REFERENCES AND METHODS FOR DIFFERENT UNWANTED
BEHAVIORS AND THOUGHTS

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 A few books discuss "habit control" in general: Wexler (1991), Miller (1978), Martin & Poland (1980), Birkedahl (1991), and Prochaska, DiClemente, & Norcross (1994) are among the best.

 Abuse--physical, sexual, psychological--must be dealt with immediately and requires professional help. Suspected physical and sexual abuse of children (under 18) must be reported to Children and Family Services authorities who will investigate and arrange for treatment. See chapter 7 for physical abuse. See chapters 7 and 9 for sexual abuse (chapter 10 for date rape). If you fear you might hurt someone, get help immediately by calling your Mental Health Center or going to a hospital Emergency Room.

 Addictions, in general, were once thought to be the result of overwhelmingly powerful drugs or innately defective personalities (e.g. inherited or moral weakness). Today, the understanding of addictions is becoming very complex... to the point it may seem very confusing. There are valid arguments for genetic, biochemical, personality (emotional), family, peer, and community/cultural influences, all affecting the use of drugs and alcohol. Behavior is complex. Moreover, addictions are often accompanied by other serious disorders. For instance, about one third of substance addicted persons are also mentally ill. This is called a dual diagnosis. Looked at another way, about half of the mentally ill are substance abusers (and more would be if they could afford it). They are self-medicating. Interestingly, certain depressed persons consume coffee and cigarettes at a very high rate (10 to 15 cups per day) and this seems dependent on specific genes being present.

 Other life events are associated with addictive behavior; there was pain in the early lives of many addicts. Teens living with a single mother are 30% more likely to use drugs than teens in homes with two supportive parents. Bad relationships with father markedly increase the risk of drug use. Perhaps half of substance abusers have been victimized and about one third are diagnosable as Post Traumatic Stress Disorder. Likewise, half of all teenaged alcohol abusers have been physically or sexually abused, suffered the loss of a parent, or witnessed hostile, violent parents. Moreover, research has shown that Antisocial Personalities quickly become dependent on drugs, especially marijuana.

 In the area of drug and alcohol use, it is well to keep in mind that we are a drug using culture (Kuhn, et al, 1998). Indeed, about 95% of American adults consume some psychoactive substance every week. Yes, every week! This, of course, includes prescribed and alternative drugs, coffee, tea, cigarettes, and alcohol as well as illegal recreational drugs. Nevertheless, if you add in America's other compulsions of eating, making money, gambling, shopping, materialism, etc., one has to take seriously Bill Moyer's (Moyers on Addiction, WNET, 3/29/98) observation that we are a "culture of addiction" that demonizes some addicts and embraces others.

 One way to de-demonize addiction is to believe the addict is a powerless victim of some drug. Another way is to believe that addiction is a disease, something physical and totally beyond the addict's control. There are new books, The Selfish Brain (DuPont, 1997) and The Craving Brain (Ruden, 1997), which seek to prove that addictions are a brain disease. Their treatment is, of course, more drugs to affect the dopamine and serotonin levels and/or tough-love and AA approaches to strip away the addict's denial of a problem. Other studies have suggested that certain genes increase alcoholism and that addictions are 50% inherited. These physiological factors must be ackowledged, but thus far their import is unclear.

 There is evidence that men and women differ in their proneness to addiction, in their preference for a specific addiction, and in how they respond to treatment. In rats, at least, estrogen enhances the effects of certain drugs, such as cocaine. Women tend to use cocaine to self-medicate depression; men use cocaine when they feel OK but want to feel better. Women tend to smoke cigarettes to control their mood and appetite; men smoke to reduce aggression and stress. Nicotine replacement treatment works better with men; anti-depressants and support groups help women more.

 The psychological view (Peele, 1998), opposing the disease model, is that addictions are behavioral adaptations to one's environment. This doesn't deny the possible long-term physical addictive qualities of substances, like cocaine, nicotine or alcohol, but the emphasis is on this being a behavior that is acquired and changed like other habits, not a disease, like cancer, or a brain disorder, like schizophrenia. From this perspective, it is believed by many therapists that an addictive habit often serves the purpose of relieving pain or distracting the victim from some stressful emotion, such as feeling inadequate, being depressed, being consumed with anger, shame, or guilt, etc. In short, addictions try to help us cope with and cover up emotions that trigger the addiction. So, the solution for many therapists is to get your emotions under control. See Clancy (1997), Dodes (2002)--powerlessness & anger, Santoro & Cohen (1997)--anger, Black (1998)--shame, Birkedahl (1991)--better habits, Ellis (1998)--upsetting thoughts, Hirschmann & Munter (1995)--poor body image, Twerski, (1997)--self-deception, and Washton & Boundy (1989)--self-misunderstanding, who take this approach.

 Addictions are commonly broken into several types, such as alcohol, drugs, eating, gambling, sex, internet and so on. Then when books, therapists, treatment centers, self-help groups, and book chapters (including this one) are organized into these specific addictions, it gives the impression that an addict usually has only one particular need or "fix." That is misleading. Experienced counselors, such as Julian Taber, believe that addicts have tendencies towards several addictions, often in the form of an addictive personality. So, if and when one addiction is stopped, another addiction soon replaces it. Thinking of the disorder in this way leads to the notion of a generalized "Addictive Response Syndrome" which probably results from basic personality weaknesses and coping skills deficiencies, not just from an overriding need to drink, eat, gamble or whatever. New research also supports the general addictive personality notion (Holden, 2001; Helmath, 2001). This goes counter to the common belief that just stopping the addict's one troublesome behavior will automatically result in a normal, wholesome adjustment. Adequate treatment or self-help will almost certainly involve more than just curtailing one out-of-control habit.

 The disease oriented approach, i.e. Alcoholic Anonymous (AA), has been essentially the only treatment available since the 1930's until this decade. Even now, AA is the treatment commonly recommended, especially by medical institutions. AA and the 12-step programs have, indeed, helped millions, but there are a lot of people they don't help (Kasl, 1992). The relapse rate of AA members is over 70%. Recently, many specialists in the area of addiction have come to believe that lots of ordinary experiences can become addictive, such as work, sex, exercise, eating, making money, shopping, socializing, etc., and anyone can, under the right circumstances, become addicted. This leads many experts to question the old notion that alcoholism is primarily an inherited disease and that the victim is powerless against it without God's help and a life-long 12-step program for guidance.

 Actually, giving up the traditional disease concept helps many alcohol treatment centers accept new treatment approaches, such as various new drugs as well as aversion treatment, behavioral shaping, family therapy, motivation interviewing, and many other forms of psychological treatment (Rodgers, 1994). And giving up the disease concept helps some people, who reject the I'm helpless and religious ideas, seek help (to control a bad habit). There is still much we don't know in this area, including such things as how many Vietnam veterans could just leave their heroin addictions behind them when they returned to the states. Also, why do 95% of the people who quit smoking do it on their own but, according to some, only 20% of drinkers stop without outside help (at the same time, 90% of smokers are considered "addicted" but a much lower percentage of drinkers considered themselves addicted)? The wholesome questioning and doubts about the causes and treatment of addictions should lead to a lot of change, experimentation, and controversy in the area of addiction treatment during the next decade.

 Addiction therapists with new and different orientations have recently made great contributions to our society, not just in the form of treatment methods, such as relapse prevention, but also by focusing on the effects of an alcoholic family member on other members (codependents, abused children), clarifying the role of shame, and highlighting the need to take care of the hurt inner child (see codependency and children of alcoholics below).

 Illegal drugs are used (1) because they help us feel good, (2) reduce or avoid unpleasant feelings, (3) aid our socializing, and/or (4) because we are physically addicted. Drug treatment needs to be tailored to fit the addict and his/her needs. Severe cocaine addictions require inpatient treatment for 90 days or more. Moderate cocaine users can benefit from outpatient drug-free programs. In general, however, all forms of treatment have many failures, e.g. at one year follow-up 25% are still regular cocaine users (Simpson, Joe, Fletcher, Hubbard & Anglin, 1999). For good general references about drugs see Weil & Rosen (1993), Marlatt & VanderBos (1997), and Easterly & Neely (1997). For quick references about drug abuse click to Yahoo! Substance Abuse, PREVLINE, National Institute of Drug Abuse, Web of Addictions, or Marijuana Anonymous World Services.

 For a listing of local drug and alcohol treatment centers, go to: The Substance Abuse and Mental Health Services Administration.

 Alcoholism is wide spread. It is a very serious personal and social problem (Milgram, 1993). Today, it is estimated that 10% to 15% of men and 3% to 6% of women are dependent on alcohol. Alcoholism rates vary by ethnic groups: 12% of whites, 15% of African-Americans, 23% of Mexican-Americans are problem drinkers. It is estimated that 25% of the people who turn to alcohol do so to deal with stress. In 10 years, it is believed that alcoholism and depression will become our most costly health problems, overtaking cancer. Excessive alcohol can damage many organs of the body. 100,000 die each year from alcohol related diseases and traumatic deaths. 40% of all industrial fatalities are alcohol related. Alcohol is also a factor in 45% of all fatal auto crashes (almost 17,700 deaths in 1992). Non-alcoholic men, aged 45-59, earn $24,000 per year, but alcoholic men only earn $16,000 and 33% have work attendance problems. About one-third of people with drug or alcohol problems are also depressed. And, 30% of suicides (46% of teen suicides) involve alcohol. Indeed, drug and alcohol addictions are thought to be dangerous ways of attempting to cope with emotional and interpersonal problems, such as shame, guilt, loneliness, resentment, fear, etc. Yet, families wait an average of seven years to seek help.

 Teenage alcohol and drug use increased in the 90's. Remember, one in five children live with an addict. Children of alcoholics have more ADHD, more conduct disorders, and more anxiety than children of non-alcoholics (see comments under Codependency). Moreover, a parent who is a heavy user of alcohol increases the chances that his/her child will start using early. 43% of sons of alcoholics become dependent. The younger one starts, the more likely one is to become alcoholic, e.g. 40% of those starting before 15 will develop an addiction (starting even younger, increases the risk further). Other factors that increase the use of alcohol by teens are: Being socially needy, having friends who push alcohol, being shy and insecure, lacking self-confidence in school, having poor self-control and sometimes psychological problems, such as depression, anxiety, self-doubts, and feeling antisocial or controlled by others (Scheier, Botvin & Baker, 1997).

 Total drug and alcohol consumption declined among U.S. college students between 1980 and 1992, but the pattern of drinking has changed. The amount of alcohol consumed in each separate drinking session increased. That is, college students are moving towards more binge drinking (defined as 5 or more drinks in a row for men and 4 for women). "Frequent" binge drinking is 3 or more times in two weeks. A large national study (Wechsler, Dowdall, Davenport & DeJong, 1993) found that 44% of college students had binged during the prior two weeks (50% of men and 39% of women). About half of the binge drinkers were frequent binge drinkers. Among the latter group, 70% of the men and 55% of the women were intoxicated 3 or more times in the last month. They drank to get drunk. Few think they have a drinking problem. As a consequence, college students are experiencing more blackouts, arrests, loss of friends, assaults, sexual harassment, and so on. Among frequent binge drinkers, 62% of the men and 49% of the women had driven after drinking.

 One doesn't have to be an alcoholic, however, to have serious problems with alcohol. 80% of drunk drivers in fatal accidents and 67% of persons arrested for drunk driving are not alcoholics. One doesn't have to be poor to have an alcohol problem, among women over 55 who make more than $40,000 a year, 23% have an alcohol problem. Only 8% of women this age, who make less than $40,000 a year, have alcohol problems.

 Alcoholism remains very resistive to treatment. Peele describes the effectiveness of treatment this way: Most American alcoholics don't seek treatment; most of those that do enter treatment don't respond to it favorably; most of those who complete treatment relapse later! As mentioned above, there has been a heated controversy between (a) "alcoholism is a disease" (AA groups) which supposedly can only be controlled by total abstinence and (b) "alcoholism is a learned behavior" which can, in less severe cases, be unlearned, controlled, and done in moderation (Miller & Berg, 1995; Miller & Munoz, 1976; Miller, 1978; Marlatt & Parks, 1982; Vogler & Bartz, 1985; Peele & Brodsky, 1991; Peele, 1998). Current evidence suggests both views may be partly right. For instance, there are very few ex-smokers who can occasionally light up and not get addicted to cigarettes again. This supports AA's position that total abstinence from an extreme addiction is required (although the cigarette habit is different from the drinking habit). Most psychologists would probably suggest that persons with serious, long-term drinking problems are not good candidates for controlled drinking experiments; it is believed that they need to abstain and probably get intensive professional treatment for alcoholism and any underlying emotional-personality problems.

 There are many treatment programs, some very expensive and with national reputations, but only 1 in 7 clients complete these programs. After a few weeks of treatment (depending on the insurance available), typically the clients are urged to attend AA. On the other hand, there are many millions of people who have been moderate to heavy drinkers and want to continue drinking moderately and reasonably; they are often able to get and keep the habit under control. All drinkers are not doomed to life-long AA meetings and total abstinence may not be necessary, but all potential addictions are a serious concern. Since controlled drinking is a new approach, we know little and there is much to be learned. Certainly there is a flood of new books and programs being offered for sale (see below).

 Cooper (1994) explains alcohol use in terms of reinforcement: internal positive reinforcement (feeling more relaxed, more assured, more powerful...), internal negative reinforcement (avoiding unpleasant feelings, such as loneliness, depression, anxiety...), external positive reinforcement (being accepted, being praised, making friends...), external negative reinforcement (avoiding unpleasant experiences, such as rejection or failure--because you never tried). This theory suggests drinking can be changed by changing the reinforcement one gets from drinking or not drinking. Surely to some extent, drinking follows the same laws of learning as all other behaviors.

 College students often believe that (1) learning to refuse unwanted drinks, (2) setting time limits on drinking, and (3) avoiding heavy drinking buddies can help you control your drinking, if you are not yet addicted. Sounds reasonable but, as we have seen, there is good reason to question just how well college students actually control alcohol consumption, e.g. college students consume an average of 34 gallons of alcohol (mostly beer) per person per year. That's drinking more alcohol than soft drinks. Yet, despite this fling into alcohol and drugs when young, millions of the potential addicts in college become sober parents who vigilantly try to guard their children against drugs and the fruit of the vine.

 An interesting social control method has developed as part of an effort to reduce bingeing in college. It is called the "social norms method." Basically, it is getting out the truth, e.g. most students think other students drink more than they actually do, which seems to encourage others to drink more. However, if it is well (and accurately) publicized that "only 27% of our students have 5 or more drinks while partying" (while students erroneously believe over half are having more than five drinks on a binge), the overall rate of bingeing goes down. The media can be powerful, although the old scare tactics didn't work.

 Alcoholic women are more likely to be depressed and anxious; alcoholic men are more likely to have anger and an antisocial personality disorder. Social pressure to drink is more common among men; women drink alone more often than men. Among adolescents, problem drinking is associated with delinquency, violence, and lower grades. Alcohol may increase blood pressure or pulse rate and, thus, may be associated with strokes. Alcohol certainly is a serious threat to a developing fetus; please, never drink when pregnant.

 In temperance cultures (where alcohol is viewed as a dangerous addiction from which you must totally abstain), drinkers tend to binge to get drunk, rather than drink beer or wine with meals every day. In cultures where drinking is accepted as a daily part of life, people seldom get drunk, and when they do have health problems from drinking, the family simply helps them get back on a healthy diet. "Demon alcohol" is not blamed and a religious solution, like AA, is not prescribed.

 Men are more likely than women to become addicted to alcohol. The slippery slope of alcoholism is pretty predictable for men: by mid to late 20's, there are binges, morning drinking, and job problems; by early to mid 30's, blackouts, shakes, car accidents, DUI arrests, poor eating habits, terminations at work, and divorces; by late 30's to early 40's, there are serious medical problems, such as vomiting blood, hepatitis, hallucinations, convulsions, hospitalizations, and life in general is a wreck. The earlier you get off the slope, the better. It can be a slow suicide, with your only "friend" in the end being a bottle. If you have any reason to believe you may be in trouble, DO SOMETHING, NOW! DENIAL IS THE GREATEST RISK.

 Do you think you may have a problem? The World Health Organization defines having over 28 (men) or 18 (women) drinks per week as "hazardous drinking." Fifteen drinks are more than consumed by 80% of Americans; 40 drinks per week are more than 95% of Americans drink. If you only occasionally binge but have 6-8 or more drinks at a time, you may have a problem. Mayfield, McLeod & Hall (1974) used four brief questions, called the CAGE questionnaire: (1) Have you ever felt you should Cut down on your drinking? (2) Have people ever Annoyed you by criticizing your drinking? (3) Have you ever felt bad or Guilty about your drinking? (4) Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (Eye-opener)? Two "yes" answers are considered a sign of possible problems (two yeses accurately identifies 80% of alcoholics).

 Peele (1998) suggests asking yourself "How much do I get out of drinking?" and compare this to "How much is drinking hurting me?" If you conclude "I'd be better off if I drank less," then you have a self-improvement project to work on. Westermeyer offers a Self-scoring Alcohol Check-up on his HabitSmart Site. One of the nice features of this questionnaire is that it will help you identify some of your reasons for drinking. That information may help you know where to focus your self-help efforts to reduce your need to drink. Another evaluation of the seriousness of drinking is used by the World Health Organization. A very similar test is at Screening Test but it also provides a quick interpretation and some information about changing.

 Watson and Sher (1998) reviewed all previous studies of people who changed their drinking habits by themselves, without treatment. Note: they say 75% of the people who successfully resolve their alcohol problems do so without treatment (others give a much lower estimate). It is important to study the self-help methods they used. The researchers found eight useful self-change processes: (1) Consciousness raising, learning more about alcoholism, being confronted by friends, spouse, or employer, being warned by a physician, etc. (2) Self-evaluation, realizing "I have a problem," weighing pros and cons of drinking, "hitting bottom," etc. (3) Situation-evaluation, seeing effects of drinking on the environment, work, or relationships, etc. (4) Committing to making a change, "I've got to quit," "That is the last time I get drunk," deciding to tough it out, etc. (5) Replacing drinking with another activity, drinking soft drinks, playing sports instead of stopping at the bar, becoming a good student, etc. (6) Changing the environment, getting beer out of the house, refusing invitations to "go out," avoiding drinking friends, etc. (7) Rewarding quitting, taking pride in accomplishments, accepting praise from others, using saved money and time in enjoyable ways, etc. (8) Getting support from others, building contacts with spouse and children, getting appreciation from co-workers, etc.

 All of these self-help procedures are described in this book, mostly in this chapter or chapter 11. Note: self-treatment doesn't have to be complex. For instance, Linda Sobell and her colleagues at Nova Southeastern University (June, 2002) studied the effects of bibliotherapy, much like the information given here, on drinking behavior. These researchers merely sent (a) written material about the effects of alcohol, (b) suggestions concerning self-monitoring, (c) ideas about lowering the risks of drinking and (d) motivational material to people who answered an ad saying "I want to do something on my own about a drinking problem." Following up one year later, they found these subjects were consuming 20% fewer drinks, binging 33% less often, and having 58% fewer negative consequences from drinking. By the way, some of these subjects, who had never sought treatment before, did after trying to change themselves. The implications are that a public health/psychosocial educational approach could economically help many problem drinkers who wouldn't seek the usual "clinical" approach, namely, waiting in denial until you deteriorate to the point of needing expensive residential treatment for alcoholism followed by a life-time of AA groups. (Note: this study did not measure how much self-change would have occurred if no information at all had been sent these subjects.)

 If you are very addicted, however, you may need to go to detox, then get into a residential treatment program, followed up by individual talking therapy and also an AA, Rational Recovery, or other support group listed below. You would be wise, even though some stop drinking on their own, to be in both therapy and a group because you may need the group to stop or curtail your drinking and you may need the therapy to learn new constructive behaviors, attitudes, emotions, relationships, and self-concepts. Keep your motivation high (Methods #5 and #14 in chapter 11; Method #14 in chapter 14). Constantly remind yourself of your reasons for drinking less--health, money, greater effectiveness, better relationships, etc. Keep a record of your behavior (Methods #8 & #9 in chapter 11). Specifically use role playing to rehearse how to handle invitations to "have a beer" or "come party with us" (Method #2 in chapter 11; Method #1 in chapter 13). Practice handling tempting situations, e.g. when someone you are with orders a drink. Practice repeatedly exposing yourself to a favorite drink for 30 minutes without drinking any of it, learning you can control this habit, then throw it away (Sitharthan, Sitharthan, Hough & Kavanagh, 1997). Most importantly, prepare carefully and in detail for possible lapses (this chapter and Method #4 in chapter 11). Always reward your progress and be proud of your developing self-control, it's a tough undertaking (Methods #16 and #19 in chapter 11).

 It is important to realize that relapse rates are quite high even among addicts who have completed a professional treatment program (remember 6 out of 7 drop out of such programs) and have received Relapse Prevention Treatment (plus perhaps attending AA). It is very hard to maintain your gains (as with weight, once "clean" we may "slack off" too much). However, Dimeff and Marlatt (1998) found that relapse prevention training doesn't prevent "slips" but reduces the harmful consequences of relapsing, enabling the addict to get back on his/her feet faster. They also recommend two more things to help prevent relapse: (1) maintain occasional contact with your addiction therapist, and (2) take very seriously the idea that other mental health problems may need to be dealt with in order to maintain your therapeutic or self-help produced gains.

 For hundreds of books about alcoholism and 12-step (AA) programs write or link to Hazelden, Box 11, Center City, MN 55012. Yoder (1990) lists many recovery resources. Even the almost 60-year-old AA "bible," which has helped millions, has been updated (J, 1996). Most of the Hazelton books focus on chronic drinkers, but actually more people are "problem drinkers," i.e. have some problems due to drinking (arguments with spouse or friends, late to work, hangovers, etc.) but are not totally dependent on alcohol, yet. With that idea in the air, there is now an impressive stack of learning or cognitive-behavioral based self-help books on the market. Sobell & Sobell (1993), Fanning & O'Neill (1996), Miller & Berg (1995), Trimpey (1996), Dorsman (1998), Kishline (1995), Sanchez-Craig (1995), and Miller (1998) have developed self-management programs (sometimes administered in cooperation with therapists) for problem drinkers who haven't become addicted, yet. Other researchers (Hester & Delaney, 1997) have developed and tested a Program for Windows, a computer program which teaches self-control methods for problem drinkers. Although research is rare in self-help, the effectiveness of some of these books and programs have actually been published, e.g. Sobell & Sobell, Sanchez-Craig, Miller and Hester. If anger seems to be an important part of your addiction and precedes your relapses, see Clancy (1997) or Santoro & Cohen (1997). The books above are your best sources of advice if you are hoping to curtail your own drinking.

 Some of the treatment manuals might serve as excellent guides for the self-helper, e.g. Higgins & Silverman (1999), Motivating Behavior Change Among Illicit-Drug Abusers, Kadden, et al. (nd), Cognitive-Behavioral Coping Skills Therapy Manual, from the NIAAA and also Monti, Abrams, Kadden & Cooney (1989). Alan Marlatt (1998) has recently coined a phrase, Harm Reduction, describing a therapy that helps the user understand the risks involved in his/her habit and then helps them make the health and mental health changes they want to make. A group of psychologists at the University of Washington has produced a manual for applying the Harm Reduction approach (Dimeff, Baer, Kivlahan & Marlott, 1999). In a well controlled study of college students, this method, using questionnaires and 45-minute interviews every 6 months, reduced drinking and associated behavior (fighting, DUI, missing class, unprotected sex) substancially. Recently, a couple of studies have combined several sessions of cognitive-behavioral treatment (aimed at controlling drinking) with a new drug, naltrexone, which supposedly reduces the craving for alcohol. One investigator, Raymond Anton at Medical University of South Carolina), reported the initial results as being more abstinence, fewer drinks, and fewer relapses (American Journal of Psychiatry, 1999, 156, 1758-1764). Even a cable TV network in California, Recovery Network, has been devoted to education and overcoming addictions. Things are changing (in response to the huge anticipated drug and alcohol problems).

 Everyone seems to agree that support from an understanding group is helpful (although Trimpey says it's not good to hang out with former drunks). Kishline (1995) has started a self-help group for problem-but-not-chronic drinkers; the emphasis is on moderation, not on life-long disease and total abstinence (see her book for help in finding a non-AA group). Several other alternatives groups, quite different from AA, have sprung up in the last 15-20 years. They can be found at Rational Recovery Systems, Women for Recovery, Moderation Management (MM), S.M.A.R.T. Recovery and LifeRing Press has put the book, Sobriety Handbook: The SOS Way, online. On LISTSERV@MAELSTROM.STJOHNS.EDU one can subscribe to a Controlled-drinking/drug use discussion group (just type SUBSCRIBE CD then your name as the message).

 In the last couple of years many big alcohol and drug abuse Web sites have blossomed, including National Institute on Alcohol Abuse and Alcoholism, PREVLINE, Substance Abuse and Mental Health Services Administration, Food and Drug Administration, SoberRecovery, Yahoo! Alcoholism, Web of Addictions, Online AA Recovery Resources, Recovery Network, Habit Smart, and Alcoholic and Addiction Resource Guide.

 Professional psychologists (Santrock, Minnett, & Campbell, 1994) in the early 90's considered Twelve Steps and Twelve Traditions (1990) by Alcoholics Anonymous World Services to be one of the best self-help books available, although the AA approach was considered highly religious and almost "cultish" by many. (AA still helps far more than any other single method.) Psychologists also approve of approaches very critical of AA, such as The Truth about Addiction and Recovery (1991) by Stanton Peele & Archie Brodsky, When AA Doesn't Work for You: Rational Steps to Quitting Alcohol (1992) by Albert Ellis & Emmett Velton, and Alcohol: How to Give It Up and Be Glad You Did (1994) by Philip Tate.

 For personal help and treatment, call your local Drug and Alcohol Abuse Treatment Center or seek individual therapy (see white and Yellow Pages). Remember: if addicted, you may need detox first, then treatment. For referrals to 12-step programs, call Alcoholics Anonymous (212-647-1680). For general information, local treatment programs, and referral to AA call the Nat. Inst. on Drug Abuse and Alcoholism (800-662-HELP or 800-622-2255 or 301-468-2600). Social support clearly helps prevent relapse. However, even if you are in AA, it is important to think in terms of going beyond abstinence into learning better self-esteem, control of emotions, ways of thinking, interpersonal skills, and new areas of interest (O., 1998).

 Spouses and children of alcoholics should know about Al-Anon and Alateen which help relatives of alcoholics (also see White or Yellow Pages for local numbers). Children of alcoholics should also know about NACoA. For parents of alcoholics, see Our Children are Alcoholics, from Islewest Press. There are many kinds of reactions to living in an addictive family; thus, in addition to behavioral approaches, there are personal growth and insight approaches (see Black, 1987; Bradshaw, 1988, 1989; Gravitz & Bowen, 1986; Woititz, 1983). Professional psychologists consider Claudia Black's (1981) It Will Never Happen to Me to be the best self-help book for children and spouses of alcoholics (Santrock, Minnett, & Campbell, 1994). Obviously, there is an enormous amount of information and helpful resources for dealing with addictions and potential addictions.

 Lack of Assertiveness is discussed in detail in chapters 8 and 13 (Alberti & Emmons, 1986).

 Attention Deficit Hyperactivity Disorder (ADD or ADHD) is, according to a leader in this specialty, Russell Barkley (1997), not intentionally defiant inattentiveness but rather a genetic, biologically determined (1) lack of a sense of time, (2) lack of problem-solving ability, and (3) the inability to use information to achieve purposeful goals, e.g. to control their own emotions or to stay on task when a more interesting option appears. According to this theory, ADHD sufferers are unable to anticipate future consequences or pitfalls, as most of us do, so they stumble along from one frustration to another. Their behavior often looks to others to be restless, “spacy,” distractible, willful, irritable, irresponsible, forgetful, undependable, impulsive, uncontrollable or random (basically I’m-not-paying-attention-to-what-you-say). Therefore, ADHD children have been shamed, punished, and called stupid or rotten. But since they lack hindsight and foresight--due to a physiological disorder--they can hardly be held fully responsible for their short attention span, disregard for the rules, and inability to follow directions.

 Therefore, ADHD is not considered primarily a psychological disorder, although behavioral principles can certainly be used to provide structure for controlling impulsive or inattentive behavior. Traditionally, there have been two types of ADHD: (1) inattentive (ADD) and (2) inattentive with hyperactivity (ADHD). However, recent authoritative texts (Incorvaia, Mark-Goldstein & Tessmer, 1998) suggest three or maybe five or six sub-types: (1) quiet, (2) overactive, and (3) overfocused or those three plus (4) depressive, (5) anxiety, and (6) explosive types. They contend each type needs a different complex treatment and that Ritalin or longer-lasting Adderall is not the complete treatment for all types (actually, not for any type). According to these authors, careful diagnosis is crucial because a stimulant may be actually harmful when given to inappropriate types. (Why a stimulant slows a ADHD child is not known.) Anti-depressants or other medication might work better in some cases, they say. An estimated 70% to 75% of 5-year-olds to teenagers with ADD or ADHD benefit from Ritalin/Adderall. The new drug, Allerall, has been on the market for a year or so. Of interest to parents, Allerall can be taken in one pill in the morning before school; Ritalin requires a second pill during the day. Also, it is claimed that Allerall works with some children who do not benefit from Ritalin. Stimulants are not a total cure and have side-effects but usually they help (for the down side, see deGrandpre, 1998). This means that an ADD patient must see an informed MD. But with or without medication, most people with this diagnosis need psychological treatment, behavioral control training, and, as children, special teaching-parenting methods.

 It may not be surprising that 90% of children and adolescents who are given the rare diagnosis of bipolar are also diagnosed as ADHD. ADHD is a much more common diagnosis than bipolar at that age, so the classification as ADHD is not a good predictor of becoming bipolar as an adult. Only very aggressive, anxious or depressed ADHD children are more likely to become bipolar as adults. Half or more of ADHD children are also diagnosed Oppositional Defiant Disorder (with the subtle implication that there is more than a brain disorder here) or Conduct Disorder. Follow-ups as adults confirm that ADHD in childhood is somewhat associated with a diagnosis of Antisocial Personality or Substance Abuse as an adult (but the connection is not so high that parents should despair). Moreover, learning problems are found in 15% to 30% of children and teens with ADHD, so tests for learning disorders are needed. In the other direction, however, about 50% of learning disabled children have ADHD. All of this indicates that this diagnosis is very complex, requiring very sophisticated investigation of several areas, both biological and psychological. ADHD and ADD certainly vary in severity--some are “out of control,” others are only moderately inattentive. So, experts and tests are needed; it is not a quick-observation-in-the-classroom or a do-it-all-by-yourself area. Therefore, my brief focus here will be more on self-help steps for adults with ADHD than on treating childhood disorders.

 ADHD and Attention Deficit Disorder (ADD) are much more commonly diagnosed among pre-teen boys than girls (4 to 9 times as often), although some doctors think the same number of girls as boys tend to be ADD and (1) active tomboys, (2) withdrawn daydreamers, or (3) constant talkers. All three types are likely to be disorganized, undisciplined, and inattentive. Girls are not as likely as boys to be over-active, impulsive and rebellious or "difficult". About 50% of people suffering from ADHD or ADD seem to get some relief at puberty, the other 50% retain some symptoms all their lives. This notion of adult ADD has only been emphasized recently; several books and Web sites for adults will be cited later. Some studies estimate as high as 20% of adults have this handicap; others say it is more like 5 or 10%. Studies have shown that 4% of adults can’t organize their activities, can’t focus on a task for long, and jump from one stimulus to another. There seems to be a genetic factor. Medication and cognitive-behavioral therapy are helpful with adults too. The psychotherapy and skills training mostly provide the client with self-awareness of the disorder (it is relieving to know what is wrong and that you aren’t just stupid, crazy, or mean) and with ways of developing a structure or some guidelines for accomplishing important tasks (Hollowell, 1997).

 Barkley, Hollowell, Incorvaia, and others make the point that structure must be given the ADHD person in real life settings (not just in a therapy or training session) and under supervision. Barkley’s example is that a training session for being on time will probably not work with a person who has no sense of time...and a poor memory. The structure must be in the immediate environment (not in their head which is jumping from place to place), i.e. provide children with supervision and very simple external prompts to staying on the right path, cues to and reminders of what to do NOW, etc. Likewise, adults frequently need To-Be-Done lists, appointment books, watches with alarms, well rehearsed self-instructions, an everything-in-its-place lifestyle (keys always left by the door), very simple filing systems or someone to maintain their files, if possible a coach on hand to encourage them and keep them on track, etc. A schedule for exercising with a buddy or for meditating would be beneficial. The ADHD must arrange the environment to make up for his/her lack of a sense of time and distractibility. And, medication may be a life-long necessity; stimulants, like Ritalin, are safe (only if used properly) and non-addictive; it doesn’t give you a “high.” ADHD is treatable, but not easily. You need expert help.

 Just because ADD and ADHD are thought by many to be biological disorders, it would be a mistake to dismiss the many psychological and interpersonal aspects of this problem. The behaviors involved in ADHD (inattentive, forgetful, impulsive, sometimes defiant and aggressive) arouse emotional reactions in most others, regardless of whether the causes of the behaviors are thought to be organic or psychogenic. Relationship problems arise. Also, it is common for the ADHD child/teens to deny any behavioral problems, so the “encouragement” of structure and/or self-control may be strongly resented and resisted. These are tough situations for parents, teachers, and other caregivers. These power struggles should be minimized as much as practical, but most parents (and safety considerations) have their limits. If the ADHD victim can at an early age recognize his/her own behavioral problems, that awareness can lessen their opposition to controlling cues and structure in the environment or by others. Remember, rewards for desired behavior work much better than authoritative control with most children. Also, tied in with their denial of problems is the mixed self-esteem often associated with this disorder, namely, people often believe the ADHD child or teen has low self-esteem but the child/teen frequently considers him/herself superior to others (even after repeated failures), both in terms of likeability and performance skills. Often there is also a hard-to-handle “I’m OK, it’s your fault” attitude. Research has shown that praise reduces the ADHD's need to exaggerate their superiority (Diener & Milich, 1997). We need to acknowledge that the genes, hormones, and brain structure don’t disengage the psychological/learning/interpersonal aspects of a disorder.

 Also, remember, ADHD is not all bad--Dr. Hollowell, who has this diagnosis and likes it, values his creativity, energy, and exciting unpredictability which he attributes to the “disorder.”

 The sources already cited are excellent: Barkley (1997), Hollowell (1997), Hollowell & Ratey (1994), and Incorvaia, Mark-Goldstein & Tessmer (1998). These books are for both practitioners and patients. Books written explicitly for the ADHD adult include: Roberts & Jansen (1997), Shapiro & Rich (1998), Kelly & Ramundo (1996), Nadeau (1996, 1997), and Adamec & Esther (2000) which is specifically for "Moms with ADD." Several books seek to help parents cope with ADHD children: Barkley (1995), Jacobs (1998), Flick (1998), Killcarr & Quinn (1997), and Taylor (1994). See Greene (1998) for dealing with the angry child, and deGrandpre (1998) for thoughts about medication. High school students should consult Quinn (1994, 1995). Theories about self-regulation in ADHD can be found in Milich & Nietzel (1994).

 An email newsletter about ADHD can be obtained at ADDGazette@onelist.com. Some of the better Web sites in this area are: NIMH ADHD Publications, National ADD Assoc., PsyCom.Net Book Service, ADD Resources (articles, providers, free book), ADD Warehouse, CHADD: Children & Adults with ADHD (they also provide a toll-free information center at 800-233-4050), ADD Born to Explore, Scientific American article, Mental Health Net: ADD, and especially for women and girls, ADDvance. Also one can search for ADD or ADHD on any search engine, such as Yahoo or Alta Vista, and get several sites.

 Bedwetting can usually be controlled with an apparatus that signals the first drop of urine. Eventually, the person learns to detect bladder tension and wakes up (Yates, 1970; see Sears catalog for bedwetting alarm). There are medications to help and even a self-help picture book for children with this problem (Mack, 1989).

cCodependency is the action of a person who becomes addicted to an addict and in the process devotes her/his life, without success, to supporting, tolerating abuse, caring for, and attempting to "save" the addict. Anyone caught in this trap should get help (see Beattie, 1987, 1989; Norwood, 1986). It is confusing, but the same term, codependence, is also sometimes used to describe a group of symptoms Adult Children of Alcoholics (ACOA's) are supposed to have: fear of intimacy, indecisiveness, discomfort with feelings, and problems maintaining friendships or love relationships. The evidence is very slim that ACOA's actually have these problems more than others (George, La Marr, Barrett, & McKinnon, 1999). On the other hand, there is some evidence that ACOA's, especially women, have higher drug and alcohol use and somewhat poorer psychosocial adjustment (Jacob, Windle, Seilhamer & Bost, 1999).

 Coffee drinking is primarily an attraction to caffeine, according to Morris and Charney (1983)--so why do I only drink decaffeinated? This attraction to caffeine is probably true if you drink a lot of brewed coffee. Gradually switch to instant coffee (it has 1/3 the caffeine), then to decaffeinated, then reduce the number of cups, then drink orange juice.

 Compulsiveness is a result of insecurity. All of us are faced with our limitations; we fear making mistakes. If we are secure within ourselves, we can handle our weaknesses and errors (but we may be quite orderly and careful). The insecure person is likely to excessively compensate for his/her real or imagined limitations by becoming overly compulsive. Thus, many mild compulsions are beneficial; some serious ones are terrible handicaps (most addicts are compulsive); others are merely bad "habits" which can be dropped with a little conscious effort. Obsessive-Compulsive disorders are dealt with in chapter 5.

 Compulsive spending, impulse buying, and over-spending to the point of financial disaster are good, fun habits gone awry. The interesting, exciting activities of shopping have become an obsessional escape and/or an irrational way to handle emotions. The compulsive shopper buys things they want at the moment even if they don't have the money to pay for them. Often this is done to cheer themselves up or to reward themselves during down times, even though their own history has been of feeling guilty and sad after overspending. The compulsive shopper feels upset, angry and terribly deprived if they can't buy (e.g. insufficient funds) what they want. Unfortunately, after the momentary gratification of buying, they soon feel guilt, sadness, or resentment of the habit, until the urge reappears in a few days. They are willing (compelled is more accurate) to go into debt with no idea how to pay for the purchase. Several studies have found 5% to 10% of the American population are compulsive buyers and another 15% or so are overspenders. Indeed, that's about 60 million struggling with overspending and only 1/3 of Americans are saving anything for retirement. We'd rather buy a new car now than save for our children's education, even though we'd agree that an education is much more important than driving a new car (those long-range goals are easily forgotten).

 Depression tends to be high among compulsive shoppers; thus, antidepressant medication is sometimes helpful... and shopping may serve the addict as a self-medication for sadness. Also, because compulsive shoppers often buy things that enhance their image (e.g. clothes or jewelry for the woman or sports equipment, a car, or a motorcycle for the guy), it is thought that buying is often intended to build our sagging self-esteem. It also seems obvious, but I don't know of research supporting this, that over-spending might be a way to "get something from" an unsupportive partner's bank account or to "get back at" a resented partner. What research does show is that habitual shoppers also have higher rates of anxiety, eating disorders, substance abuse, and poor impulse control. Overspending disorders are described in detail by Mellan (1997), Arenson (1991), Coleman & Hull-Mast (1995), and others.

 The urge to go shopping tends to occur every few days or every week or so. The urge only lasts for about an hour but, in an addict, the urge can be resisted only about one fourth of the time. Usually the compulsive shopper has no shopping list prepared in advance, only an awareness of their favorite departments. Some, however, are bargain shoppers. The fact is though that, about half the time, they never use their purchase, leaving it packaged, returning it, or disposing of it. What is accumulated are large debts, often several thousand dollars on credit cards. It is not unusual for an addicted spender to spend half the total family income on these shopping sprees.

 Clearly an out of control spender needs therapy; they can't stop themselves, but what kind of therapy is best is still unknown (one small study suggests insight therapy is not very effective). For some, anti-depressive medication will be helpful (McElroy, 1998). There are also 12-Step programs available (400 Debtors Anonymous groups in the US). Other Web sites provide a DA bibliography and more information about getting out of debt: see Debtors Anonymous Information. Some people have found it refreshing to observe the misc.consumers.frugal-living Newsgroup because the conservative attitude seen there is so different from the impulsive spending attitude. Also a private e-mail forum, called Solvency, is available and provides personal support as well as self-help information about controlling spending urges. To join this group send a message to listserv@maelstrom.stjohns.edu with this in the body: Subscribe Solvency firstname lastname

 All three books cited above give self-help suggestions for controlling compulsive spending and/or debt reduction. There are a couple of others: Catalano & Sonenberg (1993) about controlling your emotions and Mundis (1988) about controlling your budget. It is easy to recommend sensible budgeting or money management methods, like establishing three bank accounts: (1) for day-to-day spending, (2) for essential regular bills, and (3) for saving, depositing the amount needed for (2) and planned for (3) as soon as you get your pay check. By carefully setting (1) to include only a small amount for optional "spending" and by considering (2) and (3) sacred, one might control the over-spending. Any reasonable spending plan would work with most people, but, by the very nature of a serious addiction, this kind of rational decision-making probably won't work. Perhaps it would work if there is a firm commitment to the plan. In many cases, however, initially the compulsive buyer may have to turn money management over to someone else who is willing to totally control the money for all purposes, only allowing the over-spender a small amount each week of account (1) for non-essential shopping. While spending is being controlled by someone else for several months, the addict should concentrate on reducing his/her depression, building self-esteem, and, most importantly, developing truly gratifying constructive activities that demand their time. A person with a lesser addiction may just have to avoid stores. Keep in mind, the urge to shop weakens if you can restrain yourself an hour or so. Some moderately impulsive people can go shopping without money or credit cards (it is possible to have a great time shopping with a friend without buying anything, you know). If a real buy is found, you can impose on yourself a one-day waiting period, then consult with your partner about the appropriateness of the purchase before going back and buying. Several systems like this have worked for many people.

 Disorganization is a handicap but you have your own unique style, so you need solutions tailored to your personality (see Schlenger & Roesch, 1990). Gleeson (1995) helps you become efficient at work.


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