MORE SPECIFIC PROBLEMS

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 Sexual addiction: is very hard to define. There is a thin line between the normal and the abnormal. For example, thinking about sex a lot, say many times every day, is not ordinarily considered an addiction (maybe an obsession) but spending several hours a week looking at pictures of nudes may well be an addiction. Is the average young male who masturbates 3 or 4 times a week addicted? Probably not; if he had an alternative, the masturbation would stop. If a loving couple have good sex twice a day, morning and night, is that an addiction? Probably not, but if that is their only way of being reassured that they are sexy and/or loved and then one decides he/she doesn't want it so often but the other can't stop, then he or she is addicted . If someone masturbates twice a day, is that an addiction? Maybe not, but if that is their only way of imagining or gaining intimacy with another human being, then they might be considered addicted. Addiction is not just a matter of frequency or amount. My 300 pound football-playing grandson eats a lot but is he addicted to food? No. Addiction, in addition to frequency or amount, is an inability to stop a behavior even though it is doing harm--physical risk or harm to your body, legal difficulties, or emotional harm to the addict, to others, or to his/her relationships with others. The behavior is so needed the addict can't quit.

 Carnes (1983, 1992), a major writer in this area, classifies different levels of sexual addiction. His level 1 includes excessive masturbation, repeated affairs destroying loving relationships, unusual demands for intercourse, nymphomania, promiscuity, obsession with pornography, frequent use of prostitutes, strong homosexual interests, etc. His level 2 might involve exhibitionism, voyeurism, stalking to seek a relationship, indecent phone calls, etc. His level 3 is incest, child sexual abuse, date rape, stalking to harm, rape, violent control, etc. These levels make it clear that a wide variety of behaviors are considered sexual addictions. The harm done to others is obvious. After getting caught, the addict's self-respect plummets, 75% have thought of suicide. Surely there are a myriad of causes behind these diverse behaviors.

 The books by Carnes provide numerous descriptions of sex addiction cases and some discussion of the common background shared by many addicts. For instance, he found that 81% of sex addicts were themselves abused in some way. Many come from unemotional, morally rigid and authoritarian families. 83% have additional addictions--alcohol, food, gambling, antisocial behavior--and, in general, poor mental health and limited impulse control. He reports that many addicts have unusually negative self-concepts (and so do many of their mates): "I am bad," "No one could love me," and so on. Unfortunately, Carnes's recommendations about addiction treatment reflect primarily the usual medical/psychiatric endorsement of 12-Step programs. Unquestionably, being in a good 12-Step group is a good aid to self-control. But many addicts won't go and won't stay in groups. They also need therapy or training that enables them to have insight, cognitive self-awareness, new skills, and better emotional and behavioral self-control. Carnes does provide a Sex Addiction Screening Test, a Betrayal Bond test, and a book for escaping the bonds that sometimes bind a significant other tightly to an addict or to an abuser/betrayer. Carnes also edits Sexual Addiction and Compulsivity: The Journal of Treatment and Prevention, which has articles about sexual offenders, women addicts, adolescent addicts, recovery for couples, etc. So, he is a major contributor to this area.

 Patricia Fargason, board member of the National Council on Sexual Addiction and Compulsion, says sexual addicts often come from oversexualized homes where the adult's sexual interests intrude to include the children in subtle ways. Or, sometimes, the addict-to-be learns to soothe his/her childhood anxiety, fears, sexual urges, and anger by masturbating and fantasizing; thus, creating a very strong habit. Some psychoanalytic psychiatrists, like Goodman (1998), explore the psychodynamic (and the cognitive-behavioral) aspects of treatment while trying to integrate the currently popular biochemical thinking as well. There is, of course, some reason to believe that sexual activity is influenced by innate sexual drives but much stronger evidence that our daily thoughts influence our sexual drives. The sexual development area is one in which we know very little; for instance, we know very little about the development of ordinary sexual attractions to breasts or behinds or penises or hairy bodies or pornography or promiscuous sex, etc., etc. The attraction to pornography is mentioned in the section above about Internet Addiction.

 As Stanton Peele points out, an obsessive over-emphasis on sex can be seen in many teens, during early dating, when "feeling our oats" after a divorce, when a "hunk" or a "hot number" comes into our mundane lives (like Monica into Bill's) and so on. These are not purely biological addictions or some sudden gush of neurotransmitters; they are mental/psychological/emotional/physiological events in ordinary lives, not all lives but some. We get over these sexual obsessions in time and in natural ways. Our culture even idolizes some romantic/sexual obsessions; they too can be nearly impossible to stop. These normal sexual over-reactions must not blind us to the enormous hurt involved in and caused by out-of-control sexual addictions mentioned above in Carnes's levels.

 It is estimated that about 6% of the American population has a problem of some kind with compulsive sex. The fastest growing group is young professionals. Treatment programs are developing, costing $800 to $1000 per day! There are also 12-Step programs available in most major metropolitan areas. Besides Carnes and Goodman, Weiss (1996) is another major player and has a Web site, Sex Addiction Recovery Resources which advertises several of his books, including Women Who Love Sex Addicts and 101 Practical Exercises for Sexual Addiction Recovery. The National Council on Sexual Addiction and Compulsivity also provides articles, including an article on the "Consequences of Sex Addiction and Compulsivity," and referrals to treatment (phone 770-989-9754 or email ncsac@telesyscom/com). Other outstanding authors are Kasl (1990), who writes about women coping with a sexual addiction, and Anderson & Struckman-Johnson, who describe the life and motives of sexually aggressive (not necessarily addicted) women.

 There are several Web sites focusing on sexual addictions: Love & Sex Addiction, Psy Today Article; Sex Addicts Anonymous provides a sex addiction test, some literature, and a listing of local 12-Step meetings. Similar sites exist for Sexaholics Anonymous and Sexual Compulsive Anonymous, the latter provides some self-control suggestions (relapse prevention). A couple of other sites include sex addictions and/or 12-Step programs--PsychCentral, Sobriety and Recovery Resources and Recovery Zone. Still another site deals primarily with blocking access to Online Sexual Addictions.

 There are, of course, several books for therapists treating sexual addicts and their partners (see Goodman above for a scholarly overview). There seems to be a special interest in sexual addiction by religion oriented writers (and 12-Step groups) but I haven't cited most of those books. There are also books and numerous articles about President Clinton and his possible sexual addiction. I am not citing them either because relatively little is actually known, in spite of our obsession for months, about the president's sexual thoughts and life. In the main, these speculative writings seem to be for an easy publication and/or financial profit, not sound unbiased research nor a quest for knowledge in this scientifically neglected area. In terms of the application of science-based knowledge, there is a belief among professionals that compulsive sex, shopping, gambling, and Internet use are related to each other and to drug and alcohol addiction, but that the addictions are different from the anxiety-based obsessive-compulsive disorders dealt with in chapter 5. The treatment is different but perhaps it doesn't need to be.

 In case you are thinking that being a sex addict sounds like an exciting idea, you should become familiar with an addict's life--his or her internal and external worlds. The consequences of sex addiction may include severe depression (often suicidal), guilt and shame, self-demeaning despair, helplessness, intense anxiety, loneliness, moral conflict between ethical values and behaviors, fear of rejection, belief that no one will ever truly love you, a belief that the world is filled with naive, self-serving, or self-righteous jerks, distorted thinking, and self-deceit. Of course, sex addicts embarrass their relatives and friends, get and pass on sexually transmitted diseases, have financial and legal troubles, and they hurt almost everyone they have sex with, in some cases very seriously disrupting lives. It is usually an inconsiderate, morally corrupt life.

 What can an addict do? Get therapy! Get into a support group! Sexual reactions that are inappropriate and dangerous, such as attractions to children, stalking or assault, exhibitionism, voyeurism, sexual violence, etc. need immediate professional treatment. Abnormal sexual attractions, for instance, have been extinguished by pairing pictures of children with electric shock and by using covert sensitization (Rachman & Teasdale, 1970; Barlow, 1974). Is there any self-help available? No well evaluated methods that I know about. Yet, there are some possibilities:

 (1) Work to avoid temptations. We all know the situations we get into, the way we act, and the feelings we have when we attempt to contact and attract someone. Moreover, we know the conditions that trigger our seductive behavior, the lines we use, and the thoughts and intentions we have. As discussed in chapter 10 about avoiding affairs, we can identify the initial steps taken towards unwanted temptations. Perhaps discussing the urges with our significant other and/or getting marital counseling would improve the primary relationship and/or improve one's self-control. Joining a self-help group is important.

 (2) Self-punish or de-condition the sexual urges. Covert sensitization was mentioned above and you might reduce your urges by pairing the experiencing of the sexual urge or an image of the typical sexual target with very noxious thoughts (having very shaming self-critical thoughts or fantasies of getting caught and divorced or arrested or severely punished). The Methods #18 and #19 in chapter 11 provide some guidelines for this self-punishment procedure. Essentially, this is the opposite of desensitization which reduces your fear of a situation, i.e. you want to increase your fear and avoidance of a situation. By pairing the unwanted-but-tempting behavior (or imagined behavior) with an unpleasant or self-critical thought or with pain, the tendency to think about or to approach a tempting stimulus should decline.

 (3) Modify one's attitudes towards the opposite sex. See the section on Turn ons for Men and Women in chapter 10 (or just look up Centerfold Syndrome in this book's search engine). Many of the sexual addictions involve a dehumanization of the target person or group. The addict sees the attractive woman as a physical object made up of sexual parts, referred to as the Centerfold Syndrome. But, in spite of fashions, our sex-ladden culture, and the entertainment industry, men can learn to control their disrespectful lustful responses simply by recognizing them as demeaning and offensive. If you can't restrain yourself from "making a pass" at every attractive person in your environment, you need therapeutic help.

 Sexual problems, such as lack of interest or orgasms, premature ejaculations, impotence, etc., are covered in chapter 10.

 Sleep disorders include many different kinds of problems, maybe as many as 80, such as insomnia which includes being unable to go to sleep, waking up frequently, and waking up too early. Sleep problems also include sleeping too much, daytime sleepiness, bad dreams, fears of or resistance to going to sleep, snoring, restless legs, sleep apnea (disruption of breathing during sleep) and other difficulties. It is estimated that 25% of us have some kind of sleep problem; 50% will have a problem sometime in our lives. While 10% regularly have trouble sleeping, for those of us who only occasionally have insomnia it usually goes away in a few nights or weeks (often when our life calms down). Chronically waking up early is a classic symptom of depression. Difficulty going to sleep is a common result of intense anxiety. Other psychological disorders and medication for these conditions also disrupt our sleep and change the nature of our dreams. Some sleep-related breathing disorders are related to heart disease and high blood pressure. Sleep apnea is reportedly connected to sexual dysfunctions. Many of these complex connections are not understood. Regardless of the exact nature or cause of the sleep disturbance, it is a very distressful event that affects our days and our nights. Like chronic pain, if it lasts night after night, it becomes a monstrous problem that screams for a solution.

 Recent research indicates, contrary to the popular belief that losing sleep doesn't matter, that, in fact, limited sleep (less than 5 or 6 hours in 24) and interrupted sleep seriously affect our thinking, our mood, our work, and our health (Dement, 1999; Coren, 1996). Adequate sound regular sleep is important. We differ in how much we need, some need 10 hours and a few others need only 5 or 6 hours. About 75% of us disregard this need and feel drowsy sometime during the day. It may take some effort to change your too-little-sleep habits, but after getting good, adequate, regular sleep for a few nights, you might be really pleased with feeling refreshed, alert, clear-headed, and eager for the day,

 As usual, whenever a large number of people suffer from a given problem, there are many solutions offered for sale: drugs, herbs, books, specialists, and now Web sites. Of course, in extreme cases, medication can almost always help, but many of these drugs should be used only on a short-term basis (there are some drugs that can be used regularly, if necessary). In certain other cases, e.g. where hypertension, Seasonal Affective Disorder, Mental Illness, obesity, and other physical disorders are involved, your family doctor or a specialist must be consulted. But where physical problems aren't the cause, it would probably be best to adjust the body and mind so that healthy sleep comes naturally. There are a host of treatments by professionals and many self-help procedures. Why so many treatments? Because there are so many kinds of sleep problems and because there are so many different kinds of practitioners offering services to people with sleep problems. After all, not being able to sleep well has always been a problem and a mystery for humans. Everyone has solutions.

 Research has shown that cognitive-behavioral treatments (Morin & Kwentus, 1988) and various self-help methods are quite helpful.

 Healthy sleep habits can be summarized as follows:

 (a) Long range: deal with your health problems and have your doctor review your prescribed and alternative (herbal) medicines to see if they could be disturbing your sleep.

 (b) Be sure you have a good quality mattress and pillow. Sometimes pillows for supporting your neck, raising your knees, or between your knees are helpful by reducing muscle aches and pains.

 (c) During the day: Get up at your regular time. Eat moderate-to-small portions of healthy, easily digested foods, especially at the last meal of the day. Indigestion causes sleep problems.

 (d) It is important to exercise every day, but not within 3 or 4 hours of bedtime.

 (e) Avoid naps during the day and early evening.

 (f) Avoid caffeine in any form (coffee, tea, soda), alcohol, and stimulants in the afternoon or evening.

 (g) Closer to bedtime: An hour or so before bedtime, start "closing down" the day. Stop problem-solving, planning for tomorrow, worrying, and self-criticism. Many people find that organizing a list of possible solutions, preparing a To-Be-Done-List, or writing in a journal or diary allows them to retire disturbing thoughts for the day.

 (h) Develop a "bedtime ritual." Do things to relax the body and the mind, such as taking a warm bath, reading a feel-good book, listening to soft comforting music, using relaxation methods or tapes, watching TV, reading a slow-moving book, etc. For some people, a light snack is part of the process.

 (i) Go to bed at about the same time every night. Time your bedtime so you get plenty of sleep but not too much. With this regularity, the body can anticipate when it will sleep and develop a healthy rhythm.

 (j) Make the physical conditions optimal for you: make it the right temperature, make it quiet--turn off or turn down TV and the sound system and mask outside noises with a fan or wear earplugs, make it fairly dark--turn out the major lights, pull the curtains...

 (k) Condition yourself to sleep while in bed. This is a simple, powerful method, recommended as a starting point for learning to sleep (Lacks & Morin, 1992). Follow these rules: go to bed only when sleepy or sleep seems possible, only sleep (or make love) in bed and sleep only there, do not do other things in your bed, like study, watch TV, socialize, talk on the phone, daydream, read magazines, etc., and, finally, "try to sleep" for only 15 minutes then get up if still awake. The idea is to pair being in bed with good sleep. During the 15 minutes of trying to sleep, you can use thought-stopping or deep breathing exercises or meditation, repeat a religious saying, read a dull book, or count sheep. Some people find sex and/or masturbation are a good sleep-inducers. All these activities occupy your mind, helping you avoid thoughts and emotions that keep you awake. Remember, after 15 minutes, you need to get out of bed but continue to relax and prepare yourself for sleep, no big sandwich, no ice cream and cake, no calling someone to tell them you can't sleep, no worrying about being tired tomorrow, no getting mad because you can't sleep, just keep relaxing--sleep will come.

 (l) If you wake up during the night, remain inactive and resume trying to quiet the mind. Some people have a reading lamp beside their bed and a book nearby. Reading can often lull you back to sleep.

 A rather different approach, but similar to the conditioning method mentioned above, is called "sleep restriction" in which you avoid lying sleeplessly in bed by limiting your sleep time, i.e. spend only as much time in bed as you estimate you get of sleep. Example: if you think you only get about 5 hours of sleep per night, that is all the time you allow yourself to sleep each night. If you sleep well (over 90% of the scheduled time) for one week, you add another 15 minutes to your sleep time the next week. If you don't sleep well, you take 15 minutes per night away (4 3/4 hours). You learn to go to sleep quickly and to sleep soundly.

 None of the above methods focus on uncovering and reducing deeply buried underlying stress or trauma, but they establish good sleeping conditions, reduce the anxiety about not sleeping, and they produce good improvement rates. Therefore, those are the approaches I'd start with. In the cases where the above methods don't work or where nightmarish dreams occur night after night to disrupt your sleep, I'd seek help from an insight and dream oriented psychotherapist.

 For discussions of many sleep disorders, go to Yahoo and search for "Sleep Problems." You will find over 20 Web sites for information, books and services. One publisher offers several books about sleep and a Sleep/Insomnia Program Web site which provides an online sleep evaluation, plus suggestions for insomnia and nightmare reduction. Perhaps the best recent and research based self-help books are by Jacobs (1999) and Dement (1999). Other new books well rated by readers are Maas (1999), Hough & Ball (1998), Perl (1993), Moore-Ede, LeVert, & Campbell (1998), and Wiedman (1999). The causes of insomnia are very diverse and the insomniac simply has to shop around to find a solution that works well for him/her.

 Several professional Web pages focusing on specific sleep problems provide research and treatment ideas. The American Family Physician reviews Chronic Insomnia. Behavioral treatment and medication have been shown to be effective with insomnia in the elderly. The Family Physician Organization has addressed too little sleep. American Academy of Pediatrics has a handout for parents with children with sleep problems. Mental Help Net has a collection of articles at MHN-Sleep Disorders. Two other sleep problems are common: Restless Legs and Snoring. Look them up by going to Mayo Clinic. Sleep apnea occurs about 4 times more often in obese children and in African-American children than in other children. Breathing problems occur in about 3% of all children and almost 10% of adults between 40 and 65. Besides the National Institutes of Health, go to American Sleep Apnea Association, Sleep Net, or enter "sleep apnea" in a search engine. Finally, UCLA's Sleep Home Pages provide a complete 1994-present searchable sleep bibliography (click on BiblioSleep).

 Smoking is one of the hardest habits to stop without relapsing. Nevertheless, as a society, we are reducing smoking, about half of all people who have ever smoked have stopped (91% quit on their own). After World War II, a high percentage of males smoked (75% in Britain). Perhaps 40% or 50% of all adult Americans have been "dependent" on cigarettes sometime in their lives. During the 1990's, about 25% of Americans smoke, 75% of them want to stop. Two thirds believe a smoking-related disease will kill them if they don't quit. One third of all smokers tried to quit last year, but only 1 in 20 who tried to stop was successful. Quitting requires an average of seven tries, often using "cold turkey" or different methods.

 Smoking in recent years is a habit for about 40% of high school drop outs but only 10%-15% of college graduates smoke. Likewise, smoking is more and more associated with personal and social problems--bad experiences as children, doing poorly in school, unskilled work, divorce, stressful conditions (more panic attacks), unemployment, criminal behavior among males, serious mental illness, depression, drug and alcohol use, etc. Like alcohol, cigarettes with their nicotine content may, for some people, serve as a self-medication for a variety of psychological problems, especially stress and sadness. Note: a few adolescents enjoy the first puff--scientists believe this is determined by their genes. In the main, however, smoking starts for basic social reasons, even though it tastes bad to most, but it becomes an addiction because nicotine is physiologically addictive and because smoking may help us momentarily (while having "a smoke") avoid stressful and depressing thoughts (and, thus, feelings). The truth is, in spite of the belief that "I need cigarettes to relax," smokers are generally more anxious than non-smokers and more anxious than they will be if they quit.

 Note: Smoking is another addiction that is being "demonized." The statistics just cited, for instance, would seem to be demeaning to smokers by implying they are less educated and "lower class." This is not my intention. We must guard against the mental put-down of persons suffering a powerful habit and a physiological addiction. Unforunately, society more and more is seeing smoking, like over-weight, as being due to laziness, a weak will, weak character, stupidity, or slovenliness. This does not help people change; it makes them more self-critical and unhappy. Very few of us have mastered all bad habits, so we should be especially sympathetic with smokers who have, as we will see, innocently acquired an extremely persistent behavior. Let's not blame the victim!

 Partly because of the national anti-smoking campaign and the massive amounts of profit involved in helping people quit, there has been much research published in the last few years. Current findings suggest the following combination of treatments: (1) an anti-depressant, usually Zyban, (2) a nicotine replacement (first a spray and/or patch, then gum for a few more weeks), and (3) counseling or a psychoeducational program for 6 to 8 weeks. Such a program has been proposed and tested by Dr. Linda Ferry at the VA Med. Center in Loma Linda, CA. Smoking is a very strong addiction; it requires serious, concentrated, multiple treatments to stop it. Going "cold turkey" succeeds only 5% to 10% of the time. Any one of these three treatments alone will be successful only 10% to 25% of the time, but taken together the smoker successfully stops about 50% of the time, according to Dr. Ferry. For this habit, 50% is a very good success rate. Unfortunately, this is an expensive program: about $100 per month for the anti-depressant (plus the cost of the prescription), between $100 and $150 per month for the nicotine (may need another prescription but some available over the counter), and maybe $20 to $50 a session or $80 to $200 per month for a counseling/educational smoking group (perhaps self-help or American Lung Association clinics can be substituted). In some cases, health insurance may pay for the treatment. Of course, it is worth the expense for a life-time of better health and the saving of $100+ a month for cigarettes.

 The counseling/psychoeducational component consists of basic information given before quitting about smoking, its causes, and the quitting process (see this chapter). The class or perhaps an online group can also provide individual support and encouragement for several weeks. It is important that the smoker learn to meet his/her psychological needs in other ways rather than by smoking and being with other smokers. For instance, if smoking is a temporary relaxant-when-stressed for you, other ways of managing stress must be learned and put into practice daily or hourly (like cigarettes were). See chapters 5 and 12. If cigarettes and nicotine helped reduce your depression, other methods for elevating your mood must be found (chapter 6). Communication skills or new attitudes or ways of thinking may be needed instead of smoking to improve your sense (illusion) of well being (see chapters 13 and 14). New problem-solving skills are needed for ordinary problems. Finally, it is crucial to identify your high-risk situations so relapsing can be prevented. Then the counselor or group can help you learn coping techniques and give you practice dealing with those situations. This learning of new skills is very necessary (Tsoh, et al, 1997); you may not have to pay for professional help, serious work with self-help information and/or groups might suffice. Completely replacing a deeply ingrained addiction is no easy task. You will be tempted to "just have a puff on a cigarette" for years to come. Resist it. You have to find new ways to cope.

 Also, in the last couple of years, major Web sites have been developed that provide information and resources for smokers who want to quit. Your community probably does not have a comprehensive Stop Smoking program, like the one described above, so you will have to pull together your own, including prescriptions and/or over the counter drugs and a counseling/educational/self-help program. Much of the information you will need is given in the above section Methods for Controlling Behavior. The better online sites are at The QuitNet, How to Quit, Clearing the Air, MHN-Smoking, Stop Smoking sponsored by Nicorette, Dr Koop Site (search for "stop smoking") or WebMD Stop Smoking Center. Be sure to check with the American Lung Association. This organization has for years offered information and intensive stop smoking programs, now including either individual help at the ALA Call Center (1-800-548-8252) or a free online program on the Website. To find out more or to make weekly appointments with a counselor call the Call Center or 1-800-LUNG USA. Their programs have been quite successful (25% to 30% of participants were still not smoking one year later). Participants praise the support as being convenient and quite helpful.

 The "cold turkey" and the gradual reduction methods are still popular and sometimes combined with the nicotine replacement methods. Some research of nicotine replacement finds it minimally helpful; other research says it is useless. The use of anti-depressants is new but seems to be helpful. 85% of smokers have tried to quit "cold turkey" but most failed. Of those that successfully quit, 60% did it "cold turkey," 11% used a nicotine replacement, and 5% gradually cut down (Gallop Survey, NY, PR Newswire, Nov 17, 1998). If you use any nicotine replacement, however, you are advised to stop smoking entirely. There are a host of educational/commercial self-help methods and procedures on the Web for stopping smoking: You Can Quit Smoking, SMOKENDERS, Quit Smoking NOW, Nico News, Self-Help Resources, M.D. Anderson addresses cancer and smoking, and several articles are in Self-Help Magazine. A few of the many books for reducing smoking are: Maximin & Stevic-Rust (1996), Rogers (1995), Rustin (1996), Brigham (1998), Fischer (1998), Baer (1998), Shipley (1998), Krumholz & Phillips (1993), or McKean (1987). One or two will help you develop an adequate plan for a behavioral change and for coping with the psychological needs smoking may have concealed from you. In general, self-help literature and advice alone have a success rate of 10-20%, although some programs or books claim a much higher success rate. One more educational program worth mentioning: the University of Minnesota developed a highly regarded Smoking Prevention Program for adolescent students.

 Convincing evidence indicates that working together with a helper or group, being watched, and encouraged helps many of us make changes in our behavior. Doctors find that a call or two every week by a nurse helps the patient take his medicine faithfully. Support group members feel that their group, acting as a cheering section, is a real boost. Follow ups by phone after self-help programs have significantly increased the final success rate (Lichtenstein & Glasgow, 1992). There are self-help groups for people quitting smoking: Nicotine Anonymous offer local groups and QuitSmoking offer online groups (there are several available, including the Quit Net). Newsgroups are available at alt.support.non.smoking. Getting support from your friends or family or a "buddy" might substitute for Support Groups and follow-up calls. It is not impossible to kick this habit alone but if you can get help, please take it.

 One common excuse for continuing to smoke is "I don't want to gain weight." The evidence on this matter is mixed. Smokers under 30 are not less fat than non-smokers, which suggests smoking doesn't help weight-wise. A life-time of smoking may reduce your weight by 5 to 7 pounds... and your life by 5 to 7+ years. Yet, there are plenty of reports of gaining 15 to 20 pounds after stopping smoking. Research confirms average weight gains after quitting smoking of from 5 to 15 or more pounds, if no attention is paid to eating. Actually, later research shows that the weight gained goes away in a few years. Obviously, a struggling smoker might begin to eat more to make up for the highly missed cigarettes; this may be okay for a few days as the strong smoking habit is being fought, but any new unwanted eating habits need to be attacked before they become established. Check your weight every couple of days and if you gain more than two pounds start an exercise program right away; you probably need more exercise anyway. If you need something in your mouth, try sugarless gum or hard sugarless candy... or the old celery and carrots routine. "Relaxation" smokers need to find some other relaxing activity, like reading, knitting, walking, etc. Smoking for concentration under stress could be replaced by tapping your fingers, chewing gum, stroking a smooth stone. For "boredom" smoking, you could substitute a fun mental or physical activity. For "emotional-stress" smoking, substitute relaxation (Methods #1, #2, & #5 in chapter 12). Any new activity that also improves your general health or is just plain fun, e.g. reading, napping, joking, playing with the kids, cuddling, can be substituted for a smoke. All these things make stopping the bad habit easier.

 As described in the classical conditioning section early in the chapter, cigarettes are paired so often with reducing high anxiety that the smoking process becomes a temporary tranquilizer. Thus, if we become anxious, angry, or depressed, smoking (or the smoking "break") becomes a brief self-medication for these unpleasant emotions. If cigarettes have soothed our stress or hidden our depression many thousands of times, it may become harder to quit smoking because we are both withdrawing from an addictive drug, nicotine, and re-experiencing (or getting no relief from) our dreaded old emotions. Indeed, some depressed smokers do experience especially strong urges to smoke after quitting (researchers report this reaction is related to your genes). And, a variety of increased psychological distress may occur when the self-medication is stopped. For instance, people who have a history of recurrent major depression become depressed again 30% of the time after stopping smoking (Covey, Glassman & Stetner, 1997). I suspect this increasing (uncovering) of psychological stress is fairly rare in persons who have no psychiatric history of depression because, as mentioned, on average the anxiety level tends to go down (not immediately but gradually) after quitting smoking. In any case, one needs to be alert to the possibility of depression and find or develop ways, including medications for a while, of handling any increasing emotions (chapters 5, 6 & 7). Don't delay getting help if needed... and try to avoid falling back on your old self-medication--smoking.

 For ex-smokers, even those without a history of depression, feeling down is the most common cause of a relapse. Be especially cautious during "down" times. It takes several weeks for the urges to smoke to fade away. So, in any case, expect to suffer for a while, the first week may be nicotine withdrawal but after that the urges are probably psychological or habits. Researchers report that most people experience the strongest urges just prior to quitting and that the "urge for a cigarette" gradually declines after the moment you quit. You will usually find that the urges to smoke are not continuous, they come only episodically--just like in the past you only needed a cigarette episodically. The trick is to distract your attention from the brief high urge phase--or to tough it out, saying "I can handle this." The urge will soon fade away, so Nicotine Anonymous says "take it one urge at a time."

 Many examples of self-help methods for quitting smoking are given in the Methods for Controlling Behavior section above. Detailed instructions for each method are there or in chapter 11. I'll give a brief summary (see the above Web sites or books) of stop smoking suggestions: Try to select a "quit day" when you are not under stress. Pick a specific day to stop and tell your friends, co-workers, and family. Throw away (not just put away) all cigarettes, ashtrays, lighters, etc. When the urge hits you, do something else, e.g. take a deep breath, relax, and wait it out, chew some gum, pop in a lifesaver or a carrot, meditate or exercise for 5 minutes, drink water or tea, take a walk, call someone, get to work, etc. The urge will go away. Avoid environments associated with smoking as much as possible, don't sit where you habitually smoked, eat in a different place and don't linger after eating if that is your usual time for a smoke, don't have coffee in the morning or beer in the evening if smoking has been strongly associated with these activities, change your work environment if you have smoked there, avoid your smoking friends for a few weeks or ask them not to smoke. Avoid coffee, alcohol, and other drugs. Start an exercise program at the same time--women in an exercise group as well as a smoking cessation program were twice as successful and gained less weight. Record and reward your progress.

 Some people have found this method to be effective: Get very relaxed and think of one of the best days of your life, a day filled with good feelings. Now think of a small object, like a ring or a leaf, (small enough to hold between your fingers and your thumb) that would represent that day and those positive feelings. Then imagine holding that object between your fingers and your thumb, gently squeeze the object and feel the happy memories flow throughout your body. Tell yourself that anytime you imagine squeezing the object between your fingers and thumb, you will experience those wonderful feelings. So, whenever you have an urge to have a cigarette, put your thumb and fingers together and imagine squeezing the object, then you will relax, feel good, and forget about having a cigarette.

 Study your tempting situations, your urges, and your self-control methods so you can avoid those situations and handle the urges. Close calls--temptations and lapses--are fairly common. Don't think that resisting the urge gets easier and easier after quitting. The urges may decline in strength and certainly the physiological need for nicotine diminishes in several days but your confidence that you have beaten the habit increases! That can be a serious problem: you lower your guard. Ironically, it is the high self-esteem quitter who is most likely to fail! The I'm-indistructable-person discounts the risks of smoking and, thus, their motivation to resist the urges and quit is lower... and they relapse (Gibbons, Eggleston & Benthin, 1997). Lapses often occur after 3 or 4 weeks of success, so be super careful during that time. Never persuade yourself--don't even think it--that just one cigarette would be okay since you are so stressed out some evening. One puff is dangerous. One lapse often leads quickly to total relapse back to square one. But a slip doesn't have to result in a total loss of control (see relapse prevention, in this chapter and Method #4 in chapter 11--this is important).

 Shiffman and colleagues (1997) have explored lapses and relapses. What conditions are associated with lapses? Lapses are most likely to happen in the evening, in settings where the person has smoked before and is hit by an urge, with others who are smoking, when drinking alcohol or coffee, when feeling restless, sad or mad (arguing is a particularly dangerous situation), when the person is inattentive and less likely to use techniques, such as self-talk, for coping with the urges, and on a day when there was a strong urge to smoke upon waking. Note: backsliding may occur when there isn't an intense urge to smoke. The warning signs aren't infallible. But, be especially cautious when warning signs are present, don't get over-confident, learn to talk yourself into exercising self-control, and deal with your negative emotions, don't deny or swallow them. Study relapse prevention carefully.

 Constantly remind yourself why you are quitting: to live 5-8 years longer, to avoid cancer and heart disease, to make your kids proud of you, to look better, to avoid being a victim of a dirty, deadly, smelly, little habit, etc. Be determined to gain control over your own life--prove you can do it, even if you have failed several times before. Get serious about a more relaxed and healthy life-style. Good luck, it is a difficult project.

 Speech problems, like stuttering, and learning problems are sufficiently complex you should get professional help. Most schools have a speech and language pathologist and a teacher or psychologist specializing in learning problems.

 Study behavior can be helped by many of the excellent study skills books available (see reading and scheduling skills in chapter 13; students should see Armstrong,1998; James, James & Barkin, 1998; Ellis, 1997; or O'Keefe & Berger, 1994; parents should look up Sedita, 1989). Don't overlook the important motivation information discussed in this chapter. However, students who are already unmotivated in school may feel "lectured" or "talked down to" by some books in this area. Perhaps a lot of gentle, unpushy but persistent attention from parents will help. It is important.

 Unwanted thoughts and worries, including unwanted fantasies or suspicions, can be treated just like a behavior. That is, they can be controlled by the environment and self-instruction, and they are influenced by immediate rewards and punishment. Three methods are frequently used to change thoughts: (1) thought stopping (chapter 11), (2) paradoxical intention (chapter 14), and (3) scheduling a specific time to worry, say 5 minutes every hour and the entire time must be spent on the worry (which isn't permitted any other time). Chapter 14 has a discussion of Stopping bad memories or thoughts. For jealousy and suspicions, see chapter 7. For more serious obsessive disorders, see chapter 5 and a therapist.

 Time management is a skill; see chapter 13.

 Tics have been eliminated by massed negative practice, i.e. forcing the tic to occur rapidly over and over while experiencing something unpleasant, such as smelling salts (Hersen & Eisler, 1973).

 Toilet training, while not self-help, has been taught rapidly using attention, shaping, and lots of rewards (Azrin & Foxx, 1976).

 Workaholism is an addiction to work; it has been called the least recognized and, therefore, one of the more dangerous addictions because it often looks like wholesome hard work which is praised and rewarded. How can you tell the difference? Workaholism as a word should probably be limited to an unhealthy over-involvement with work that results in neglect of the family, poor relations at work, absenteeism and unproductiveity, eventual burnout at work, and/or health problems due to stress. In such cases, it is obviously a disorder.

 There are probably several kinds of workaholics (Killinger, 1997), including the people happily and highly invested in their work ("I love it but the wife doesn't like it and I miss being with my kids") and employees driven to overwork by fears, threats, perfectionism, compulsiveity, or competition. The happy 10-hour-a-day person who feels his/her life work is important and has a good family life, meaningful relations at work and with friends, would not be seriously labeled a workaholic. Robinson (1998) describes the unhealthy workaholic personality but in this book mostly discusses dealing with it in Cognitive therapy. In an earlier book, Robinson (1992)suggests self-help methods for slowing down, deciding what is important in life, and re-building strained relationships (see other books below).

 Certainly liking your work is better than hating it, but few jobs are worthy of all your time even if you love it. If you work more than 50 hours a week, you need a honest understanding of why you are driven. Do you really enjoy your work that much or is it a way "out of the house," "a way to make up for your inadequacies and low self-esteem," "a control compulsion," or "an escape from the spouse?" Are you driven by some need--power, control, status, money, success, compulsive perfectionism, or a guilty conscience? If your motivation isn't clear, talk with your family or even your colleagues or see a therapist. Try to find the right job, relax, exercise, and don't neglect your family (Fassel, 1993; Morris & Charney, 1983; Oates, 1979). Often greater efficiency is more important than long hours. As an example, see study skills in chapter 13. Although it is just getting started, Workaholics Anonymous may provide some information and WA group locations.

When to seek professional help

 A wise self-helper will, of course, realize his/her limitations. Professional help is needed if the problems are too severe for self-help, this includes behaviors beyond one's control: serious alcoholism, drug abuse, suicidal depression, intense hostility (where there is any risk at all that someone will be hurt), confusion, criminal tendencies, or any problem serious enough to interfere with school or work. Professional help is also appropriate if you have made a couple of genuine attempts to help yourself without success. Don't be ashamed of your self-help efforts and don't hesitate to seek expert help. It's just smart.

 There are complex issues involved in selecting a good therapist for your particular problem. A section in chapter 2 gives best advice I have about Finding a Therapist.

Bibliography

 References cited in this chapter are listed in the Bibliography (see link on the book title page). Please note that references are on pages according to the first letter of the senior author's last name (see alphabetical links at the bottom of the main Bibliography page).


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