To non-smokers and those who have an occasional cigarette at a party or outside a bar, it is baffling why smokers just can’t simply quit. What’s the big deal?
If you think this, then the conclusion may be: “well they just don’t want to quit”; or “they are uneducated, and don’t know how much damage they’re doing to themselves and those around them”; “they have no conscience” or “they have no self-control”.
The problem with these conclusions is that the scientific evidence doesn’t support them.
70% to 80% of smokers want to quit – and many of them desperately want to quit – and most smokers fail.
A majority have tried to quit multiple times – and about 40% are still drawn to smoking -even after losing fingers and toes to gangrene, or lungs to cancer and COPD, as a result of smoking. Many suffer heart attacks, mouth, throat and colon cancer, or labour under serious diabetes problems; some even lose their close relationships with their families.
They wish that if only they could quit, their lives would be so much better – yet they continue to smoke.
So, there is more to the compulsion to smoking than meets the eye.
Perhaps kindness and compassion for smokers may be a more rational reaction – than dismissal, frustration, irritation, anger or contempt?
There are very good reasons why the chemicals in cigarette smoke are so compelling – and it’s to do with our brains and our bodies. It’s not a mystery.
Although nicotine in the smoke is a comparatively benign substance, and it doesn’t cause the damaging effects of the other harmful substances in the smoke – it is highly addictive. It is the nicotine that causes the addiction – but it is the tar and other substances that cause the damage.
In addition to nicotine, there is another substance, in smoke, that creates a potentially “pleasant” psychoactive effect. It is a monoamine oxidase inhibitor – which results in chemicals in the brain staying longer in the space between neurons and firing those neurons.
And the effect the smoker feels? Well, there can be numerous combinations of “positive” effects.
Those smokers who feel down, moody and unmotivated, may feel a pleasant “lift” or “boost”. Anxious, fearful and nervous smokers, may feel calmer, and more able to think straight. Smokers who are tired, sleepy or lethargic, may be able to focus, concentrate and pull themselves out of their procrastination.
Smoking helps some people become more energetic, have better reactions times and become more effective or efficient. Smoking enables people who are mentally tired with work or constant rumination, to feel like they are taking a break and “relaxing” from their thoughts. They can just let their minds gently wonder. They may even feel that after their “reverie” with a cigarette, they have managed to solve a problem that they have been grappling with.
Some people use smoking as a bonding experience. Ironically, all the community stigma that surrounds smokers makes some feel like a “band of brothers and sisters”, as they stand outside in smoking areas or in smoking rooms. It enables instant connection and the sense of “belonging”.
In short, the effects of smoking depend on how you are feeling in the moment.
Insidiously, mental illness and other addictions result in many becoming vulnerable to smoking – either to cope with: their illness; the difficult side effects of their medication; and the social stigma against mental illness addiction that so oppresses and shames them.
By way of examples, ADHD, schizophrenia, bipolar disorder, anxiety and major depressive disorders, and personality disorders, can all result in life-long suffering – that smoking may appear to “take the edge off”.
There is now persuasive research that some people are more genetically susceptible to being addicted to cigarette smoke. They may get more of a “buzz” from it, they may be more tolerant to its side effects, the effects may wear off faster, and they may feel the withdrawal effects (when not smoking) more keenly. They may have more trouble starting to quit – and staying quit.
There are many other vulnerability factors as well: adverse childhood events (which afflicts 2 out of every 3 Singaporeans); traumas; family and peer modelling; rebelliousness, isolation and loneliness, financial distress, problems in relationships and at work; and many more factors, may all conspire to lead smokers to smoke daily.
Once they smoke enough cigarettes for long enough – the brain changes, it becomes “hijacked” by the smoke.
Smokers experience brain changes as:
Tolerance – the need for more smoking, more often, to get the same effect;
Withdrawals – 45 minutes to two hours after smoking, they may feel the exact opposite of what they felt when they smoked – and therefore need a cigarette to feel “normal”;
Impulsiveness – in the moment (of smoking), they forget about the harms of tobacco and their resolves to quit, and habitually light up;
Smoking triggers – smoking cues are everywhere – and they trigger the urges and cravings – and once these build up, they become overwhelming;
Stress – their stress response slowly but inexorably ratchets upwards, daily – so that even things that used to be experienced as minor, now elicit strong and intolerable emotions. If health, relationships, jobs and self-image are all on the line because of smoking – the stress can be intense.
Luckily – there is a solution. Smokers now have access to psychotherapy, nicotine replacement therapy, quit smoking medication, and any number of other tools to help them on their quit journey. In other countries, new nicotine delivery technologies like e-cigarettes and heat-not-burn are being improved and refined – and they are much safer than smoking.
As the COVID-19 confinement continues, you may have a nagging question on your mind – “what have I managed to achieve”?
Tidy, clean desk draws, closets, and glove compartments; a surprising proficiency in a new language; the final 100 pages of War and Peace; an impressive yoga position; a dazzling new magic trick?
Several weeks into the confinement in Singapore and with several weeks to go before we can be physically social with our friends, some of us may be deflated.
When the confinement/circuit breaker started, we may have vowed to use all the new free time to do things we have never got around to doing.
Now that time is gradually slipping by – we may think that we still haven’t accomplished our goals.
As a psychotherapist, I listen to many people starting to stress that this opportunity of more time isn’t panning out the way they imagined – and that critical voice in their heads is telling them they are inadequate and unworthy.
Feeling Stuck in Shame
What I hear is the frustration of “stuckness.”
Clients tell me: –
I must be more productive
I should have achieved more since confinement began
I should be able to concentrate more and procrastinate less
I must have more enthusiasm, motivation and energy
Note the use of the words “should” and “must”. Our inner critic loves to remind us of all the things we should have done or must do.
It is important to be compassionate to ourselves and banish these words from our vocabulary – at least for the time being.
We may have overestimated what we could achieve in confinement; and underestimated the power of the inner critic, worry and low mood. These are preventing us from feeling satisfied with what is.
Perhaps we had the fond notion that confinement would be like a holiday – more rest, more family time, novel and interesting things to do, and relief from work and the other routines in life.
Reality may now be striking home. Anxiety about our jobs, income, and savings; fear about us and our loved ones contracting the virus; worry that food, masks, and other resources may be scarce; boredom at a routine in the cramped confines of home; the resurrection or development of old family dynamics, fraught with irritations, frustrations, disappointment, mistrust and anger. For some, isolation and loneliness may be an even more crushing weight.
Reframing our Expectations
What will help is kindness – and, in particular, kindness to ourselves.
Perhaps some of us are high achievers, driven by: concrete stretch goals, targets and objectives; KPIs; reports; numbers; test or exam scores.
But COVID-19 confinement is not the time to measure yourself in this way. It’s like drinking soup with chopsticks – frustrating.
I recommend that we redefine productivity and measure our day by whether:
we have achieved an emotional connection with ourselves and others,
got some exercise,
meditated for a few minutes,
did some yoga or Tai Chi,
read something (other than COVID-19 news or social media content);
did something creative, like photography, videos, painting, made some music, baked something new; and
spent “me time” – just sitting quietly, relaxing and enjoying being in the moment.
This confinement is not a competition – so we do not need to compare ourselves against others.
We must permit ourselves some numbing out to Netflix and videos – and not beat ourselves up if we eat some chocolate, cookies or chips.
Let’s also be realistic and recognise that our routines will be different – and that we won’t accomplish the same things in confinement. We will have accomplished things – but they just won’t be the usual things.
Manage your expectations, be gentle with yourself and kind to others – and you will find that there is meaning and purpose to your confinement.
In an article titled “Drug syndicates get crafty as supply disrupted, prices spike”, Andrew da Roza, addictions therapist at Promises Healthcare, told Straits Times reporter Zaihan Mohamed Yusof that “anecdotally”, the costs of illegally imported prescription medication and illicit drugs have risen, “although supplies appear to be available”. Mr da Roza goes on to say that he has noticed that some drug addicts are managing withdrawal symptoms and cravings by substituting their drugs of choice with alcohol, new psychoactive substances and over-the-counter medication. The article also mentions that people may seek alternative methods to obtain illicit substances as supply chains are disrupted – such as turning to the Dark Web to get their needs fulfilled by mail.
It wrote that we (Promises) have seen a 25% increase in visits to the clinic “because people are having a harder time managing compulsive behaviours such as substance abuse, smoking and gambling during the circuit breaker period.”
If you are having trouble managing an addiction, you should know that Promises Healthcare has kept its doors open all through the pandemic in service of promoting mental health. Further, in keeping with social distancing measures, our clinic is also offeringteleconsultations in place of regular visits. Support groups have also moved meetings online, which are going ahead as scheduled – on platforms like Zoom instead of physical gatherings. Do contact us for more details.
COVID-19 has posed a challenge to everyone, and those more physically vulnerable in our community clearly need our care and attention.
There are also people whose mental vulnerability deserves equal care.
Mental illnesses such as depression, anxiety, and addictions are exacerbated by a pandemic crisis in multiple ways.
Collective family and community fears are (in themselves) contagious; and the constant bombardment of medical and financial bad news, can leave those with mental illnesses lost in a cascade of negative rumination and catastrophising.
The mentally ill and people with addictions commonly have compromised immune systems, and suffer stress or substance, tobacco and alcohol abuse related diseases – leaving them wide open to severe pneumonia with acute respiratory distress symptoms – and other complications from COVID-19.
Isolation, separation and loneliness – caused by working at home and social distancing – are perhaps the worst contributors to: low mood; agitation; irrational fears; moments of panic; self-disgust; resentment; anger; and even rage.
People whose ability to pause, use reason and find practical solutions can be severely compromised. They may find themselves bereft of the motivation, and ability to engage in even the simplest tasks of self-care.
Added to this, listlessness, boredom and frustration can lead to despair. Then self-harm and suicidal thoughts may arise, take hold, and even overwhelm them.
Those in recovery or active addiction may also turn to their compulsive and impulsive behaviours of choice, to sooth and find momentary respite from the moods and thoughts that have hijacked their mind. Triggers, urges and cravings may become relentless and unbearable.
The solution may begin with finding a way out of isolation.
Starting the journey out of this darkness can start with talking to people who can demonstrate unconditional positive regard, show kindness and compassion, and help reframe the situation. Such people can assist those suffering to put a name to and validate their emotions.
In short – therapy can help!
In times of COVID-19, working with a therapist via teleconsultation can be effective using ZOOM, Skype, WhatsApp video and FaceTime.
Although the calming and soothing sensation of the physical presence of a therapist is absent, for those in isolation – distraught with shame and despair – Internet enabled therapy can prove a lifeline.
Isolation can be further broken, using similar Internet methods, by attendance in recovery groups such as Alcoholics Anonymous, Narcotics Anonymous and Sex and Love Addicts Anonymous – all of whom now hold Zoom meetings in Singapore.
These Zoom opportunities in Singapore are supplemented by Zoom, Skype and telephone conference meetings in Hong Kong and Australia (in Singapore’s time zone) and in the U.K. and the US (during our mornings and evenings).
Having broken the isolation, the second step therapists can provide is guidance and motivation towards self-care. This would include tapering or abstinence from the addictive substances or behaviour. A well thought through relapse intervention and prevention plan, specifically tailored to a person’s triggers, will also assist.
Triggers may be particular places, situations, people, objects or moods.
The acronym “HALT” is often used by those in recovery; which stands for the triggers of being: Hungry; Angry; Lonely; or Tired.
When these triggers arise, people are encouraged to
HALT their behaviour;
breathe deeply, with long outward breaths;
think through consequences;
think about alternatives;
consult with others; and
use healthy tools to self-soothe.
Daily mindfulness, meditation, exercise, sleep hygiene, healthy eating and following a medication regime are important aspects of self-care – and for some suffering mental illness – these actions – and time – may be all they need to find their footing again.
Luckily, the Internet gives a vast array of possible self-care options, including things to distract us, soothe us and improve us.
Everything is available from: calming sounds and music; guided meditations; games; home exercise, yoga and tai chi; self-exploration and improvement videos; video chats with loved ones; to healthy food delivery options. They can all be had with a few keystrokes.
Today we live at a time when suffering from mental illness and addictions is commonplace. But we also live at a time when the solutions are literally at our fingertips – if we only reach out for them.
With COVID-19 forcing many of us to practice social distancing and to work from home; isolation and the constant access to Internet devices makes staying in recovery from compulsive sexual behaviour a very tall order.
There are many reasons why COVID-19 is interrupting recovery from sex addiction. Restless, irritability, and discontent will inevitably arise for all of us, when our routines are disrupted – but there is more to it than that for people in recovery for addictions.
Some will experience acute urges and cravings to act out because:
isolating at home, away from colleagues and friends leaves a recovering person lonely, and without the support of recovering others;
if they are now living 24 hrs a day with traumatised partners and disrupted families, tensions may reach flashpoints;
some may already be very anxious and depressed, and the additional worry about health and contracting the virus may prove too much;
some may have suffered financial problems from their acting out, and may be dismayed by their financial future, given the impact of COVID-19 is having on savings, jobs and salaries;
they may now repeatedly look at electronic devices for work, COVID-19 news and distraction – and those may be the very devices that caused or exacerbated the problems in the first place;
unstructured time will inevitably lead to both the distress of ruminating about the consequences of the present, and the triggers of fantasising about past acting out.
When people are struggling with an addiction, their mind can play tricks on them. COVID-19 can present a series of excuses to put their recovery “on hold”.
One person in recovery said:
“I started to tell my wife that I was looking out for the family when I decided not to attend recovery meetings and therapy. She then asked whether there were other things I could do, that didn’t involve meeting others.
I told her, pretty emphatically: “no, recovery requires the support of others”.
Then she Googled and found recovery meetings online by Zoom, Skype, and telephone conference. I was stumped. I realised that my mind was once again leading me astray.
I checked with my therapist and found that I could do therapy by Zoom, and he also gave me lots of online recovery videos to watch, information to read, and exercises I could do.
My sponsor and I now do our recovery work using WhatsApp video.
Calling my recovery friends and supporters was what I was doing before COVID-19 anyway.
I found that some of my recovery work, like meditation, prayer and daily gratitude lists is solitary work any way, and that I now have plenty of time to do that – if I chose to.”
Many people had to finally admit that they could either work hard on their list of excuses – or they could work hard on their recovery – but not both.
One of the greatest problems that people find preventing them from finding and staying in recovery from sex addiction is shame. Online connectivity platforms like Zoom, WhatsApp and other online social platforms can help with that.
People feel safer engaging online – which is one step removed from physical interactions. They feel greater comfort being at being home, in a familiar and secure space. They can also control whether and when they are seen or heard, and they can leave a meeting at any time.
Partners and family of those in recovery may also feel more assured. Their loved ones are not outside the home visiting triggering locations. They are also demonstrating their commitment to staying the recovery course – virus or no virus.
Partners and the whole family may also have more opportunity to join in healthy recovery activities – daily meditation, exercise, healthy eating, and good sleep hygiene.
Being at home gives people in recovery a unique opportunity to initiate family activities like games, puzzles, movie watching, making meals, arts and crafts, walks and swims. In recovery, this is called: “making living amends”, to the loved ones who have been hurt.
So at this isolating and stressful time, consider individual therapy and the STAR group therapy delivered by Zoom – and remain on the recovery path.
Attending group therapy for compulsive sexual behaviours (sex addiction) is commonly very difficult.
The fear and shame associated with the compulsion, and the desire to hide and minimise the behaviour subsumes a person’s thoughts. This drowns their motivation to attend. Procrastination or an outright rejection of the benefits of therapy group becomes inevitable.
Ironically, it is the benefits of group therapy that would motivate a person to attend in the first place. But they not be willing to attend unless they get these benefits first.
A chicken and egg conundrum.
The Benefits of Group Therapy – Shame Busting
One of the main benefits is group therapy’s ability to “bust” shame and fear.The same shame and fear that prevented the person from attending.
It is in a group environment of compassion, kindness and lack of judgment, that a person can find the courage to face their reality, and gain hope and purpose in their recovery.
In group, people discover that they are not alone in their secret thoughts, urges and cravings – and that they are not uniquely “broken”. It lifts the impossibly heavy weight of secrecy, lies and half-truths, that people carry – often for years.
They also find out that others – very much like them – have found a way to start a journey to change their behaviour, beliefs and feelings.
Sexual Compulsivity is an Issue of Intimacy
At its roots, sexual compulsivity is an issue of intimate relationships. Group therapy is therefore a uniquely effective way to learn how to build healthy relationships.
Having and maintaining personal boundaries and respecting the boundaries of others, is a skill set that can best be learned, and safely experimented with, in a group. Effective communication and emotion management are also learned skills – and a group of peers is the best place to practice them.
Simply by interacting with someone struggling in similar ways, learning from them – and, in turn, helping them – enables recovery to bloom.
Group Therapy and Self Knowledge
One aspect of sexual compulsive behaviour is the struggle with self-knowledge.
A person struggling with compulsivity may common to ask: what motivates my behaviour; why this particular behaviour; why is volition and control so hard; why can’t I learn from my experience; how did I get my calculation of the risks so wrong?
In group therapy, we also ask: what needs is this behaviour really serving; is it really satisfying my longer-term needs; what is the price I am “paying” for dealing with my needs in this way; are there other ways to meet those needs at the “right price”; and what else can I do to meet my needs?
The “Mirror” of the Group members
By exploring these questions together in a safe space, a group can feedback their observations of each other’s journeys – and pool their collective wisdom.
Having a “mirror” of four to six people, reflecting back their experiences of who a person is, enables that person to truly see themselves as they are – perhaps for the first time.
Group Therapy – the Safe Space Rules
To create a safe space, the group therapy the rules are made clear.
Confidentiality is paramount. Further, members are encouraged to talk about themselves and their perspectives, and not assume or impose things on others.
Advice is offered only if expressly requested. Comments are positive and constructive; and a person’s strengths and skills are celebrated.
The Outcomes of Group Therapy
With the dark pall of shame lifted – what other outcomes can be expected from group therapy?
The benefits are many. Self-awareness, self-esteem, honesty, skilful management of relationships, emotions and communications – and greater motivation to stay the recovery course.
Ultimately, not only does behaviour change, but so do perspectives and desires.
Needs are better understood and met. Purpose and meaning in life return – and having a full life becomes a probability –notjust something other lucky people have.
If you’re interested to start your CSBD group therapy journey, with a safe, non-judgmental and connected space for peer support and learning, you may want to consider writing in to firstname.lastname@example.org to be a part of our Sex Therapy And Recovery (S.T.A.R.) program facilitated by Andrew da Roza.