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.
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.
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.
My partner says his sexual behavior is normal – but he is hiding it and I know something is wrong. Am I crazy? What are the signs of compulsive sexual behavior disorder?
Partners of people with sexual compulsivity often come to the clinic in great distress.
They have just learned about the latest infidelity, daily Internet porn use, visits to Orchard Towers, massage parlors or KTV lounges. The images accidently left on the family computer may be shocking or alarming.
Perhaps they have discovered condoms in the person’s luggage after a business trip, unexplained expenses on their credit cards, and unexplained absences from their hotel rooms late at night when they tried to call the person. Childrens’ birthdays, graduations and family celebrations may be mysteriously abandoned for “essential” business trips.
Partners may notice strange messages or nude photos on the mobiles; or perhaps odd phone calls at night, that seem to make the person excited or embarrassed. They may come home intoxicated at 3:00 am, after a night out with colleagues, with unexplained credit cards slips in their pockets for hundreds or thousands of dollars. They may find an STI clinic report.
The person acting out will likely try to vigorously “manage” all this fallout with their partners.
They may rationalize, minimize, intellectualize, normalize – or simply lie, to explain away all this overwhelming cumulative evidence. They may “gaslight” their partner, making them think they are crazy.
And it may work…for a time.
Meanwhile partners may feel: shocked; rejected; confused; angry, even rageful; anxious; and depressed. They may even blame themselves and feel inadequate as a partner and ashamed.
They may: become irritable, angry or overly anxious with their children; stop doing things they enjoyed, stop seeing people; forego self-care and grooming; or try to become overly sexual and breach their own boundaries to save the relationship.
They may become sleepless, without appetite and lose weight – or over eat and gain weight; and they may use medication and alcohol to numb their emotional pain. They may keep getting flus and colds that refuse to go away; or chronic backaches and neck aches that make sleep or activities painful.
The shame may be crushing.
Some partners may have experienced earlier traumas in their own childhood or adulthood, in which emotional and sexual or other physical abuse, neglect and rejection were prevalent. The acting out person’s behavior may therefore trigger strong trauma reactions, and lead to bonded relationship traumas, resulting in self-harm or even attempted suicide.
How can a partner respond when they get a feeling something is not quite right?
If they can persuade the person acting out to undertake a clinical assessment, the person will be able to understand that their behavior has become a serious self-destructive compulsion, and that they need treatment.
Even if the person won’t attend therapy, the partner can take an assessment of the extent of their trauma, and the role of the person acting out. The partner can then receive sex addiction treatment, and explore the options for the family. Do they stay or go?
Promises Healthcare Pte Ltd. provides therapy for both those with compulsive sexual behavior and their partners, so that together they can find a way out of their suffering and plan a better future for their families.
“My partner’s sexual behaviour has left me devastated – should I stay or should I go?”
Many clients come to therapy wondering whether they should leave or stay, after they have discovered their partner’s infidelity, or other compulsive sexual behavior. This may include a combination of: serial affairs at work; Internet pornography; sexual massages; use of sex workers; and use of anonymous dating Apps. Excessive alcohol, drugs and workaholism may also be involved.
Even though the behavior is intolerable or very risky, and causing great suffering – there may often seem compelling reasons to stay.
Young children may be involved. If the acting out partner has been a “good enough” parent, the children will suffer greatly if they leave. Further, the burden of parenting the children alone may seem too much.
The client may worry about the family finances – that they may not be able to support themselves and their children if the partner withholds money or does not agree to split the money appropriately.
The client may have to return to their country of origin and may not be able to bring the children with them, if their partner contests this.
Leaving may cause the client great shame, particularly with their family, friends and work colleagues.
The client may fear loneliness; or may ardently fantasize that things will get back to the way they were – eventually. After all, the couple may have a long, shared history, and may have weathered many other difficulties together.
Starting with a new relationship in future may be as daunting as living alone forever.
Some clients may be so angry and resentful, that leaving may seem like the partner getting away it. Leaving may appear like giving the partner a license to continue their intolerable behavior – unchecked and unavenged. It may result in the partners frittering the family money away.
Friends and family may be unhelpful – full of directive and conflicting advice. Clients may be ashamed, or too anxious of the reaction they will receive to even share about their suffering.
If the partner is assessed for a compulsive sexual behavior disorder and subsequently undertakes recovery; and the client works in therapy on taking care of themselves; learning and growing from the experience; and improving their relationship – there may still be hope in keeping the family together.
Ultimately, both need to work on themselves and the relationship, if it is to be saved.