Treating Psychiatric and Addiction Comorbidity With a Cognitive-behavioral (Non-12-step) Approach by Tom Horvath

As more addiction treatment programs treat comorbidity it seems likely that client confusion about treatment approach will increase. Comorbidity is here defined as having both a mental health disorder (such anxiety or depression) as well as an addictive disorder. Client confusion might arise because CBT (cognitive behavior therapy) has become the treatment of choice for many mental health disorders, but 12-step based treatment remains the most widely available treatment for addictive disorders. Clients receiving CBT for their mental disorders can be confused when they compare the self-empowering strategies of CBT with the emphasis on powerlessness in a 12-step approach. Although 12-step treatment now often incorporates relapse prevention and other CBT components, there remains a fundamental difference in the two approaches on the issue of personal empowerment.

At present there appear to be three potential solutions to this problem. Some providers might persuade themselves that this fundamental difference in treatment approach does not actually exist. If the client agrees, all may be well. However, if the client does experience a conflict between self-empowerment and powerlessness, then one approach could be dropped in favor of the other. Thus, the second possible solution would be to take a purely CBT approach and the third solution, a purely 12-step approach. Because a 12-step approach to mental health disorders is yet to be developed and tested, solution three appears to be only a theoretical possibility.

In a purely CBT approach to both mental health and addiction, clients are taught a basic model of behavior change. This model suggests that changing negative emotional experience (e.g., anxiety or depression) and maladaptive behavior (e.g., addictive behavior) can be accomplished by identifying, testing and modifying underlying beliefs. The leaders in the use of this model for mental health disorders include Albert Ellis, Ph.D. (1913-2007), who developed Rational Emotive Behavioral Therapy (REBT) and Aaron Beck, M.D., who developed Cognitive Therapy. For addictive disorders the most prominent leader is Alan Marlatt, Ph.D., who developed relapse prevention. Many of the other CBT oriented addiction treatments (e.g., behavioral marital therapy, the community reinforcement approach, social and coping skills training) have typically been developed by teams of researchers funded by government grants and working in universities.

The underlying beliefs that are the initial focus of CBT addiction treatment include the following, all of which are inaccurate (accurate beliefs shown also): Craving is unbearable (it is uncomfortable but it goes away). Craving makes me use/drink (I always have a choice). The experience of craving is harmful to me (it may be distracting but it hasn't ever harmed me). I need to use or I can't cope or have a good life (in time my life will be even better, and I'll have new and better coping skills). I can't change (others with even worse problems have changed; I can change if I focus and persist). If I slip I have to go all the way (I can pull out of a slip at any point, I don't need to let it become a binge). If I stop using my life will be unbearable forever (there will be an initial transition period of weeks to months that will require substantial focus and persistence--probably more than I expected--but over time the process of recovery becomes easier and eventually may even become effortless). If I feel a certain way I have to act that way (I don't; I may not be able to choose my internal experience but I can choose my behavior).

In early recovery, other dysfunctional beliefs emerge: My addictive behavior was completely destructive (I used because there were benefits, which at first might have been significant, but now are overshadowed by the costs). I have to completely avoid temptation (if I work by small steps in time I will build up strength to cope with temptation).

The support group of choice for a pure CBT approach to addiction is SMART Recovery (smartrecovery.org), but clients may still wish to attend 12-step meetings. Despite their overall emphasis on powerlessness 12-step meetings contain many elements compatible with a CBT perspective (e.g., paying attention to "stinkin' thinkin'") and remain an unparalleled opportunity for obtaining social support.

When clients in comorbidity treatment feel confused about how to integrate self-empowerment and powerlessness, a pure CBT approach to treatment may be the solution.

About the Author

A. Tom Horvath, Ph.D., ABPP, is a board certified clinical psychologist and president of Practical Recovery (Alcohol Addiction Treatment Center in San Diego), an addiction treatment facility in La Jolla (San Diego), CA, focusing on collaborative care and self-empowerment.

Ending Recoveryism by Tom Horvath

Racism, dogmatism, and sexism are the judgments that one race, set of beliefs, or sex are superior. I am introducing the term "recoveryism," defined as the judgment that one approach to recovery is superior. Recoveryism often gets even more extreme: there is only ONE approach to recovery. Any other "approach" is just pseudo-recovery. Individuals who try these pseudo-recoveries will not recover until they finally seek the one true way.

A recent example of recoveryism is found in James Frey's book, A Million Little Pieces. Although aspects of Frey's book have come under intense criticism, I suspect the recoveryism aspect of his writing is accurate. He describes his two month stay in residential treatment, and the intense hours just before and after that experience. Given the information about the age, prestige and location of the facility (see especially page 7) it is reasonable to suppose that he attended Hazelden, in Minnesota. On page 409 he receives his aftercare plan, presented in a file to him. As he glances at it he realized that "it is filled with AA literature and schedules of AA meetings." He has made known to the staff many times that "I don't believe in the Twelve Steps. I don't believe in God or any form of higher power. I refuse to turn my life and my will over to anything or anyone, much less something I don't believe in." Nevertheless the aftercare plan is as it as, according to the counselor giving it to him, "because you won't stay sober without AA...because it is the only thing that works."

See pages 151, 166, 222, 230, 291, 333, 345, and 377 for other poignant examples of how the staff attempts to persuade Mr. Frey into their point of view, and how he holds on to his own view about his behavior and what needs to be done about it. Unfortunately few individuals are likely to have the self-confidence and tenacity of Mr. Frey, who throughout the narrative (including the dramatic final sequence) pursues his own approach to recovery. For many US clients treatment is a mixed experience, and for some it is clearly more detrimental than helpful. In no other arena of healthcare is there anything approaching the lack of client choice, as there is in addiction care.

In all of the attacks on Frey's accuracy (did he really get dental care without painkillers, because he was in recovery?), I have not seen any attacks on his description of the intense persuasion attempts he was subjected to.

It would not be recoveryism to suggest that for specific individuals one recovery approach is better than some or all of the other approaches. Unfortunately we know little about how to find the best (or at least a better) recovery approach for each individual. In practice, we should allow individuals themselves to choose their own path of recovery.

If recoveryism is to end we need to 1) make information about the full diversity of recovery options available to all who need it (I have previously termed this "information parity") and then 2) allow them to choose among them. More precisely, we need to support individuals in crafting their own unique recovery paths. I suggest that there are as many paths to recovery as there are individuals. I think we are just beginning to discover how diverse these paths can be.

What often scares families in crisis is that they have lost confidence in their loved one's capacity to make wise choices given the recent addictive choices. However, there is no eliminating choice in recovery. If we don't allow those in need to choose their own new path, it won't be long before they are annoyed and angry, and choosing their old path.

The majority of recoveries occur outside the treatment system. These recoveries are termed "natural recoveries" because neither treatment nor a support group is attended. It is only from doing studies on large populations of individuals that natural recoveries have come to light. It is not in the treatment industry's interest to emphasize that natural recoveries occur. The industry's ads, at their most enlightened, make statements like "if you don't get help with us at least get it somewhere." What they should be saying is "if it's time to make a change, then do so; if you find you need help, call us."

For now we can support the end of recoveryism by stopping any effort to say what recovery cannot be. We need to focus instead on what recovery might be. If an approach is showing some success, rather than suggest that disaster is just around the corner, let's support what seems to be working. The recovery approach can be modified over time, and indeed is likely to be. This open-minded perspective is more likely than a rigid one to help individuals make changes sooner rather than later. Let's just say Yes to recovery.

Adapted with permission from an article originally published in the SMART Recovery newsletter.

About the Author

A. Tom Horvath, Ph.D., ABPP, is a board certified clinical psychologist and president of Practical Recovery (Alcohol Addiction Treatment Center in San Diego), an addiction treatment facility in La Jolla (San Diego), CA, focusing on collaborative care and self-empowerment.

Should People Who Need Addiction Recovery Have Choices? by Tom Horvath

Imagine talking to your child or partner, who is obviously drinking or drugging too much.

"Why don't you get it? It's SO obvious! You are becoming addicted! Look at the damage you are causing, to yourself, to me, and to everyone who cares about you. YOU NEED TO STOP! I'm arranging to send you to treatment."

And imagine an angry response, perhaps something like "This is my life, I'll live it the way I want...You just don't respect my lifestyle...You are blowing this way out of proportion...Just because you are a prohibitionist doesn't mean I have to be one...You can take your treatment program and..." Looking in from the outside, we could say that this drinking/drugging individual is "not making good choices." The obvious solution is to step in, take some control, and make their choices for them, at least for awhile. To put it another way, if you act like a child, we're going to treat you like one for awhile (and maybe a long time, depending on how you respond).

How well does this obvious solution work? In fact, not very well. Need evidence to support this fact? Can you think of a more tightly controlled environment than a prison? Is there drug use in prison? Of course there is! Can you think of a stricter institution than the military? Is there drug use in the military? Of course there is (and there is government data to prove it). How about prohibition? Did drinking stop in the US between 1919 and 1933? Drinking occurred at a lower rate, but the law was repealed because it was broken so often it was a farce and law in general was in danger of becoming a farce.

How about people living in residential addiction treatment facilities? Although facilities don't publicize this fact, residents are routinely discharged because they have violated the rule about not using substances. Doubt this? Call any addiction facility and ask them, "I want to send my child to your facility, but I'm concerned that someone else will use, and jeopardize my child's recovery. If someone began drinking or using, what would you do?" Notice how quickly they assure you that if a resident used the resident would be discharged and your child would continue to be secure. Then ask "how often do you discharge someone for using (or having sex, or other major rule violations)?" Now the response gets interesting! The specific answers will vary of course, but I predict that you will notice in all cases an increased level of stress in the conversation. The stress is there because even in the supposedly safe haven of residential treatment, all is not as it appears on the surface.

OK, so if forcing them to change doesn't work so well, isn't that better than nothing? Not necessarily. Raising the level of defensiveness in the user is not likely to increase their openness to new ideas or new ways of living. How likely is it that a process of change will begin if someone is busy defending the current way of living?

The alternative approach that we use at Practical Recovery is to work with our clients. It is usually possible to get the individual with addictive behavior into our offices for one meeting, as a favor to the concerned family member. We emphasize that this is a one-time meeting, and that what happens after that is up to them. In some cases, these individuals come directly. Either way, we begin by finding out what they like about their addictive behavior. Then we acknowledge that what they are getting (or used to get) is worthwhile. For instance, addictive behavior can lead to relaxation, a reduction in social anxiety, a sense of companionship with others, increased productivity, better sex, and so forth.

We acknowledge that addictive behavior as an adaptive effort, one they have engaged in to improve their lives. It becomes relatively easy at that point to elicit the negative aspects of the addictive behavior, and to observe that the initial benefits may not be present anymore. For instance, stimulants can make you more productive when you first use them in small doses, but later they make you exhausted.

Although every individual's situation is different, in general when individuals with addictive behavior understand that our job is to help them get the benefits of addictive behavior (such as relaxation and the other benefits just mentioned) without having to actually engage in the addictive behavior, they become open to receiving some assistance or at least making needed changes on their own. We don't label them as addicts or alcoholics. We don't insist on any particular means to ending their negative addictive behavior. We give them a way to understand the choices they have already made, and point out choices they could make now. Emphasizing choices does not look like the obvious solution when someone is making such unhealthy choices in the present. However, in the long run emphasizing choice works better for most people. Otherwise they spend their energy rebelling against being controlled instead of focusing on finding out how to make recovery work.

About the Author

A. Tom Horvath, Ph.D., ABPP, is a board certified clinical psychologist and president of Practical Recovery (Alcohol Addiction Treatment Center in San Diego), an addiction treatment facility in La Jolla (San Diego), CA, focusing on collaborative care and self-empowerment.

Healing people - Health Pointers for the Fitness Babes by http://www.healingpeople.co.uk/

Exercise is an essential in life. Most people will certainly nod their heads to this. Exercise is not only perfect for losing weight, it is also good for keeping a reasonable body weight, for giving a boost on the metabolic rate and also for burning those unwanted excess calories. Exercise also revs up the heart and the lungs' machinery making them more efficient in doing their natural functions.

Aside from these, exercise also works for strengthening the bones and keeps people looking good and feeling good about themselves. Exercise also gives people the stamina to enable them to keep up with the pace of their lifestyles. Unfortunately, not many people chose to do what is good for them. Most people could not decide exactly what to do when waking up in the morning; whether to exercise or to press the snooze button one more time.

The following tips are very helpful in reaching and maintaining the ideal body weight. This is especially great for women since they get through a lot of things going on in their bodies and are more susceptible to osteoporosis. Not to mention that many women are under the pressure of keeping themselves beautiful. It is recommended that one or two of these tips at a time are incorporated to the work out routine.

Worry not that the exercise routine is not enough. It is important to keep the commitments one makes. Ideally, it is advised to exercise three to five times a week for 20-60 minutes. However, this is not exactly the case in the real world. One should not frustrate herself by aiming for the ideal when she knows for herself that it is utterly impossible. If she an manage it two times a week for twenty minutes per session, that will do just great.

It is best to focus on doing what one knows she can do than to reproach herself for having not done enough. She can start from this point and then progress on afterwards. This should make her feel successful for having kept her commitment to herself.

Weight lifting should always come first. Many women always do cardio exercises first before weight lifting. A disadvantage of this is that it is possible to miss a critical component of the routine and spend all of it on cardio training. A women may notice this by not being able to see results even after devoting long hours at the gym. This can be avoided by reversing the order. This will guarantee visible positive outcome.

Remember to monitor heart rate. It is recommended to exercise at 75-85% of the maximum heart rate. Many people stick with just pumping up only 50% of their maximum heart rate. To ensure that one is working out at the prescribed target heart rate, she should use a heart rate monitor or any exercise equipment with this feature.

Work out for only an hour or less. Doing this will keep one from dreading the gym. Focusing on the exercise and the aim to be accomplished will make each work out session more and more efficient.

Have some sort of fitness social support. Being in a fitness community maybe the important element lacking in your training program. A social support can do amazing wonders and therefore should not be underestimated. It would be helpful to work out in a gym once in while if one customarily does her work outs at home. One can also try classes in activities that have always been interesting such as yoga, pilates or sailing perhaps. One can also join clubs such as a walking club or a running club for instance.

Pep talk yourself. One should not pressure herself too much; rather, it is best to congratulate one's self and give out words of encouragement in between exercises. One should never forget to say some positive feedback for herself.

About the Author

Healing People http://www.healingpeople.co.uk/

Healing People - Working Out for Extreme Fitness by http://www.healingpeople.co.uk/

Many people think about building muscles as abandoning life outside the gym and devoting hours in the gym like a monk in a monastery. Perhaps the only way to chisel the body into a hot muscular physique is by toiling hour by hour over the rusty iron day in, day out and year in, year out.

This need not be so. Although hard work is truly required, extreme fitness demands one to be a slave of the iron weights. Full-body work outs can make one progress and it easily fits in one's schedule. This is very convenient if one is looking forward to achieving extreme fitness but finds it hard to hold on to a single work out routine.

Genuine full-body work outs done by athletes with an aim in mind makes for maximum muscle contraction using heavy weights, makes room for full recovery so one can actually grow and continue to train hard plus it also prevents burnout which is inevitable due to excess training.

So if one is ready for extreme fitness, here is all there is to know about full body work out:

Full-body work out is a time saver. The biggest plus about having the whole body trained all at once is probably having to go to the gym less frequently; perhaps around two to three times for every seven days would be enough.

Another advantage of working out the entire body all at once is that one need not spend two or more hours of strenuous exercise in the gym for every session; one only spends one hour in the gym for every session. So that's just three to four hours per week in the gym right? With full-body work outs, it is all about the quality of exercise one does for session and not the quantity, nor even the amount of time you allot per session.

Full-body work out boosts the cardiovascular system for extreme fitness. One must allot two to four sets for every body part into the one hour session. Jam packed with exercising, each one hour session then gets the heart and the rest of the cardiovasular system pumping and up to speed in a flash.

Now feeling pumped up, next find out what rules does one have to follow when engaging in full-body work outs:

Training commences only once every two to three days. This is so easy isn't it? What is great about this is that there is time spared during rest days so that one can indulge in a few cardio exercise sessions instead of depending on cardio execises one normally does at the end of each work out session which after all, are not at all very effective.

Heavy lifting is strongly advised. Contrary to popular belief, especially among athletes. It is not true that it is good to get trapped on training lightly than one actually could so as to conserve energy for the other body parts that will come later in the routine. What is true is that one cannot achieve optimal progress if one is not training heavy, no matter which program that person is doing.

One exercise only per muscle group. This is very easy to follow and is also important. Doing basic exercises which are also intense means you do not have to do another different exercise for that body part.

Keep work out short. Resistance training affects the natural homones of the body connected to muscle building. Intense exercising boosts the testosterone levels and long work outs increase those of catabolic cortisol. Sixty minutes of work out allows you to get the best of both worlds.

Now with this convenient and powerful work out regimen, one can now truly experience extreme fitness.

About the Author

Healing People http://www.healingpeople.co.uk/

Healing People - Moderate Exercises to Fitness! by http://www.healingpeople.co.uk/

Have you ever felt tired and stressed out from work and by the time you get home you see your three children running towards you asking you to play basketball with them? You refused and promised them that you will after you take you rest.

Instead of disappointing your children, why not say, "yes" after all? You will be surprised by the amount of energy you will have after that 30-minute activity.

Did you know that by exercising at a moderate pace for only 30 minutes, you would feel a lot better, mentally? It has been proven that this improves the appetite and sharpens your style in problem solving. Not only that. You will also feel that it is easier to sleep at night if you do moderate exercises even for only 30 minutes every day.

What are the benefits of regular exercise? It promotes self-discipline and has a positive impact how you perceive life. Exercise helps in lifting your spirits and getting you out of any depression. For first timers, it can be done for 15 minutes for 2 to 3 days a week. You can increase the time you spend once your body gets tuned up for it.

DON'T you ever force your body! If you get hurt, then stop. You can take a break from exercising for a few days and then you can start again but you need to start from day 1.

Here are some moderate exercises you can do and enjoy:

1. Do the Walking. Make use of your surroundings. You can walk your dog, with your partner or child. Encourage your family to do the walking exercise daily and you will find yourself burning calories while enjoying the surroundings and getting enough sunlight that is also good for your body.

2. Discover the wonders of Yoga. Yoga is one effective exercise that energizes not only your body but also your soul. You may want to learn even the basic yoga positions that are not too complicated but proven effective. A five-minute yoga exercise can perk you up and recharge your body with the energy you lost for the whole day. You relax and at the same time you stretch!

3. Engage yourself into sports. Play basketball, football, baseball, tennis or badminton. Many doctors have recommended sports as an effective way to stay fit and healthy. Sports can also be done in moderation. Do not take it seriously. Shooting basketball with a friend is one moderate exercise that is also considered a sport.

4. Join exercise programs at work. If you still do not have exercises programs at work, then why not start it? You can talk to your boss about it and start with your colleagues. You do not only lose calories but it is also one good way to bond with them. This can be done 30 minutes, 3 times a week.

5. Exercise while doing household chores. Gardening, raking leaves, lawn mowing, doing the laundry, vacuuming and car washing are effective moderate exercises at home. Make use of these chores to sweat and burn calories. Instead of using machines and gadgets to perform these chores, why not do it with your hands and lose some fats?

Making exercises as part of your daily routines will surprise you of how much calories you will lose. Doing these moderate exercises of the same amount every day can burn 150 calories up to 1,000 calories a day!

About the Author

Healing People http://www.healingpeople.co.uk/

Healing People - Fitness Apparel by Healing People

In a sports apparel specialty store you will delight at the wide range of clothing plus accessories that is available in the market. Specific sporting apparels like golf, fitness exercise, equestrian and yoga are very much available. The apparel for sports like surfing or rafting and even mountaineering are abounds. The wetsuits are perfect for surfing apparel. The sports apparel include caps, batting gloves and rafting vests. Here's a short list on how to choose your sports and fitness apparel

1. The Golf wear

The golf apparel can be found in any specialty sport store. The golf apparel usually includes a trouser with a t-shirt. In golf apparel, comfort is the most important factor. Chinos are also very popular golf wear. Hats and caps of varying designs and makes are also available. Of course outlandish gears worn by some professional golfers are also available.

2. The Running / Fitness wear

The running apparel is best made with cotton to retain moisture that causes friction and might lead to possible chafing. The running shorts and tights including the cotton socks are the basic running gear. When running apparel is being chosen, try to select a base layer top which keeps you dry for an extended run. Comfortable and fit running shoes must be matched to keep you fresh on the run.

The fitness gear pertains to all kinds of apparel including aerobics and gymnastics. The multi-colored tights and leotards are the best and most comfortable during a workout. The fitness gear must be selected with care. Choose the proper material and correct size when selecting the fitness gear is a must.

3. The athletic apparel

The athletic apparel must be chosen with the climate and weather in thought. An apparel that is not suited for the weather will hinder the performance of an athlete. A popular athletic wear is the running or jogging pants with a drawstring waist. These type of athletic apparel can be purchased at discounted rates. The all weather gear is designed to keep most of the elements out. An athlete depends on the athletic gear to perform at his best.

4. The Equestrian apparel

The equestrian gear is mainly about breeches and boots. There are specialty equestrian stores that stock clothing and other equipment for riding. The casual equestrian gear could be riding breeches matched with a plain shirt. The paddock boots available also at equestrian apparel stores complete the set for an equestrian. A pair of riding pants and a jersey can be bought at an equestrian apparel store. When having lessons on riding, you may want to look online for equestrian stores to see and choose an outfit which lets you ride with great style and comfort. A little pricey in most cases but may be worth the price. A western style of gear is also available in specialty shops.

5. The Yoga apparel

The yoga apparel must be very comfortable and loose for easy movement. A t -shirts and a loose-fit short are basic yoga apparel which will keep you fresh and comfortable. Also, it does not cost much. The designer yoga apparels are available at special yoga stores. Yoga Capri pants and unitards are available at yoga apparel store. The special Asana clothing can be found at very exclusive yoga outlets.

About the Author

Healing People http://www.healingpeople.co.uk/