What actually helps: values, sober sex and why the group matters

The point at which most people recognise something needs to change is a kind of tipping point: when they see that the sex they are having has moved them away from the values they hold for themselves, and that the negative consequences are outweighing what was positive. That looks different for everyone, but it is usually when willingness to change increases. Change doesn't happen immediately, and not everyone is at that point on day one. To get started you only need a broad awareness that there is something you want to change. The full awareness, honest reflection on how far this has taken you from who you want to be and what it has cost you and the people around you, often comes much later, because it is very painful to own. Admitting that something we have enjoyed, and probably still want, has caused that depth of harm is hard to come to terms with. But that is where the meaningful therapeutic work can begin.

What men have tried

Most people have tried a lot by then. I don't think I have ever met anyone for whom therapy was the first thing they tried. They have tried online self-help, sexual health services, basic behavioural approaches such as planning and goal-setting, willpower alone, or enforced abstinence: deleting apps and contacts, asking friends or family for help, putting passwords on their phones. Some have asked a GP or looked online for basic advice, which is sometimes useful. Some have tried twelve-step programmes, with mixed results. Some find them useful to a degree, particularly for having space to think and connecting with others going through something similar. But many haven't succeeded with them by the time they get to me, mostly because abstinence is generally promoted, and that can feel unachievable when no attention is paid to replacing what the behaviour provides. It can also feel like a prescriptive way of thinking about sex and relationships that many men simply don't see themselves in. They have more nuanced ideas of what sex and sexuality are.

A smaller number have had one-to-one therapy. Usually the reason it didn't work isn't that the therapy was bad. It is that the problem wasn't fully conceptualised. Something in the relationship meant the person couldn't talk fully or honestly, or wasn't held to account, or the therapist misunderstood what was driving the behaviour, when it wasn't about the sex at all. People say they enjoyed the therapy and it felt good to talk, but the behaviour didn't change, or didn't change for long, because the structure underneath wasn't addressed.

Why is it at the top?

Our approach is to think very carefully with people, not about stopping or changing the behaviour, but about understanding their relationship to it: what it has been doing, what function it has served, how it has helped them cope, and why they have come to rely on it over every other possibility. We do talk about alternatives. But almost every person I work with already knows the alternatives. They just don't choose them, because sexual reward has been primed so strongly in their development, their brains and their bodies that it becomes the most desirable thing. There might be seven or ten other things that would feel quite nice right now, but they will never feel as good as this. So what we are most curious about is: why is it at the top? The work doesn't begin with a list of things to do to stop, or new boundaries, or abstinence goals. It begins with mapping and understanding, and that in itself is very powerful and therapeutic.

Mapping requires compassion. To understand why we have come to relate to our sexual response in a particular way, we have to look back kindly at what we were given and what we were left without, what was modelled and what wasn't, the opportunities and messages that encouraged or inhibited our exploration of sexuality. Some men arrive at the point of total breakdown, and almost all arrive with intense self-criticism: they are in the wrong, to blame, broken. Sometimes there will be things we need to make amends for. But we can't do that without understanding why we were drawn to these behaviours. Doing so reduces the internal threat that keeps shame high, which matters because shame is often a big precursor to relapse.

Through the mapping we help people understand how their brains operate in relation to threat, drive and soothing, and why their capacity to self-soothe may be underdeveloped. We look at the context: how men are socialised to think about emotions and sex, experiences as a sexual minority, religion and culture and the shame that can come with them, gender norms that leave little room to explore the emotional side of sex, and more individual or traumatic experiences, including early attachment, where certain emotions weren't modelled or were actively discouraged. The compassion-focused approach shows why the pattern developed, but it also opens up the possibility of building something. It gives a rationale for developing skills to respond differently to internal and external threat, and to our sexual drive. Most of us, myself included, were never consistently taught to regulate emotions around sex. Nor were we taught how to cope with drive. What do you do when you feel horny? How do you sit with it, be curious about it, tolerate it for a while when you can't act on it? Nobody talks to you about that. So building the capacity to self-soothe is about responding better to threat, and also responding better to drive.

Values, preferences, then boundaries

From there we think in detail about preferred directions. We start with values: who do you actually want to be sexually, and what do you want your sexual life to look like? We do that alongside preference. A lot of approaches avoid discussing preference because it feels dangerous, as if talking about what you are into might tempt you back. In this work we embrace it. What do you actually like? What makes you feel fulfilled? What taps into arousal most strongly? Sometimes those are the so-called problematic behaviours, and there is something within them that meets a need or reflects a genuine preference. We draw that out honestly, and then sit it alongside values. Which parts of this are compatible with my values? To what degree could I do this and stay in line with them? How might I modify it? Then we think about boundaries. In many approaches boundaries come first: set boundaries and don't deviate. We do talk about boundaries early, as a scaffold, but we don't hold people to them until much later, because first we want people to be able to take ownership of their preferences safely, be comfortable with the feelings that brings, and see how it aligns with their values. Then the boundaries that follow allow a sexual life that honours their needs and what they are into, keeps them safe, and moves them in the direction they want. That only works with a compassionate understanding of where you are coming from first. Without it, you will feel fearful of these behaviours and run from them. The behaviours have a function. We may absolutely need to change them because they are causing harm, but we need to understand why they are there, and be honest about the parts we may need to hold on to for a sexual life that meets our needs in the longer run.

That means this approach doesn't necessarily lead to abstinence. It leads to a changing relationship with the sex we have, and with sexuality more generally: tolerating the feelings that come up, noticing what brings comfort and discomfort instead of running from it, being curious about what that means, and then making decisions about the behaviours we engage in, how we communicate with partners, and how we relate to our own bodies over time.

Sober sex

In the work we talk about sober sex. It is a colloquial term for sex that doesn't involve behaviours that cause us harm, or doesn't involve them in a way that causes harm. But sobriety here isn't about sobriety or abstinence. It's about being conscious, being grounded in active decision making that puts our best interests first. Sometimes that might include some risk, or forms of sexual expression that would be a challenge for other people. What matters is being conscious about what you are doing while you are doing it, how it aligns with your values consistently, and being honest about the boundaries you are setting. If we can't do that, we will quickly escalate into the same pattern. That is the work of compassion. Again, it isn't about being nice to yourself. It is about taking responsibility, and building the resilience to sit with discomfort when parts of us want to push further, deviate from the plan, or take that extra risk, while not denying ourselves something that may be important for our sexuality and wellbeing.

Why the group

We deliver this in groups, and very purposefully. The group does something one-to-one therapy can't replicate. First, hearing and connecting with different perspectives and stories of compulsivity thickens our own narratives. We recognise ourselves in others, are gently challenged by them, and reflect more deeply by holding what is going on for people with similar and slightly different experiences. The more perspectives we hold, the more actively we can think and the more informed our decisions become. Second, the group models compassion. It is hard to do for ourselves. We were never taught, and it feels alien when we have been told our whole lives that this is wrong, or that we are wrong, or when there has only been silence. Silence creates shame, and shame tells us to run from difficult feelings. In the group, men respond compassionately to each other, and it is often easier to do that for someone else first. Hearing someone's story, thinking about what you would suggest, making sense of their dilemmas, helping them feel held: doing that for someone else helps you do it for yourself. It becomes a practice, and because we are continually responding with kindness to what others bring, those skills of soothing and compassion become embedded over time, often without thinking. Third, there is being witnessed and heard. Shame struggles to continue to exist when it's witnessed, not judged, and made sense of in a shared and safe space. It immediately reduces threat, and that lets thinking emerge, including thinking about alternatives. Everyone we meet knows the alternatives. It is just that connecting with these alternatives can feel impossible whilst the pull of particular sexual behaviours remains strong. Accessing that alternative depends on practising regulation, soothing and compassion, so that the parts of our brain that can think, evaluate and make accurate decisions based on all of our needs, are switched on consistently.

Sex that feels theirs

Over time, the work pays less attention to the behaviour, its cost and how to stop it, and much more to where you are going and what you actually want from your sexual life. We are trying to move sex from something we have to do to cope or escape to something that feels like a choice. We explore what your arousal actually is, when it is there and how to respond, and when it isn't there, why we are pulled towards sex anyway and what else might help with whatever we are feeling. We build the ability to tolerate a whole range of emotions, from everyday stresses around money, work and relationships to the nuanced feelings that come up in sex. Can we name it, sit with it, and respond differently? Then we can step back and decide what our next action is, if any, and start to build a sexual life that feels fulfilling, safe and contained, whatever that looks like for each person.

At the heart of this is the ability to sit with intimacy. That doesn't mean monogamy or getting married. There is nothing like that in this programme. It means: can I be honest about what I'm feeling and what my body is doing, and what you are feeling and what your body is doing, and can we use that to have a connection that works for both of us? That is what sex is at its heart. Without those skills we cut off or deny parts of ourselves and start performing, which leads to risk and the consequences I have described. What we help people move towards is being able to have whatever sex they want in a way they show up for, are present for, without needing to mask or escape anything, and making decisions about sex with full knowledge of how it affects them and their partners, holding everyone's best interests in mind. What we hope people gain is a complete reconnection to body and sexuality. It isn't "I don't use drugs any more" or "I don't go to the sauna any more". It is: I can choose to have sex that fulfils me, I can sit with the feelings it takes to work out what I actually want, and I can decide what that looks like, holding in mind my needs, my preferences, my boundaries and my values. The aspiration is that the sex people are having feels theirs. It might not always be perfect, and there will be ups and downs, but they have actively opted for it, thought about their own needs and other people's and the risks, and decided consciously and consistently. That helps people feel in control, and when we feel more in control we are less likely to reach for something to fix, escape or avoid. So this isn't simply stopping a behaviour. It is changing the architecture underneath it, so that our relationship to sex is grounded in us and in our own needs.

Because men asked for it

Why did we develop a group programme? Frankly, because men asked for it. There is an inherent loneliness in this process. Going through it with no one to talk to is one of the cruellest experiences, and it compounds the loneliness, shame and emotional burden that often drive the behaviour in the first place. I think therapy can risk perpetuating that when it is only one-to-one. In my previous work, the men I saw asked for a group. People know there must be others going through this, and they wanted somewhere to talk and share it. The group grew out of that. But it isn't a nice-to-have. I think it is imperative in this work, because it allows a development of skills, understanding and a changing relationship with body and sexuality that isn't possible one-to-one. What has surprised me is how well people engage and how many come. When you start a group you don't know whether it will fall flat or stay a small side project. It has become the foundation of the way we approach this work. Not because it is an efficient way of getting more people through. It's actually the opposite.

What we have found is that the group is fundamental to helping people take a different position on their sexual lives. Some go on to one-to-one work later, and the group then supports much deeper conversations. People tell us they feel part of a community, they feel safe, and they can understand and share things in a way they never have before. In our research, and in my experience and opinion, the outcomes have been strong and consistent: reductions in the compulsive behaviour, reductions in other mental health distress, improvements in sexual function, and improvements in the ability to be self-compassionate, which are skills people take forward into their lives.

Where the gaps are

There is still more to do. Existing treatments aren't long enough, and more time and resource need to go into these approaches. We probably need better group interventions at every point in the cycle, from people more acutely affected by drugs or risk-taking through to people who develop serious mental health problems as a result. Support is fragmented. Too often people are taken into an acute mental health setting with no conversation about sex, or into a drug service with no conversation about the compulsive sexual behaviour. As a field, we are still learning. My view is that what we still too often get wrong is that we fixate on a behaviour. We try to change the behaviour as the route to stability. But it is very rarely about the behaviour. It is about how someone has been socialised towards sexuality, sexual response and the rewards of sex, and why they have come to over-rely on it. If we don't understand that, and don't make space to think about why it has risen to the top, we will never change the pattern.