Addiction clinicians increasingly understand that a client presenting for treatment for one addiction needs evaluation for the presence of other addictions. Extensive literature supports the proposition that a person with one addiction is often likely to have another (Carnes & Delmonico, 1996; Carnes et al, 2004; Johnson, M. 1999; Milkman & Sunderwirth, 1987; Miller N.S. et al, 1995; Orford, J., 1985; Stewart, S.H. et al., 2000; Washton, A.H., 1989). This issue of the Journal provides information on several combinations of coexisting addictions – drugs and gambling, sex and gambling, drugs and eating disorders, sex and drugs. Addictions can interact in several ways (Carnes, in this issue). The continued untreated presence of one addictive disorder can inhibit recovery or lead to relapse in another addiction. Treatment of patients with multiple addictions begins with assessment in various areas, including the patient’s particular addiction interaction pattern, and the effect of the addictions on his or her life and relationships. Questions to consider in the first category include: Are the addictions alternating? Or are they parallel? Do they interact in an escalating fashion?

Two ways that addictions can interact are ritualization and reinforcement. In this paper, ritualization and reinforcement dynamics will be described between sex and drugs. Our goal is to present a working model that has been found to be helpful in mixed addiction patterns. Behavioral relapses, just as substance use relapses, increase the risk of active return of the addictive cycle of mood-altering cycles. Being aware of the underlying patterns of ritualization and reinforcement which exist on a behavioral level can make treatment more effective and predict approaching relapse.

The recovery process must include attention to all dynamics that increase risk of relapse. Below we present three common examples of ritualization in sexually addictive behaviors and how they reinforce maintenance of an addictive cycle that includes abuse of substances:

(1) Addicts who isolate as the paramount feature of a particular ritualized pattern of sex and drugs.

(2) Women who try to manage childhood trauma and domestic violence through addictive rituals

(3) Gay addicts who use ongoing multiple partners as a ritual to maintain intensity.

Underlying all addictions is desire and craving. In recovery, people work their program, attend meetings, do the 12 Steps, access their feelings, claim their personal power and healing, find their inner child, meditate, use affirming self-talk, and read recovery literature. But, ultimately, is recovery about a particular substance or behavior? Or is recovery really about the entire addictive process? If the latter is true, then global desire and craving must be addressed. Desire is a restless state of mind that longs for what it doesn’t have. Craving may be seen as the wish to escape some pain the mind does have. Desire and craving are not necessarily pathological, and in fact are an inescapable part of the human experience.

Abstinence as a theme helps get lives back in control, but it doesn’t solve the problem of the essential nature of desire, which is part of the human condition. Desire cannot be eliminated, but it can be managed in healthy and unhealthy ways. Becoming conscious of the consequences of a given course of action leads to using judgment.

Desire is obviously complex. It is a mixture of likes and dislikes, attractions and aversions, preferences and judgments, all occurring within the superstructure of the personality and reality. In relation to any given object, each person has unique perceptions, different likes and dislikes. This object relationship becomes paramount to the nature of the addictive process. When the patterns of perceptions and reactions to the object are made conscious, the nature of addiction is better understood.

In all addictions, thinking, and thus judgment, is impaired. Cognitive distortions, fantasy, euphoric recall, secrecy and preoccupation are all part of the addictive process. This process is present whether the addiction is to alcohol or other substances, gambling or sex. All lead to the same circular process that results in pain and suffering. At the same time, craving relief from pain and anxiety leads to finding temporary solutions. However, the satisfaction is phenomenon. The attempt to regain temporary satisfaction leads to ignoring consequences. Hence, the addictive process is born with its inherent powerlessness and unmanageability.

Cycles of avoidance and excess are characteristic of every addiction pattern. As the addictive process is refined, the addict finds it increasingly valuable and tries to protect it. Ritualization is a means to protect the addictive process to insure it does not vary and is predictable. Reality becomes a threat to the process. Hence rituals are designed to keep reality distant. As addicts go through this process, their boundaries change. Boundaries collapse when addicts act out, and may be excessive and rigid when they’re acting in, (e.g.in an attempt to be abstinent). Feelings run from anger while acting out, to fear of acting out, when acting in. Thinking becomes very rigid, all or nothing, with judging replacing judgment. The resulting episodes of inner emptiness drive the addictive process further in an irrational attempt to escape the emptiness.

When addictive process begins to fail, the resulting pain can lead many to sobriety and willingness to enter the recovery process. Willingness to drop the ritualizations and critically investigate desire can lead to recovery.

Therapists and patients alike must be aware that each of us carries forward wounds or vulnerabilities from childhood. Personal experiences impart a characteristic spin or bias to the way the world is seen. (Examples include: “The world is a dangerous place.” “I can’t rely on others.” “I have to please others to be loved.” “My needs are never going to be met.” “It’s too risky to love others – they always leave.” “The only way to be safe is to be invisible.”) This bias affects our perceptions. Exploration of that wound, that hurt child, is fundamental in helping to understand the unconscious drives, desires and pain that underlie the addictive process.

Recovery from addictions often requires understanding sexual abuse, childhood trauma, neglect and abandonment, traumatic stress from the past. This includes domestic violence, urban violence, military combat, as well as emotional trauma, intentional or unintentional. The adult addict needs to be aware of how past pain and violence is acted out, either against others or when hurt is directed at self. For many people violence, harm, danger, substance abuse disorders, and sexual addiction interact as part of a ritualized pattern.

In addition to being compulsive in nature, addictive patterns can also have a significant degree of impulsivity. Gambling, for example, is a behavior that becomes established by classic operant conditioning, the conditioning of the “big win.” Operant conditioning is reinforcement of behavior by reward, or alternatively by punishment when it’s done in a negative reinforcement pattern. But gambling is a unique because it provides reinforcement in a variable ratio schedule reward system. This means that reward – and hence positive reinforcement – is intermittent and unpredictable. Not knowing whether the big pay off will happen or not is the most powerful addictive pattern that exists. In animals this pattern is the slowest to be extinguished when the rewards are withdrawn. That is the reason gambling, sex, and other high-risk, high-reward behaviors are so powerful in the addictive process.

Linda Leonard (2001) speaking of Dostoevski, a gambler who wrote the book The Gambler to pay his gambling debts, says, ““Essential to the gambler are the elements of risk-taking, fear, and danger. The gambler has a remarkable ability to cope with dangers while lacking the ability to control the impulses that precipitate the dangers. So he creates dangers to keep himself stuck, and to give the illusion of his own power. Excitement, in an exalted end in itself, euphoria and anguish, alternate in the gambler’s soul.”

In 12-Step addiction recovery, a Fourth Step needs to include writing down not just the substance abuse, but the sex and other out-of-control behaviors that are concurrent. Many patients in addiction treatment have not done an adequate fourth step about their other behaviors. For example, some individuals use drugs ritualistically with sexual behaviors. They may do this to re-enact sexual scenarios from movies, books, fantasy, or past experience, trying to re-create the optimal; to create mood or enhance sexual pleasure; to intensity sexual experience; or to decrease inhibitions and fears.

Each addict has a characteristic pattern in his use of compulsive behaviors. Some use alcohol and drugs to decrease sexual dysfunction and performance anxiety, or as an excuse or rationalization that permits the expression of sexual aggression or violence. Others use alcohol and drugs with potential sexual partners -- “wining and dining” is more than a metaphor. The goal is to re-enact scenarios with other people, or to increase the vulnerability and decrease the resistance or inhibition of potential sexual partners.

Reinforcement is a powerful tool for acting out the narcissistic perception of others. Narcissism can be seen as a defensive facade covering up feelings of emptiness and rage, despite outward appearance of strength. Other people, in going along with these reinforced patterns, are seen only as objects, extensions of the self, present only for the person’s gratification. Addicts can behave in narcissistic ways. They perceive the function of the world to be a mirror for their hope that they can be good or powerful; should this not happen then they may react with outrage, reject the other person, or try to humiliate him or her.

Desire is a reinforcer because when it is gratified, it sets off a cascade of neurochemical events associated with the pleasure centers in the brain.  Memory reinforces this inclination, and variable ratio schedules reinforce this even more powerfully. Intention forms around the anticipation of satisfaction, with the result that chemical changes occur even before the gratification. Just imagining the gratification initiates the change; in addiction language, the ritual – the thoughts and behaviors that precede the actual use of drugs or sex – is an important part of the addictive cycle.

In early recovery, when addicts only partially understand their reinforcement system, they try to avoid high-risk situations such as the bars, as part of their relapse prevention plan. Unavoidably, along with the desire to avoid the pain of relapse, the desire for the object (the drink, the sexual activity. . .) is still present. The frustration of desire leads to resentment, and the addict is drawn back to a familiar pattern of behavior. He next tries to use the patterned behavior without the alcohol and drugs or the sex. In early recovery, the ritualized behaviors continue, but addicts. As they try to remove the alcohol and drugs, may use alternative drugs such as sexual performance enhancers, but the overall pattern remains the same. The wound is still expressed. For example, the alcoholic may understand how to talk the talk of AA, but does not have the ability to practice it because the compulsive and impulsive patterns are not addressed. Rote compliance without growth in recovery always forces someone else to pay the addict’s psychological debts. The pain and suffering continue, and may lead to loss of faith in the recovery process.

What is known about desire and reinforcement? We know desire is uninvited; it is compulsive. The intention to act is there, but fortunately intention can be broken; it is the weakest part of the chain, and is amenable to intervention by the therapist. As the book Alcoholics Anonymous (1976) states,

It is not the desire that is the cause of our pain, but rather the identification with desire as one’s fate. Desire is seen as fate. To yield to the narcissistic urge brings back the ritualization and reinforcement, which in turn leads to more heartache and pain. When it is learned there is more to life than desire, perceptions can change and addiction and recovery can be framed in a hopeful light. Hope plus courage allows access to an open heart and spirituality. When the interactions between behaviors, drugs, and the narcissism are considered, the addictive process becomes clearer and leads to deeper recovery.

Solo behaviors are defined as those that are acted out without other people. Real people are excluded because they are perceived as serious threats to the soothing satisfaction of the addictive process. Solo-addicts are vehement in protecting their addictive process. Hence, their addictive behaviors are often more highly ritualized than non-solo addictive behaviors. Again, ritualization is a primary method to guarantee and insure a predictable outcome of the addictive process.

The solo-addict basically creates a play, hence the term “acting-out”. He is the producer, writer, director, the only star, and the audience. The play can be speeded up or slowed down, or prolonged as long as desired, making anything happen. The delusion that the play will end and one will return to normal life is false. The play is stored in fantasy when not acted out. Hence, it is a play that never ends. It is not only highly ritualized, but also highly refined, because the addict keeps practicing to make sure there are no interruptions. Rituals insure predictability and freedom from the intrusion of reality. The resulting fantasy or play gives the illusion that all desires have been obtained with total absence of cravings or pain.

Ritualization is highly narcissistic. No one is allowed, as a person, into the system, or the play. Humans have to be dehumanized, and non-human things are humanized. Addicts will use anything to keep the illusion and the fantasy going, including various substances. Masturbation is the primary solo sexual behavior. Masturbation can be so intensive and so prolonged that the addict disconnects from “anything below the neck”. As a result, addicts may continue in the addictive process, denying consequences such as injuries and continuing to masturbate even when the penis has become macerated. Masturbating for hours and hours to keep the “high” and avoiding ejaculation is called “edging”. To keep the pain away and to stay in the trance, rituals often involve specific drugs. Alcohol and marijuana are major choices for slowing things down. Crystal methamphetamine, cocaine, amyl nitrite, nicotine and caffeine are used to speed the play up. These drugs may be used concurrently or alternately. Solo-sex may occur in various venues, for example, at home, in a movie theater, hotel room, or porno book store. What all venues have in common is isolation from any unforeseen intrusion.

Cybersex is a rapidly proliferating form of solo polyaddictive behavior. Although it may appear interactive, in reality, it is still a solo activity. Pictures and verbal exchange are allowed only as they fulfill the personal fantasy. In other words, there is no interest in connecting with another human being. The huge attraction of Internet sex is its easy availability, apparent anonymity, and the illusion of low cost. Costs in time, lost relationships, legal costs, job firings are not considered. Cybersex can be combined ritually with various other addictions. An example of a user, who eventually sought help, was a man whose ritual included sitting at the computer continuously, engaged in cybersex, masturbating most of the time as well as drinking two quarts of vodka. After one 45-hour episode, his wife accidentally found him collapsed unconscious and naked over the desk beside his computer surrounded by trays of cigarette butts. His ritual included sex, nicotine and alcohol.

Polyaddictive solo behaviors have the illusion of being victimless. “I’m not hurting anyone” is a typical statement, as is “This way I can’t get any sexually transmitted diseases.” But there are serious consequences. Other people in the addict’s life will eventually be brought into the drama, but as objects. As mentioned, time is stolen from work, jobs are lost, and there is withdrawal from family relationships. Addicts may anxiously await the departure of their spouse/partner so that they can begin watching pornography and masturbating until she/he gets home. Most such people do not get into treatment until they get caught, I.E., when the significant other feels profoundly betrayed.

The ritual trance is refined and reinforced as greater pleasure is desired. Nothing is tolerated that may interrupt the trance, nothing. In addition to cybersex, anything else may be used to further the experience. Escalation may lead to using animals, clothing articles, hidden video cameras in bathrooms or changing rooms as well as sex toys, urethral stimulators, dildos, and necrophilia. All can be made into things or props that have meaning for the addict, so that the illusion can be maintained. Escalation of the cybersex can lead to interest in child pornography, a federal offense. The illusion of anonymity is shattered when a work supervisor, the FBI or Homeland Security officers bluntly confront the solo addict with a full print-out of all sites visited on his computer.

Estimates suggest 80 percent of addicts who engage in solo polyaddictive activities that emphasize sex are male. However when the predominant solo activity in polyaddicts features food, the majority are female.

What is so hard to believe about this disorder is that people may act out in ways that they themselves find disgusting, ways that are against their own ethics and principles. One has to deal with the profound shame that keeps driving and reinforcing this process of escape, of the illusion that one is free. The addict’s ritual is highly personalized, so that what another person might think is disgusting might fit into someone’s need for power, control, freedom from sense of compassion, from vulnerability, from needs.

Addicts’ refusal to acknowledge they have any needs typically comes from their childhood experiences. Children who have their needs met inconsistently -- or not met at all -- generally make two decisions about what to do with their needs. One is, “I’ll take care of them myself and I don’t need anybody myself,” This is the basis for solo activities. The other is,

“If I’m going to relate to other people, it’s only going to be in terms of their body parts -- their genitals, breasts, legs, etc., but I won’t relate to them as persons. I’ll relate to parts of clothing, or dildos, or videos, where people aren’t real, because every time people get into my drama they mess it up. I want this to be perfect. I want to keep the trance exactly as I want it --when I want it, how I want it, as often as I want, as fast as I want it, as slow as I want.” With such rejection of dependency needs, the addict really cannot let another human into his life.

Drugs assist this process. Some, such as alcohol and marijuana, slow it down. Others speed it up, such as crystal methamphetamine, currently the most popular stimulant drug in the gay community. “Poppers” -- amyl nitrite and butyl nitrites – are vasodilators which give instant rushes of extra oxygen to the brain, and support the narcissistic illusion of being all-powerful. Cocaine and/or nicotine may be necessary for carrying out the ritual. The addict may be unable to act out if he does not have every ingredient as part of his ritual recipe.

One patient was a home repairman who would work all week by himself, pay all his bills and then rent a hotel room for the weekend. He would stock the room with pornographic tapes, alcohol, and cocaine, and chain smoke while masturbating continuously all day and night highly intoxicated. His addiction was highly ritualized: If any of these props were missing, he could not act out. The consequences that eventually led him to treatment included despair, loneliness, and the damage to his penis as well as his general health.

A medical student under the stress of medical school began to go down to the strip bars over the weekends and eventually during week nights. Beer was only $4 for all you could drink, so he started using the bar and alcohol as his daily reward. He was physically attractive and maintained good grades. He was able to maintain this lifestyle until he married, when he discovered that his ritual was so engrained, he couldn’t give it up. So he continued his addiction secretly, inventing medical obligations to explain to his new wife why he had to leave the house. His marital sex life deteriorated because all his energy was going in a different direction. His wife sensed the distance, and when she eventually discovered the truth, she ended the relationship.

Working with solo polyaddicted clients requires first an understanding of their characteristics. These include:

Denial, shame, objectification, power, isolation and fantasy – all reinforce and support the rituals of the solo polyaddictive acting out. The irony for the addict is that none of the addictions work, and moreover bring profound negative consequences, including the loss of jobs, money, relationships, self-esteem, control, power, spirituality, mental health. Depression and despair fill the emptiness. Chronic suicidal ideation is very common. Physical health often deteriorates unless the body is part of a narcissistic defense. The distorted thought echos, “If I’m worthless, why would I care for myself or ask for help?” Eating disorders, financial debt, and numerous chronic unattended medical problems are common.

How then to help them? Addicts who favor solo polyaddictive sexual behaviors are characterized by emotional isolation and by objectification of others. The key to overcoming emotional isolation is to connect with heart. The goal is to connect with heart to a higher power, to peers, Twelve-Step programs, to the therapist, to partners and to self. Solo-polyaddictive sex addicts are masters at creating isolation. They may bargain to attempt to negotiate only one-to-one psychotherapy, and nothing else. It helps to point out that the most important word in the first step is “We.”

Solo-polyaddicts have taught themselves they need no-one. Isolation is seen as protective, not dangerous. Isolation is confused with privacy. Distance from others is maintained to reduce any potential narcissistic wound. The primary focus in treatment is to gently confront the need to isolate. This begins by building trust, a lengthy process. It is helpful to trust the program first, and later to trust others. Establishing true community is mandatory. One-on-one therapy can never substitute by itself.

An effective tool in treating objectification of others is often referred to as the 3 Step Rule. Since solo-polyaddicts are highly visual, the first step is to break visual contact with the person (or photograph) being objectified. The second step is to state to oneself, “This is somebody’s daughter/son, this is somebody’s wife/husband, this is somebody’s mother/father.” The goal here is to make the“object” back into a person, a human being. Once a full human being has been accepted, the third step is to look again at the person or picture with empathy, wishing them well as they go on their way.

As is the case with men, women often exhibit a pattern of mixed addiction, in which one addiction reinforces another. However, there are some differences between male and female addicts. One of the chief differences is that women’s addictions tend to be played out in the context of relationships and interactions with other people; they are less likely to be in isolation. A second major difference is that childhood trauma, particularly childhood sexual abuse, plays an important part in the addictive process for many women.

Alcoholism is about three times as common in women who have experienced childhood sexual abuse as in the general population (Russell and Wilsnack, 1991). Up to 80 percent of women alcoholics were sexually abused in childhood. The factors that predispose an individual to addictive behaviors, such as childhood sexual abuse, result in impairment of the self that predisposes to addictive behaviors in many arenas (Young, 1990). Carnes & Delmonico (1996), in a study of 290 recovering sex addicts including 57 females, found that the greater the frequency of sexual and/or physical abuse in childhood (From 1= one time to 5=very often on a 5- point Likert scale), the greater the number of addictions they developed in adulthood. These included alcohol and other drugs, codependency, eating disorders, nicotine, gambling, spending, and working. It is imperative, therefore to assess female alcoholics for the presence of other addictions and compulsive behaviors.

Women addicts experience several patterns of polyaddictive behavior. These include:

Women may use alcohol and other drugs to numb their feelings. They may medicate in preparation for sex, to avoid the pain of recalling past trauma and from the pain that they anticipate from repetition of the old traumatic events. Some women, especially sexual abuse survivors, become sexually anorexic. They may find themselves able to be sexual only while under the influence of alcohol or other drugs. Their sexual relationships may be dysfunctional in general.

Washton (1989) reported that 50% of cocaine addicts (both male and female) seeking outpatient treatment are compulsively sexual; many of these have a second primary addiction, sex. Edlin et al. (1992) compared the sexual behaviors of young street women 18-29 years old comprising 289 who were current regular crack cocaine smokers and 236 who never smoked crack. They found that 70.5% of the crack smokers had sold sex, versus 4.3% of the nonsmokers; the crack smokers had an average of 30 lifetime male sex partners, the nonsmokers 5; 37% of the crack smoking women had had more than 100 lifetime male sex partners, vs. 3% of the nonsmokers.

Many crack-addicted women engage in any manner of sexual activity. Sex-for-drugs exchanges are far more common among female crack addicts than they ever were among female narcotics addicts. Crack smokers are at equal or greater risk for HIV and other STDs than are IV drug users. Non-IV cocaine use was associated with greater HIV seropositivity (84%) among female prostitutes in New York, and New Jersey than among intravenous drug abusers (46%) (Sterk, 1988) . Exchange of sex for money or drugs is often the link between drug use and STD. Typically female prostitutes who are crack users trade sexual favors for crack, and during one night might have sex with many partners. Sterk concluded that although her survey was in prostitutes, the implication is that many women who use crack but who would not define themselves as prostitutes may also be at increased risk of HIV infection.

Cigarettes, sex, and food are often intertwined. Cigarette commercials for women emphasize how you can stay thin by smoking, and imply that you will be more sexually attractive to men if you are thin and if you smoke.

Eating disorders, sex, and drugs are also often connected. Women may binge eat in adolescence to comfort themselves. They may try to make themselves sexually unattractive by overeating or undereating. Some sexually anorexic women use food compulsively both to self-nurture and to consciously or subconsciously make themselves less attractive sexually. Combining eating disorders and drugs is very common. Among tenth grade girls, those who were bulimics and purged reported higher rates of heavy drinking, marijuana use, cigarette use, and greater levels of depressive symptoms (Killen et al., 1987). Getting drunk at least several times a month was reported by 11% of the bulimics, 23% of the purgers, and 8% of normals. Smoking marijuana weekly or more was reported by 14% of bulimics, 12% of purgers, and 6% of normals.

Among 35 adult women with bulimia, alcoholism and drug dependence was significantly more common than in normal controls -- for example, 23% of bulimics had alcohol dependence, and 0% of controls, and 34% of bulimics had drug dependence and 3% of controls (Bulik, 1987).

Mary Bellofatto (1993), working at an inpatient eating disorder facility, reported finding that in treating over 35000 eating disorder patients, it is not uncommon for an eating disorder to be masked by substance abuse or an affective disorder. A large percent of her eating disorder patients were previously been treated for a chemical dependency problem only later to discover a hidden or primary eating disorder; additionally, over 84% of her patients at admission met criteria for an affective disorder. Their families of origin commonly had addiction and/or psychiatric problems: 47% of the patients’ mothers had an eating disorder and 49% of them were depressed. Forty-six percent of the fathers were alcoholic, 34% were depressed, and 30% were violent. Up to 70% of bulimic patients were victims of sexual and/or physical abuse as children.

Some young women have a connection between opioid dependency and eating disorders. A typical pattern may involve initial marijuana use, leading to increased appetite and weight gain. Bulimia develops in response to the weight gain. Heroin use may then ensue, usually because of a sexual relationship with a heroin user. Opioids help control the symptoms of the bulimia, such as vomiting and purging. If such women enter treatment, they are often overwhelmed by their bulimic symptoms when they stop using narcotics. (Blume et al, 1992).

Some women become compulsively sexual, re-enacting their abuse (repetition compulsion, hoping for a better outcome), and may get involved indiscriminately in sexual relationships; alcohol may be part of their ritual. The sexual addiction may include periods of sexual anorexia. Carnes describes a pattern where a woman was either thin and sexually compulsive, or at different times overate and was fat and sexually inactive (Carnes & Moriarty, 1997).

Alcoholic women, bulimic women, and female drug addicts all have a high incidence of childhood sexual abuse (Young, 1990). Carnes found the same for female sex addicts (Carnes, 1991). Carnes has classified sexual addiction behaviors into ten patterns (1991). These are fantasy sex, anonymous sex, paying for sex, trading sex, voyeuristic sex, exhibitionistic sex, intrusive sex, pain exchange, and exploitative sex. There are significant gender differences in the prevalence of these behavior types. Men tend to engage in behavioral excesses that objectify their partners and require little emotional involvement (voyeuristic sex, paying for sex, anonymous sex, and exploitative sex). A trend toward emotional isolation was clear in Carnes’ research. It is not surprising, then, that solo sex (see above) is primarily a male phenomenon. Women, in contrast, tended to be excessive in behaviors that distort power either in gaining control over others or in being a victim (e.g. Fantasy sex, seductive role sex, trading sex, and pain exchange). Sexually addicted women use sex for power, control, and attention. Sex addiction, according to Carnes, seems to intensify the wounds already present in each gender. In women, these wounds involve power and victimization issues, whereas men have difficulty with bonding, intimacy, an the tendency to objectify others.

Although alcohol consumption is considered to be sexually disinhibiting, there is no simple correlation between alcohol consumption and sexual behavior. In one study women who had stronger beliefs about alcohol’s ability to cause decreased nervousness about sex or enhance the sexual experience were more likely to drink in conjunction with sexual encounters, and, if drinking, were more likely to drink larger amounts. The highest level of drinking occurred among women who had strong expectancies and negative attitudes about sex – those who felt nervous or guilty. Thus it appears that expectancies about the effects of alcohol on sex may motivate heavy drinking in some women, particularly those most conflicted about sex (Leigh 1990b). These women may use alcohol to reduce their sexual inhibitions. In a 1981 survey (Klassen & Wilsnack, 1986), most women drinkers (heavier drinkers most often) reported that drinking lessens sexual inhibition and helps them feel close to others. However, only 8% reported becoming less particular in sexual partner choice, 22% were more sexually assertive, but most women reported that drinking did not actually make them less discriminating in their choice of partners. Tellingly, 60% had been targets of other drinkers’ sexual aggression .

Alcoholic women reported substantially higher rates of sexual dysfunction than did nonalcoholic women. Most of the alcoholic women with sexual dysfunctions reported already having these problems before the onset of their alcoholism (Covington & Kohen, 1984). In another study (Klassen & Wilsnack, 1986), the greater the alcohol consumption, the higher the lifetime rates of sexual dysfunction, including lack of interest in sex and lack of orgasm. These findings suggest that a preexisting sexual dysfunction may motivate a woman to drink, perhaps because of expectations that alcohol will enhance her sexual experience. Self-medicative drinking because of sexual dysfunction may cause subsequent problem drinking and alcohol dependence. In fact, sexual dysfunction was the strongest predictor of chronic problem drinking in a longitudinal study (Wilsnack et al., 1991). Since heavy alcohol consumption has detrimental effects on physiological sexual functioning, a self-reinforcing

cycle may occur in which heavy drinking becomes both cause and consequence of sexual dysfunction. The same authors found that among women who were problem drinkers, the most consistent predictor of persistent problem drinking five years later was sexual dysfunction. These findings suggest a need to address issues of sexuality and sexual dysfunction in the treatment and recovery of alcoholic women, and a need to assess drinking behavior among women presenting with sexual dysfunction.”

Although men are physically abused more often than is generally recognized, women are the predominant victims of domestic violence, often suffering both physical and sexual abuse. Although alcohol does not cause domestic violence, it is often disinhibiting for the abuser; at times the female partner also participates in drug use. Alcoholic women are more stigmatized in our society than are men; they are often considered to be sexually promiscuous, fallen women. The expectation that alcohol (and other drug use as well) makes women promiscuous leads to the acceptance of sexual aggression toward a drinking or drug-using woman. Rape, domestic violence, and other victimizations are far more common in the experience of chemically-dependent women compared to other women in their communities. (Blume,1990). A study of 100 alcoholic women physicians (Bissell & Skorina, 1987) reported that 22 women had been beaten and 21 had beaten spouses or lovers themselves. One had assaulted her father, another her grown son. ’Several studies have found an association between female drinking and increased victimization in marital violence (Miller and Downs, 1993; Kaufman Kantor and Straus, 1989). According to a 1992 U.S. Survey of alcohol and family violence, a wife’s drinking, whether alone or with her husband, led to more severe violence both by and toward the wife (reported in Wilsnack, Wilsnack, & Hiller Sturmhofel, 1994).

Compared with a sober woman, studies show that a drinking woman is considered more sexually disinhibited and available by both men and women. This misperception puts a woman at risk for unwanted sexual advances. Two studies show that up to 50% of sexual assaults by acquaintances involve alcohol consumption by the victim or the assailant (Koss et al, 1987; Muehlenhard and Linton, 1987.) In an acquaintance rape situation, both men and women who learn about it consider the incident less likely to be a rape if the victim and assailant had been drinking together (Norris, 1994). Both men and

women attributed more responsibility for the assault to an intoxicated rape victim than to a sober one; at the same time, the offender was blamed less when he was drunk than sober. This attitude makes women who have been sexually assaulted while drinking, more reluctant to report it. One of the authors of this paper described a patient:

Codependency is often a major factor in relapse to chemical dependency. In codependency, the self-esteem of one person is regulated by the distorted behavior of another. Codependent women do not believe they are capable of being loved; they settle for being needed. They are attracted to needy partners in whom they see potential. They believe they can fix what is wrong with them and be loved. Addiction is a family disease, resulting in dysfunctional family patterns. One possible scenario is a chemically dependent man in relationship with a woman who uses some combination of prescription drug addiction, compulsive overeating, sex, and workaholism to cope with her problems and with her relationship. Women are socialized to value relationships strongly. This trait is even stronger in a woman who is codependent. She may drink, drug, or agree to uncomfortable sexual behaviors, or tolerate emotional or physical abuse, in order to maintain a relationship or placate a partner and prevent abandonment.

Among callers to an 800-COCAINE hotline, 87% of women said they were introduced to cocaine by men, and 67% said they continue to receive cocaine as from men. Many were using cocaine to “go along” with their male companion. (Washton, 1986). Chemically dependent women are much more likely to have a husband or other life partner who is a drug and/or alcohol abuser (Unger, 1988). Addicted women are far more likely than addicted men to be married to, or romantically attached to, other addicts (Unger, 1988).

In chemically dependent women who do not improve despite treatment and patient education, a second diagnosis of codependency must be considered.  Both clinical studies and general population surveys (e.g Jacob & Bremer, 1986; Kolonel & Lee 1981) have found a positive association between women’s level of alcohol consumption and those of their partners. Wilsnack and Wilsnack (1993) reported that the perceived frequency of a spouse’s drinking had a stronger association with women’s problem drinking than with men’s problem drinking. Husbands’ drinking had a stronger influence on their wives’ drinking than vice versa.

This woman’s coaddictive dependency on her abusive, alcoholic husband was more important to her than her sobriety or even her safety. Her codependency is her primary addiction. She is unlikely to attain either until her codependency issues are dealt with in therapy.

In other women, a primary addiction may be masked by codependency:

In addition to illustrating the interaction between addiction and coaddiction, this case demonstrates the common perception (by both sexes) that using alcohol makes women more uninhibited and more available sexually; thus this woman pretended to be drunk so as to be less accountable for her sexual behavior.

In her article, “The role of incest issues in relapse,” Young (1990) states, “One of the greatest unacknowledged contributors to recidivism in alcoholism and other addictions may be the failure to identify and treat underlying childhood sexual abuse issues.” Women treated for substance abuse commonly have a history of childhood sexual abuse and rape. Women (1) who are resistant to treatment or who relapse, or who (2) trade one addiction for another rather than recovering from addiction are often ones who have undiagnosed and untreated histories of sexual victimization. When they were using, the substance abuse may have masked their PTSD symptoms. “

Substance abuse may enable some victims to compartmentalize their internal experiences so that they are able to function as well as they do in daily life (Root,1989). When they give up the substance, memories of past traumatic experiences may surface and they may express PTSD symptoms such as intense negative affect, flashbacks, or other memories related to the traumas, sleep disturbances, hyperarousal, and irritability. These women are likely to feel much worse when they have given up the substance. They also lack the skills with which to cope with these intense feelings, so they are likely to cope with them by relapsing.

For such patients it may be counterproductive to insist on abstinence from substance abuse as the first priority for treatment. The patients need to first develop tools to deal with their PTSD symptoms and their abuse history, or else attempts to remove the substance are likely to result in relapse or in “treatment failure. “ It may be more productive to teach them coping skills simultaneously with helping them decrease their addictive behaviors and help them to develop increased motivation to change them. Abuse survivors are at risk of relapse until the childhood sexual abuse issues are addressed. In a complex web, the abuse survivor needs to balance recovery from both disorders. A key aspect for this balance may be to help the survivor to begin to frame drug abuse as both reenactment and increasing the risk of recurring trauma. Furthermore, the survivor needs to begin to see how addictive acting out constitutes self abuse and further trauma.

Relapse prevention theory (Marlatt & Gordon, 1985) holds that it is the effect of high-risk situations and the individual’s response to them that is most closely associated with relapse. However, internally generated phenomena can also predispose to relapse, such as effects of childhood sexual abuse. A relapse should be viewed as an indication of the existence of underlying material such as unresolved traumatic experiences that has contributed to the etiology of the addiction (Young, 1990).

Most women treated for alcoholism have much lower self-esteem than men at an equivalent stage of their disease. Confrontational treatment programs might be counterproductive. Women generally need to address the problems of low self esteem, guilt, shame, lack of assertiveness and decision-making skills, and personal relationships early in treatment because these issues are often implicated in relapses. (Blume et al., 1992).

In dealing with women, therapists need to pay attention to the sexual dysfunction issues, help them overcome their codependency and develop a healthy body image, to get in touch with their own power, to deal with the trauma issues, and deal with their issues in the context of their relationships, recognizing how important relationships are to them.

The goal in treating men and women with trauma in their past is to realize that these are people who are looking for the ideal relationship with another, but cannot find right relationship. Treatment of sexual dysfunction, dealing with self-esteem, resolution of trauma, and the need to find right relationship -- healthy relationship -- are an integral parts of treatment for such patients. These elements have to be integrated into the treatment program in order to avoid ritualization and reinforcement.

A previous section described solo polyaddictive behaviors. Many addicts, however, include multiple partners and multiple addictions in their acting out. The result is significant relationship issues complicating their life. This section focuses on treatment approaches to such complex cases.

Treatment of patients with multiple addictions begins with assessment in various areas, including the patient’s particular addiction interaction pattern, and the effect of the addictions on his or her life and relationships. Questions to consider in the first category include: Are the addictions alternating? Or are they parallel? Do they interact in an escalating fashion? If a relationship is involved, other questions arise: Is the partner unaware of the addictive behaviors? Is the relationship stressed? Damaged? Destroyed? Is the partner participating in the addiction? Is the partner fueling it with a parallel addiction or with their own codependence?

When treating gay male couples, the therapist must recognize that there are particular issues that differ from those of heterosexual couples. For example, in order to advance in a corporate or other work setting, most people have to keep their homosexuality secret or very circumscribed within other areas of their life. Within the relationship, competition may arise regarding the relative income. Like many heterosexual relationships, the relationship may be stressed by issues around how relocation or geographic changes related to one career may affect the other.

Also, monogamy is a strongly debated issue within the gay community. Many gay couples, especially those who live together for longer than five years, are not continuously sexually exclusive. This population accepts the norm of emotional monogamy along with sexual variety. Many speculated early in the HIV epidemic that AIDS would lead to an upsurge in both monogamous relationships and a decrease in multiple partner sex. †No significant increase in the rate of monogamy in gay male relationships has been reported to this point. †Unfortunately, the recent slow but steady climb in the rate of seroconversion seen in gay males tends to indicate that the attitudes towards multiple partner and safer sex may not have changed significantly. †

Open polygamy is still much more likely among gays than among heterosexual couples. Accurate assessment of this issue is difficult to obtain in part because infidelity in both same sex and heterosexual relationships is shrouded in secrecy and shame. Studies are needed in both populations regarding the incidence of compulsive behaviors, spousal coercion, and power imbalance in “swinging” or other open relationships. A blanket label of addictive or dysfunctional for such behaviors may be neither useful nor scientifically based.

Within many relationships, loneliness and fear along with dysfunction within the relationship precipitates a need for relief, change or a need to experience something new or different. In some cases, this may be effective. If there is a satisfactory response and a relief of the loneliness, the result may be a very comfortable response and the experience goes unnoticed. It may enhance the relationship. However, if an addictive process begins, the desired satisfaction fails to materialize. The perceived need and desire return and escalate. Eventually the process triggers more dysfunction, more loneliness, more fear, which will lead to more acting out, desire for more relief and, eventually, more consequences.

A common factor in addictive behaviors is the role of ritual. Rituals can be related to geography, individuals, places, or things. In addition, external factors, may be incorporated into the ritual process. These early rituals may be to be instigated by either positive or negative triggers. Positive triggers would involve more celebratory situations, such as joy, success, and acceptance and “good days” while negative triggers would imply negative situations, such as shame, fear, loss or just a “bad day.”

Another origin of these rituals lies within post-traumatic stress disorder (PTSD) triggers, including flashbacks, avoidance and hypervigilance. In some instances the potential of re-enactment of trauma serves to escalate the addictive behavior. The other function of PTSD symptoms and sequelae is to help induce the trance and to facilitate the dissociation of negative affect, as well as potential negative impact of the addictive behavior. Another similar process involves the re-enactment of trauma, overtly, such as replaying the scenarios, repeating the specific behaviors of the trauma, or covertly such as the type of relationship, the loss of control, or some other experience of being wounded physically, emotionally or spiritually.

Because of the complexity and plurality of these rituals, they can be disrupted or de-escalated by numerous factors such as physical or geographic interventions, or external occurrences. An example of this would be unwanted people or the police appearing in the environment. In addition, the absence of the desired object or the presence of an undesirable object can also disrupt the ritual. When a ritual is disrupted in this manner, violence or coercion may come into play in order to reclaim the ritual. To disrupt the ritual imposes reality and gives access to the emotions that were being managed by the ritual.

Preparation for the acting out is a ritual designed to facilitate a trance state. This trance induction begins with music, clothes, cologne, all the sensual elements that are woven into acting out. For many, a component of the ritual lies in the “costume” – the silk or velvet, the leather, the party clothes, the exhibitionist’s outfit -- whatever is involved in the ritual and acting out. Often, without the trappings of the ritual and acting out, the process may be frustrating or unsatisfying.

Geographic factors play heavily into the reinforcement and escalation of rituals. The desire to act out may be triggered by being out of town, being in town, near a favorite site, or perhaps a new site. Excitement can be added by novelty because the novelty carries uncertainty and tension that increases the excitement of the ritual. On the other hand, in order to effectively carry out the ritual and obtain the induction of the trance. the ritual may require being in the same place at the same time. Visual, auditory, and olfactory cues are also involved in ritualization. This is especially important where cocaine is a component of the addictive pattern. Other factors that act to escalate the ritual include sensual cues that enhance the complexity of the sensory experience and exaggerate the experience.

When sexual behaviors are involved, the potential for anonymity is important because it allows for deepened emotional objectification. Being out of town, in costume, or otherwise anonymous, the addict is no longer interacting with a person and can more completely exist within the world of the trance. Biochemical arousal also escalates addictive rituals. Stimulants such as cocaine, caffeine, and nicotine, can be used to heighten the all of the experiences previously described. In an opposite fashion, disinhibitors such as alcohol and benzodiazepines can be used remove inhibitions, impair judgment and facilitate the next layer of behavior.

Arousal can also be linked to risk factors and their inherent fear or danger. The “near-miss” can intensify the ritual of acting out. The intent of the hypervigilance from PTSD is to heighten awareness and, theoretically, prevent further trauma. However, when the rush of adrenalin is a component of the ritual, the posttraumatic hypervigilance can facilitate the ritualization process. By entering a reenactment setting and triggering the hypervigilant warning process, the addict can precipitate a flood of adrenalin and be catapulted into a higher level of arousal.

In active addiction, all of the same processes can be used to de-escalate addictive processes. Chemical stimulants may be used to “overshoot” the excitement and distract from another type of acting out. Likewise, alcohol or benzodiazepines may sedate and, thereby, inhibit further ritualization or acting out. Awareness or reminders of consequences of addiction, such as physical harm, infection, illness, exhaustion, motor vehicle accidents or citations can limit or abort an active ritual. Similarly, the presence or absence of a coaddict or primary relationship or family or a job may serve to de-escalate acting out. By avoiding certain geographic settings, eliminating certain items of clothing, certain cologne scents, or certain music, the addict can prevent aspects of ritualization and avoid acting out. Similarly, the addict may use intermediate items or levels to modify the rate or intensity of the acting out process or behavior. Likewise, posttraumatic symptoms may be used either to induce avoidance or temper acting out.

Using these aspects of ritualization in recovery is an important tool. The recovering addict must carefully learn the symptoms of the addictive trance and evidence of an active ritual, then identify positive, affirming rituals to de-escalate the process and eliminate the trance. By doing this, the addict who is working a recovery program learns to counteract the pull of a trigger. Practicing using these tools creates rituals for recovery. Making a phone all to a sponsor, charting a course to a meeting, or even thinking about the meeting place or time can short-circuit the craving and the addictive ritual. The experience of more frequent and consistent positive affect, the accomplishment of goals in recovery, pride in the recovery process and investment in recovery relationships can act to limit unhealthy ritualization.

As recovery progresses, insight becomes one of the most helpful factors in de-escalating addictive urges. Understanding the difference between intense feelings and adrenaline-driven arousal helps reduce the seductive allure of arousal. Awareness of overindulgence also disrupts the shame that can induce the ritual. Realizing that one has exceeded limits or boundaries or needs to pace oneself begins to trigger efforts to make conscious choices, rather than act in unconscious ritual.

Developing a more positive and shame-free self-image is also a factor in recovery. By experiencing positive, healing behaviors, thoughts and experiences as the result of automatic, recovery-based rituals, the recovering addict begins to experience hope, trust, and confidence in himself. The needs of primary relationships can move to the forefront and be incorporated into the de-escalation of remaining uncomfortable feelings or rituals.

The sexual arousal curve (Figures 1 and 2) can be a useful metaphor for ritualization and acting out. Components of the sexual arousal curve are early arousal, escalation phase, plateau phase, orgasmic inevitability, an orgasm, followed by a period for recovery. Much the same way as early sexual arousal happens in courtship and “romantic” rituals, early phases of addictive acting out rely on rituals and their reinforcement. Unfortunately, in this metaphor, many addicts experience acting out on a conscious level much like waking up at the moment of orgasmic inevitability. No matter happens, the addict is so far into the process, and so much has happened unconsciously, that the acting out is going to happen regardless of interventions. Recovery involves uncovering the triggers so that awareness begins earlier in the cycle. One key in recovery is to identify the pain, consequences and suffering that result from the addiction. By heightening awareness of negative consequences, in essence, identifying the inevitability of destruction, the addict counteracts the trance induced by the rituals. During active addiction, the goal of the sexual compulsive may be a soothing process, much like the chemical user may look for numbing, sedation, or some way of lessening the pain and drama. Regardless of these efforts, the inevitability of pain leads to a sense of helplessness. In some instances, the failure of this process may lead to power abuse, dyscontrol and escalation of the addictions. The inescapable result of the repetitive failures is a sense of rage. The tendency with rage is to project it onto a victim. Perhaps the victim will be the self and result in solo acting out. It may be an external victim or coaddict. Regardless, the end result is victimization and remorse.

This projection process leads to numerous complications. These may be occupational, legal, or covert consequences such as isolation. All of these lead to a sense of remorse and pain, which re-starts the cycle of behaviors. Parallel solo pain-relieving addictive behaviors can be sedative use, other substance abuse, masturbation, voyeurism, pornography, low risk behaviors or simply dissociation. Rageful behaviors which are projected onto another person include exhibitionism, frotteurism, affairs or infidelity within the relationship, anonymous sex or one-night stands. While many of these behaviors may appear superficially consensual, they may involve significant victimization. Other behaviors reflect the need for power and domination and include sadomasochism, the violence of rape, and the re-enactment of trauma-related behaviors.

The cycle of behavior, rage, helplessness and pain leads to that desire for relief. When successful, the addict experiences a brief period of euphoria, the high, and then slumps into the abyss of withdrawal. The pain of withdrawal fuels the drive for more relief and the repeated failure of the relief effort escalates the need for reinforcement along with the consequences of failure and the increased shame. The shame reinforces the pain and sets up the cycle again.

Treatment of all addictive processes is based on disruption of the addictive cycle. An important component of addiction treatment is to disengage rituals. When the addict is involved with other people – a primary partner and/or acting out partners, addiction treatment also needs to help the addict disengage from chaotic enmeshed primary relationships and to build relationship skills.

In active addiction, all of the addict’s emotional and physical energy is devoted to the addiction and its singular goal. The addict needs to develop relationships that are not about manipulating people, places and things to fuel the addiction. Instead of the singularly pleasurable rewards of the addiction, the addict must learn to develop relationships that are useful in many areas of life. The therapist, sponsor, peers and group therapy can be very useful here. The goal is to develop intimacy in a nonsexual setting.

One component of recovery is developing frustration tolerance. Much like a child, the addict must develop the ability to delay gratification, sublimate desires in one’s own best interest, and accepting logical consequences. By developing and integrating these types of coping skills, the addict learns to tolerate the uncomfortable feelings associated with life without the magic of the addictive trance. With these coping skills in place, the addict can build a self-image that relies on competence and manageability. On the foundation of a balanced self-image, the addict can begin the process of restructuring cognitive distortions around relationships.

The traditional approach of addiction specialists to focus on a particular addictive behavior has often been effective. However, there remain a large number of addicts who repeatedly relapse. This paper suggests that being aware of multiple and polyaddictive ritualistic behaviors that occur concurrently, alternately, secondarily, can be crucial in reducing relapse. Focusing treatment on the addictive process rather than a single addictive behavior can more easily uncover destructive addictive dynamics. Each addictive behavior identified in one individual can provide another window for revealing highly guarded and secretive internal cognitions, defenses, and intents. The addictive process is a complex one with many facets. This paper focuses on desire and craving, ritual and reinforcement, avoidance of past trauma and anxiety and employing cognitive distortions and narcissistic defenses. Examples of polyaddictive behaviors have been presented in solo-polysexaddicts, female polysexaddicts and gay polysexaddicts. Treatment must always treat the most serious and life- threatening addiction first. However, persistent follow-up and vigilance regarding treatment of co-existing addictive behaviors through awareness of the addictive process can promote success in maintaining ongoing recovery.

**Adapted from a course given at the Annual Scientific Conference of the American Society of Addiction Medicine, April 17, 1997.

Alcoholics Anonymous World Services (1976) Alcoholics Anonymous. New York: Author.

Bellofatto, M, 1993. Addiction & Recovery 13(5))249-257.

Bissell, L. and Skorina, J. K., (1987). One hundred alcoholic women in medicine: An interview study. Journal of the American Medial Association 257:2939-2944.

Blume, S. (1990). Chemical dependency in women: Important issues. Amer. Journal of Drug and Alcohol Abuse 16(3 & 4), 297-307.

Blume, S, Counts, S. J., and Turnbull, J., (1992). Women and substance abuse. Patient Care, July 15, 1992, 141-156.

Bulik, C.M. (1987) Drug and alcohol abuse by bulimic women and their families. American Journal of Psychiatry144:1604-1606.

Carnes, P.J. (1991). Don’t Call it Love. New York: Bantam.

Carnes, P.J. & Delmonico, D. L. (1996) Childhood abuse and multiple addictions: Research findings in a sample of self-identified sexual addicts. Sexual Addiction & Compulsivity 3(93):258-267.

Carnes, P. with Moriarty, J. Sexual anorexia: Overcoming sexual self-hatred. (1997). Center City, MN: Hazelden.

Carnes, P.J., Murray, R.E., & Charpentier, L. Addiction interaction disorder. In

Coombs, R.H. (Ed) (2004) Handbook of addictive disorders: A practical guide to diagnosis and treatment. Hoboken, NJ: John Wiley & Sons., pp 31-59.

Carnes,P.J., Nonemaker & Skilling (1991).. Gender differences in normal and sexually-addicted populations. American Journal of Preventive Psychiatry & Neurology 3:1, 16-23.

Edlin, Brian R., Irwin, K.L. et al., (1992). High-risk sex behavior among young street recruited crack cocaine smokers in three American cities: An interim report. Journal of Psychoactive Drugs 24(4):363-371.

Johnson, M. (1999). Cross-addiction: The hidden risk of multiple addictions. New York: Rosen Publishing Group.

Johnson, R. Femininity Lost and Regained (1991) New York:Haworth Press.

Kasl, C. (1989) Women, Sex & Addiction. New York: Ticknor & Fields.

Killen, JD, Taylor CB, Telch, MJ et al. Depressive symptoms and substance use among adolescent binge eaters and purgers: A defined population study. Journal of Public Health 1987, 77:1539-1541.

Klaasen, A.D. And Wilsnack, S. C., Sexual experiences and drinking among women in a US national survey Archives of Sexual Behavior 15:363-392, 1986.

Koss, MP, Gidycz, CJ and Wisniewski, N., 1987. The scope of rape: Incidence and prevalence of sexual aggression and victimization. Journal of Consulting and Clinical Psychology 55:162-70.

Leonard, L. (2001). Witness to the Fire: Creativity and the Veil of Addiction. Boston, MA: Shambala.

Leigh, B.C. (1990). The relationship of sex-related alcohol expectancies to alcohol consumption and sexual behavior. British Journal of Addiction 8(7): 919-928.

Marlatt, G.A., and Gordon, J.R. (1985). Relapse Prevention. New York: Guilford.

Milkman, H. & Sunderwirth, S. (1987). Craving for ecstasy: How our passions become addictions and what we can do about them. San Francisco, CA: Jossey-Bass.

Miller, N.S., Belkin, B.M., & Gold, M.S. (1995). Multiple addictions: Co-synchronous use of alcohol and drugs. New York State Journal of Medicine, 90,596-600.

Miller, B.A., and Downs, W.R. (1993). Interrelationships between victimization experiences and women’s alcohol use. Journal of Studies on Alcohol 11 (suppl.):109-117.

Muehlenhard, C.L. and Linton, M.A. (1987). Date rape and sexual aggression in dating. In Marlatt G.J. and Gordon J.R. (1985) (Eds). Relapse Prevention: Maintenance Strategies in the Treatment of Addictive Behaviors. New York: Guilford.

Norris, J., (1994). Alcohol and female sexuality: A look at expectancies and risks. Alcohol Health & Research World 18:197-201

Orford, J. (1985). Excessive appetites: A psychological view of addictions. New York: Wiley.

Root, M.P.P. (1989). Treatment failures: The role of sexual victimization in addictive behavior. American Journal of Orthopsychiatry. 59(4):542-549.

Russell, S. A. and Wilsnack, S. C. (1991). Adult survivors of childhood sexual abuse: Substance abuse and other consequences. In: Roth, P. , ed. Alcohol and Drugs are Women’s Issues. Vol. †I: A Review of the Issues. Metuchen, NJ: Scarecrow Press, pp. 61-70.

Schneider, J. (1988). Helping the codependent spouse. Medical Aspects of Human Sexuality, January 1988, 46-51.

Sterk, C. (1988). Cocaine and HIV seropositivity (letter). Lancet 1:1052.

Stewart, S.H., Angelopoulos, M., Baker, J.M., & Boland, F. J. (2000). Relations between dietary restraint and patterns of alcohol use in young adult women. Psychology of Addictive Behaviors, 14,77-82.

Unger, K. (1988). Chemical dependency in women. Western Journal of Medicine 149:746-750.

Washton, A.M. (1986). Special report: Women and cocaine. Med Aspects of Human Sexual 20:128-132.

Washton, A.M. (1989) Cocaine may trigger sexual compulsivity. U.S. Journal of Drug and Alcohol Dependency, 13,8.

Wilsnack, S.C., Klassen, A.D.,Schur, B.E. and Wilsnack R.W. (1991). Predicting onset and chronicity of women’s problem drinking: A five-year longitudinal analysis. American Journal of Public Health 81(3):305-318, 1991

Wilsnack, S.C., and Wilsnack, R.W. (1993). Epidemiological research on women’s drinking: Recent progress and directions for the 1990s. In: Gomberg, E.S.L., and Nirenberg, T.D., eds. Women and Substance Abuse. Norwood, NJ: Ablex Publishing, pp. 62-69.

Wilsnack, S., Wilsnack R., and Hiller-Sturmhofel, S. (1994). When women drink; Epidemiology of women’s drinking and problem drinking. Alcohol Health & Research World 18:173-180.

Washton, A.M. (1986). Special report: Women and cocaine. Medical Aspects of Human Sexuality, 20:128-132.

Young, E. B.1990). The role of incest issues in relapse. J. Psychoactive Drugs 22(2):249-258.

Figure 1

Figure 2