Theoretical Assumptions on Pornography Problems Due to Moral Incongruence and Mechanisms of Addictive or Compulsive Use of Pornography: Are the Two “Conditions” as Theoretically Distinct as Suggested? (Analysis of the Grubbs moral incongruence model)

Comments on Pathway 1 of the Model: Dysregulated Pornography Use

The first pathway in the model is a simplified illustration of the processes involved in the development and maintenance of what Grubbs et al. describe as addictive or dysregulated pornography use. This pathway, in its present form, includes limited individual examples of differences (e.g., impulsivity, sensation-seeking, coping deficits), as predisposing factors leading to pornography use followed by dysregulation. The figure suggests that the dysregulated behavior leads to distress, both directly and indirectly, over self-perceived pornography-related problems. However, the key factors which are associated with the dysregulation of pornography use are only mentioned incompletely and superficially by Grubbs et al. (2018). Although this pathway is not the focus of the model, it would have benefitted from including more information on the development of dysregulated use of pornography in order to better distinguish (or connect) the two pathways.

Several studies have already emphasized that there are additional individual characteristics that may promote the development of addictive or dysregulated pornography use. Prominent examples include sexual excitability and motivation (Laier & Brand, 2014; Lu, Ma, Lee, Hou, & Liao, 2014; Stark et al., 2017), social cognitions (Whang, Lee, & Chang, 2003; Yoder, Virden, & Amin, 2005), and psychopathology (Kor et al., 2014; Schiebener, Laier, & Brand, 2015; Whang et al., 2003). These characteristics may not have a direct effect on symptom severity of addictive pornography use, but the effects are moderated and/or mediated by affective and cognitive reactions to external or internal triggers and executive (inhibitory control) functions resulting in the decision to use pornography (Allen, Kannis-Dymand, & Katsikitis, 2017; Antons & Brand, 2018; Brand et al., 2016b; Schiebener et al., 2015; Snagowski & Brand, 2015). Central to addictive pornography use are cue-reactivity and craving responses (e.g., Antons & Brand, 2018; Brand, Snagowski, Laier, & Maderwald, 2016a; Gola et al., 2017; Kraus, Meshberg-Cohen, Martino, Quinones, & Potenza, 2015; Laier, Pawlikowski, Pekal, Schulte, & Brand, 2013; Snagowski, Wegmann, Pekal, Laier, & Brand, 2015; Weinstein, Zolek, Babkin, Cohen, & Lejoyeux, 2015). It has been argued that the gratification experienced when using pornography reinforces—due to conditioning processes (Banca et al., 2016; Klucken, Wehrum-Osinsky, Schweckendiek, Kruse, & Stark, 2016; Snagowski, Laier, Duka, & Brand, 2016)—the aforementioned affective responses toward pornography-related stimuli, which leads to a continued use of pornography (cf. Brand et al., 2016b). Previous studies indicate that hyperactivities of brain-reward systems, especially those including the ventral striatum, are associated with an increase in craving and other symptoms of an addictive pornography use (Brand et al., 2016a; Gola, Wordecha, Marchewka, & Sescousse, 2016; Gola et al., 2017).

In their model, Grubbs et al. (2018) potentially subsume the well-known craving concept under the term emotional dysregulation. However, craving is much more than emotional dysregulation, since it represents the emotional, motivational, and physiological responses to addiction-related stimuli (Carter et al., 2009; Carter & Tiffany, 1999; Tiffany, Carter, & Singleton, 2000) resulting in both approach and avoidance tendencies (Breiner, Stritzke, & Lang, 1999; Robinson & Berridge, 2000). The relevance of studying craving processes in relation to findings revealed by the Cyber Pornography Use Inventory-9 (CPUI-9) (Grubbs, Volk, Exline, & Pargament, 2015b) has been noted, particularly as findings relating to compulsive use of pornography (as operationalized by the “perceived compulsivity” aspect of the CPUI-9) seem sensitive to both motivation to abstain from pornography and frequency of use when attempting to abstain (Fernandez, Tee, & Fernandez, 2017).

The component of “low self-control” in the model by Grubbs et al. (2018) potentially includes or refers to reduced executive functions and inhibitory control, as inhibitors of craving responses (Bechara, 2005), which further facilitates diminished control over the use of pornography. A dysfunction of control mechanisms, such as executive functioning, when being confronted with pornographic cues and coping with stress, were found to be poorer in individuals with tendencies toward addictive pornography use (Laier & Brand, 2014; Laier, Pawlikowski, & Brand, 2014a; Laier, Pekal, & Brand, 2014b). The dysregulation of pornography use may result from an enhanced responsivity toward pornographic cues and craving as well as reduced control mechanisms promoted by individual characteristics such as high sexual motivation, loneliness, psychopathology (Brand et al., 2016b; Stark et al., 2017), and impulsivity (Antons & Brand, 2018; Romer Thomsen et al., 2018; Wéry, Deleuze, Canale, & Billieux, 2018). In the model by Grubbs et al., these complex associations are limited to one dimension that implicitly summarizes some of these aspects. However, depicting the complexity of Pathway 1 would be helpful in distinguishing more precisely between the etiology of pornography-related problems in general, whether potentially due to moral incongruence and/or addictive or dysregulated use.

Comments on Pathway 2 of the Model: Experienced Problems Related to Pornography Use Due to Moral Incongruence

Based on previous studies, Grubbs et al. (2018) illustrate the interaction of several concepts that are theoretically linked to PPMI. While the findings are based on previously published research, they suffer from assumptions about “perceived addiction” and may in part be generating a false dichotomy based on how constructs and the scale are operationalized, together with being based on a small number of potentially limited studies conducted to date.

Grubbs et al. (2018) argue that religiousness is the very first predictor of self-perceived pornography-related problems and feelings of distress in Pathway 2. Judging from the arrows, Grubbs et al. seem to suggest a (at least partial) direct effect from religiousness to self-perceived problems. In addition, Grubbs et al. included an arrow from religiousness over moral disapproval of pornography and overuse of pornography to moral incongruence and then to self-perceived pornography-related problems and feelings of distress (see Fig. 1 in Grubbs et al., 2018). This seems to indicate a partial mediation from religiousness to self-perceived pornography-related problems and feelings of distress and the mediators could be moral disapproval, pornography use, and moral incongruence. In this case, it would be very interesting to see which additional factors may contribute to using pornography since religiousness and moral values diminish its potential use. In other words: Why do people with certain moral values use pornography, although the use violates their moral values?

One observation worth mentioning is that studies included in the meta-analysis investigated largely Christian male populations. For example, in the study by Grubbs, Exline, Pargament, Hook, and Carlisle (2015a), 59% of the participants were Christians (36% Protestant or Evangelical Christians, 23% Catholic Christians), raising the question if the model is particularly designed for a certain subgroup of religious individuals. Furthermore, approximately one-third (32%) of participants in this sample were religiously unaffiliated including atheists and agnostics. This raises questions as to how Pathway 2 of the model on PPMI may be valid for non-religious individuals when religiousness is the very first predictor. There are further potential interactions between persons’ characteristics and religiousness that are possibly involved in experiencing distress related to pornography use that may relate to pornographic content. For example, in individuals with a non-heterosexual orientation (at least 10% of participants in Grubbs et al., 2015a), there may be conflicts between an individual’s religiousness and sexual orientation/preference (which might violate religious beliefs), and such conflicts may impact feelings of distress related to the use of such pornography (e.g., non-heterosexual content). Such potential interactions are important to consider when analyzing effects of religiousness on PPMI. Similarly, with current pornography frequently depicting violence toward women and having popular themes of rape and incest (Bridges, Wosnitzer, Scharrer, Sun, & Liberman, 2010; O’Neil, 2018), should such content be considered when assessing moral incongruence? Unfortunately, those motivational and pornography-content-related factors are not included explicitly in the pathway/model. We argue that the factors leading to pornography use despite incongruence with moral and/or religious values are likely more complex and nuanced than presented.

Additional factors warranting consideration may include media-specific aspects and individual characteristics. Examples of media-specific factors, which have also been summarized by Grubbs et al. (2018), are affordability, anonymity, and accessibility (the triple A engine) as suggested by Cooper (1998), and the observation that Internet pornography offers the chance to escape from reality, as suggested in the ACE-model by Young (2008). Factors leading to pornography use, even though the use violates one’s moral values, could also lie in individual characteristics, such as trait sexual motivation (Stark et al., 2017). Past experiences associated with pornography use (e.g., experienced gratification and sexual satisfaction) (cf. Brand et al., 2016b), could also increase the likelihood of using pornography (continuously), given that sexual behaviors are naturally reinforcing (cf. Georgiadis & Kringelbach, 2012).

Our main point is that more connections between the two pathways are worth considering. This is particularly important since Grubbs et al. (2018) argue that they are aiming to contribute to “interpreting pornography addiction literature.” In addition, Grubbs et al. state: “More simply, as we review below, perceived addiction (as it has been considered in prior literature) is often likely functioning as a proxy for more general views of pornography use as problematic due to feelings of moral incongruence.”

We agree with “perceived addiction” not being the ideal term and potentially highly problematic. The use of the CPUI-9 total score to define “perceived addiction” does not seem appropriate given that the three subscales incompletely assess various aspects of addiction. For example, craving is not sufficiently considered (see above), addiction is not defined by quantity/frequency measures (these may vary widely in substance-use disorders; see also discussion of quantity/frequency measures as related to CPUI-9 scores in Fernandez et al., 2017), and many other aspects relevant to addictions are not adequately considered (e.g., interference in relationships, occupation, school). Many of the CPUI-9 questions, such as those related to emotional distress and derived from measures linked to moral/religious conceptions, do not correlate well with the two more strongly correlated CPUI-9 subscales related to compulsivity and access (Grubbs et al., 2015a). For this reason, some researchers (e.g., Fernandez et al., 2017) have stated, “our findings cast doubts on the suitability of the Emotional Distress subscale as part of the CPUI-9,” particularly as it is the Emotional Distress component that consistently does not show a relationship to quantity of pornography use. Further, the inclusion of these items in a scale that defines “perceived addiction” may skew findings diminishing the contribution from perceived compulsive use and inflating the contribution of perceived moral incongruence (Grubbs et al., 2015a). While these data may provide support for the separation of these items from the others in the scale (potentially in support of the proposed model), the items focus only on feeling sick, shame, or depressed when viewing pornography. These negative feelings represent only a possible subset of negative consequences related to Internet-pornography use, and ones that are arguably linked to specific aspects of specific religious beliefs. To disentangle addictive use and PPMI, it is very important to consider not only the PPMI side, but also potential interactions between mechanisms of addictive or dysregulated use and those contributing to PPMI in order to better understand the two conditions and whether they are, indeed, separate. Grubbs et al. (2018) argue (in the section: “What about a third pathway?”) that there might be an additional pathway of problems related to pornography use, which could be the combination of experiencing “objective dysregulation” and PPMI simultaneously. We argue that a combination of both pathways may not be a third one, but possibly a mechanism underlying “both” problems with pornography use. In other words, we posit that some of addiction-related processes and motivational factors may operate across PPMI and “dysregulated use.” These similarities may exist even if the time spent viewing pornography may differ with respect to generating distress or impairment in PPMI and “dysregulated use.” In “both conditions,” pornography is used more than intended, which may result in negative consequences and distress, and pornography use is continued despite negative consequences. The psychological processes underlying such use may be similar, and these should be investigated in more detail.

Comments on Potential Connections Between the Two Pathways Instead of Suggesting a Third Pathway

Multiple important questions remain: What is the nature of PPMI in terms of underlying psychological processes? Do people who report PPMI have the feeling of diminished control over their (small or medium) use of pornography? Do they feel that it is hard to resist using pornography? Do they experience a conflict between a high motivation to use pornography on the one hand and simultaneously a feeling that pornography use is forbidden because of moral values on the other hand? It is important to better understand the nature of desire and motivation to use pornography (Brand et al., 2011; Carpenter, Janssen, Graham, Vorst, & Wicherts, 2010; Stark et al., 2015, 2017) in individuals with PPMI. The desire and motivation of pornography use, the dynamic of affective and cognitive reactions when using pornography—e.g., in terms of incentive salience theory and dual process theories of addiction (Everitt & Robbins, 2016; Robinson & Berridge, 2000)—and consequently the experienced problems to control use, could be similar in individuals with PPMI and in those with dysregulated/addictive use. In this context, an important topic is craving (see above). Do individuals reporting PPMI experience craving and the urge to use pornography in their daily lives? Are they preoccupied by using pornography? Do they frequently think about using pornography or about whether they violate their values when using pornography? Do they have negative feelings when they do not have the chance to use pornography? These questions should be addressed in future studies on PPMI in order to better understand the etiology of this phenomenon. Additionally, an interesting topic to distinguish between PPMI and an addictive use of pornography would be the pornography-use-related expectancies, as demonstrated for other types of Internet-use disorders, behavioral addictions, and substance-use disorders (Borges, Lejuez, & Felton, 2018; Taymur et al., 2016; Wegmann, Oberst, Stodt, & Brand, 2017; Xu, Turel, & Yuan, 2012). Do individuals with supposed PPMI use pornography in order to avoid negative mood or to cope with daily stress? Do they expect a strong gratification (Cooper, Delmonico, Griffin-Shelley, & Mathy, 2004) that cannot be achieved by another activity? Are there specific situations in which they feel hardly able to control their pornography use (Kraus, Rosenberg, Martino, Nich, & Potenza, 2017) even if it is a violation of moral values?

The potential connections between the two pathways would be very interesting and could inspire future research. Investigators could potentially disentangle phenomena characterizing some individuals who perceive themselves as addicted to pornography or having PPMI, respectively, despite possible differences in pornography-use quantity or frequency.

Potential connections between the two pathways could be:

Comments on Clinical Implications

Grubbs et al. (2018) argue: “Regardless of whether an individual actually experiences excessive pornography use (e.g., addiction) or PPMI, we acknowledge both clinical presentations can be associated with emotional pain, psychological suffering, and significant interpersonal consequences. It is for this reason we advance our model of PPMI as an alternative conceptualization to help illuminate what the focus of clinical attention should be.” We agree with the view that both situations (and others) deserve attention by clinicians if individuals seeking treatment experience functional impairment or distress. Specifically, as noted previously by other researchers (Fernandez et al., 2017), it is important to consider individual clinical factors including those relating to moral incongruence. However, for the clinical differentiation of an addictive use of pornography and PPMI, a better understanding of common and differential mechanisms of both phenomena is mandatory. We further argue that a combination of processes involved in multiple forms of problematic pornography use may underlie psychological distress, compulsive use, and other factors experienced by individuals and should therefore be treated individually.

Grubbs et al. (2018) state: “In short, we posit that PPMI are real problems with real psychosocial consequences, but that the etiology of those problems is distinct from a true addiction. In clinical settings, being able to differentiate between these etiological variants is likely important.” As mentioned above, we agree with the view that both aspects—PPMI and dysregulated use—deserve attention in clinical settings. We would like to emphasize this point as we believe that the views posited by Grubbs et al. should not be interpreted as minimizing the impact of pornography use on individuals and their functioning. That is, we strongly believe that a PPMI model should not be used to minimize the clinical impact of problematic pornography use in its various presentations or to draw the conclusion that pornography viewing for individuals with proposed PPMI is innocuous, over-reactive, or otherwise inconsequential. However, it is possible that the processes of the development and maintenance of both perceived compulsive/addictive use and PPMI are less distinct than suggested by Grubbs et al. and there may be parallel or possibly synergistic rather than orthogonal mechanisms explaining psychological distress. It should also be noted that distress may change relative to stages of addictions and that this model should be tested in multiple clinical populations (e.g., actively treatment-seeking versus remitted), given potentially different levels of insight relating to distress and impact. It is plausible that the etiologies of both compulsive/addictive use and moral distress share some main motivational, affective, and cognitive processes. We believe that there are open questions relating to etiology and treatment of compulsive/addictive or distressing use of pornography, and understanding factors beyond those captured by the CPUI-9 and studied to date are needed to advance research and clinical practice. In this process, consideration of multiple facets of presentation are important, including motivations for seeking treatment, impact of pornography viewing, and goals of treatment. In some cases, it likely makes sense to use Acceptance and Commitment Therapy techniques, as suggested by Grubbs et al. However, in other cases, behavior modification and other techniques of cognitive behavior therapy may be helpful if the client’s goal is to better cope with his/her desires and cravings to use pornography and his/her cognitions, inhibitory control, and pornography-related expectancies (Potenza, Sofuoglu, Carroll, & Rounsaville, 2011). Multiple aspects should be taken into account when individuals experiencing problems related to pornography use seek treatment (Kraus, Martino, & Potenza, 2016). Therefore, multiple aspects—moral incongruence and mechanisms of an addiction process, such as craving, inhibitory control, decision making—should be considered fully when examining individuals’ problems related to pornography use to provide optimalized, individualized treatment.