus it became a disorder, except they don’t call it sex addiction – they call it compulsive sexual behaviour disorder.

The issue, of course, is that they didn’t put it under addictions, but under impulse control disorders, so many specialists considered it a rather conservative take.

When a patient comes to me and asks, “Am I a sex addict?” I say: “Look, if you prefer the word compulsive, that’s fine, if you prefer the word impulsive, that’s fine.” These are just human-made terms that dramatically shift every 5 to 10 years. Scientists need to have nosological inquiries, but from the patient’s point of view, there’s no reason to get hung up on and argue about terms – compulsion, impulse disorder, or addiction. Thinking about it from the patients’ perspective, what is important is that they are drawn into something excessive and harmful. And the treatment paradigm, whether you call it a compulsive disorder, an impulsive disorder or an addiction, is an addiction paradigm. That’s what counts! And all the treatments you would apply to any addiction, including the 12-step programme, you will apply to the disease of these impulsive and compulsive behaviours.

Sure, the ‘Twelve Steps’ was developed by Alcoholics Anonymous, and Sexaholics Anonymous, among others, apply it. But there must be some difference between alcohol and sex.

Sex is a primordial addiction. As I show in my book Infidelity, scientific research indicates that the brain did not develop to be addicted to opiates or cocaine, it developed to be addicted or obsessed, if you prefer, to those things that are crucial for our survival. That’s food and sex. Without them, we can’t survive. Our brains require us to have this irrational exuberance for another person. We also have a sometimes contradictory drive to bond and rear a child. These processes are driven by evolution.

In your book, you call this a conflict of reproductive strategies, two often contradictory drives. It reminds me of your patient, a devoted husband and father who is so entrapped by any single thought about sex that relief can only be brought about through masturbation, which takes place even at work. This leads to suffering, of course.

It is a desire to procreate, even when it is not in our best interest.

What about the cultural aspects? When a European watches an American movie, he finds the fear of bare breasts almost comical. And when he visits the US, he is struck by Victorian prudery. Does the American attitude towards sex play any role in the escalation of infidelity?

We have a very compartmentalized and binary view of sex, as well as fidelity and infidelity. It is much less accepted for men and women to have an affair than in Europe. We are much less fluid. When something is forbidden, it is not less, but more desirable. It just makes you go underground and search for something that’s even more exciting. When I think of America’s black-and-white attitude about sex and fidelity, President Clinton comes to mind. The terrible thing he did was his exploitation of power against an intern. But in terms of a person having an affair, having a mistress, I don’t condone it, but it happens.

This lack of understanding and forgiveness present in American culture does not help the problem of sexual compulsivity. It creates incredible anger and guilt. Another aspect is American pornography, which I think can be very addictive. I imagine it is our biggest export, frankly. It’s pretty insane.

One of your patients, described in the book, can’t stop watching porn, and eventually he destroys his laptop with a hammer.

Pornography functions best in a society where it is forbidden. American pornography thrives on salacious and misogynistic images. Men will often watch porn late at night when their wives are asleep. A binary view of sex does not help to fight compulsions. At the same time, once people do develop a compulsion, it is just like with an alcoholic. There are very strict guidelines, and you must be binary. You can’t say to an alcoholic: “Well, just have two drinks.”  

How do you react to the popular argument that you can do without alcohol, you can do without gambling, but you cannot do without food and sex? Many people seem to think that precisely due to evolutionary reasons, being addicted to sex is absurd. Total abstinence is impossible.  

Food addiction is about hedonic foods - you eat carbs, you eat sugars, you eat things that make you feel starving after two hours. Sex addiction is not about having a lot of great sex with your partner. We are not talking about people who have tons and tons of happy and healthy sex with their partners. We are talking about people who have rather dysfunctional sex. Their sex life with their partners is pretty abysmal. It’s common for a sex addict to have zero sex with their partner, but they might only have fetishistic and peculiar extramarital sexual relationships with other folks and pray to God to never do it again.

But sex is beautiful! The more sex you can have, the better! But you want to make it volitional and conscious. Some people have extreme sexual prohibition and find nearly any kind of sexual activity to be unacceptable, but most people enjoy sex. Yet, wisely, they don’t want to be doing something that is getting them in trouble and destroying their lives. Both men and women come to me because they are caught up in something like that – sexual activities that they don’t want to be doing. Getting back to your question, you can’t do without food, and most people need sex, but you certainly can live without the excess of carbs and sugars of hedonic foods and, likewise, without disturbing sexual behaviours. My goal is for my patients to have great sex in whatever way they want it. If they want a polyamorous relationship, go for it, I am not the person to judge them or tell them what they should do. I am just here to help them not do what is self-destructive – what they have identified as against their mores or ideals.

Americans probably consume more medicines than any other world population. We keep hearing about the opiate crisis and its victims. How, in this context, does the pharmacological treatment of behavioural addictions look in the US?

Unfortunately, big pharmaceutical companies have pulled out of neuropsychiatric disorders in general, particularly schizophrenia, bipolar disorder and depression. I know that the popular sentiment is that pharmaceutical companies are creating diseases so that they can make money, and I understand that point of view, but to me, the more disturbing concern is that the industry is not interested in psychopharmacology. It is very glib and perhaps even politically correct to say that psychiatrists, together with pharmaceutical companies, are trying to capitalize on the suffering of others and turn normality into pathology. But I don’t think it’s the case.

There is good use of medications for people who have behavioural disorders. One of the things about psychiatric drugs in general – and one of the reasons people complain about them – is that some meds can eliminate sexual libido. But for some people who are early in treatment, it could be a good thing. SSRIs, which are anti-compulsive drugs and anti-anxiety drugs, might have a place. 

Anti-psychiatrists would say that it’s just another example of the medicalization of unwanted behaviours. They might also add that following this direction could lead to even more psychiatric power at the cost of individual freedom.

I am a big fan of the anti-psychiatrists, because they keep us honest. People like Thomas Szasz and R. D. Laing were very eloquently warning about over-medicalizing and over-pathologizing immoral behaviour due to economic incentives. It is very important to realize that we are all affected by biases that are social, economic and political. It’s good to be sceptical of doctors. When you see a healthcare provider, and he or she says: you are a sex addict, and you should be in treatment with me for the rest of your life and spend your life savings on my care – you should think twice about that! They may be correct. But healthy scepticism about costly treatment is wise.

You have publically spoken about the healthcare crisis in the US, which, at the same time, is one of the richest countries on Earth with probably the most advanced medicine. What are the main challenges for mental health care in your country today?

The major problem is that we don’t have care for people who are seriously mentally ill. You have a whole population that was institutionalized back in the 50s and 60s, we had institutions that had roughly 550,000 people in the mental asylums. And for good reasons – the asylums were helpful. Now, we have just 2 or 3% of the state beds that we had in the 50s, which means that, not coincidentally, we have a lot of people on the streets. Not coincidentally, the jails are now de facto asylums. I have a project coming out called Bedlam. It’s a book and a film that is dealing with this issue of the lack of care for people with serious mental illness. To make it super simple, it is a multi-front problem, the lack of pharmaceuticals, the lack of research, the lack of resources, very poor policy decisions, but what it all boils down to is the lack of advocacy, and that boils down to stigma. 

People who have a serious mental illness often don’t talk about it. As James Baldwin, the African-American novelist and activist, said, not everything that is faced can be changed, but nothing can be changed until it is faced. Serious mental illness is the best example. People don’t acknowledge it, they don’t talk about it, and as a result, there is a tremendous lack of resources. That is the number one mental health problem. I would also say that it is the number one social crisis in the world. Look at the WHO data – mental illness will soon exceed the societal and economic costs of cancer, plus cardiac disease, plus all non-communicable diseases. It’s a national and international crisis!

Does American privatized healthcare business play any role in this? Europeans find it hard to understand that every treatment is a service priced according to the market, and that often you can’t even know the price in advance. And then the bills can be coming for months!

Right now, because of the structure of our system, treatments that don’t pay are marginalized, and patients who don’t pay may not be treated. For many people, mental illness means impoverishment and even homelessness, and that translates into insufficient treatment. I am not an economist, but I can say that to me, a good solution for people with serious mental illness might be universal healthcare, in which everyone has a stake. This would make us more focused on prevention and early intervention.

By the way, some places do it better than here in the US. In Trieste in Italy, they do a great job with serious mental illness; they are a WHO exemplar of good care. But they also have universal healthcare, there is no housing crisis, there is no substance abuse epidemic, which is an enormous contributor to serious mental illness, and completely underestimated in my view. If you look at the street population, it is not just people with schizophrenia and bipolar disorder; you also get depression and anxiety from not having a roof over your head. Substance abuse does not cause, but complicates the diseases.

Are behavioural addictions spread largely democratically among different social and income groups and classes in the US?

As a therapist, I honestly don’t see any class issues; I work with and treat all kinds of folks, including people who are homeless. What causes addiction? Certain opportunities cause it, certain personality types, access. But at the end of the day, I don’t see these as divided by class, race or religion.

How about generations? Are we more susceptible to behavioural addictions than our parents?

I don’t think behavioural addictions are a generational problem, but the acceptance of the problem is. While the older generation thought of them as absurd, the youngest generation of physicians, psychologists and social workers think it’s reasonable. The disorders can be generational in terms of socio-cultural access. If you grew up in a place where there is no gambling, you wouldn’t become a gambling addict, just as if you grew up in a culture with no opiates, you wouldn’t become an opiate addict.

How about kids who grew up with constant access to the virtual world? It’s no coincidence that gaming addiction plagues South Korean teenagers, I would say.

Certainly, you won’t find many old gaming addicts, but you will find teenagers with such addictions in South Korea, because of the access to culture and the speed of the internet. In terms of sex and pornography, younger people have much more access, but for the older population, it is also getting easier. And in some ways, the older population is even more susceptible because it’s a new thing for them. For instance, in the US, there is an outbreak of sexually transmitted diseases in the retirement communities in southern Florida. Suddenly older guys have Viagra, but they didn’t grow up in a generation that used condoms!        

The history of psychiatry is marked by disorders appearing and disappearing. Do you foresee the inclusions of behavioural addictions in future DSMs?

Certainly, it will change in the years to come. When I was trained, the brilliant minds in the field considered sex addiction to be silly. People were ignoring the subject. Now, we see it’s a problem, and one reason is that a lot of people have personal contact with pornography and sense its enormous power. Also, because of the ICD, it will definitely evolve.

Or behavioural addictions will dissipate and be regarded as mere symptoms of deeper mental problems. I recall one of your patients with attention deficit disorder, who was in constant pursuit of stimulation – driving 200 kilometers per hour, going swinging.

It is complicated because, on the one hand, you have a comorbidity, and on the other, you have to talk about the primary and secondary diagnosis. Addictions are often comorbid, and they are often synergistic. If you have an addiction to cocaine, an addiction to sex and an addiction to gambling, those things become a vortex and reinforce each other so that their combination is much greater than the sum of the parts. If you have an addiction, either before or after, you are going to develop anxiety. Comorbidity is often the rule. The issue, however, is that the argument against addiction in general, and sexual compulsivity in particular, is that it is not an independent disorder – it is a function of another disorder, like bipolar or OCD. I don’t agree with that.

Eventually, all the behavioural addictions will be identified by neural pathways. This does not mean they are purely biological, but it means there will be a unifying way to describe them. I mean, in terms of what happens in the frontal lobes and the reward centre, and in the basal ganglia. Now we are diagnosing everything by symptoms, and distinguish primary and secondary diagnosis, but eventually, I believe, all these diagnoses will be made based on substantive brain findings that show the neural circuits that are at play here. Then the whole thing, whether it’s an addiction, depression, anxiety, will be subsumed under the category of a certain role in the network.  

It might still seem that sex addiction is more difficult to treat than Facebook addiction, and that it leads to consequences far worse than gambling. Are there lighter and heavier behavioural addictions?

No, if it’s your addiction, it’s horrible. In the US, we see young people’s lives ruined by the internet, by sexual dysfunction, we see people completely destroyed by gambling. You can’t say one is lighter or better. And, also, you can’t say one is easier to treat than the other. Illness certainly becomes easier to treat when there is an operationalized and accepted approach. So, for instance, if you live in a place where there is no terrible stigma about your disorder, where you can find a therapist to have a conversation with and who understands how to treat it, instead of giving you the impression that you are disgusting, then you’re in luck! This is what changes things from horrible to difficult. What determines how good or bad, treatable or untreatable, a mental illness is, has something to do with the illness, but has a whole lot to do with the subculture that is responding to the illness – your family, your friends, your doctor. Schizophrenia can be a difficult illness, but if you live in a family in which no one can talk about it, and denies it exists, then it’s an immediate killer.

What you are saying is essential – stigmatization can kill. Recently, we had a public march for dignity in Warsaw. Its slogan was: ‘Anyone can become mentally ill’. Some three months later, during a social campaign encouraging people to vote, mentally ill people were mocked. What are the feasible solutions to this problem of stigma? 

Great, we must keep talking about the stigma. I am a documentarian. I make films, but I also write about the crisis. One of the things we have been following in the Bedlam project is the mental health movement in Los Angeles, which has been the epicentre of the crisis, but is now also the epicentre of transformation. There is the new head of the LA Department for Mental Health, Jonathan Sherin, MD, and the activist Patrisse Cullors, a co-founder of the Black Lives Matters movement and an advocate for prison abolition in Los Angeles. The two of them, in their very different ways, are completely transforming mental health treatment from jail to community-based health care. Cancer was changed by activism, HIV was transformed by activism, and I believe mental health will be, too. It’s people telling their stories, telling their family stories, not hiding behind the veil of shame and secrecy. That’s what changes things.

In Bedlam, we focus on Los Angeles, California, also because the best way to tell a story is to be an individual in a place, but it’s a national story and an international story. The film is being shown around. Public Broadcasting Station’s Independent Television Service and Independent Lens assessed the change of people’s attitudes after watching Bedlam just two weeks ago at a film festival, and they found 93% of the viewers changed their attitude after watching it. We are hoping that when the book comes out, it will reach even further. We haven’t yet premiered the movie in Europe, but hopefully that will happen. I am super grateful because I am happy to be in my office and see my patients improving their living, but my impact beyond the confines of the office is a real privilege.

Is that why you became a psychiatrist?

My motivation to become a psychiatrist was my sister developing schizophrenia when I was 14 years old, but my own family and sister tried to hide the illness, with terrible consequences. I decided to work with families and alleviate the kind of suffering that I saw in my family. My work is about making the unspeakable spoken and thereby tackling problems that we’d rather not face. I learned about the importance of that as a child.

I appreciate you sharing something most people wouldn’t want to talk about.

Secrecy often doesn’t make any sense! There is a lot of truth to the 12-step recovery programme expression: you are only as sick as your secrets.

Parts of this interview have been edited and condensed for clarity and brevity.


Kenneth Paul Rosenberg:

Kenneth Paul Rosenberg, MD, is a Clinical Associate Professor of Psychiatry at the Weill Cornell Medical College and New York Presbyterian Hospital, and a member of the American Academy of Addiction Psychiatry, the Society for Sex Therapy and Research and a Distinguished Fellow of the American Psychiatric Association. He has produced films for PBS and HBO to educate the public about medicine and psychiatry.

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Marcin Moskalewicz

is an Associate Professor of Philosophy at Poznań University of Medical Sciences, Poland, and Head of the Unit for Philosophy of Mental Health. He also leads the Phenomenology and Mental Health Network at the Centre for Values-Based Practice in Health and Social Care at St. Catherine’s College, University of Oxford.