Supportive-expressive psychotherapy proves effective in treating hard drug users by helping them maintain gains made in addiction treatment.

Supportive-expressive psychotherapy is a time-limited, focused psychotherapy that has been adapted for heroin addicts and cocaine addicts. The therapy has two main components:

• Supportive techniques to help patients feel comfortable in discussing their personal experiences.
• Expressive techniques to help patients identify and work through interpersonal relationship issues.

Special attention is paid to the role of drugs in relation to problem feelings and behaviors, and how problems may be solved without recourse to drugs.

The efficacy of individual supportive-expressive psychotherapy has been tested with patients in methadone maintenance treatment who had psychiatric problems. In a comparison with patients receiving only drug counseling, both groups fared similarly with regard to opiate use, but the supportive-expressive psychotherapy group had lower cocaine use and required less methadone. Also, the patients who received supportive-expressive psychotherapy maintained many of the gains they had made. In an earlier study, supportive-expressive psychotherapy, when added to drug counseling, improved outcomes for opiate addicts in methadone treatment with moderately severe psychiatric problems.

References:

Luborsky, L. Principles of Psychoanalytic Psychotherapy: A Manual for Supportive-Expressive (SE) Treatment. New York: Basic Books, 1984.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Psychotherapy in community methadone programs: a validation study. American Journal of Psychiatry 152(9): 1302-1308, 1995.

Woody, G.E.; McLellan, A.T.; Luborsky, L.; and O'Brien, C.P. Twelve month follow-up of psychotherapy for opiate dependence. American Journal of Psychiatry 144: 590-596, 1987.

Source: National Institute of Drug Abuse, "Principles of Drug Addiction Treatment: A Research Based Guide."

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Thoughtful quotes about the past, living in the past, and trying to change the past.

Words of Wisdom

 

"I do not possess what I remember so much as it possesses me." (Richard Bode)

"The trouble with you is you think you have time." (Don Juan to Carlos Costaneda)

"One can never change the past, only the hold it has on you." (Merle Shain)

"Among the dead there are those that still have to be killed." (Fernad Desnoyers)

"What's past is prologue." (Shakespeare)

"The past should be a springboard, not a hammock." (unknown)

"Every journey into the past is complicated by delusions, false memories, false naming of real events." (Adrienne Rich)

"Life is thickly sewn with thorns, and I know no other remedy than to pass quickly through them. The longer we dwell on our misfortunes, the greater is there power to harm us." (author unknown)

"Life can only be understood backwards, but must be lived forwards." (Soren Kierkegaard)

"One must never lose time in vainly regretting the past or in complaining against the changes which cause us discomfort, for change is the essence of life." (Antole France)

"It's but little good you'll do watering last years crops." (Frederick Loomis)

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next:Pleasure

Note to editor: all references which are now in parentheses, in the form of a name and a data, should be numbered as footnotes and placed at the end of the book with the other footnotes, chapter by chapter. The references might best be grouped as a bibliography-reading list, with the footnotes referring to them by name and date.

Are you sad? Do you have a low opinion of yourself? Does a sense of helplessness and hopelessness weigh you down? Do you feel this way for days or weeks at a time? Those are the elements of depression.

If this is how you are feeling, you surely want to regain a pleasant outlook on life. You also need to prevent depression returning later. Happily, there now are aids to attain those goals. (But fighting depression takes effort. And there are certain benefits of being depressed which you may be reluctant to give up.)

Nowadays, a depression sufferer usually can get relief with active cognitive psychotherapy, or with tested anti-depressant medications, or with both. The U. S. Public Health Service summarizes as follows: "Eighty percent of people with serious depression can be treated successfully. Medication or psychological therapies, or combinations of both usually relieve symptoms in weeks."1 Both kinds of treatment have been shown in controlled experimental research to benefit a large proportion of depression sufferers, within a few months or even weeks. Drugs, however, control the depression, whereas psychological therapy can cure it. (For information about the scientific results, see Appendix B and the books cited in the reference list.) All this is good news indeed for depression sufferers.

Only a quarter century ago, medical and psychological science had little to offer depressed people. Traditional Freudian-based therapy put you on a couch or in an easy chair, and started you talking at random. You and your therapist hoped that in the course of two to five expensive hour-long sessions a week, continuing for many months or years, you would come across sensitive incidents in your past. Those "insights" were expected to relieve you of the pain the incidents induced. But the success rate was not high, nor was psychoanalysis proven effective by scientific tests.

Traditional therapy was founded upon the crucial assumption that people are irresistibly disturbed by their past experiences, and cannot change their emotional life by changing their current patterns of thinking. Recent scientific research has shown, however, that this assumption is false. People can indeed overcome depression by changing their current thought patterns. That is, though you may have been disturbed by events in your past, you now (in Albert Ellis's phrase) disturb yourself by your current mental habits.

Modern cognitive therapy -- which fully coincides with the wisdom of the ages on this point -- begins with the assumption that we have considerable control over our own thinking. We can choose what we will think about, even though following through on the choice requires effort and is not always fully successful. We can select our goals, even though the goals are not infinitely flexible. We can decide how much we will agonize over particular events, though our minds are not as obedient as we would like them to be. We can learn better ways to understand the data of our objective situations, just as students learn to gather and analyze data scientifically, rather than being forced to accept the biased assessments we have tended to make until now.

This book teaches you a newly-sharpened version of cognitive psychotherapy that has a more comprehensive theoretical base and wider curative outlook than earlier versions. You may use it by yourself to overcome depression, or you may use it in conjunction with a therapist. Most sufferers can benefit from the assistance of a wise counselor, though finding such a helpful person is not easy.

There is still more good news: Psychiatrist Kenneth Colby, famous for his artificial-intelligence computer simulation of paranoia, has developed a computer-based system of psychotherapy for depression based on the key ideas of this book. You "speak" to the computer, and the computer speaks back on the screen, which helps you help yourself. A disk to run the program on an IBM-PC computer is included with this book. It can be a help and a comfort to many readers.

My Personal Story and Negative Self-Comparisons

This book emerges not only from the body of new scientific discoveries, others' and my own, but also from my personal experience of deep and prolonged melancholy. Here is my story.

I was depressed -- badly depressed -- for thirteen long years from early 1962 to early l975. When I say that I was depressed I mean that, except for some of the hours when I was working or playing sports or making love, I was almost continuously conscious of being miserable, and I almost continuously reflected on my worthlessness. I wished for death, and I refrained from killing myself only because I believed that my children needed me, just as all children need their father. Endless hours every day I reviewed my faults and failures, which made me writhe in pain. I refused to let myself do the pleasurable things that my wife wisely suggested I do, because I thought that I ought to suffer.

As I look back now, in comparison to re-living the better of the days when I felt as I did then, I'd rather have a tooth pulled and have the operation bungled, or have the worst possible case of flu. And in comparison to re-living the worse of those days in the first year or two, I'd rather have a major operation or be in a hellish prison.

Over the years I consulted psychiatrists and psychologists from several traditional schools of thought. A couple of them left me with the impression that they didn't have a clue about what I was saying and had simply somehow passed the necessary exams to get into a well-paying business. A couple of them were human, understanding, and interesting to talk to, but could not help me. And toward the end of that time, the psychiatrists and psychologists did not even offer me hope, and certainly no hope of a quick cure. My own training in psychology was no help, either.

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Then I read about what was, at that time, a new and different approach to psychological problems -- Aaron Beck's Cognitive Therapy, which in Albert Ellis's somewhat different form is called Rational-Emotive Therapy. (I shall consider them together under the label "cognitive-behavioral therapy" or just "cognitive therapy", along with Frankl's Logotherapy, recent variants such as Interpersonal Therapy, and also behavioral therapy.)

The core of cognitive-behavioral therapy is a thoughtful problem-solving procedure that quickly can get to the root of the depression, and directly yank out that root. Within that vision of the individual as able to change his or her depressed thinking, I then developed an analysis of the cause of depression centering on the depressed person's negative self-comparisons. And I worked out the logic of what I call "Values Treatment," which can provide a powerful force for people to use the resources of cognitive therapy and thereby cure themselves of depression; that is what Values Treatment did for me.

Within two miraculous weeks I banished my depression, and I have since then been able to keep depression at bay. (Such a quick cure is not usual, but it is not wildly exceptional, either.) Starting April, l975, I have almost always been glad to be alive, and I have taken pleasure in my days. I have occasionally even been ecstatic, skipping and leaping from joy. And I am joyful more often than most people, I would judge. Though I must still fight against depression from time to time, I have not lost more than a minor skirmish since then, and I believe that--if my family and community stay safe from catastrophe--I have beaten depression for life. The Epilogue at the end of the book gives the details of my passage from sadness to joy.

After I had cured myself, I wondered: Could I use my new advances in cognitive therapy --- Self-Comparisons Analysis and Values Treatment -- to help others, too? I proceeded to counsel with other persons who were depressed, and I found that these ideas could indeed help many of them get over their depressions and find new joy in life. Then I wrote a short version of this book, and leading psychiatrists and psychologists who read it agreed with me that the book -- including Self-Comparison Analysis, and the therapeutic approach derived from it -- makes a new contribution not only to sufferers from depression but also to the theory of the subject. And people to whom I have given early copies, some of whose cases I'll mention later, have reported dramatic salvation from their own depressions - not in every case, but often.

*** I hope that there will soon be a smile on your face, too, and laughter bubbling inside you. I don't promise you instant cure. And you will have to work at overcoming the depression. You must exercise your intellect and will in outwitting the traps that your mind lays for you. But I can promise you that cure and joy are possible...A tip for the road: Try treating your fight to overcome depression as an adventure, and think of yourself as a valiant warrior. More power to you, and luck.

Afterword For Those Interested in the Scientific Evidence

 

The experimental evidence for the success of cognitive therapy in helping depression and other miseries has been mounting up. For thirty years now, a variety of studies have shown cognitive therapy to be helpful. And in 1986 the National Institute of Mental Health of the U. S. Department of Health and Human Services completed a tightly-controlled three-university study lasting six years (and costing ten million dollars!) comparing a) encouragement only, b) drug therapy, c) Beck's Cognitive Therapy, and d) Interpersonal Psychotherapy; both these latter psychotherapies emphasize the key element of altering one's own thinking and behavior. The results at the conclusion of treatment showed that the active psychotherapies were as successful as the standard drug imipramine in reducing the symptoms of depression and improving the patient's ability to function. Drug treatment produced improvement more rapidly, but the active psychotherapies caught up later. Severely depressed and less-severely depressed patients both benefited from the active psychotherapies.(7)

These findings are extraordinarily impressive because drug therapy has been the favorite of the medical establishment in recent years. And cognitive-behavioral therapy has none of the side-effect dangers, physical and psychological, that accompany drugs. Furthermore, as noted earlier, the drugs control rather than cure depression. Hence, even if drugs are to be used, psychotherapy is appropriate in combination with the drugs in order to root out the underlying causes and move toward real cure.

 

Afterword About Drug Therapy for Depression

 

Neither I nor anyone else can give you authoritative advice about whether drugs are right for you. It surely makes sense to hear what one or more physicians has to say to you about drugs. Finding a wise physician, however, is particularly difficult when the ailment is depression. The problem is, as two noted psychiatrists put it, that depression "may arise from a biological malfunction, from actual losses, deprivations, or rejections, or from personal limitation. The difficulty in sorting out such causal fact is a source of enormous confusion in the diagnosis and treatment of disorders of mood."(2) And as two other reliable psychiatrists put it, "depression is almost certainly caused by [many] different factors", and hence "there is no single best treatment for depression."(3) Your best bet is listen to medical advice, and also advice from one or more psychologists, and then make your own decision about whether you want to try drugs first, or psychological therapy first, or both together.

Perhaps the most important piece of knowledge is that, contrary to what some physicians will tell you, drugs are not an all-purpose cure for depression. Perhaps the only major exception is the case of a person who has suffered real tragedy from death or other great loss, and is slow in putting the tragedy behind her/her. A sprained brain is very different than a sprained ankle. An out-of-order brain is very different than an out-of-order kidney or pituitary gland. Even if drugs relieve the depression while you are taking the medication, you almost surely need to straighten out your thinking so that the depression will not recur after you stop the drugs, and so that you will know how to fight off depression if it does recur.

Depression is not likely to be caused simply by a biologically-induced chemical imbalance that a drug can neatly restore to balance. As Seligman4 puts it, "Does the physiology cause the cognition, or does the cognition cause the physiological change? ..the arrow of causation goes both ways.." And as another psychiatrist has recently written, "Drugs do not cure the illnesses, they control them."(5)

Only psychotherapy offers true cure in most cases of depression. And as the official statement of the American Psychiatric Association judiciously puts it, "All depressed patients need and can benefit from psychotherapy,"(6) rather than relying upon medication alone. Patients treated with cognitive-behavioral psychotherapy as well as drugs have fewer recurrences than patients treated with drugs alone, in one study.(5.1) Miller, Norman, and Keitner, 1989

I do not intend to suggest, however, that drug therapy may not be appropriate for you. Modern anti-depression drugs offer hope to some people who are otherwise doomed to misery for long periods of time. I myself probably would and should have tried such drugs during my long depression if they had been as well- established as they now are. Drugs are particularly indicated when the depression continues for a very long time, because "One thing seems sadly certain: the person who remains chronically depressed over time has a reduced chance of recovering."(8) What I am suggesting is that you should not only consider drugs, and that it might be wise to try cognitive therapy first. You can read more about anti-depressant drug therapy in Chapter 00.)

bntro 9-148 depressi February 19, 1990

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Dear Mr. Peele,

I wondered what your thoughts were on the connection between individuals who have suffered sexual trauma (incest, molestation, rape, etc.) who then developed a chemical addiction. It seems to me there is a strong correlation here. I have read so many studies where sexual abuse appears to be a predictor of drug and alcohol addiction. Do your experiences reflect this thinking?

Diane

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Dear Diane:

I read claims like yours often. Even people who generally agree with me make such claims. I don't believe it. In general, my feeling is that no type of specific trauma results in any type of specific dysfunction in adulthood. It is not merely my distaste for deterministic models of psychology and psychiatry that makes me say this. Whenever research on childhood and family trauma or experience is conducted (e.g., about childhood violence, FAS/"crack babies", children of alcoholics) is conducted, it finds that the majority of people from such backgrounds do not develop the malady in question. More importantly, even the heightened susceptibility to the problem is clearly not due to transference of a trait directly from parent to child. Rather, it is the culture of violence, drinking, etc. of which the household is part that supports and conveys this heightened likelihood to engage in a behavior or, more generally, it is the entire deprived, degraded, or disorganized home that leads to a host of disorders. This applies as well to fetuses born to drug or alcohol-abusing mothers, whose problems are the result of an entire environment of pre- and post-fetal abuse.

Stanton

References

Family violence:

R.J. Gelles and M.A. Straus, Intimate Violence, New York: Simon and Schuster, 1988.

J. Kaufman and E. Zigler, Do abused children become abusive parents?, American Journal of Orthopsychiatry, 57:186-192, 1987.

Children of alcoholics

E. Harburg et al., Familial transmission of alcohol use: II. Imitation and aversion to parent drinking (1960) by adult offspring (1977), Journal of Studies on Alcohol, 51:245-256, 1990.

FAS/Cocaine babies

E.L. Abel, An update on incidence of FAS: FAS is not an equal opportunity birth defect, Neurotoxicology and Teratology, 17:437-443, 1995.

R. Mathias, Developmental effects of prenatal drug exposure may be overcome by postnatal environment, NIDA Notes, January/February, 1992, pp. 14-15.

Two summaries of recent evidence that what have been identified as crack babies are victims primarily of poverty are provided in the Media Awareness Project library: J. Jacobs, The crack of doom is simply poverty; S. Wright, Crack cocaine babies aren't doomed to failure, studies show.

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Article on saying goodbye to a dying loved one and the opportunities that come from talking with a dying person.

Have you said goodbye to a dying loved one yet? Chances are good that you will. With medical advancements in the diagnosis and treatment of cancer and other degenerative diseases, we can anticipate 'dying time' much more accurately than ever before. A terminal diagnosis is a gift of time and a wake-up call that time is running out. How will you use the time? Will you see the end of life as an opportunity to talk, love, and grow from the experience of talking with the dying person, or will you bring out the crying towel and simply wait for your loved one to die?

The last stage of a loved one's life is a final opportunity to say "I love you" and to say goodbye. It is a chance to carry on a relationship until the very end or beyond; a time for growth; a time to let go of any hurt that may have been caused by a difficult relationship. Our book, Final Conversations: Helping the Living and the Dying Talk to Each Other, is for all who have lost a loved one to a terminal illness; it is for everyone who will lose someone in the future. It is for the surviving partners and for anyone who wants to understand the practical power and importance of communication at the end of life, and to learn how to have a better and more fulfilling final conversation.

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Final conversations, simplified in our book to "FC-talk," include all the moments of talking, touching, and spending time with the Dying. (We decided to capitalize the Living and the Dying when we mean the person or people rather than the process.) These communicative moments potentially begin when you find out that someone you love is dying, and continue until the moment the person dies. FC-talk is not necessarily the "last" conversation that the Dying had with someone, although in some instances it is.

Seventeen years ago, Ellen was losing the love of her life. Her husband, Michael, was dying of a brain tumor. He was in his early forties and he was leaving a young wife and two young children. Ellen revealed that her FC-talk focused on keeping their relationship genuine until the moment of his death and beyond if possible. She wanted to be sure that Michael knew he was loved and that she had completed her relationship with him up until the moment of his death. She repeatedly told him that I loved him, that I would always love him. I really didn't want to live my life without him, but I didn't get to make a choice about it. I would do my very best job to raise our children right. I was just glad that we got to spend the time that we did together. I thought it was a privilege to be able to have shared my life with him. I was grateful for the time that we had and to have had his children.

Ellen emphasized that the message of love had to be clear, leaving no doubts. I think if you're smart enough of a human being, you actually convey to the person that you love them while it has meaning and while it has emotion. This was a conversation [that really mattered]; I mean, we were going to be separated. We knew we were going to be separated. And I just needed to be able to complete with him and to let him know that I've always loved him and that I always would love him. It was a privilege for me to grow up and spend my life with him. I think conversations that you have with people who you know are on borrowed time . . . even though we're all on borrowed time, we don't live like we're on borrowed time . . . I mean, I guess what I'm trying to say is that we should all live as if we all know we're terminal. Because we all are terminal!

I completed my relationship with him. I didn't walk away thinking, Aauugh, I should have said, I didn't say, I could have said, I wanted to say. There wasn't anything that we didn't really say. And in the final analysis, the most important, the absolutely most important things were all said. Because the person who is left doesn't get stuck holding a bunch of untied knots. It's complete. You're not dragging anything along with it. We both completed the relationship.

We both were able to let each other know that we didn't want it to go that way. But since it was going to go that way anyway, we made the most of that final time. After speaking together, we gave Michael the chance to complete his relationship with his family and his friends. We also gave him the opportunity to tell us anybody that he didn't want to come there. And there were some people, just a few, that he said, "I don't want to deal with them. I don't want to see them." So, it was a new level that a lot of people experienced in relationship to him and his death. Some were shocked that they were able to complete their relationship with Michael [through their FC-talk].

Because Ellen was in love with Michael to the end, she remained open to love and was lucky to find love for a second time. Ellen has now been happily married to Wally for many years.

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Ellen isn't the only one who married again following the death of a beloved spouse. Cathy, Sondra, and Victoria all talked about the importance of FC-talk as a critical tool to assist the Living in moving on past the death. All of these young wives talked about the importance of the Dying giving the Living permission, and sometimes motivation, to continue living life. In these cases, the Dying gave the living permission—even encouragement—to marry again someday. Cathy's husband, Don, was thirty-two years older than she, so he knew that she would outlive him. Don began the conversation with Cathy about marrying again long before their FC-talks, and again when he was dying. Because he knew he was that much older than I, he said that I needed to make sure that I move on. Cathy often dismissed his suggestion while he was alive, but would remember it later. She appreciated his ultimate concern for her and their daughter Christina's future happiness.

Part of the completion of the relationship for these four dying husbands was their unselfishness and release of any personal jealousy of the Living. They knew that life is meant to be lived fully, with love, just as each of these marriages had been lived. For these wives, there was not going to be any guilt or looking back with regret. Completing the relationship honored love itself by acknowledging the love that had been, and by embracing the potential for the love that would be. All four of these women married again.

Sondra's husband, Steve, died of acute leukemia. He had just had four heart attacks in a two-week period. Clearly, he didn't have much longer to live. Steve told Sondra: "I don't want you to fear death. I don't want you to mourn if I pass away." The last thing that he wanted was any fear of that. And he said, "Death is part of life." I'll never forget that. "Everybody is going to die." He told me many times that "the worst thing you could ever do is to mourn my death. Don't mourn me; rejoice because I'm in a better place." Then he said, " I want you to remarry." He made me realize that this is not something that you're going to ever become bitter over. I had always thought previously that if somebody marries somebody, that you show your real love to them [after they die] by never marrying again, and you show that devotion to that person for a long time, even past their death. And, he said, "No, you will love." And he told me that "your real love for someone is to want the best for them."

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A similar message was given to Victoria byher young husband, Kerry,whowas dying of cancer. Kerry was Victoria's first love. They had married young, and she was devastated at the thought of his death. Victoria recalled: We had great passion. I had never been with anybody else beyond casual dating. And I remember sitting in the hospital and saying, "I'll never marry again, there's no way." And he said, "I sure hope you will. I hope being married to me was good enough that it'll make you want to marry again."

Victoria elaborated on the importance of this FC-talk as a love message. When he told me I'd be okay without him, that I could live without him, that I should marry again, he was providing for my family. He was attempting to make sure that we had the best we could, that I would take good care of the girls, that I would have a good life. He was just continuing to be the loving husband and father that he had been all along. He was continuing to take care of us. I have known a lot of women that weren't given that kind of permission, that gift, who really felt uncomfortable with that idea [of moving on to love again]. Her words imply that women who do not receive that gift of letting go can remain stuck in uncompleted relationships and the memory of love—sometimes for the rest of their lives.

So, what did the Living teach us about love? Many things, as we describe in our book, but three points are worth mentioning here:

• Tell the people you love that you love them. Tell them often. Tell them now. Tell them before time runs out.
• Death is a great triage nurse for love. The dying process fails to nurture pettiness and triviality, and then only love remains. Love, the highest of human emotions, is nurtured to the end. Count on it.
• When you love someone so much that you think you can't live through their death yourself, that's when you really have to make yourself participate in FC-talk. To be able to say what needs to be said does help the Living cope. FC-talk helps the Living make the transition to a life without the Dying.

About the authors: Keeley and Yingling are communication experts who personally have had final conversations with loved ones, and who interviewed over 80 volunteers who wanted to share their experiences with others. Portions of this article were excerpted from the authors' book Final Conversations: Helping the Living and the Dying Talk to Each Other (VanderWyk & Burnham, 2007).

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Walk by any college computer lab or dorm late at night and you will see hundreds of students frantically typing away on their computer terminals - but instead of school research and paper-writing, they're most likely spending several hours every night slaying monsters at gaming sites or chatting aimlessly with Internet pals hundreds of miles or even continents away. College counselors are starting to see those students who can't stop surfing the Internet at the risk of jeopardizing their grades. And administrators fear the rise of attrition rates due to Internet misuse on campus.

Caught in the Net reveals how the combination of unstructured, free, and unlimited Internet use breed college communities of severe addicts, who are just beginning to awaken to the seriousness of plummeting grades and ruined social lives. Case studies, observations, and suggestions for a new outlook on the Internet in our universities serve as a wake-up call to students, faculty, parents, and counselors.

Dr. Young tours nationally on college campuses. Please contact us to arrange a College Lecture that will enlighten students, faculty, administrators, and college counselors. Click here to order Caught in the Net

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Book and Music

From the experience of loss, I was forced to begin a search.
Whatever it was I was looking for,
I ended up finding myself.

This book evolved from a fierce desire to know and understand myself, and the way in which individuals learn, grow and develop, (socially and spiritually), and as an expansion of my previous book, "Pools of Peace". Even though I had more than enough pages completed, I continually found myself thinking of ways to expand its contents as my own personal development and understanding expanded. I decided that "Pools" had the right amount of information within it, and further expansion on my philosopy was best put into a more detailed form.

As my thirst for knowledge of human development increased, the need for this information to be documented became paramount. Not only was there a need to share this knowledge with you, the readers, and with those who are close and dear to me, but a strange feeling of wanting to share it with myself. I believe that this came from the need to purge myself of the feelings and thoughts within. It was almost like giving myself a test on this subject that is so close to my heart; a way of laying out my inner self on paper and saying, "Yes!, this is exactly what I am feeling". Upon completion of such an exercise, the information seems to slip back into my pysche to become silently, but permanently resident within the core of my being. It is now first nature to me, and I am in a position to act without fear or reserve when any situation comes my way where Love and Compassion are the only answers.

Download a FREE book about developing Awarenessto bring about radical positive change.

Index of Chapters Book and Music Introduction to Getting off The Roller Coaster The Struggle of the Ego The Concept of "The Now" Understanding and Working Through Fears The Mirror Action of Life Conditioned Emotions and Choosing. Cultivating a New Discipline. A Good Way to Love. Affirming Your Right to Love The Gratitude Principle. Co-Creating With God. The Peaceful Balance. Appendix I Appendix II Bibliography To My Readers APPENDIX I: A verse to meditate on APPENDIX II: Lyrics to Songs and their stories 12 Chapters and approx 190 pages. Fully formatted and ready to be printed.

This FREE book has an optional Companion CD or Audio Tape You can listen to these songs at www.broadjam.com or BUY IT FROM MY PURCHASE PAGE INDEX OF SONGS Don't let go of your dreams. The Believing Way It's gonna be alright. Miracles Matter. Talk to Me. Breakaway. Don't be afraid.

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Ideas on how to improve social skills in children with ADHD as many ADHD children often lack the social skills necessary to get along with their peers and communicate with others.

How to Improve Social Skills in Children with ADHD

The direct teaching of social rules or conventions which guide interactions and which most children learn without direct input. These might include how to greet somebody, how to initiate a conversation, taking turns in a conversation, and maintaining appropriate eye contact.

Modelling of social skills such as the above for the target child to observe ; or shared viewing and discussing of a video-tape of two people talking or playing, including reference to any non-verbal messages which can be discerned.

Providing specific and structured activities which are to be shared with one or two selected classmate(s). These might range from some jobs to be completed in the school during break or lunch time, games involving turn-taking (board games based on logic or spatial intelligence such as Chess rather than games based on inference-making like Cluedo, simple card games ), tasks or mini-projects to be completed on the computer ( e.g. preparing large print labels for work to be displayed around the classroom or having the major responsibility for printing a class newsletter ).

Identifying particular skills in the target child and inviting him/her to offer some help to another child who is less advanced (e.g. if your child is really good with the computer then maybe they can help another child who may find computers more difficult).

Encouraging his or her participation in school clubs or organised/structured activities during the lunchtime.

Direct advice about when, and for how long, the child may go on about a favourite topic, perhaps with the use of a signal by which to indicate when to stop ( or not to start ! ). Giving notice of something fifteen minutes before the need to go out or change then a reminder every 5 minutes then every minute 2 minutes before the deadline - you must make sure to make it clear each time e.g. in 15 minutes we need to get ready to go to the shop, in 10 minutes we need to get ready to go to the shop, in 5 minutes we need to get ready to go to the shop, 2 minutes to get ready to go to the shop, 1 minute to get ready to go to the shop. Keep things very clear and specific.

Recognising the Viewpoints and Feelings of Other People

In the classroom setting, instructions should be very precise with no opportunity to misunderstand what is expected. It may be necessary to follow up group instructions with individual instructions rather than assuming that the target child has understood what is needed or can learn "incidentally" from watching what other children do.

Direct teaching about social situations such as how to recognise when someone is joking or how to recognise how someone else is feeling. This latter might begin with a series of cartoon faces with clearly drawn expressions indicating anger, amusement, etc., with the target child helped to identify the various feelings and guess what caused them.

Games or role play to focus upon the viewpoint of another person. This might include simply looking at pictures of children or adults interacting or working together or sharing some activity, and asking what is happening or what a given individual is doing, and what he might be thinking.

Direct teaching of what to do ( or what not to do ) in certain situations, such as when the teacher is cross either with the individual child or with the whole group.

Avoiding Social or Communications Breakdown

• Helping the child to recognise his/her own symptoms of stress or distress, with a "script" by which to try relaxation strategies ; or having in place a system where it is acceptable for the child briefly to remove him/herself from the class as necessary.
• The establishment of a "buddy" system or a system where the child in question is encouraged to observe how other children behave in particular situations.
• Having selected peers specifically model social skills. The buddy might also be encouraged to be the partner of the ADHD child in games, showing how to play, and offering or seeking help if the child is teased.
• The use of the "Circles of Friends" approach designed to identify (social) difficulties, and to set targets and strategies by which other children in the class can be helpful and supportive, with the long term aim of increasing social integration and reducing anxiety.
• The availability of a regular time slot for support from an adult in terms of feedback concerning (social) behaviour, discussing what is going well and less well, and why ; and enabling the child to express concerns or versions of events.
• A clarity and explicitness of rules in the classroom to minimise uncertainty, and to provide the basis for tangible rewards.
• Reminders about conversation rules ; and using videos of TV programmes as a basis for observing appropriate interaction.
• In a group setting, adopting the circle time strategy of limiting verbal contributions to whomsoever is in possession of some object (while ensuring that the object circulates fairly among the whole group).
• Using a video of a situation to illustrate behaviour that is inappropriate in, for example, causing irritation to other children, then and discussing why ; making a video of the target child him/herself and discussing where there are incidents of good social behaviours.
• In respect of repetitive questioning or obsessive topics of conversation ......... :
• Provide a visual timetable plus bulletins of any innovations so there is no uncertainty about the day's routine.
• Make it clear that you will only respond to a question when a given task has been completed.
• Agree a later time for responding to the question and allow the child the opportunity to write it down so they don't forget.
• Specify one particular place, such as the playground, where the question will be answered.
• Explain quietly and politely that the child has asked this before and maybe suggest that it might be a good idea to write down the answer so that the next time they want to ask the same question rather than you becoming a bit exasperated with them that they can pick up the card where the answer is written.
• If obsessive talking appears to mask some anxiety, seek to identify its source, or teach general relaxation techniques.
• Specify times when the obsessive topic can be introduced, or allow an opportunity as a reward for finishing a piece of work.
• Provide time and attention, and positive feedback, when the child is not talking about the given topic.
• Agree with the child and his classmates a signal to be used by those classmates when they are tired of the topic.
• Allow some practice of talking at a reasonable volume, with an agreed signal to be given if it is too loud ; or tape-recording speech so that the child can evaluate the volume him/herself.

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Peer Awareness

A common theme in much of the on going research and studies about social skills in the child with ADHD is that the work intended to help the child needs to involve other children to at least some extent. If the focus is upon peer interaction, there is little logic in seeking to improve performance by using only one to one sessions.

It would therefore be desirable for perhaps two or three non-ADHD peers to participate in the activities or video watching so that there could be a shared discussion and an actual possibility to practice some of the skills by the children in various make believe situations and not simply by target child and adult. This latter arrangement risks being somewhat abstract when evidence suggests the value of working on social skills within a social context.

Also, if peers are involved in the training strategies and share the same rules, this may reduce stress upon the ADHD child and increase the rate at which (s)he internalises the targeted behaviours in real situations they can identify with.

The idea that simply placing a child with ADHD in a mainstream class will not actually be the solution for that child to develop socially appropriate behaviours. There needs to be direct teaching or modelling of the behaviours, and it is likely that the number of such behaviours needs to be limited to one or two at a time if true learning and consolidation is to take place.

Learning from peers can take three forms:

Where the target child is placed within a group of peers whose positive social skills will be modelled constantly by others and where it has been made clear to the ADHD child what to observe and imitate. So the need to explain carefully what you want your child to watch the other children doing needs to be fairly specific - e.g. watch how this group take turns to throw the dice in the game.

The training approach involves peers being shown how to prompt some particular response from the child with ADHD and then to offer praise when the child acts appropriately. So the group you are working with need to know exactly what you are wanting your child to learn - e.g. turn taking so they can go round with the dice with the person with the dice passing this to the next child saying it is now your turn to throw the dice all round the group until it comes to your child's turn. Then the child before can hand your child the dice and say clear that it is now their turn to throw the dice and thank them for waiting nicely for everyone else to have their turn. Then once the child has thrown the dice for them to then pass the dice to the next child saying it is now your turn to throw the dice when that child can then say thank you for giving me my turn. Things like this although may sound very strange help our children to learn the idea of turn taking by constant reinforcement as they learn much better by various forms being taken - watching - speaking the instruction and then interaction of praise for getting it right.

The peer-initiated approach involves showing peers how to talk with the ADHD child and how to invite him or her to respond. It enables the other children to learn that this particular child has a problem and that you are trusting them to help the child to learn how to take part correctly, this therefore also helps the other children to work on the skills they need to continue to involve the child in other activities by asking them in the right manor and how to explain the rules in a way your child will understand in the future.

There is evidence that involving all children in the development of social skills has more benefits than working with the targeted child(ren) only ; there is also the point that this approach avoids singling out the child with the ADHD characteristics which might otherwise introduce a further disadvantage before one even begins ! There is a similar risk in a constant pairing of the ADHD child with a support assistant in that a dependency may be established, and any need or motivation to interact with other children is reduced.

A further implication behind all this is that there will be benefits in providing some sensitive awareness-raising among classmates of the nature of ADHD characteristics and behaviours. There is evidence ( e.g. Roeyers 1996) that giving peers this kind of information can improve the frequency and quality of social interaction between the ADHD child and classmates ; and that it can increase empathy towards the ADHD individual whose idiosyncrasies become more understandable and are not seen as provocative or awkward.

The whole point of this being a Social problem leads everyone to realise that the best way to help your child is to involve them in controlled social situations as this helps not only your child but it also allows others to learn how to involve your child in other situations without this causing as many problems as it may have done in the past.

REFERENCES

• Roeyers H. 1996 The influence of non-handicapped peers on the social interaction of children with a pervasive developmental disorder. Journal of Autism and Developmental Disorders 26 307-320
• Novotini M 2000 What Does Everyone Else Know That I Don't
• Connor M 2002 Promoting Social Skills among Children with Asperger Syndrome (ASD)
• Gray C My Social Stories Book
• Searkle Y, Streng I The Social Skills Game (Lifegames)
• Behaviour UK Conduct Files
• Team Asperger Gaining Face, CD Rom Game
• Powell S. and Jordan R. 1997 Autism and Learning. London : Fulton.
  (With particular reference to the chapter by Murray D. on autism and information technology )

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Accompanying with the steady increase in the number of people with eating disorders has been a rise in the number of people with exercise disorders: people who are controlling their bodies, altering their moods, and defining themselves through their overinvolvement in exercise activity, to the point where instead of choosing to participate in their activity, they have become "addicted" to it, continuing to engage in it despite adverse consequences. If dieting taken to the extreme becomes an eating disorder, exercise activity taken to the same extreme may be viewed as an activity disorder, a term used by Alayne Yates in her book Compulsive Exercise and the Eating Disorders (1991).

In our society, exercise is increasingly being sought, less for the pursuit of fitness or pleasure and more for the means to a thinner body or sense of control and accomplishment. Female exercisers are particularly vulnerable to problems arising when restriction of food intake is combined with intense physical activity. A female who loses too much weight or body fat will stop menstruating and ovulating and will become increasingly susceptible to stress fractures and osteoporosis. Yet, similar to individuals with eating disorders, those with an activity disorder are not deterred from their behaviors by medical complications and consequences.

People who continue to overexercise in spite of medical and/or other consequences feel as if they can't stop and that participating in their activity is no longer an option. These people have been referred to as obligatory or compulsive exercisers because they seem unable to "not exercise," even when injured, exhausted, and begged or threatened by others to stop. The terms pathogenic exercise and exercise addiction have been used to describe individuals who are consumed by the need for physical activity to the exclusion of everything else and to the point of damage or danger to their lives.

The term anorexia athletica has been used to describe a subclinical eating disorder for athletes who engage in at least one unhealthy method of weight control, including fasting, vomiting, diet pills, laxatives, or diuretics. For the rest of this chapter, the term activity disorder will be used to describe the overexercising syndrome as this term seems most appropriate for comparison with the more traditional eating disorders.

Signs and Symptoms of Activity Disorder

The signs and symptoms of activity disorder often, but not always, include those seen in anorexia nervosa and bulimia nervosa. Obsessive concerns about being fat, body dissatisfaction, binge eating, and a whole variety of dieting and purging behaviors are often present in activity disordered individuals. Furthermore, it is well established that obsessive exercise is a common feature seen in anorexics and bulimics; in fact, some studies have reported that as many as 75 percent u and se excessive exercise as a method of purging and/or reducing anxiety. Therefore, activity disorder can be found as a component of anorexia nervosa or bulimia nervosa or, although there is yet no DSM diagnosis for it, as a separate disorder altogether.

There are many individuals with the salient features of an activity disorder who do not meet the diagnostic criteria for anorexia nervosa or bulimia nervosa. The overriding feature of an activity disorder is the presence of excessive, purposeless, physical activity that goes beyond any usual training regimen and ends up being a detriment rather than an asset to the individual's health and well-being.

In her book, Compulsive Exercise and the Eating Disorders, Alayne Yates lists the proposed features of an activity disorder, a summary of which is listed below.

Features of an Activity Disorder

• The person maintains a high level of activity and is uncomfortable with states of rest or relaxation.
• The individual depends on the activity for self-definition and mood stabilization.
• There is an intense, driven quality to the activity that becomes self-perpetuating and resistant to change, compelling the person to continue while feeling the lack of ability to control or stop the behavior.
• Only the overuse of the body can produce the physiologic effects of deprivation (secondary to exposure to the elements, extreme exertion, and rigid dietary restriction) that are an important component perpetuating the disorder.
• Although activity disordered individuals may have coexisting personality disorders, there is no particular personality profile or disorder that underlies an activity disorder. These persons are apt to be physically healthy, high-functioning individuals.
• Activity disordered persons will use rationalizations and other defense mechanisms to protect their involvement in the activity. This may represent a preexisting personality disorder and/or be secondary to the physical deprivation.
• Although there is no particular personality profile or disorder, the activity disordered person's achievement orientation, independence, self-control, perfectionism, persistence, and well- developed mental strategies can foster significant academic and vocational accomplishments in such a way that they appear as healthy, high-functioning individuals.

Activity disorders, like eating disorders, are expressions of and defenses against feelings and emotions and are used to soothe, organize, and maintain self-esteem. Individuals with the eating disorders and those with activity disorders are similar to one another in many respects. Both groups attempt to control the body through exercise and/or diet and are overly conscious of input versus output equations. They are extremely committed individuals and pride themselves on putting mind over matter, valuing self-discipline, self-sacrifice, and the ability to persevere.

They are generally hard-working, task-oriented, high-achieving individuals who have a tendency to be dissatisfied with themselves as if nothing is ever good enough. The emotional investment these individuals place on exercise and/or diet becomes more intense and significant than work, family, relationships, and, ironically, even health. Those with activity disorders lose control over exercise just as those with an eating disorder lose control over eating and dieting, and both experience withdrawal when prevented from engaging in their behaviors.

Individuals with anorexia nervosa and bulimia nervosa and those with activity disorders usually score high on the EDI subscales of perfectionism and asceticism and have similar distortions in their cognitive (thinking) styles. The following list includes examples of the thinking patterns of people with activity disorders that are similar to the mental distortions in those with eating disorders.

Medical Reference from "The Eating Disorders Sourcebook"

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Cognitive Distortions in Activity Disorder

DICHOTOMOUS, BLACK-AND-WHITE THINKING

• If I don't run, I can't eat.
• I either run an hour or it's not worth it to run at all.

OVERGENERALIZATION

• Like my Mom, people who don't exercise are fat.
• Not exercising means you are lazy.

MAGNIFICATION

• If I can't exercise, my life will be over.
• If I don't work out today, I'll gain weight.

SELECTIVE ABSTRACTION

• If I can go to the gym, I am happy.
• I feel great when I exercise, so if I exercise I'll never be depressed.

SUPERSTITIOUS THINKING

• I must run every morning or something bad will happen.
• I must do 205 sit-ups every night.
• I can't stop at 1 hour and 59 minutes, it has to be exactly 2 hours, so when the fire alarm went off I couldn't get off the Stairmaster, I had to keep going, even if the gym was burning down.

PERSONALIZATION

• People are looking at me because I'm out of shape.
• People admire runners.
• I am a runner, it's who I am, I could never give it up.

ARBITRARY INFERENCE

• People who exercise get better jobs, relationships, and so on.
• People who exercise don't get sick as much.

DISCOUNTING

• My doctor tells me not to run, but she is flabby so I don't listen to her.
• No pain, no gain.
• Nobody really knows the effects of not having a period anyway, so why should I worry?

Physical Symptoms of Activity Disorder

• A key in determining if a person is developing an activity disorder is if she has the symptoms of overtraining (listed below) yet persists with exercise anyway. Overtraining syndrome is a state of exhaustion in which individuals will continue to exercise while their performance and health diminish. Overtraining syndrome is caused by a prolonged period of energy output that depletes energy stores without sufficient replenishment.

Symptoms of Over-Training

• Fatigue
• Reduction in performance
• Decreased concentration
• Inhibited lactic acid response
• Loss of emotional vigor
• Increased compulsivity
• Soreness, stiffness
• Decreased maximum oxygen uptake
• Decreased blood lactate
• Adrenal exhaustion
• Decreased heart rate response to exercise
• Hypothalamic dysfunction
• Decreased anabolic (testosterone) response
• Increased catabolic (cortisol) response (muscle wasting)

The only cure for the above symptoms is complete rest, which may take a few weeks to a few months. To a person with activity disorder, resting is like giving up or giving in. This is similar to an anorexic who feels like eating is "giving in." When giving up their exercise behaviors, those with activity disorder will go through psychological and physical withdrawal, often crying, yelling, and making statements like

• I can't stand not exercising, it's driving me crazy, I'd rather die.
• I don't care about the consequences, I have to work out or I'll turn into a fat blob, hate myself, and fall apart.
• This is worse torture than any effects of the exercise, I feel like I'm dying inside.
• I can't even stand being in my own skin, I hate myself and everyone else.

It is important to note that these feelings diminish over time but need to be carefully attended to.

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Approaching an Individual With an Activity Disorder

In January 1986, the Physician and Sports Medicine Journal discussed the subject of pathogenic (negative) exercise in athletes and listed recommendations for approaching athletes practicing one or more pathogenic weight control techniques. The recommendations can be reformulated and extended for use when approaching individuals with activity disorders who are not necessarily considered athletes.

Guidelines for Approaching the Activity Disordered Individual

• A person who has good rapport with the individual, such as a coach, should arrange a private meeting to discuss the problem in a supportive style.
• Without judgment, specific examples should be given regarding the behaviors that have been observed that arouse concern.
• It is important to let the individual respond but do not argue with him or her.
• Reassure the individual that the point is not to take away exercise forever but that participation in exercise will ultimately be curtailed through an injury or by necessity if evidence shows that the problem has compromised the individual's health.
• Try to determine if the person feels that he or she is beyond the point of being able to voluntarily abstain from the problem behavior.
• Do not stop at one meeting; these individuals will be resistant to admitting that they have a problem, and it may take repeated attempts to get them to admit a problem and/or seek help.
• If the individual continues to refuse to admit that a problem exists in the face of compelling evidence, consult a clinician with expertise in treating these disorders and/or find others who may be able to help. Remember that these individuals are very independent and success oriented. Admitting they have a problem they are unable to control will be very difficult for them.
• Be sensitive to the factors that may have played a part in the development of this problem. Activity disordered individuals are often unduly influenced by significant others and/or coaches who suggest that they lose weight or who unwittingly praise them for excessive activity.

Risk Factors

One outstanding difference between the eating disorders and activity disorders seems to be that there are more males who develop activity disorders and more females who develop eating disorders. Exploring the reason for this may provide a better understanding of both. What are the causes that contribute to the development of an activity disorder? Why do only some individuals with eating disorders have this syndrome and others who have this syndrome don't have eating disorders at all? What we do know is that the risk factors for developing an activity disorder are varied, including sociocultural, family, individual, and biological factors, and are not necessarily the same ones that cause the disorder to persist.

Sociocultural

In a society that places a high value on independence and achievement combined with being fit and thin, involvement in exercise provides a perfect means for fitting in or gaining approval. Exercise serves to enhance self-worth, when that self-worth is based on appearance, endurance, strength, and capability.

Family

Child-rearing practices and family values contribute to an individual choosing exercise as a means of self-development and recognition. If parents or other caregivers endorse these sociocultural values and they themselves diet or exercise obsessively, children will adopt these values and expectations at an early age. Children who learn not only from society but also from their parents that to be acceptable is to be fit and thin may be left with a narrow focus for self-development and self-esteem. A child reared with phrases such as "no pain, no gain," may endorse this attitude wholeheartedly without the proper maturity or common sense to balance this notion with proper self- nurturing and self-care.

Individual

Certain individuals seem predisposed to need a high level of activity. Individuals who are perfectionists, achievement oriented, and have the capacity for self-deprivation will be more likely to seek out exercise and become addicted to the feelings or other perceived benefits the exercise provides. Additionally, individuals who develop activity disorder seem outwardly independent, unstable in their view of themselves, and lacking in their ability to have fully satisfying relationships with others.

Biological

Just as with eating disorders, researchers are exploring what biological factors may contribute to activity disorders. We know that certain individuals have a biologically based predisposition to obsessive thoughts, compulsive behaviors, and, in women, amenorrhea. We know that in animals the combination of food restriction and stress causes an increase in activity level and, furthermore, that food restriction with increased activity can cause the activity to become senseless and driven.

Furthermore, parallel changes have been detected in the brain chemicals and hormones of eating disordered females and long-distance runners that may explain how the anorexic tolerates starvation and the runner tolerates pain and exhaustion. In general, activity disordered men and women seem to be different biochemically than nondisordered individuals and are more easily led and trapped into a cycle of activity that is resistant to intervention.

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Treatment for an Activity Disorder

The principles of treatment for individuals with activity disorders are similar to those with eating disorders. Medical issues must be handled, and residential or inpatient treatment may be necessary to curtail the exercise and to deal with depression or suicidality, but most cases should be able to be treated on an outpatient basis unless the activity disorder and an eating disorder coexist. This combination can present a serious situation rather quickly. When lack of nutrition is combined with hours of exercise, the body gets broken down at a rapid pace, and residential or inpatient treatment is often required.

Sometimes hospitalization is encouraged to patients as a way to relieve the vicious cycle of nutrient deprivation combined with exercise before a breakdown occurs. Activity disordered individuals often recognize that they need help to stop and know that they cannot do it with outpatient treatment alone. Eating disorder treatment programs are probably the best choice for hospitalizing those with activity disorder. An eating disorder facility that has a special program for athletes or compulsive exercisers would be ideal. (See the description of The Monte Nido Residential Treatment Facility on pages 251 - 274).

Therapy for an Activity Disorder

It is important to keep in mind that activity disordered people tend to be highly intelligent, internally driven, independent individuals. They will most likely resist any kind of vulnerability such as going for treatment unless they become injured or face some kind of ultimatum. Excessive activity protects these individuals against desiring to get close, to take in something from another, or to depend on anyone.

Therapists will have to maintain a calm, caring stance with the goal of helping the individual define what he or she needs, rather than focusing on taking things away. Another therapeutic task is to help the individual receive and internalize the soothing functions the therapist can provide, thus promoting relationships over activity.

THERAPEUTIC ISSUES TO DISCUSS IN THE TREATMENT OF ACTIVITY DISORDER

• Overactivity of mind or body
• Body image
• Overcontrol of the body
• Disconnection from the body
• Body care and self-care
• Black-and-white thinking
• Unrealistic expectations
• Tension tolerance
• Communicating feelings
• Ruminations
• The meaning of rest
• Intimacy and separateness

The following section discusses a problem that is the polar opposite of too much activity exercise resistance. "Exercise resistance" is a fairly new term used to describe an intense reluctance to exercise, particularly seen in women.

Eating Disorders: Exercise Resistance in Women

by Francie White, M.S., R.D.

Just as binge eating disorder lies at the opposite end of the disordered eating spectrum from anorexia nervosa, exercise resistance is an activity disorder at the opposite end of the spectrum from addictive or compulsive exercise. As a dietitian specializing in eating disorders, I have noticed a common phenomenon in women with emotional overeating patterns, many of whom qualify as having binge eating disorder.

These women often suffer from entrenched inactivity patterns that are resistant to intervention or treatment. Many professionals assume that inactivity is due to factors such as a harried lifestyle, industrialization, laziness, and, in overweight individuals, the discouraging factor of physical difficulty or discomfort in moving. Behavior modification counseling programs, use of specialized personal trainers, and other types of motivational strategies to encourage a physically active lifestyle seem to be ineffective.

Over a three-year period, beginning in 1993, I began exploring what I call "exercise resistance" in a binge eating disordered population of six groups of ten to twenty women each. The following information is what emerged from studying these groups.

For many women with a history of body image problems, moderate to severe overeating histories, and/or a history of repeated attempts at weight loss, exercise resistance is a common syndrome that requires specialized treatment. Remaining inactive or physically passive appears to be an important aspect of the psychological defense system within the eating disorder itself, providing a balance of sorts from the psychological discomfort that accompanies exercising. This psychological discomfort varies from moderate to severe anxiety and is related to a profound sense of physical and emotional vulnerability.

Underactivity or physical passivity appears to offer a sense of control over body and feelings, just as disordered eating and over-exercise do. Exercise resistance may simply be another component in the menu of options from which men and women find themselves suffering in this time of epidemic eating and body image problems. If we are to begin to look at exercise resistance as a separate syndrome worthy of specialized understanding and treatment, here are some factors to consider.

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WHAT DIFFERENTIATES THE EXERCISE RESISTANT INDIVIDUAL FROM SOMEONE WITH SIMPLE LOW MOTIVATION OR POOR EXERCISE HABITS?

• The individual strongly resists any suggestion to become more physically active (barring any physical impairments and given several workable options).
• The individual reacts with anger, resentment, or anxiety to any suggestion to become more physically active.
• The individual describes experiencing moderate to severe anxiety during physical activity.

RISK FACTORS FOR DEVELOPING EXERCISE RESISTANCE

• A history of sexual abuse of any kind at any age.
• A history of three or more weight loss diets.
• Exercise used as a component of a weight loss regimen.
• A larger body size as a boundary or defense against unwanted sexual attention or sexual intimacy (be it conscious or unconscious).
• Parents who forced or overencouraged exercise, especially if the exercise was to compensate for perceived, or actual, overweight in the child.
• Early puberty or development of large breasts and/or early significant weight gain.

THE MEANING OF EXERCISE RESISTANCE

To better understand exercise resistance, we can borrow from our understanding of how weight loss diets have affected eating behavior. We know that weight loss diets are a key aspect in the historical mistreatment of overweight individuals, in many cases actually contributing to binge eating, which increases over time. Responses from the women surveyed support the view that exercise resistance may be an unexpected, unconscious backlash against the current cultural emphasis on slimness and the overfocus on the symptom; for example, the weight, instead of the inner psychodynamic issues.

QUESTIONS TO ASK THE INDIVIDUAL WITH EXERCISE RESISTANCE

• What feelings and associations emerge for you at hearing the term exercise? Why?
• When did being physically active change for you from "playing" as a child to "exercise"? When did it shift from something natural, an activity you did spontaneously (for example, from an internal drive), to something you felt you should do?
• Has physical activity ever been something that you did to control your weight? If so, how was that for you, and how has it affected your motivation to exercise?
• How did your exercise attitudes change during and after puberty?
• Does being physically active relate in any way to your sexuality? If so, how?

A theme ran through the comments of the women studied that echoes the information in chapter 4, "Sociocultural Influences on Eating, Weight, and Shape." Most of the women expressed that they felt extremely degraded and vulnerable by their direct experiences of being encouraged to exercise as a means to achieve an acceptable body. Instead of being encouraged to exercise for fun, exercise for these women was connected to body image, or the pursuit of an acceptable body.

Many of the women's stories included experiences of deep humiliation, public or otherwise, at being overweight and unable to achieve this illusive standard. Other women actually acquired a lean, thinner body and experienced unwanted sexual objectification by peers and adults. In a significant number of the women, rapes and other sexual abuse occurred after weight loss, and, for many, sexual abuse was connected to the onset of exercise resistance and binge eating.

Many women are confused as they experience the desire to be thinner while at the same time feeling anger and resentment at what they have been told they have to do to achieve it, for example, exercise. For some, exercise resistance and weight gain may be symbolic boundaries, expressing a rebellious refusal to patronize a system in which the playing field for women is not about sports, or even achievement, but about sexual attractiveness to men"We'll play, you pose." This system is one in which women and men equally participate and perpetuate. Women objectify one another and themselves right along with men.

The above discussion of exercise resistance by Francie White was written specifically for inclusion in this book. It is important to understand this area as another disorder on the continuum of those being discussed. The understanding and treatment of exercise resistance are similar to that of eating disorders in that the therapist must impart an empathy for the need for the behaviors instead of trying to take them away.

When working with an exercise resistant individual, one must explore and resolve the source of the resistance, such as underlying anxiety, resentment, or anger. The goal of treatment is that the individual will be able to become physically active by choice, not coercion. It is important to begin by validating the resistance and even in some cases prescribing it, making statements such as:

• It is important that you can choose to not exercise.
• Resisting exercise serves a valuable function for you.
• Continuing not to exercise is one way for you to keep saying "no."

By making these comments, the therapist helps validate the need for the resistance and eliminates the obvious conflict.

It is important to clarify that the issue of addressing exercise resistance is to help individuals who are compelled to "not exercise" just as we try to help others who are compelled to do so, both of which leave the behavior out of the realm of choice. Little attention has been paid to exercise resistance, but it is clear that those who have it, like those with exercise obsession or disordered eating, appear to be in a love-hate relationship with their bodies; derive inner psychological or adaptive functions from their behavior; and are involved in a struggle not just with food or exercise but with the self.

For an examination of the struggle with self and other dynamics that result in eating disorders, the next three chapters will deal with the main areas in which the causes of eating disorders are understood, with a chapter devoted to each of the following:

SOCIOCULTURAL

A look at the cultural preference for thinness, and the current epidemic of body dissatisfaction and dieting, with an emphasis not only on weight loss but also on the ability to control one's body as a means of gaining approval, acceptance, and self-esteem.

PSYCHOLOGICAL

The exploration of underlying psychological problems, developmental deficits, and traumatic experiences such as sexual abuse, which contribute to the development of disordered eating or exercise behaviors as coping mechanisms or adaptive functions.

BIOLOGICAL

A review of the current information available on whether or not there is a genetic predisposition or biological status that is at least partly responsible for the development of an eating or activity disorder.

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Dear Dr. Stanton Peele:

Thank you for providing information on your web site that is thoughtful, provocative and informative.

Mine is a question that deals with personal freedom and MJ use and relationships. I married an inmate who when he came home after being released began to smoke MJ regularly. I was a bit shocked by his smoking since he never mentioned to me during the time we corresponded and visited regularly that he enjoyed MJ and that he planned to resume smoking it upon his release. (He was not placed under probation or parole because the PO wanted to "give him a break.")

However, his smoking MJ has caused me a lot of personal difficulty since I feel he smokes in an irresponsible manner (before going to work as a self-employed handyman, during our hiking in a public park, in his car while driving alone). I smoke neither tobacco nor MJ. I consider myself a light drinker. I don't like my husband's smoking MJ because I think that it creates a division between us and, more important, I think that it stunts his growth as an individual living a meaningful and responsible life.

I will be frank with you about my resentment over learning that he enjoyed smoking MJ after he came home from prison. He says, in his defense, that smoking MJ in California is not a felony (so he won't be facing 3 strike sentencing), that he works to contribute to the household expenses, and that he comes home at night, it relaxes him, and that for these reasons, I should not be concerned or upset.

I am, and that worries me. I would be grateful if you would provide me with some insight on the difficulty I experience over my husband's smoking MJ. I have thought of bartering with him. He would like me to get up earlier in the mornings because he's a morning person and I'm not by nature. However, I would gladly get up earlier if he would curtail his smoking or quit altogether. Please advise. I considered leaving the marriage over this. Thank you.

Sincerely,
A Wife

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Dear Wife:

You married an inmate? I guess you're finding out that even when they are not committing felonies, some people continue to act in consistently antisocial ways. This is important for understanding substance abuse and addiction. That he would not even mention he was a pot head to you — "didn't think it was relevant" — seems to show that he has a different value system than you do — but perhaps his prison time might also have told you that. I mean, littering is not a felony, but could you marry a litterer?

He does have a point — if mj relaxes him at home at night, perhaps it isn't society's business — but it is yours (it isn't illegal to drink alcohol, but you wouldn't want to marry someone who got drunk every night). Yes, I think bartering is worth attempting. What are you going to ask for exactly? No public mj smoking? Not smoking every night? Not smoking at all? I'm interested to know how he reacts.

Yours,
Stanton

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