By David Ley, 2016-08-31 (reposted with permission)
Clinical and psychological assessment is a nuanced, and sophisticated area. It’s also a deeply contentious area, with many “pet” assessments which are developed by thought leaders, to evaluate or test their specific theories. Psychological instruments convey a
level of science, and therapeutic value, which are sometimes deserved, and other times are used in ways which potentially violate informed consent by patients.
For example – the Myers-Briggs Type Inventory is a test with a great deal of history, often used in business settings and in relationship counseling. But, modern research largely reveals that it is a clinically meaningless and invalid (link is external)test based on antiquated, failed theories. Ethical, informed clinicians no longer use the test, so as not to waste our patient’s time, or to give them the false idea that the test is serving a clear clinical function. The sex addiction treatment industry commonly uses similar outdated and unsupported instruments in ways which pose potentially serious ethical concerns. The Sexual Dependency Inventory (SDI) is one such measure, prominently used by many in the sex addiction industry, despite some alarming weaknesses.
The Internet is filled with numerous online tests and screening tools which allegedly measure sex addiction. Most of these online tests are free, and appear to work as marketing tools for sex addiction therapists and treatment programs. One however, the Sexual Dependency Inventory-Revised (SDI-R) 4.0, is quite expensive, and commonly used by many sex addiction therapists who sometimes mandate their patients complete the test as a part of treatment. I recently encountered the SDI, in a forensic matter where a therapist had used the SDI 4.0 inappropriately, making custody recommendations on the basis of this test. This case led me to take a closer look at this instrument, which in turn, led to serious concerns about its use in clinical settings. I chose to draft this post in order to better inform patients who may encounter ill-advised use of the SDI by therapists.
The Sexual Dependency Inventory
The SDI-R 4.0 is described by authors as the only “broadband measure of potentially problematic sexual behaviors and preoccupations.” (Green et al, p. 127). It is a very long instrument, with over five hundred items, which allegedly assess an extremely wide variety of sexual and relationships issues. I was able to find and download the “SDI R- 4.0 Therapist Manual (link is external)” from IITAP, free on their website and is not identified as restricted or copyrighted. Nevertheless, in keeping with professional ethics regarding test security, I choose not to publish any verbatim items from the test in this article. Quotes used herein are used under Fair Use doctrine, and for the protected
purposes of clinical criticism.
The International Institute for Trauma and Addiction Professionals (IITAP) is an organization, founded by Patrick Carnes, PhD. and currently run by his daughter, which established their own training and certification for sex addiction therapists, and offers the
SDI-R 4.0 for a substantial fee through their website www.recoveryzone.com. The test is accessed by individuals through an interesting and relatively unique use of “tokens” which are purchased by clinicians, and then distributed to patients by the therapist. It’s apparently up to the clinician to set the fee for the patient to receive a token which allows them access to the test and report of test results. Most clinicians charge their patients between $85 and $250 per test. (This cost range is supported by the websites of various online therapists, as well as internal emails from IITAP staff.)
The Sexual Dependency Inventory – Revised, 4.0 is a muddled instrument which takes a “kitchen-sink” approach to testing, essentially throwing everything in, to see what sticks. It has few scientific publications describing it or its development. A very early (1998) version
of the test was briefly evaluated and showed some initial potential value. However, that version was less than a fourth as long as the currently administered test. There have been no further validity evaluations of the SDI-R 4.0 or replications of these results. Applying these initial findings from 1998 to the current version is contrary to industry standards: For instance, each time the WAIS (IQ test) is updated, the makers must develop and publish extensive statistical modeling and conversion scores, to allow comparison of the new version to past results. There is no evidence that such comparisons have been conducted or published. Indeed, in much of what is written about the SDI, it is typically quite difficult to determine what version of the test is being described. When there are apparently substantial changes happening across versions, this is a troubling lapse.
The SDI-R 4.0 now includes within it a number of distinct instruments, such as the Sexual Addiction Screening Test (SAST), tests of attachment, assessments of motivation for change, and numerous items and scales which allege to distinguish or identify various
sexual preoccupations, predilections and tendencies. The manual offers little information regarding any over-arching theory which ties these various items and tests together, and merely states “The SDI is actually a whole battery of relevant tests organized into one
cohesive report.” (page 3 of Manual). Unfortunately, many of these individual tests have limitations and problems themselves and combining them all into a single measure would require research to evaluate the degree to which these instruments may overlap or even
conflict, and whether their combined use leads to increased “convergent validity” in assessment and treatment. Moreover, there could be issues with ordering effect wherein responses to some questions impact how an individual responds to subsequent items. No
such research is evident in the manual, or published literature.
The SDI relies of course on the disputed, consistently rejected pop psychology concept ofsex addiction, as well as makes references to more unique concepts such as “eroticized rage,” “sexual anorexia,” and “intimacy disorders.” These concepts are used heavily in the theories of Patrick Carnes, PhD., but have not been adopted at a broader level in the mental health or addictions industry. They reflect antiquated and stigmatizing psychoanalytic theories. They are not accepted diagnoses or generally supported theories of psychological practice, mental health, or sexual development. It is also unclear how the items and structure for the SDI were deductively generated or developed. A 2015 paper indicated that during a structural analysis of the SDI, some items were retained as “critical items,” despite evidence that they had no statistical value.
The SDI-R 4.0 includes items assessing sexual behaviors related to various sexual subcultures, from the Lesbian, Gay, Bisexual and Transgender communities, to swinging communities, and those who engage in kink-related or BDSM types of behaviors. These
varied items, and issues imply that these behaviors are inherently evidence of disturbance in relationship, sexuality or mental health. There is no evidence in the manual, or in published research, that these items have been normed on members of these sexual populations who are not experiencing problems. As a result, it is quite likely that this test will inaccurately assess individuals who are struggling or questioning with their sexual orientation, kink, or interest in nonmonogamy.
In 1992, SDI author Patrick Carnes wrote: “The giving or receiving of pain, also known as sadomasochism or S&M, is a type of sexually addictive behavior in which pain is associated with sexual pleasure. There is a blatant imbalance of power between the giver and the receiver, although both partners may be consenting. . . .
Victims may perceive their feelings towards their torturer as loving, but there is no genuine trust or intimacy when a relationship is based on hurting one another.” This inaccurate and biased perception of BDSM relationships still pervades the SDI.
People who practice BDSM are often stigmatized inappropriately by sex addiction therapists.
The SDI-R 4.0 Manual and test interpretation contains troubling errors regarding sexual disorders, such as this statement: “Dressing and behaving like the other gender with a psychological preference to be the other gender (transvestitism)” (page 35 of manual) actually appears to be describing the issue of transgender or gender dysphoria. Transvestism is a paraphilia related to wearing the opposite gender’s clothing. Similar confusion regarding “cross-dressing” is noted in the manual. Errors such as these in a published clinical test, are troubling and invite a high potential for misinterpretation by both patient and therapist. They suggest a significant lack of awareness of sexological or sexual health treatment in the creation and development of this instrument. Given that it purports to assess and measure paraphilias and sexual behaviors, this is quite troubling.
Another glaring error lies in the marketing and general descriptions of the test, by the therapists who use it. It is frequently described online by clinicians who use it, as having “96.5% accuracy (link is external).” The origin of this misstatement is in the manual, where
one subtest, the SAST is described as having been “proven 96.5% accurate in identifying a clinical population.” (page 39, manual). Even this statement about the SAST is disputable, as there is no true “clinical” definition or criterion for such sexual behavior problems, and the SAST is not congruent with the most recent criteria proposed for Hypersexual Disorder. The SAST may be prone to false positives, because of its inclusion of issues related to moral and social attitudes towards sex. The fact that therapists use this statement inaccurately suggests either ignorance or deceptive advertising on their part – either of which are troubling.
Validity testing is a critical component in the development of any psychological test, and is a way to determine if a given test identifies issues that distinguish a clinical population from a nonclinical one. In other words, if there was research showing that the test
misidentified a person who is having no problems related to sex, then we would be concerned that this test may more generally mistakenly pathologize normal sexual variations in people. One of the severe weaknesses of the SDI, is its lack of “clinical cutoff scores” which identify problematic users from a normative population. Thus, without these cutoff scores, there is great chance of pathologizing normal behaviors. The SDI has been described (link is external)as limited in its reliance on self-report, with no external validation of confirmation on the patient’s affirmations. Such self-report responses can easily be influenced by feelings of shame and guilt, as opposed to actual clinical issues.
As far as I am able to determine, the only validity testing done on the SDI was conducted in 1998, on an early and different version of this test. As a result, we have no current evidence regarding what this instrument actually does. Based upon the information reviewed and described above, this writer concludes that use of the SDI R 4.0 in clinical or forensic settings is extremely questionable, unless a patient
is provided with informed consent regarding the limited validity and reliability of this experimental instrument. Results and predictions of the SDI-R 4.0 should be regarded with extreme skepticism without other corroborating information, test results or behavioral
evidence. The report itself can mislead patients into a belief that the conclusions reflect a scientific or clinical evaluation that is definitive which has the potential to cause psychological harm to those taking the test. The SDI R 4.0 is an internal, “home-grown” instrument, used only within the isolated “cottage industry” of sex addiction treatment. It seems that the test has been created more for a revenue stream for its authors than as a benefit for patients. The absence of the SDI-R 4.0 in generally accepted literature and methods raises significant ethical concerns about therapists administering and charging patients for clinical use of this instrument.
People seeking help for sexual and relationship matters are extremely vulnerable, dealing with intense issues of guilt, shame, fear and isolation. They are eager and desperate for help and reassurance. Such individuals are unfortunately highly disposed to believe and
trust based on the appearance of credibility and expertise. In dealing with such problems, clinicians must be extremely careful and thoughtful to educate patients about the limitations of our tools and methods. Therapists currently using the SDI-R 4.0 should
undertake a critical evaluation of its role and usefulness in their therapeutic approach.
There are numerous free tests available to them, with greater levels of research and support, which are less onerous for their patients, and which stand less likelihood of stigmatizing healthy aspects of sexual diversity.
David Ley PhD. http://www.psychologytoday.com/experts/david-j-ley-phd Albuquerque NM
Email: davidleyphd@gmail.com Twitter: @DrDavidLey