Book review - Working with drug and alcohol users.

This comes from the quarterly magazine of the United Kingdom Association for Transactional Analysis (Summer 2013)

The book review editor states:

The second book takes us to clinical work with alcohol and drug dependent clients. Tony White’s Working with Drug and Alcohol Users: A Guide to Providing Understanding, Assessment and Support was also published last year, by Jessica Kingsley. Tony White, a TSTA living and working in Australia, also wrote Working with Suicidal Individuals: A Guide to Providing Understanding, Assessment and Support, reviewed by Sue Brady in the Transactional Analyst (Autumn 2011). Jo Moores, TA psychotherapist and trauma specialist, gained experience of the complex world of substance dependency when working with The Big Issue In the North. Jo recommends Working with Drug and Alcohol Users as both ‘an accessible and concise introduction to our relationship with substances and the different roles they play in our lives’, and also as ‘a reflection of the author’s extensive experience and practice wisdom’. After an overview, Jo engages critically with Tony’s ‘TA theory of addiction’. She argues for the importance of the development of our theory on this central issue.

Readers are invited to write in with their views.

Dr Celia Simpson

Review

Working with Drug and Alcohol

Users: A guide to providing

understanding, assessment and

support.

By Tony White

Published by Jessica Kingsley

Publishers, London, 2012.

Review by JO MOORES

TONY WHITE’S BOOK brought back to me a vivid memory of working with people who were street homeless and who invariably had substantial drug and alcohol problems. The memory was of a young woman fresh from detox who was talking about how she could build a life for herself without drugs. She became deeply distressed and disclosed experiences of being raped. For her, life without the emotional blanket of heroin felt untenable as she was flooded with traumatic memories. A few days later I saw her back on the streets asking for money, eyes glazed over and, as Tony White would say, back in a symptomatic relationship with her drug of choice.

This book is an accessible and concise introduction to our relationship with substances and the different roles they play in our lives. Speaking in the same breath of cocktail parties and injecting heroin users, White destigmatises the very human act of using substances to alter our minds, moods and experiences. Working with Drug and Alcohol Users manages to be both a beginner’s guide to the complex world of substance dependency and a reflection of the author’s extensive experience and practice wisdom.

Part One is titled ‘The Foundations of Drug and Alcohol Counselling’ and contains useful information about different kinds of drugs, self disclosure, drug induced psychosis, gateway and poly-drug use and the different perspectives on addiction and treatment that have developed over the past century . In addition to providing the reader with a basic introduction to Transactional Analysis, Tony White then builds his case for the centrality of relationship and identity formation in the development of substance addiction, using the concepts of symbiosis and attachment to outline what he calls his ‘ TA theory of addiction’.

He contends that there has been an inadequate development of the Parent and Adult ego states resulting in a marked difficulty to self-soothe, set boundaries and limit the hedonism of the Free Child. He argues that ‘as a consequence the drug user will seek out another person or thing to take on the personality functions of her own Parent and Adult ego state and form a symbiosis with that. Drugs can do this well for some’ (p.57). He observes that listening to the dependent substance user talk about their relationship to their drug of choice is like listening to someone talk about ‘their husband or wife’. He also suggests that the symbiotic relationship may be with people, organisations or beliefs, citing an example of recidivist offenders who appear to only function well in prison. White then focuses on attachment theory, using research evidence to underpin his contention that certain kinds of problematic attachment are closely correlated to drug and alcohol dependencies in later life. He suggests that difficulties with separation/individuation and the formation of identity lead to the equivalent of a dependent personality disorder, where addicted drug users experience strong proximity-seeking behaviour and deep fears of being without their drug of choice.

Chapter Four offers a clear framework for assessing different types of substance use and misuse, from the experimental and recreational user at one end of the spectrum to the symptomatic and ‘true’ addict at the other. The author presents an overview of mainstream drug counselling responses for the first four types of drug and alcohol use, including some gems of clinical experience around working effectively with the Rebellious Child. Using the concept of the four ‘Ls’ – Liver, Lover, Livelihood and Legality, he offers a simple yet effective way for both the counsellor and the drug user to think about harm. For the last two types of use, the symptomatic and the dependent user, he argues that while both are addicted, their relationship to their drug of choice is different. He contends that symptomatic users are self-medicating, that their drug use is to solve a problem rather than being used in a habitual way, and that once the underlying difficulty eg PTSD, depression etc is attended to, their need for drugs dissipates.

Part Two outlines specific drug and alcohol techniques and interventions such as Harm Reduction Counselling, making a thorough Assessment, working with Ambivalence using Motivational Interviewing and how to work effectively with Relapse. The author’s work focuses on Relapse Process work rather than Relapse Prevention, as he suggests relapse is often inevitable and that coming off drugs is like leaving a relationship: it’s a process, often a painful one, with the varying degrees of difficulty reflecting the duration, intensity, quality and meaning that each relationship has. In this chapter, White writes compellingly of the ‘beginning of the end’ when the dependent drug user gathers enough momentum for change, where the drug counsellor is looking to heighten separation anxieties to enable their ‘psychological extraction’ from drug careers. He uses a number of touching case study examples to show the turmoil and emotional charge involved in letting go of this once crucial part of the client’s identity and existence.

The chapter on Motivational Interviewing is necessary reading for those interested in this approach, as it presents both powerful and effective examples of change with cautionary notes on the contraindications of this as an adverse therapeutic intervention. There is also a separate chapter on working with teenagers and drug use.

The strengths of this book are in the author’s generous sharing of his clinical experience and wisdom and in his promotion of Transactional Analysis as an important resource to those working in drug and alcohol treatment services.

However, it seems to me that Tony White’s ideas of a ‘TA theory of addiction’ lack the same breadth and depth he so ably demonstrates in his clinical practice and seem a little overstated, particularly if attachment, clearly not a TA theory, is deemed to be one of the twin pillars of his argument. There is much research that indicates a relationship between attachment and addiction, but I have an instinctive wariness of arriving at such limited conclusions about such a complex human experience. Indeed, if we are to focus on the possible roots of such difficulty, we need to acknowledge what Thomas Boyce described as the ‘symphonic causation’ of addiction, the political, social and economic determinants as well as the psychological ones. The complex world of addiction theory has been described as ‘conceptual chaos’ (Shaffer, 1986), with many contradictory perspectives sitting side by side without resolution. While White acknowledges that his theory overlaps with other addiction approaches there is little attempt to integrate or synthesise his thinking, which I think undermines the robustness of his case. Contemporary neuroscience, in particular the growing trend to identify addiction as a ‘brain disease’ based on a malfunctioning dopamine system, with the social, ethical and treatment implications that carries, does not get mentioned in the book.

I had hoped to find relevant pieces of literature from the TA canon such as Jody Boliston-Mardula’s work on Appetite Paths (Boliston-Mardula, 2001), Robin Hobbes’ articles on TA and Attachment (Hobbes, 1997) and Jo Stuthridge on TA and Trauma (Stuthridge, 2006). Their lack of inclusion left me with a sense of theoretical incompleteness and insularity.

Trauma and PTSD are mentioned clinically but are surprisingly absent from theory. This matters, as White later hypothesises a difference between symptomatic drug use and dependent drug use, between people with addiction problems who have experienced trauma or have an underlying mental health problem and those who haven’t, a distinction in my experience that often doesn’t hold up. Stuthridge writes that trauma impairs the developing Adult ego state’s capacity for selfnarrative, resulting in disassociated ego states (Stuthridge 2006). These un-integrated aspects of self are then enacted with others again and again as the ‘traumatic script’ plays out. Rather than a lack of introjected adequate Parent and Adult ego states as Tony White suggests, an alternative perspective would suggest that there is a reliving of the original unsatisfying, abandoning or abusive relationship, a view that would certainly fit with the daily repeated experience of chaos and distress that is the dependent drug and alcohol user’s life

While researching my response to this book I became curious about the TA canon on drug and alcohol addiction, a story that was once central and now appears to have been marginalised. Indeed it was difficult to find the articles by Mardula and Hobbes as they are not included in our core publication, the TAJ. Given that addiction has been described as one of the most pressing public health emergencies facing westernised societies (Buchmnan et al., 2010), I am curious about why this discourse has fallen from favour, and grateful to Tony White for bringing this important and timely conversation back to the table.

References

Boliston-Mardula, J. (2001). Appetite Path Model. TA UK,

61 pp9-14.

Boyce, W.T. (2006). Symphonic causation and the origins

of childhood psychopathology. In Chichetti, D. & Cohen,

D.J. (Eds.), Developmental Psychopathology (2nd ed.) Vol.

2: Developmental Neuroscience (pp797-817). New York,

NY: John Wiley and Sons.

Buchman, D.Z. et al. (2010). The Paradox of Addiction

Neuroscience. Neuroethics 4(2), pp65-77. DOI

10.1007/s12152-010-9079-

Hobbes, R. (1997). Attachment Theory and Transactional

Analysis, Parts One and Two. (Retrieved from

http://www.elantraining.org/downloads.html#sh3).

(Originally published in ITA News, 46 & 47).

Shaffer, Howard J. (1986). Conceptual crises and the

addictions. Journal of Substance Abuse Treatment, 3,

pp285-296.

Stuthridge, J. (2006). Inside Out: A Transactional Analysis

Model of Trauma. Transactional Analysis Journal, 36(4),

pp268-283.

Jo Moores CTA, has a private psychotherapy practice in South Manchester. She has an interest in working with trauma using a combination of Transactional Analysis and EMDR, and enjoys working with couples. She worked at The Big Issue In the North for nearly a decade, working to improve services for homeless people and those struggling with drug and alcohol dependencies. Her web address is
www.psychotherapymanchester.com

Suicide pact

In the city where I live, at the moment there is considerable media interest in an elderly couple who died. Apparently the man shot his wife dead, called the police and then shot himself dead before the police arrived. The police are trying to work out if it was a murder - suicide or a suicide pact. This raises some interesting points about suicide pacts that I discuss in my book - Working with suicidal individuals - where I note there are three types of suicide pacts shown in the diagrams below.

If the elderly couple had a suicide pact then it is the first type of suicide pact shown. Both parties want to die and agree to do so together. However certain things about this type of suicide should be publicly known. Both parties need to be equally involved in the preparations and act of making the suicide attempt. If the elderly man shot his wife dead, then shot himself but did not die then it is highly likely he would be charged with murder even if it was a suicide pact, (that is the wife wanted to die and wanted him to shoot her).

In the other two types of suicide pacts there is only one person who wants to die but the external party relates to the suicidal person in such a way that elevates the chance of a serious suicide attempt. The relationship between the two becomes supportive of suicide as a solution to the suicidal person’s problems and hence we have some kind of a pact.

As the second diagram shows some people take the view that suicide is a choice that a person has the right to make. It is everyones right to decide how and when to die. This is not an uncommon view held in the community, by a significant number of people and has logical and philosophical merit. If a suicidal person has a close relationship with the other who has these views then in one sense one could see this as a suicide pact. Not only is the suicidality being logically supported by the other but the suicidal person will also introject those views into their own Parent ego state, thus increasing the likelihood of a serious suicide attempt.

The third relationship occurs when the suicidal person has been suicidal for some time, may have even made an attempt and remains suicidal. Again not an uncommon scenario as for many, suicidality slowly increases over time, 75% tell others about their suicidal thoughts and the ratio of attempts to completed suicides varies from 1 to 40, up to 1 to 200.

Living with or having a close relationship with such a suicidal person is a very difficult and stressful thing to do. The non suicidal person can suffer greatly in this way, sometimes for years. Of course this person does not want to live like that and one way it is going to stop instantly and for ever, is if the suicidal person dies. If that happens then all that stress disappears instantly and forever (and the suicidal person knows this as well). It seems reasonable to conclude that any close person at some level wants the suicidal person to die as the Free Child in all of us would want the great stress to go away. Hence in this way the other supports the suicide of the suicidal person and hence we have the third type of suicide pact. 

I discuss such case studies of this type in my book and this is where it gets murky and unclear. If one lives with a suicidal person, that is very stressful as I mentioned before. If that goes on for months or years does the non suicidal other begin to alter their behaviour consciously or unconsciously such that the likelihood of a completed suicide increases? Starting to not notice higher risk indicators, brushing off suicidal comments as just another one like the 30 before, altering behaviour such that the likelihood of finding the loved one making an attempt decreases. As I said before all of us have a Free Child and that ego state wants the horrible stress to stop, no matter how much we love the suicidal person. It could be argued that because of this everyone at some unconscious (or conscious) level would begin to act in such ways as just described.

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Injunction - Don’t be you (the sex you are):

In this life script message the parents some how communicate to the child that they should have been born the opposite sex. A female may be born fourth in a line of girls as the parents tried to have a boy and this can leave the child with a deep sense of disappointment about itself. Some parents openly tell the child that she was meant to be a boy. They may dress the child as the opposite sex and engage it in activities of the opposite sex. The child maybe given a name that is usually used for the opposite sex or could be applied to the opposite sex. The child may be named after a relative who was the opposite sex. All these type of things can communicate to the child that it was meant to be born the opposite sex.

However it does not only have to relate to one’s gender. Some parents want their children to go to university and some simply do not have the academic ability to do so. Or the parents may want the child to be musical or sporty and the child has little talent and or interest in doing such a thing. Some parents put children in beauty or talent contests. Are they doing so for the child or because they want the child to be some way for their own psychological needs? In these instances the child again realizes that mother or father want them to be a particular way and realize they cannot or don’t have any interest in it and this can lead to emotional problems as described below.

We are who we are

It is possible for this injunction to lead to quite significant levels of maladjustment especially in the case of “Don’t be the sex you are” message. One’s gender is a basic and integral part of how people perceive and view them self. It is part of the core understanding of who we are. If they receive the message they should have been the other gender that can lead to quite a deep and profound sense of disappointment in relation to the parents and the child being in some cases disappointed in itself for some how not getting it right.

This injunction can be a basis of ego dystonic homosexuality and ego dystonic heterosexuality, some transvestism and some transgenderists. The DSM-5 would refer to this as a dissociative disorder where there is a disturbance in ones identity, in this case sexual identity. They note that such things can result from prolonged and intense coercive persuasion. One could see this as a euphemism for parenting in childhood which is a prolonged and intense period of persuasion.

This can also lead to pathological reasons for seeking cosmetic surgery. Repetitive cosmetic surgery can result from this injunction. Also there may be extreme fitness training as the person is trying to transform them self physically into something else, alternatively some have eating disorders for the same reasons.

They can also adopt the opposite gender role in relationships. Females will have more masculine qualities and less feminine qualities and the male is the other way around. So the male will adopt the traditional female roles in relationships and the female will adopt the male roles.

The tom-boy can be from a Don’t be you injunction. The parents wanted a boy and they got a girl so they treat her like a boy anyway. The girl adopts the typical male type of dress, activities, hobbies and employment. The same of course applies for the other way around when boys are treated like girls because the parents wanted a girl.

Others refuse to accept the age they are. They do not like getting older so they will adopt activities that are appropriate for younger ages, or they may ‘hang out’ with others who are much older or younger than them self. Some refuse to accept the aging in the body and will behave in a way that can at times be dangerous. For instance some men in their 60s will do heavy physical work or strenuous sporting activities that they could handle in their earlier 20s because they do not want to admit they are getting older and they still see themselves as a young person.

This can also give rise to what is called a chronophillia. That person who is sexually and romantically attracted to a person who is considerably older or younger. They just never fall in love with someone who is approximately the same age. This can be due to the fact that the parents let them know there was something wrong with who they were as a person, so they cope with it by changing their psychological view of self to fit with what the parents did want. 

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Hysteric personality

Teenager and criminal personality thinking

In the previous post - Problems with polygraph lie detection - I talked about the psychology of the anti social personality. I think this below is quite a good summary of it except for number 2. One simply has to go into a prison and one finds many low IQ anti social personalities. As I have mentioned before the teenager and the criminal personality have some similarities in the way they think.

The Bali 9 are a group of nine teenagers and young adults who tried to smuggle drugs through Bali (Indonesia). They got caught and now a few are on death row and the others have long terms of imprisonment. The press have followed their plight as they are so young and Australians on death row in other countries tends to attract attention in the press.

A recent news article on them gave quotations of what three of them were thinking at the time of doing the crime. The three quotes.

1.  “I was young and basically I thought I was invincible”

2. “The only thing I was thinking, really, was to make some money, quick money.”

3. “You think it’s not going to happen to me. It happens to other people. I’m lucky.” 

“Looking for adventure, never been out of the country before, I thought, Yeah, why not.“

These are good examples of how the anti social and the teenager can think

1. A sense on invincibility and hence a lack of anxiety

2. The sense of simply not thinking it through and what is called a lack of foresight. The anti social and the teenager are very good at living in the here and now and not worrying about the future. They have the ability to just not think about it.

3. A sense of specialness and uniqueness and that the rules don’t apply to me. Also a lack of foresight and not thinking it through by seeing it as some kind of adventure to go through.

Also not one of them displayed any understanding of the immorality of what they were doing and hence a lack of conscience.

These thinking styles show why the deterrent effect of the law has little impact on such people as they believe the rules in some way do not apply to them and they will end up OK in the end.

It should also be noted that there are also some similarities between the anti social personality and the narcissist. Indeed I recently stated on a blog that whilst working in prison I would have diagnosed more narcissists than anti socials even though logically that does not make sense. Then my friend Rita told me about the work of Robert Hare on psychopathy. He states that the psychopath is a mixture of aggressive narcissism and anti social traits. Which reassured me that perhaps my diagnostic skills were not all that wonky.

Suicide and teenage thinking

As said above anti social and teenage thinking can be quite ‘wrong’ and in extreme cases this can lead to a very tragic outcomes such as ending up on death row like some of the Bali 9.

The other case is with suicidal behaviour and why in my book - Working with suicidal individuals - I suggest one predictor of suicidality is does the person “think like a teenager”?.  Do they have the thinking errors as cited above? One way of assessing this is to ask the person about their post-suicide fantasy. What do they think the outcome will be after the suicide attempt and this can identify teenage style thinking if in some way they see them selves as surviving in some form, or being able to observe how others react afterwards, or have some kind of consciousness afterwards and so forth.

Teenagers are a difficult group when it comes to suicidal behaviour as the type of  thinking being discussed here makes them less predictable. At the same time it puts them at higher risk because they do not fully comprehend the outcome of their suicidal actions, just as the Bali 9 did not fully comprehend the outcome of their actions and just like the criminal personality does not fully comprehend the outcome of their criminal actions.

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Problems with polygraph lie detection.

This test relies on the liar have an emotional reaction to the act of lying. The more the reaction the greater the indication of lying as the polygraph picks up the emotional tension. This statement describes what happens to some people when they lie

Thus the lying transaction could be diagramed as such

The lying transaction. 

The Parent ego state of the individual tells the Child ego state that it is wrong to lie. The Child ego state feels guilt in response to that parental directive if they choose to lie. The Child ego state also experiences another emotion, that of fear of getting caught.

For most people this applies. However there are a group where this does not apply and that is with the anti social personality. As a consequence one of the personality traits of this personality is that they lie more than most. Another feature of the anti social personality is they do not feel fear like the average person. They fail to comprehend the long term consequences of what they are doing and hence feel less anxiety. A teenager is also like this. They will take risks because they do not perceive the potential danger and thus do not feel the fear in the first place.

I didn't do it!

So the polygraph is less effective with the anti social personality and to a lesser extent the average teenager.  The anti social will have less of a fear reaction and hence it wont show up on a polygraph test. They also have poor moral development in their Parent ego state and hence do not have a moral directive against lying. Hence they do not feel guilt like the average person and again this make the polygraph test ineffective.

I would also add one other possible flaw with the poly graph and one sees this particularly with drug uses. In the drug subculture lying is endemic. People often lie to conceal the activities they are doing. As a result lying can become habitual like any behaviour can. When working with them you will find them lying at times when there is no reason to. They are simply doing it out of habit. I would suggest that such a person who lies habitually would also have much less of a fear and guilt reaction in a polygraph test.

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Desensitization in the military

I heard a recent news report on the radio which stated that in the Australian military the number of people returning from combat with PTSD has doubled in the last three years. One possible explanation for this is the soldiers are no longer being properly psychologically prepared before they go into war.

One is reminded of the stereotypical image of the drill Sargent. His face one inch from the trainee soldier with spittle coming out his mouth, shouting that the soldier’s mother is a whore and his father is a faggot. Why would he do such a thing? He is not really talking about the mother’s occupational history nor the father’s sexual orientation. He is brutalizing the young soldier because he knows if he does that then the soldier will desensitize and therefore be more psychologically prepared to go into a war zone. He is less likely to come back with PTSD.

In Australia at the moment the Defence department is undergoing considerable public scrutiny. Some of its members have been doing things like having sex with female members and then streaming it live onto the internet. Emailing pornographic pictures of female soldiers and so forth. Clearly these are very wrong things to do but we need to be careful.

The department of defence is a special case in terms of government organizations. It is not like the department of transportation nor the education department. The defence department is about training people to kill others. It is about training mainly men to go into a war zone and be able to walk around knowing the next step they take may be onto a mine which will blow of his leg and his genitals. This type of thing is not required in the department of transportation whose biggest task is to make sure the trains run on time.

The department of defence must be a brutalizing organization. It must in some way assault the soldiers as there is no other way to get them to psychologically desensitize. People just will not go through the psychological process of desensitization unless they are being faced with some form of repugnant abuse.

This is what war is.

As it officially sanctions brutal treatment of the training soldiers it is inevitable that some of its members will then start brutalizing each other. That’s what happens in human groups. The culture of the group is defined by the leadership and then its members will inevitably behave the same way. That can be in a family of four or an organization of thousands. The leadership defines the acceptable behaviour by their actions (not words!) and then the membership will sooner or later display that behaviour to those outside the organization but internally to each other as well.

I don’t know of an answer to this dilemma. It is very wrong for people to send offensive internet images of others or behave in any abusive form to another person. At the same time we have to have a military that has a culture of brutality and therefore it is inevitable some of the membership will do the same to those they live with.

The danger is that the military will become a more ‘sensitive’ organization. If they do not maintain the level of abuse of the soldiers then there will not be the necessary desensitization occurring. Therefore they are going to be sent into war psychologically under prepared and more will develop PTSD. This is an abomination. Not only do we send off these young men to fight our wars and possibly die but we under prepare them so they can come home further damaged for years afterwards with PTSD.

What the politicians will probably say is that we can brutalize them in their training but then teach them not to brutalize each other. I have my doubts if that is possible because human group psychology just does not work that way.

It’s like the mother who smacks her son for hitting his sister. In human psychology actions speak far far louder than words.

I can’t see a realistic solution. The politically correct solution is clear but as I said I have my doubts if that is possible. May be the military is already becoming more sensitive and we are beginning to see the consequences of that with a dramatic increase in PTSD.

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Unconscious communication

The woman on the left with the hand flicking the hair, "I'm the gorgeous one here"?
The woman on the right with the mouth as it is, "I want to say something to these women but I must not"?

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New book review - Working with suicidal individuals

Here is another book review I found from the journal, Mental Health Practice. 

Also included is the latest list of university, college and training institutes that have the book. It is good to see such a wide variety have found the book to be an addition to their curriculum. Of particular note have been the additions in Europe most notably Poland, Norway, Sweden, another one in Slovenia, Ireland and the Netherlands. Also are a couple from South Africa and the first one from India.

Current list of university, college and training insititute libraries that have the book - Working with suicidal individuals.

330 libraries.

Trinity College Dublin (Ireland)
Dublin Institute of Technology (Ireland)
National University of Ireland, Maynooth (Ireland)
Queen’s University, McClay Library Belfast (Ireland)
Queen’s University, Medical Library Belfast (Ireland)

National library of Scotland (Scotland)
University of Strathclyde (Scotland)
University of Stirling (Scotland)

National Library of Wales (Wales)
Swansea University (Wales)
University of Glamorgan (Wales)
Bangor University (Wales)

PJ Library (Norway)
University of Bergen (Norway)
Norges teknisk-naturvitenskapelige universitet (Norway)
University of Oslo (Norway)
University of Tromso (Norway)
Universitetet I Agder (Norway)
NLA Høgskolen (Norway)

Maribor General Hospital Library (Slovenia)
Medical High School Juga Polak, Maribor (Slovenia)

Uniwersytet Opolski (Poland)
Uniwersytet w Bialymstoku (Poland)
Nicholas Copernicus University (Poland)

National library of the Netherlands (Netherlands)

TA Centre Library (Serbia)

Mitt hogskolan library (Sweden)
Stockholm University (Sweden)
Högskolan Dalarna (Sweden)
Mid Sweden University (Sweden)
Hogskolan I Gavle-Sandviken (Sweden)

Central Library of Zurich (Switzerland)
Swiss Federal Insitute of Technology Zurich (Switzerland)

Freie Universitat Berlin (Germany)
Humboldt University of Berlin (Germany)
State and University Library of Dresden (Germany)
Bibliotheksservice - zentrum baden-württemberg (Germany)
Universitat Des Saarlandes (Germany)
University of Erlangen-Nuremberg (Germany)
Universitat Leipzig (Germany)
Bavarian State Library (Germany)

Unisa: Muckleneuk Campus (South Africa)
Stellenbosch University Library (South Africa)

Jawaharlal Nehru University (India)

Curtin University (Aust)
University of Western Australia (Aust)
Murdoch University (Aust)
Edith Cowan University (Aust)
Bond University (Aust)
Monash University (Aust)
Australian National University: Online (Aust)
Victoria University (Aust)
Swinburne University of Technology (Aust)
Bankstown Campus library (Aust)
University of Sydney (Aust)
University of Adelaide (Aust)
University of Newcastle (Aust)
University of Melbourne (Aust)
University of Queensland (Aust)
University of Ballarat (Aust)
University of New England (Aust)
University of Western Sydney (Aust)
University of the Sunshine Coast (Aust)
TAFE Gosford campus library (Aust)
TAFE Bathurst campus library (Aust)
TAFE Tamworth campus library (Aust)
Deakin University (Aust)
LaTrobe University (Aust)
State library of Queensland (Aust)
Queensland University of Technology (Aust)
RMIT University (Aust)
Charles Sturt University (Aust)
MacQuarie University (Aust)
Australian Catholic University (Aust)
James Cook University (Aust)
National Library of Australia (Aust)

University of California  San Diego (USA)
San Diego Christian College (USA)
Open Library. California State Library (USA)
University of Southern California (USA)
University of California San Francisco (USA)
University of California Merced (USA)
University of California  Riverside (USA)
Loyola Marymount University California (USA)
Golden Gate University (USA)
California Institute of the Arts (USA)
California State University, Sacramento (USA)
MiraCosta College California (USA)
Carthage College (USA)
Beacon College Library (USA)
Freed Hardeman University (USA)
American University (USA)
Aurora University (USA)
Bay Path College (USA)
Kutztown University (USA)
Rogers State University (USA)
Mount Mercy University (USA)
North Central University (USA)
Plymouth State University (USA)
Philadelphia University (USA)
Davidson College (USA)
Daytona State College (USA)
DeSales University (USA)
Doane College (USA)
Fuller Theological Seminary (USA)
Simpson University (USA)
Union College (USA)
University of Saint Mary (USA)
Viterbo University (USA)
Biola University (USA)
University of Alaska - Fairbanks (USA)
Boise State University (USA)
Pepperdine University (USA)
Alverno College Library (USA)
Concordia University Technology Center (USA)
Graceland University (USA)
Lancaster Bible College (USA)
Lord Fairfax Community College (USA)
Seton Hall University (USA)
Wayne State College (USA)
Huntingdon College (USA)
University of Nebraska at Omaha (USA)
Catholic University of America (USA)
Gallaudet University (USA)
Virginia Tech (USA)
Old Dominion University (USA)
City University of Seattle (USA)
University of Washington (USA)
George Washington University (USA)
University of Miami (USA)
Miami Dade College (USA)
Georgia Southern University (USA)
University of Nevada - Reno (USA)
University of South Alabama (USA)
Iowa State University (USA)
Dordt College Iowa (USA)
University of Iowa (USA)
Training Library Ohio (USA)
Cornerstone University (USA)
College of Our Lady of the Elms (USA)
College of Western Idaho (USA)
Cameron University Oklahoma (USA)
Northwest Oklahoma State University (USA)
Butler Community College (USA)
Frostburg State University (USA)
Arizona State University (USA)
Arizona Western College (USA)
Brigham Young University Utah (USA)
Bloomsburg University (USA)
Massachusetts Institute of Technology (USA)
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Breaking a bad habit - ego syntonic or ego dystonic

Habit is all about the relationship between repetition and automaticity. If a person starts a new behaviour and repeats it every day how long does it take for that behaviour to become automatic (habitual).

A person smokes marijuana everyday for a year. He then stops smoking marijuana = the new behaviour. How long will it take for the non smoking to become habitual or automatic. The answer is there is not a linear relationship between repetition and automaticity. Instead the relationship results in an asymptotic curve as shown here.

The early days of the repetitions of the new behaviour (not smoking marijuana) result in a quick increase in automaticity. After a time this slows and there is a plateau effect in the automaticity where more repetitions result in little increase in the automaticity.

A behaviour is generally regarded as fully habitual when a person reaches 95% of asymptote. A 100% is when further repetitions result in no more increase in automaticity and there is a complete plateau. Research suggests that the time to reach 95% of asymptote takes 66 days. There can however be considerable variation with a range from 18 to 254 days.

Hence it can be said that for one to become a fully habitual non marijuana smoker will take 66 days. At that time the fully formed habit assists the person not to smoke marijuana again.

Habit - friend or foe?

The cigarette smoker who has smoked for sometime finds it hard to stop for a number of reasons, one being that it is simply a habit. In this case the smoker can see the habitual quality of smoking as a hinderance to stopping. The habit is a foe.

If the person should stop smoking for 66 days then they have broken one habit but started another. They have broken the habit of smoking but picked up the habit of being a non smoker. This maens for the person to again become a habitual smoker they have to break the habit of being a non smoker. This is not an easy thing for people to do as most of us know. In this case the habit is a freind.

Ego syntonic and ego dystonic

Something is said to be ego dystonic when the person perceives it to be foreign to them, outside them or not belonging to them. Something is ego syntonic when the person sees it to be part of them, belonging to them or forms part of who they are

These are two important concepts in psychotherapy. Is the problem ego syntonic or ego dystonic for the client?

A client may present with agoraphobia or perhaps insomnia. The therapist needs to ascertain in his own mind does the client see self as

1. A person who can experience agoraphobia, (ego dystonic)

2. An agoraphobic (ego syntonic)

Does the client experience self as  

1. A person who can suffer insomnia, (ego dystonic)

2. An insomniac (ego syntonic)

Unfortunately in most circumstances by the time the client gets to therapy the problem has become ego syntonic.

A person sleeps normally and then for some reasons starts to sleep poorly. Initially this will feel abnormal to the person and the problem is seen as ego dystonic. They perceive self as someone who sometimes does not sleep well but not as an insomniac.

Over time if the insomnia continues the person’s view of it changes. It becomes something they expect to happen because it has happened many times before. They tend to start to view it as part of who they are - an insomniac. When this change occurs the problem then becomes ego syntonic. The insomnia is perceived by the person as part of who they are and how they live.

The shift from ego dystonic to ego syntonic can be seen to have at least three aspects.

1. It becomes habitual

If a person has slept poorly most nights for the past year then the insomnia is partly a habitual way of being for the person regardless of any other causes for it.

2. It becomes part of the persons life style

As it becomes a habitual pattern of being the person will adjust the practicalities of their life style to fit for it. They will tend to do the same things like get up and do such and such and then go back to bed and then wake up again. They develop a routine at night time that incorporates the insomia.

3. It becomes part of the person’s self perception or part of their identity.

Finally it becomes how the person sees self and a sense of who they are as a person. I am an insomniac is part of the person’s sense of identity.

If a person has slept poorly three nights in the last four months then it wont be habitual, they have no routine when being awake and it is not part of who they see they are.

How long does it take a problem to shift from being ego dystonic to ego syntonic?

In trauma debriefing research indicates that therapy should start within 6 weeks of the trauma. The earlier you start the better. After 6 weeks it is harder to treat the problem (PTSD) as it has become ego syntonic.

As mentioned above research on the formation of new habits indicates that it takes 66 days for a new habit to fully form. After that the person will behave habitually in the new way. Of course this varies on how often the new behaviour occurs and if there are any relapses along the way.

This suggests that it will take about 1.5 to 2 months for a problem to move from being ego dystonic to ego syntonic if the new problem occurs regularly.

If it is ego syntonic then not only does one have to treat the insomnia, but also the habit of not sleeping and the routine involved, along with the self perception of the client as an insomniac.

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