NIH analysis of SAMe for the treatment of depression indicates SAMe does decrease symptoms of depression.

The objective of this report was to conduct a search of the published literature on the use of S-adenosyl- L-methionine (SAMe) for the treatment of depression, osteoarthritis, and liver disease; and, on the basis of that search, to evaluate the evidence for the efficacy of SAMe. A broad search revealed sufficient literature to support a detailed review of the use of SAMe for three conditions: depression, osteoarthritis, and cholestasis of pregnancy and intrahepatic cholestasis associated with liver disease.

Depression will affect 10 to 25 percent of women and 5 to 12 percent of men in the United States during their lifetimes. Approximately 10 to 15 million people experience clinical depression in any given year. The annual cost for treatment and lost wages is estimated at $43.7 to $52.9 billion.

Osteoarthritis is the most common form of arthritis. An estimated 15 percent of Americans suffer from arthritis, and the annual cost to society is estimated at $95 billion. It is the second most common cause cited in claims for Social Security disability benefits.

Intrahepatic cholestasis of pregnancy occurs in 1 in 500 to 1000 pregnancies and is associated with an increased risk of premature delivery and fetal death. Intrahepatic cholestasis is a relatively common complication of a number of acute and chronic liver diseases such as viral hepatitis, alcoholic hepatitis, and autoimmune liver diseases. In two series of chronic liver disease patients, 35 percent had intrahepatic cholestasis characterized by elevations of bilirubin and liver enzymes. While an economic cost is difficult to assign to cholestasis, pruritus causes significant morbidity in affected patients.

Empirical evidence of the efficacy of SAMe for the treatment of these three conditions would be helpful to health care providers who manage them and would be useful in identifying areas for future research.

Reporting the Evidence

Searches of the literature yielded 1,624 titles, of which 294 were selected to review; the latter included meta-analyses, clinical trials, and reports that contained supplemental information on SAMe. Ninety-nine articles, representing 102 individual studies, met the screening criteria. They focused on SAMe treatment for depression, osteoarthritis, or liver disease and presented data from clinical trials on humans. Of these 102 studies, 47 focused on depression, 14 focused on osteoarthritis, and 41 focused on liver disease (all conditions).

Methodology

A panel of technical experts representing diverse disciplines was established to advise the researchers throughout the research. In consultation with the funding agencies and taking into account the uses for which SAMe was generally recommended, the use of SAMe to treat depression, osteoarthritis, and liver disease was selected as the focus of the report. The aim was to perform a meta-analysis whenever the literature was appropriate for such an analysis.

Search Strategy

Twenty-five biomedical databases were searched through year 2000: MEDLINE®, HealthSTAR, EMBASE, BIOSIS Previews®, MANTIS, Allied and Complementary Medicine, Cochrane™ Library, CAB HEALTH, BIOBASE, SciSearch®, PsychINFO, Mental Health Abstracts, Health News Daily, PASCAL, TGG Health & Wellness DB, and several pharmaceutical databases. The researchers searched using the term SAMe and its many pharmacological synonyms, the three focus disease states, study design, and article type. They also searched the bibliographies of review and meta-analysis articles and questioned experts to identify additional citations. An additional 62 articles were identified from these sources, particularly from review articles and from citations suggested by the advisors.

Selection Criteria

Reports were included in the synthesis of evidence if they focused on SAMe for one of the selected diseases and presented the results of randomized clinical trials on human subjects. Language of publication was not a barrier to inclusion. About 25 percent of the selected studies were in foreign languages, mainly Italian.

Data Collection and Analysis

All selected titles, abstracts, and articles, in all languages, were reviewed independently by two reviewers who were fluent in the appropriate language, and all disagreements were resolved by consensus. Information was collected about patient demographics, disease state, intervention, study design, and outcomes. Sufficient numbers of homogeneous studies existed to permit a meta-analysis of the efficacy of SAMe for treatment of four conditions: depression versus placebo and active (pharmacological) therapy, osteoarthritis versus placebo and active (pharmacological) therapy, cholestasis of pregnancy versus placebo and active therapy, and intrahepatic cholestasis associated with liver disease versus placebo. The remainder of the liver disease studies were too heterogeneous for pooled analysis and were assessed qualitatively.

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Findings

Researchers identified 102 relevant studies in the three selected areas: 47 studies for depression, 14 studies for osteoarthritis, and 41 studies for liver disease. The majority of the studies enrolled small numbers of patients, and the quality of the studies varied greatly, as judged by the Jadad criteria. Results are summarized in five evidence tables. After removal of duplicate studies, the distribution of studies across the three selected areas was as follows:

Out of 39 unique studies considered, 28 studies were included in a meta-analysis of the efficacy of SAMe to decrease symptoms of depression.

• Compared to placebo, treatment with SAMe was associated with an improvement of approximately 6 points in the score of the Hamilton Rating Scale for Depression measured at 3 weeks (95 percent CI [2.2, 9.0]). This degree of improvement is statistically as well as clinically significant and is equivalent to a partial response to treatment. Too few studies were available for which a risk ratio could be calculated for either a 25 percent or 50 percent improvement in the Hamilton Rating Scale for Depression. Therefore a pooled analysis could not be done, but the results generally favored SAMe compared to placebo.
• Compared to treatment with conventional antidepressant pharmacology, treatment with SAMe was not associated with a statistically significant difference in outcomes (risk ratios for a 25 and for a 50 percent decrease in the Hamilton Rating score for depression were 0.99 and 0.93, respectively; effect size for the Hamilton Rating score for depression measured continuously was 0.08 (95 percent CI [-0.17, -0.32])).

Out of 13 unique studies considered, 10 studies were included in a meta-analysis of the efficacy of SAMe to decrease pain of osteoarthritis.

• One large randomized clinical trial showed an effect size in favor of SAMe of 0.20 (95 percent CI [-0.39, - 0.02]) compared to placebo, thus demonstrating a decrease in the pain of osteoarthritis.
• Compared to treatment with nonsteroidal anti-inflammatory medication, treatment with SAMe was not associated with a statistically significant difference in outcomes (effect size 0.11; 95 percent CI [0.56, 0.35]).

Eight unique studies were included in a meta-analysis of the efficacy of SAMe to relieve pruritus and decrease elevated serum bilirubin levels associated with cholestasis of pregnancy.

• Compared to placebo, treatment with SAMe was associated with an effect size of nearly a full standard deviation (-0.95; 95 percent CI [-1.45, -0.45]) for decrease in pruritus and of over one and one-third standard deviations (-1.32; 95 percent CI [-1.76, -0.88]) for decrease in serum bilirubin levels.
• In two clinical trials that were not pooled, conventional therapy (ursodeoxycholic acid) was favored over SAMe for the treatment of pruritus. One of them was statistically significant. For serum bilirubin, the results of three small trials varied, and no conclusion could be drawn.

Out of 10 unique studies considered, six studies were included in a meta-analysis of the efficacy of SAMe to relieve pruritus and decrease elevated bilirubin levels associated with intrahepatic cholestasis caused by a variety of liver diseases.

• Compared to placebo, treatment with SAMe for pruritus was associated with a risk ratio of 0.45, meaning that patients treated with SAMe were twice as likely as placebo treated patients to have a reduction in pruritus (95 percent CI [0.37, 0.58]).
• Studies that compared SAMe to active therapy were insufficient in number to permit pooled analysis.

Twenty remaining studies were too heterogeneous with respect to both diagnosis (a wide variety of liver conditions) and outcomes to permit pooled analysis. They were assessed qualitatively.

Future Research

The review has identified a number of promising areas for future research. These areas are discussed briefly.

A need exists for additional review studies, studies elucidating the pharmacology of SAMe, and clinical trials. A better understanding of the risk benefit ratio of SAMe compared to conventional therapy, especially for depression and osteoarthritis, is very important. To that end, additional analysis of existing data could be done, but it would likely be more productive to support new definitive clinical studies to address this issue.

Good dose-escalation studies have not been performed using the oral formulation of SAMe for depression, osteoarthritis, or liver disease. Once efficacy of the most effective oral dose of SAMe has been demonstrated, larger clinical trials are indicated for the use of SAMe for depression, osteoarthritis, and cholestasis. Such trials would need to enroll large numbers of patients with homogeneous diagnoses, and focus on significant clinical outcomes. Ideally, they would compare SAMe to both placebo and standard care. Information on side effects and adverse events should be systematically collected in these trials.

For liver conditions other than cholestasis, additional smaller trials should be conducted to ascertain which patient populations would benefit most from SAMe, and what interventions (dose and route of administration) are most effective. Additional smaller clinical trials of an exploratory nature should be conducted to investigate uses of SAMe to decrease the latency of effectiveness of conventional antidepressants and to treat of postpartum depression.

Source: The National Center for Complementary and Alternative Medicine at the National Institutes of Health. Current as of August 2002.

next: St. John's Wort and the Treatment of Depression
~ depression library articles
~ all articles on depression

female sexual problems

Vaginismus occurs when the vagina is unable to relax and permit the penetration of the penis during intercourse (or inhibit medical examination or tampon insertion).

Normally, the vaginal sphincter (which is a group of muscles) keeps the vagina closed. When it expands and relaxes, it enables intercourse, childbirth, medical examination and insertion of tampons. Vaginismus occurs when the vagina is unable to relax and permit the penetration of the penis during intercourse (or inhibit medical examination or tampon insertion). When vaginismus occurs, the sphincter goes into spasm. Vaginismus is not uncommon. With some women, vaginismus prevents all attempts at successful intercourse. It may occur later in life, even if a woman has a history of enjoyable and painless intercourse.

What Causes Vaginismus

Frightening or painful experiences can cause some women to believe or fear that penetration might be painful or even impossible.

Cultural and religious backgrounds are sometimes strict and can reinforce the 'ideal of the virgin'.Concepts such as penetration, intercourse and even sex can cause fear or trepidation in the mind of a young woman. Stories about painful first intercourse reinforce fears of penetration. Fear about penetration can compound and create a pattern of sexual anxiety, causing the vagina to remain dry and unrelaxed before intercourse.

Recurring or lasting vaginismus can derive from adolescent conditioning and unsatisfying early sexual experience or abuse. In some cases, vaginismus may eventuate after a history of successful and enjoyable intercourse - due to a vaginal infection, the physical after-effects of childbirth, tiredness or some other cause, which causes painful intercourse, possibly leading to a pattern of further vaginismus even though the original cause has disappeared. The anticipation of painful penetration - even though there may be no physical impediment to normal, painless intercourse - can be a common cause of vaginismus.

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Treatment for Vaginismus

It is possible to practice techniques which will prevent vaginismus, that is, to train the vaginal sphincter to relax and permit penetration?

It usually takes time and practice to 'retrain' the vaginal sphincter. Until you are confident that you can master these techniques, you and your partner should avoid attempts at forced penetration and concentrate on other sexual activities...of which there are many! Make sure that any pain you have experienced during attempts at intercourse is not a result of medical problems - consult your medical practitioner.

If the problem is found to be vaginismus try these techniques over time. Don't rush but set your goals - 'I will have enjoyable sex and enjoyable sex includes intercourse', 'I will enjoy penetrative sex'.

Relaxed and on your own, think about a level of discomfort you can tolerate for a short moment, deliberately let your vagina become tense. Then let it relax, use a lubricant and gradually insert your fingers or a vaginal dilator (obtainable through your doctor, or a sex therapist) into your vagina until you reach, but don't exceed, your discomfort level. Be realistic - allow some discomfort, perhaps expect it, but don't let it become painful - just progress one step at a time. There is no hurry, practice in the bath or shower if you prefer.

Find a position that suits you - lying back, on your side, squatting. It's your choice - allow yourself to enjoy the experience. Over time, progress further into your vagina, moving from your little finger to your index finger or perhaps using a larger dilator. Feel confident - you're not inserting anything into your vagina that won't fit; after all the vagina can expand to allow the birth of a baby! As you progress, incorporate water-based lubricants such as KY Jelly in your training - use as much or as little as you like. Gradually, you will train your vagina to expect these new feelings and larger objects.

Now you're ready to practice with your partner. Follow the steps again, but this time let your partner insert their finger or the dilator into your vagina - gradually. Proceed with patience - eventually your vagina will relax enough to permit your partner's penis to penetrate, perhaps a little at a time. Practice, practice, practice. Allow the experience to be enjoyable for you both - take time to discover each other's desires and turn-ons.

next: Types of Male and Female Sexual Problems

teenage sex

We know that for centuries rapists have used alcohol as a means to sedate their victims in order to commit sexual assault. Today, rapists can choose a wide variety of substances to commit crimes of assault.

In recent years, survivors of sexual assault have been drugged by sedating substances, usually when slipped into a beverage. These drug related sexual assaults pose unique difficulties for both survivors and for those who are trying to reduce the risk. The general advice provided here is that any substance can be used to sedate women and men for the purposes of raping them.

Based on the information the authorities have about the use of these date rape drugs, we know that people of all ages are potentially vulnerable -- however, we also know that both sexual assault and high risk drinking occurs more amongst youth and young adults. We also know that both young women and young men have been drugged and sexually assaulted, and that women are more likely to be sexually assaulted, not only with rape drugs, but in other ways as well.

What exactly are date rape drugs?

Technically speaking, any substance that renders you incapable of saying "no" or asserting yourself and your needs can be used to commit rape.

This can include things like alcohol, marijuana or other street drugs, designer or club drugs like ecstasy, over-the-counter sleeping pills and antihistamines, even cold medications. However, the term "date rape drug" usually applies to the drugs Rohypnol, Gamma Hydroxy Butyrate (GHB) and Ketamine Hydrochloride.

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How date rape drugs work

Rape survivors generally report that they had consumed little or no alcohol and felt terribly inebriated. The next thing they remember is waking up with the knowledge of having survived a sexual assault. One can only imagine how frightening this may be for survivors. Imagine what it is like to wake up, knowing that you have been assaulted, but not being able to recall the details. The effect of many of the drugs is that they cause amnesia and unclear memories.

Police authorities report these date rape drugs (Rohypnol, Gamma Hydroxy Butyrate (GHB) and Ketamine Hydrochloride) are being used in bars, nightclubs, restaurants, parties, coffee shops, etc. One survivor recounted a story of being raped after being drugged on an airplane flight. Imagine how she felt when no one helped her, and she was incapable of preventing the assault.

What makes these date rape drugs so effective

The drugs are virtually undetectable; they are tasteless, odorless and colorless. All traces of the drugs leave the body within 72 hours of ingestion and are not found in any routine toxicology screen or blood test - doctors and police have to be looking specifically for them and they have to look quickly! Date rape drugs are easily slipped into drinks and food and are very fast acting. They render the victim unconscious but responsive with little or no memory of what happens while the drug is active in their system. The drugs also make the victim act without inhibition, often in a sexual or physically affectionate way. Like most drugs, date rape drugs render a person incapable of thinking clearly or of making appropriate decision. This makes for a very passive victim, one who is still able to play a role in what is happening but who will have no clear memory of what happened after-the-fact. Without any memory of events the victim is often unaware that they have even been raped, and if they are aware or have suspicions they make very poor witnesses.

How do you know if someone has used a date rape drug on you?

It is difficult, but not impossible to know. First, there are some very clear signs that sexual activity has taken place even if you have no memory of actually "doing it." (It is important to note here that if you have had sex but can not remember doing it or offering consent you have been raped under the law, whether a date rape drug has been used or not.) Signs that a sexual assault has taken place can include; soreness or bruising in the genital area, soreness or bruising in the anal area, bruising on the inner and/or outer thighs, bruising on the wrists and forearms, defensive bruising or scratching (the kind that would occur during a struggle), used condoms near you or in nearby garbage containers, and traces of semen or vaginal fluids on clothes, body or nearby furniture.

Since people who have been slipped a date rape drug appear to others to be very intoxicated, an extremely reliable sign that you have been raped using a date rape drug is gossip from others about your behavior or the behavior of those around you. Aside from indications of sexual activity, other clues that a date rape drug may have been given to you include:

• feeling "hung-over" despite having ingested little or no alcohol
• a sense of having had hallucinations or very "real" dreams
• fleeting memories of feeling or acting intoxicated despite having taken no drugs or drinking no alcohol
• no clear memory of events during an 8 to 24 hour period with no known reason for the memory lapse
• and stories from others about how intoxicated you seemed at a time when you know you had taken no drugs, medications or alcohol

Short of being told that you have been given a date rape drug, there is no way to be sure without medical testing. If you suspect that you have been given a date rape drug you need to get to a hospital quickly and you must request that you be properly tested. The drugs can be found in your system if you act quickly. If you suspect that you have been raped using any one of these drugs go to a hospital and request a preliminary rape exam with testing for date rape drugs. This is the only way to know for sure.

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How Can You Protect Yourself from Being a Victim of a Date Rape Drug?" />

How can you protect yourself from being a victim of a date rape drug?

The introduction of date rape drugs into mainstream culture has put a very powerful weapon in the hands of sexual predators. Rapes can be easily committed behind a foggy haze of intoxication often leaving the rape victim oblivious to the fact they have been assaulted. It is a frightening thought that begs the question: "What, if anything, can be done to stop a person from falling victim to a rape using a date rape drug?" There are some simple behavior modifications you can make to ensure that you do not fall prey to a rapist armed with a date rape drug. To protect yourself always follow these simple rules:

• Don't accept drinks from other people.
• Open containers yourself.
• Keep your drink with you at all times, even when you go to the bathroom.
• Don't share drinks.
• Don't drink from punch bowls or other large, common, open containers. They may already have drugs in them.
• Don't drink anything that tastes or smells strange. Sometimes, Gamma Hydroxy Butyrate (GHB) tastes salty.
• Have a non-drinking friend with you to make sure nothing happens.
• Keep your eyes and ears open; if there is talk of date rape drugs or if friends seem "too intoxicated" for what they have taken, leave the party or club immediately and don't go back!

If these behavior modifications don't feel like enough protection, or if you don't think you can follow these rules on a given night, you do have another option. There is a new defense against date rape drugs that has recently been approved for use in North America; it is a simple and inexpensive test kit that can be used to detect the presence of date rape drugs in drinks. The so-called "Drink Safe Technology" is actually a package of drink testing strips or coasters that work like those litmus paper strips you use in chemistry class. The strips and coasters change color when they come in contact with a date rape drug. The strips fit in your purse or pocket and can be used quickly and discretely. To find out more about "Drink Safe" visit the website at http://www.drinksafetech.com.

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If you think that you have been drugged and raped:

• Go to the police station or hospital right away.
• Get a urine (pee) test as soon as possible. The drugs leave your system quickly. Rohypnol leaves your body 72 hours after you take it. Gamma Hydroxy Butyrate (GHB) leaves the body in 12 hours.
• Don't urinate before getting help.
• Don't douche, bathe, or change clothes before getting help. These things may give evidence of the rape.
• You also can call a crisis center or a hotline to talk with a counselor. One national hotline is the National Domestic Violence Hotline at 800-799-SAFE or 800-787-3224 (TDD). Feelings of shame, guilt, fear and shock are normal. It is important to get counseling from a trusted professional.

GHB (Gammahydroxybutyrate)

GHB is used in some countries as a general anesthetic, treatment for insomnia, treatment for alcoholism, an aid in childbirth by increasing the strength of contractions and decrease in pain, and assists in dilation of cervix.

The street names for GHB are: Easy Lay, EZ Lay, Liquid Ecstasy, Ellie, Clear X, Liquid X, X-rater, XTC, Chemical X, Liquid Dream, Scoop, Scoop Her, Get-Her-to-Bed.

GHB is an odorless, colorless, liquid that acts on the central nervous system as a depressant/anesthesia. It looks exactly like water. It was banned in the United States in 1990 under the Samantha Reid Date-Rape Prohibition Act of 2000. It is also illegal in Canada and many parts of Europe. It is not produced or manufactured by any pharmaceutical company; instead it is made in illegal drug labs or by amateur chemists in their homes. It can be easily made with common and readily available ingredients and novice chemistry skills and the recipe is easy to find. Making, possessing and/or using this drug is illegal.

GHB is used as a recreational drug often at Rave parties and offers an alcohol and hangover free high

GHB can cause these problems:

• euphoria
• amnesia
• intoxication
• dizziness
• visual hallucinations
• enhances state of relaxation, desire, enjoyment, and decreases inhibitions
• problems seeing
• unconsciousness (black out)
• problems breathing
• dream-like feeling
• coma
• death

GHB begins to take effect 10 - 15 minutes after ingestion. The effects last for 3 - 6 hours when taken without alcohol and 36 - 72 hours when mixed with alcohol or other drugs. In very high dosages unconsciousness, or even coma, can occur within 5 minutes.

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Ketamine Hydrochloride

Ketamine is a legal drug sold as a veterinary sedative or hospital grade anesthesia and goes by the brand names Ketaset® or Ketalar®. It is in the same family of drugs as PCP or angel dust (phencyclidine). When used in humans, the drug acts as a dissociative anesthesia; it renders the user vaguely aware of, but comfortably detached from, all bodily sensations.

In undiluted form it looks like an off-white powder, in diluted form it looks like slightly cloudy water.

The street names for Ketamine are: Special K, Super K, K, OK, KO, Vitamin K, Kid Rock, Ket Kat, Make-Her-Mine.

Ketamine can cause these problems:

• has a dissociative action, type of out of body experience, yet conscious
• loss of grasp with primary senses - distorted perceptions of sight and sound
• feelings of peace, detachment from body, enter a type of transitional world of darkness, leading to a near death type of experience
• often causes those under influence to feel connected to emotionality
• loss of memory, includes amnesia, hallucinations
• patients state they are awake but paralyzed
• can cause violent reactions in some who take the drug in excessive amounts, with aggressive displays, impaired self control, hallucinations and other toxic side effects such as nausea and vomiting
• problems breathing
• dream-like feeling
• coma
• death

When taken orally or nasally (snorted), the effects of Ketamine take 10 - 20 minutes to be realized. When taken intravenously the effects are instantaneous. The effects last less than 3 hours and the drug is detectable in the system up to 48 hours depending on the method of ingestion. Since it is often mixed with other mind-altering drugs, like heroin and cocaine, many people do not ever realize they have been given this substance.

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What makes the 3 main date rape drugs - Rohypnol, Gamma Hydroxy Butyrate (GHB) and Ketamine - so dangerous?

These date rape drugs are sometimes used to assist in a sexual assault. Sexual assault is any type of sexual activity that a person does not agree to. It can include inappropriate touching, vaginal penetration, sexual intercourse, rape, and attempted rape. Because of the effects of these rape drugs, victims may be physically helpless, unable to refuse sex, and can't remember what happened. The date rape drugs often have no color, smell, or taste and are easily added to flavored drinks without the victim's knowledge. There are at least three date rape drugs:

Rohypnol (flunitrazepam)

Rohypnol is a prescription sedative/depressant belonging to the Benzodiazepine family of drugs used as a powerful sedative or sleeping medication. Similar drugs in this family are Valium and Halcion.

The street names for Rohypnol are: Rophy, Ruffles, Roofies, Ruffies, Ruff Up, Rib, Roach 2, R2, R2-Do-U, Roche, Rope, Ropies, Circles, Circes, Forget It, Forget-Me-pill, Mexican Valium.

This drug is not manufactured or approved for use in North America but can be found as a street drug. Rohypnol is a pill and dissolves in liquids. New pills turn blue when added to liquids. However, the old pills, with no color, are still available. The tablet is white and looks slightly smaller than an aspirin and may be packaged in bubble wrap, which gives it a false sense of safety or legality.

The effects of Rohypnol can be felt within 20-30 minutes of ingestion with the strongest effects felt within one to two hours. The effects may last up to 8 hours. Mixed with alcohol, the effects last longer, up to 36 hours. After ingestion it can be found in the blood stream for 24 hours and in urine samples for 48 hours.

Rohypnol can cause these problems:

• can't remember what happened while drugged
• sleepiness
• muscle relaxation or loss of muscle control
• drunk feeling
• problems talking
• difficulty with motor movements
• loss of consciousness
• confusion
• problems seeing
• dizziness
• lower blood pressure
• nausea, stomach problems

The pills are small and white with a split-pill line on one side and the word "ROCHE" with the number 1 or 2 in a circle stamped on the other. They are quickly dissolved in liquid especially when crushed first.

next: Dating an Older Guy

Family and Friends are Victims of Eating Disorders Too

Friends and family members are often the forgotten victims of eating disorders. If someone you care about has an eating disorder, it is difficult to know what to do for the person or for yourself. No matter what effort might be taken, such as helping find a therapist, sitting up all night talking, taking away laxatives, and so on, ultimately you have no power over another person's behavior.

You do have power over what you choose to do about the situation, and the more knowledgeable and prepared you are, the better chance you have for success. Even when you don't know how your friend or loved one will react to your concern, it is important that you express it and offer to help. Even if your concern or help is received poorly, don't give up. It is difficult but important that friends and family members keep trying to reach out to a suffering loved one in order to facilitate the person getting help and to support her during her struggle. Your efforts, love, and encouragement may be crucial to your loved one's recovery. People who have recovered from eating disorders often cite being loved, believed in, and not given up on as crucial factors in their getting help and getting well.

If you have observed behaviors in friends or loved ones and are concerned that they have a problem with food or weight, that is enough reason to say something to them. You do not need to wait until you have signs or proof of a full-blown eating disorder. The sooner you discuss things the better, for your sake and for theirs.

How to Approach and Talk to Someone You Suspect Has an Eating Disorder

PICK A TIME AND PLACE WHERE THERE WILL BE NO INTERRUPTIONS AND NO NEED TO HURRY

You must allow for privacy and plenty of time for both you and your friend or loved one to say everything that needs to be said.

BE EMPATHIC AND UNDERSTANDING

The first step, and most important thing to remember throughout your experience with a loved one who suffers from an eating disorder, is to have empathy. The best way to describe empathy is that it is like standing in someone else's shoes. Empathy is an effort to understand someone's experience as she experiences it and to convey that understanding. The only way to do this is to not be invested in changing the person or in getting her to change her perspective; that can come later. Before a loved one is going to be able to see another perspective, she will need to know that someone recognizes the legitimacy and importance of her own.

Don't worry that empathizing is not enough and that you need to do something or get your loved one to take action. It is true that if you stop at empathy you can "love and understand someone with an eating disorder to death," but empathy is a necessary first step and must be continually maintained. Once a person knows you understand and are not going to try and take over or take the eating disorder away, then you can begin helping in other ways, such as getting information, finding specialists, making appointments, reassuring, and even confronting. Just remember that all of this needs to take place after a person first feels understood and accepted.

Asking for help is usually one of the hardest things for those suffering from eating disorders to do. They need to learn that asking for and receiving help is not a weakness and they do not need to handle everything alone. Ultimately this helps them to learn that they can reach out to people instead of their eating disorder behaviors to escape from their pain. Even if there are limits to what you can do, they need to know you can help.

EXPRESS YOUR CONCERN ABOUT WHAT YOU HAVE OBSERVED AND SPEAK FROM YOUR OWN EXPERIENCE

It is important to stay calm and keep to specific personal examples. It is best to use "I" statements rather than "You" statements. Using "I" statements means that it is only in your opinion or from your own perspective that you are speaking. Using "You" statements sounds judgmental and is apt to create a defensive reaction.

Instead of saying:

You're too thin, say, I look at you and see you wasting away and I'm scared.

You have to stop throwing up, say, I heard you throwing up and I'm worried about your health.

You are ruining our relationship, say, I'm concerned for you and felt like I had to say something or we would both run the risk of being dishonest with each other.

You must get help, say, I'd like to help you to find help.

Be careful not to use "You" statements that are disguised as "I" statements (e.g., "I think you are just trying to get attention"). Don't focus all of your discussion on food, weight, exercise, or other be-haviors. It is easy to get caught up and stuck in discussing your loved one's behaviors, such as eating too little, not weighing enough, bingeing too much, purging, and so on. These are valid concerns and important to comment on, but focusing on behaviors alone can be counterproductive.

For example, a person with anorexia nervosa will be pleased rather than alarmed to hear that she is painfully thin. Remember, the underlying issues, not just the behaviors, are important. Loved ones may be less defensive when approached with the idea that they seem sad, not "themselves," or unhappy. They are likely to be less threatened about discussing these problems.

PROVIDE INFORMATION ABOUT RESOURCES FOR TREATMENT

It is wise to be prepared with helpful information and suggestions in case your friend or loved one is ready and willing to receive them. Try to have the name of a doctor and/or therapist, the fees they charge, and how to make an appointment. If a treatment program is needed, have that information as well. Ask your loved one to consider going to at least one appointment and offer to go together. Of course, if you are a parent of a minor you will have to go to the first appointment and you should be included on some level. It is important that your loved one feel safe and confident that his therapist is there for him.

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DO NOT ARGUE OR GET INTO A POWER STRUGGLE

Expect to be rejected in the beginning and don't give up. It is very likely that the person you are concerned about will deny the problem, become angry, or refuse to get help. It does no good to argue. Stick to your feelings, how you experience the situation, and your hope that the person will get help. Parents may eventually have to use their authority over a child and force them to go to treatment. In this situation let the therapist help negotiate power struggles.

ACCEPT YOUR LIMITATIONS

There is a limit to what you can do for another person. It is easy to fall into the trap of believing that if you said or did the right thing, then your friend or loved one would be helped and you would not feel powerless. There is a lot you can do, but ultimately you alone cannot change the problem or make it go away. You must learn to accept your own helplessness and limitations as to what you can and cannot do -but don't give up. Keep in mind that people often need to hear something several times before they act on it.

It is important to remember that your friend or loved one has a right to refuse treatment. Even minors forced to go can sit silently refusing to get help. If you believe that her life is in danger, you must get immediate help from a professional. Go to the appointment yourself even if your loved one refuses. A professional can help you deal with a person who is in denial or resisting treatment. It is possible that an intervention (discussed next) can be set up that may facilitate your loved one agreeing to get help.

INTERVENTIONS - GETTING HELP FOR A PERSON WHO IS IN DENIAL OR REFUSES IT

If you are concerned that someone you care about has an eating disorder that is severe or life threatening, and you have tried to talk to her about entering into treatment without success, you could try an intervention. Interventions are well known in the field of drug and alcohol abuse, but not for eating disorders. An intervention is a carefully orchestrated event planned in secret by significant others with the help of a professional for the purpose of confronting a loved one in order to discuss concerns and compel the person to get help for her problem.

Interventions should be carefully planned, or they may do more harm than good. The professional involved should have experience in eating disorders and in interventions. The timing, the people involved, the structuring of what is said, getting the person there, and the treatment plan options are all critical for a successful intervention.

If you want to do an intervention for a loved one, you need to enlist the help of a professional and a few people (try for six or so) who are significant in your loved one's life, such as relatives, friends, coaches, coworkers, teachers, and so on. These people will all need to meet together and carefully plan the intervention. A summary of an intervention follows.

On the day of the intervention a plan will be carried out regarding how to get the person to the intervention or to bring the intervention to her. Presenting a united front, the participants will tell the loved one in a caring, compassionate, and straightforward way what they have personally observed and what their concerns are. The examples should include health and functioning, not just weight or eating behaviors.

Each person should give specific examples and express the desire that the loved one be healthy and happy. How the eating disorder has affected the person physically, emotionally, psychologically, and in relationships should be discussed. Although the intervention is planned in advance, it is important to be natural and informal enough to help the loved one be as comfortable as possible.

Expect that the person with the eating disorder will feel set up and become angry. Try to understand the anger and reassure the individual that you are not trying to control her but that you could not go on without doing something about the situation. Encourage your loved one to express whatever feelings she has and listen in a nonjudgmental manner. Do not argue about whether there is a problem. Validate anything the person says and then reiterate your worries and what you have observed.

Provide information regarding the plan or options for treatment. Explain that arrangements have been made and are ready to be carried out, and execute the plan if the person agrees. If your loved one persists in denying the problem and refusing to get treatment, you will have to accept it. Remind yourself that the eating disorder is serving a purpose in her life and you cannot force her to let it go. Don't give up; the issue may have to be addressed repeatedly before a person agrees to get help.

Every individual involved in the intervention will then have to decide what the next step is and what course the relationship with the loved one will take. For example, husbands have actually threatened to divorce their wives unless they get help. This may sound extreme and unfair but, when there are children involved who suffer from the caretaking of an anorexic mother, this drastic measure is easier to understand and can turn out to be the motivation that initiates treatment and even recovery. Please remember that this is only for extreme cases. Interventions should be used only as a last resort, after other attempts to get the person help have been exhausted.

GUIDELINES FOR OTHERS WHEN A LOVED ONE IS IN TREATMENT

Aside from the above suggestions for approaching and talking to a person with an eating disorder, there are additional considerations listed below for parents or significant others who live with and/or love someone who is in treatment for an eating disorder. Remember, each case is unique and warrants special individualized attention. The guidelines listed should be discussed and followed with the assistance of professional help.

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BE PATIENT-THERE ARE NO QUICK SOLUTIONS

Recovery from an eating disorder takes a long time. Even if you are aware of this, you may still be inclined to think that your loved one should be improving faster and that more progress should be made. Long-term thinking and endless patience are necessary. Research suggests that recovery from anorexia and bulimia takes approximately four-and-a-half to six-and-a-half years (Strober 1997).

AVOID POWER STRUGGLES

As much as possible, find alternatives to power struggles, especially when it comes to eating and to weight. Don't make mealtimes or eating a battle of wills. Don't try to force or restrict eating. Leave these issues up to the therapist, dietitian, or other treating professional unless your involvement is discussed, requested, and worked out with help from a therapist or other helping professional.

AVOID BLAMING OR DEMANDING

Don't try to find causes or someone to blame for the eating disorder, and don't plead or demand that your loved one stop her behaviors. Neither of these will help; they will only serve to oversimplify the situation and will cause even more shame and guilt. It is easy for your loved one to feel responsible for your or anyone else's feelings. You can help prevent this by avoiding blame or making demands.

DON'T ASK YOUR LOVED ONE HOW YOU CAN HELP - ASK A PROFESSIONAL

Your loved one will not know how you can help and may feel worse if you ask. A professional is in a better position to give you advice.

DEAL WITH FEELINGS OF ALL FAMILY MEMBERS

Family members are often the forgotten victimss, especially other children. They need to talk about their feelings. It doesn't help to keep feelings bottled up inside; therefore, it is useful for all family members to express themselves in journals, letters, or verbally as a way of getting their feelings out and communicating.

SHOW AFFECTION AND APPRECIATION VERBALLY AND PHYSICALLY

A little unconditional love goes a long way. There are many ways to show affection and support besides talking - for example, hugging a lot or spending special time together. Consider writing letters or just little notes to your loved one, even if you live together. This is a good way to express encouragement, concern, and support without expecting a response or putting the person on the spot.

DO NOT COMMENT ABOUT WEIGHT AND LOOKS

Avoid making appearance a focus. Don't comment about your loved one's or other people's looks. Physical appearance has become too important in our society and especially in the eating disordered person's life. It is best to stay away from the topic of weight altogether. It is a trap to answer questions like "Do I look fat?"

If you say no, you won't be believed, and if you say yes or even hesitate for a moment, your reaction may be used as an excuse to engage in eating disorder behavior. Telling someone with anorexia that she looks too thin is a mistake because chances are that this is what she wants to hear. Telling a bulimic she looks good on a particular day may reinforce her binge-purge behaviors if she believes that they are responsible for the compliment.

DO NOT USE BRIBES, REWARDS, OR PUNISHMENTS TO CONTROL YOUR LOVED ONE'S EATING BEHAVIOR

Bribing, if it works at all, is only temporary and postpones the person's dealing with internal means of controlling her behaviors.

DON'T GO UNREASONABLY OUT OF YOUR WAY TO PURCHASE OR PREPARE SPECIAL FOODS

It is fine to help out by buying foods your loved one likes and feels safe eating - to a point. Don't drive all the way to the frozen yogurt store because that is all the individual will eat. Don't be pushed into any action by the threat, "I won't eat unless . . . " If a person refuses to eat unless very strict circumstances are adhered to, they may ultimately need inpatient treatment. Giving in to every whim will only postpone the inevitable.

DO NOT MONITOR SOMEONE ELSE'S BEHAVIOR FOR HER, EVEN WHEN ASKED

Do not become the food or bathroom police. Often loved ones will ask you to stop them if you see them eating too much or tell them when you see they have gained too much weight. They may seek your praise for the amount of food they are eating. Monitoring your loved one's behaviors may work for a short time but always ends up backfiring in the end. Get professional help and do not become a monitor until such time as the professional requests otherwise.

DON'T ALLOW YOUR LOVED ONE TO DOMINATE THE REST OF THE FAMILY'S EATING PATTERNS

While nurturing others, individuals with eating disorders often will deny their own needs for food. As much as possible, the family's normal eating patterns should be maintained unless they also are in need of altering. Don't let the person with the eating disorder shop, cook for, or feed the family unless she also eats the items bought, prepared, and served.

ACCEPT YOUR LIMITATIONS

Accepting your feelings and your limitations means learning to set rules or say "No" in a caring and reasonable but firm and consistent manner. For example, you may have to discuss cleaning the bathroom, limiting the amount of food your loved one goes through, or charging her for binged food. You may have to tell your loved one that you can't always be there when she needs to talk and that calling you at work is not acceptable. You may want to establish certain rules - for example, that laxatives or ipecac syrup aren't allowed in the house. If the illness progresses, you may have to add many more rules and reevaluate your own limitations. Do not get overinvolved and try to become a substitute for professional care. Eating disorders are very complicated and difficult to treat; getting professional help is necessary.

GETTING HELP AND SUPPORT FOR YOURSELF

If you care about someone who has an eating disorder, it can be painful, frustrating, and confusing. You need knowledge, guidance, and support in dealing with the situation. The more knowledge you have about the causes of eating disorders and what to expect in regard to treatment, the easier it will be for you. Check the resource section in the back of this book for reading material and other resource suggestions.

You are going to experience a range of emotions: from helplessness and anger to despair. You may find yourself losing control of your feelings and actions. You may even become preoccupied with your own and other family members' eating and weight. It is important to get help for yourself.

You need to talk about your own feelings as well as getting guidance in how to deal with your loved one. Good friends are important, but a therapist or support group may also be necessary. There are support groups and therapy groups you can attend that include your loved one and groups for parents and significant others only. These groups are hard to find, and it may be worth your while to start a support group yourself and let local hospital programs, therapists, and doctors know about it. You will find information about support groups in the resource section. An individual therapist may also be important, so you can discuss in detail your particular situation, your feelings, and your specific needs.

Whether your significant other or loved one with the eating disorder gets help, let her know that you are getting help for yourself. This may help your loved one take the situation more seriously, but, even if it does not, you must take care of yourself. If you do not stay healthy and strong, you will not be able to help someone else. Remember the instructions on an airline flight to first put on your own oxygen mask, then to put one on your child? With your own "oxygen mask" on, you can safely explore, pursue, and participate in helping and supporting those you care about and love.

By Carolyn Costin, MA, M.Ed., MFCC - Medical Reference from "The Eating Disorders Sourcebook"

next: Helping Someone with an Eating Disorder
~ eating disorders library
~ all articles on eating disorders

sex therapy

I became a sex therapist in the mid-1970s because I was impressed with how well standard sex therapy techniques were able to help people overcome embarrassing problems such as difficulty having an orgasm, painful intercourse, premature ejaculation, and impotence. The use of sex education, self-awareness exercises, and a series of behavioral techniques could cure many of these problems within a matter of only several months. I noticed that as people learned more about the sexual workings of their bodies and gained confidence with their sexual expressions, they would also feel better about themselves in other areas of their lives.

But there were always a number of people in my practice who had difficulty with sex therapy and the specific techniques I gave them as "homework." They would procrastinate and avoid doing the exercises, would do them incorrectly, or, if they could manage some exercises, would report getting nothing out of them. Upon further exploration I discovered that those clients had me major factor in common: a history of childhood sexual abuse.

Besides how they reacted to standard techniques, I noticed other differences between my survivor and nonsurvivor clients. Many survivors seemed ambivalent or neutral about the sexual problems they were experiencing. Gone was the usual sense of frustration that could fuel a client's motivation to change. Survivors often entered counseling because of a partner's frustration with the sexual problems, and they seemed more disturbed by the consequences of sexual problems than by their existence. Margaret,¹an incest survivor, tearfully confided during her first session, "I'm afraid my husband will leave me if I don't become more interested in sex. Can you help me be the sexual partner he wants me to be?"

Many of the survivors I talked with had been to sex therapists before, with no success. They had histories of persistent problems that seemed immune to standard treatments. What was even more revealing was that survivors kept sharing with me a set of symptoms, in addition to sexual functioning problems, that challenged my skills as a sex therapist. These included --

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• Avoiding or being afraid of sex.
• Approaching sex as an obligation.
• Feeling intense negative emotions when touched, such as fear, guilt, or nausea.
• Having difficulty with arousal and feeling sensation.
• Feeling emotionally distant or not present during sex.
• Having disturbing and intrusive sexual thoughts and fantasies.
• Engaging in compulsive or inappropriate sexual behaviors.
• Having difficulty establishing or maintaining an intimate relationship.

Considering their sexual histories, touch problems, and responses to counseling, I quickly realized that traditional sex therapy was horribly missing the mark for survivors. Standard treatments such as those described in the early works of William Masters, Virginia Johnson, Lonnie Barbach, Bernie Zilbergeld, and Helen Singer Kaplan often left survivors feeling discouraged, disempowered, and in some cases, retraumatized. Survivors approached sex therapy from an entirely different angle than other clients did. Thus they required an entirely different style and program of sex therapy.

Over the course of the last 20 years, the practice of sex therapy has changed considerably. I believe many of these changes were the results of adjustments other sex therapists and I made to be more effective in treating sexual abuse survivors. To illustrate, I will show how sex therapists have challenged and changed six old tenets of traditional sex therapy through treating survivors.

Tenet 1: All Sexual Dysfunctions Are "Bad"

In general, traditional sex therapy viewed all sexual dysfunctions as bad; the goal of treatment being to cure them right away. Techniques were directed toward this goal, and therapeutic success was determined by it. But the sexual dysfunctions of some survivors were, in fact, both functional and important. Their sexual problems helped them avoid feelings and memories associated with past sexual abuse.

When Donna entered therapy for difficulty achieving orgasm, she seemed most concerned with the effect her problem was having on her marriage. She had read many articles and a few books on how to increase orgasmic potential but had never followed through with any suggested exercises. For several months, I worked unsuccessfully with her, trying to help her stick with a sexual enrichment program.

Then we decided to shift the focus of her treatment. I asked Donna about her childhood. She reported some information that hinted at the possibility of childhood sexual abuse. Donna said that during her upbringing her father was an alcoholic whose personality changed when he was drunk. She disliked it whenever he touched her, she pleaded with her mom for a dead-bolt lock on her bedroom door when she was 11 years old, and she had few memories of her childhood in general.

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After several sessions during which we discussed dynamics in her family of origin, Donna told me she had a very upsetting dream [that included a graphic description of sexual abuse by her father that the client felt was historically true].

No wonder Donna had been unable to climax. The physical experience of orgasm had been intimately associated with her past abuse. Her sexual dysfunction had been protecting her from the memory of her father's assault.

In numerous other cases, I encountered a similar process. Steve, a 25-year-old recovering alcoholic, had a chronic problem with premature ejaculation. As we explored his inner psychological experience in therapy, he was able to identify that when he allowed himself to delay ejaculation, he would start to feel an urge to rape his partner. Premature ejaculation was protecting him from this very upsetting feeling. It wasn't until he connected this urge to rape with his intense rage at his mother for sexually abusing him as a child that he was able to resolve the internal conflict and comfortably prolong gratification.

Impressing upon Donna or Steve the idea that their sexual dysfunctions were bad would have done them a disservice. Their dysfunctions were powerful coping techniques.

I also encountered another type of situation that challenged the old tenet that sexual dysfunctions are bad. For some survivors who had experienced little difficulty with sexual functioning, the onset of sexual dysfunction signaled a new level of recovery from sexual abuse.

Tony was a 35-year-old single man who had been in and out of abusive relationships for years. His partners were often sexually demanding and generally critical. Tony's father had raped him repeatedly when he was young, and his mother had molested him in his teens. As Tony resolved issues related to his past abuse, his choice of partners improved. One day he told me that he had been unable to function sexually with his new girlfriend. This was extremely unusual for him.

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"She wanted to have sex, so she began to do oral sex on me," Tony explained. "I got an erection and then lost it and couldn't get it back." "Did you want to be having sex?" I asked him. "No, I really wasn't interested then," he replied. "So your body was saying no for you," I remarked. "Yeah, I guess so," he said somewhat proudly. "Wow, do you realize what's happening?" I declared, "You're becoming congruent! For all these years, your genitals have operated separately from how you really felt. Now your head, heart, and genitals are lining up congruently. Good for you!"

That day in therapy with Tony was a turning point for me as a sex therapist. l was amazed that I was actually congratulating him on his temporary sexual dysfunction. It felt appropriate. Instead of functioning, the goal of treatment shifted to self-awareness, self-care, trust, and intimacy-building. Insight and authenticity became more important than behavioral functioning.

While healthy sexual functioning is a desirable long-term goal, conveying the idea that all dysfunctions are bad and must be immediately cured is too simplistic. In working with survivors and others, sex therapists need to see sexual problems in context and we need to find out how people feel about a symptom before attempting to treat it. Therapists must respect dysfunctions, learn from them, work with them, and resist the urge to automatically try to change them.

Tenet 2: All Consensual Sex Is Good

In general, traditional sex therapy didn't make distinctions between different types of sex as long as sex was consensual and did not cause physical harm. That way of thinking does not hold up considering the sexual addictions and compulsions that are by products of sexual abuse. Little distinction was given to the type of sex that fostered addictive and compulsive behavior. The lack of distinction between the more specific nature of sexual interaction has left some people, including survivors, fearful of all sex. From working with survivors we have learned that sexual addictions and compulsions develop to a type of sex that incorporates or mimics the dynamics of sexual abuse.

On business trips Mark, a married man with two children, could not stop himself from cruising strange neighborhoods looking for pretty women whom he could watch from inside his car while masturbating. He knew all the video parlors in a four-state area and could not pass one without stopping to masturbate. He sought counseling because his wife had caught him in bed with his secretary. She threatened to leave him unless he got help.

When Mark entered therapy he described himself as being addicted to sex. I asked him to describe sex. He used terms like, "out-of-control, impulsive, exciting and degrading."

Mark's preoccupation and addiction was to a type of sex that was fueled by secrecy and shame. It was undertaken in a high state of dissociation; filled with anxiety; focused on stimulation and release; and lacking in true caring, emotional intimacy, and social responsibility. This type of sex was associated with power, control, dominance, humiliation, fear, and treating people as objects. It was the same type of sex that he was exposed to as a young man when his mother's best friend would pull down his pants, molest him, and laugh at him.

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Helping Mark recover involved helping him make connections between what happened to him in the past and his present behavior. He needed to learn the difference between abusive and healthy sex. Sex, per se, was not the problem. It was the type of sex he had learned and developed arousal patterns to that had to change. Healthy sex, like healthy laughter, incorporates choice and self-respect. It is not addictive.

To help people overcome fears of sex, sex therapy involves teaching conditions for healthy sexuality. These include consent, equality, respect, safety, responsibility, emotional trust, and intimacy. While abstinence can be an important part of recovery from sexual addictions, it won't be enough unless new concepts and approaches to sex are also learned.

Tenet 3: Fantasy and Pornography Are Benign

In traditional sex therapy, therapeutic use of sexual fantasy and pornography was generally viewed as benign and often even encouraged. Because the goal of therapy was functioning, fantasy and pornography were seen as therapeutically beneficial: giving permission, offering new ideas, and stimulating arousal and interest. Books on becoming orgasmic frequently recommended that women read something juicy, like Nancy Friday's collection of sexual fantasies, to "get them over the hump" and be able to climax.

In the early years of my practice, like other sex therapists I knew, I kept a collection of pornography in my office to lend out. While most pornography was degrading to women and contained descriptions of sexual abuse and irresponsible sex, the common attitude in the field was that "thinking it" is not "doing it." The implication was that sexual thoughts and images are harmless; as long as you don't act out a perversion, it's not damaging.

Through working with survivors, sex therapists have learned that sexual fantasies and pornography can be very harmful. Reliance on them is often a symptom of unresolved issues from early sexual trauma.

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Joann and her husband, Tim, came to see me for marital sexual counseling. On the very rare occasions when Joann was interested in sex with Tim, she would manipulate the lovemaking in such a way as to encourage Tim to have forceful anal sex with her. Sexual contact invariably concluded with Joann curled in a ball on the bed sobbing and feeling isolated. Tim had some difficulty understanding why he went along with this scenario, but what I found equally curious was Joann's response when I asked her why she did it. Joann shared that ever since she was about 10 years old, she had been masturbating to fantasies of anal rape. They turned her on more than anything she knew.

In the beginning of their marriage, Joann was able to have sex without the fantasies; but as stresses with Tim increased, she found herself more and more drawn to them. Often the fantasies would intrude during sex. She felt controlled by them, filled with shame and disgust.

Joann's behavior had its roots in early abuse by her father. He would spank her in a sexual manner or penetrate her anally with his finger as he masturbated himself. The sexual fantasies Joann developed were not harmless or enhancing her sexuality. They were upsetting and unwanted, symptoms of unresolved guilt and shame from the abuse she had experienced in childhood. Her fantasies were reinforcing abuse dynamics, reenacting the trauma, punishing her unjustly, and expressing deep emotional pain at the betrayal and abandonment by her parents.

For survivors, using pornography and experiencing certain sexual fantasies are often part of the problem, not part of the solution. Rather than condemn certain sexual behaviors, I encourage people to evaluate their sexual activities according to the following criteria:

• Does this behavior increase or decrease your self-esteem?
• Does it trigger abusive or compulsive sex?
• Does it emotionally or physically harm you or others?
• Does it get in the way of emotional intimacy?

Sex therapists can help people understand the origins of their negative sexual behaviors by showing compassion and not condemning. Survivors benefit from learning ways to gain control over unwanted reactions and behaviors.² They can develop new ways of increasing arousal and enhancing sexual pleasure such as staying emotionally present during sex, focusing on body sensations, and creating healthy sexual fantasies.

Tenet 4: Use Standardized Techniques In a Fixed Sequence

Another tenet of traditional sex therapy was the importance of using a fixed series of behavioral techniques. Sex therapists relied heavily on "sensate focus" exercises that were developed by William Masters and Virginia Johnson³. Versions of these techniques exist in the standard treatments for low sex desire, pre-orgasmia, premature ejaculation, and impotence. These structured step-by-step behavioral exercises were designed to improve self-awareness, sexual stimulation, and partner communication. Through working with survivors, however, we have learned that sex therapy techniques need to be expanded, modified, and individualized. Time must be spent teaching appropriate developmental skills and pacing therapy to prevent retraumatization.

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One day in 1980, the bulb on my little projector broke and I could not show Fred and Lucy the tape on the first level of sensate focus exercises. Instead I gave them a handout and complete verbal instructions. They were to take turns lying down and massaging each other in the nude. The next week they came back and reported on how it went. Lucy said the exercise was all right, but Fred's belt buckle kept hurting her as she passed over it. Even though they had been given specific instructions to take their clothes off, Lucy, an incest survivor, said she never heard them. Instead, she adapted the technique to make it less threatening.

Standardized techniques performed in a fixed sequence generally don't work for survivors because these techniques fail to respect the important needs survivors have for creating safety, pacing experiences, and being in control of what's happening. Just being able to sit, breathe, feel relaxed, and stay present while touching one's own body can be a challenge.

Survivors need a lot of options for exercises that offer opportunities to heal without being overwhelmed. I rely on the techniques for relearning touch described in my book The Sexual Healing Journey. These techniques can easily be modified, adapted, and rearranged in different sequences by survivors themselves.

It is essential that sex therapists assess a client's readiness before suggesting a particular sex therapy exercise. I often find that a client's curiosity about an exercise is a good indicator of readiness to try it. Starting, stopping, and shifting among different techniques. Nudity, genital exploration and exchanging sexual touch with a partner are often advanced challenges, generally not appropriate to suggest in the early stages of therapy.

Sexual healing is generally an advanced type of healing work for survivors, less important than issues such as overcoming depression, improving self-esteem, resolving family-of-origin issues, and securing physical safety and health to name a few. Any sex therapy therefore needs to take a back seat to general recovery issues that might arise. Sex therapy needs to be integrated with other aspects of resolving sexual abuse.

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Tenet 5: More Sex Is Better

In traditional sex therapy, the main criteria by which we judged success was how regularly and frequently clients were having sex. I used to ask lots of questions about frequency and evaluated success by how much a couple conformed to the national average of engaging in sexual activity once or twice a week. Ths focus on quantity often ignored issues of quality. Working with survivors taught me that with physical and sexual interaction, high quality is more important than large quantity.

Jeannie, a 35-year-old survivor of childhood molestation, and her boyfriend, Dan, sought therapy to address sexual intimacy problems. They planned to marry in the next year. It was concerning both of them that Jeannie would "check out" during sex. "I feel like I'm making love to a rag doll," Dan lamented. She agreed to sex to please him, fearing he would end the relationship if she declined too often.

For Jeannie, more sex brought on more problems of dissociation. The sexual contact she was having was getting in the way of her recovery from sexual abuse and her ability to create an honest intimacy with Dan. In therapy, as the reality of what was going on emerged, the couple decided to take a vacation from sex for awhile. Jeannie needed time and permission to validate her inner experience. The break from sex enabled her to honor her real feelings, learn new skills, and eventually be able to say yes to it without anxiety. Jeannie also learned that Dan loved her for herself, supported her getting in touch with her inner feelings, and viewed sexual interaction as less important than emotional intimacy and honesty.

When survivors progress in healing and start having sexual relations more regularly, it's not uncommon for the frequency of their sexual interactions to vary. To ensure positive sexual experiences, survivors often need to give themselves a safe, comforting envirornment and plenty of time for intimate relating. Sex emerges from mutual good feelings and a sense of emotional connection between partners. The high quality and specialness of sexual encounters become more significant than how often they occur.

Tenet 6: An Athoritative Behavioral Goal-Focused Style Works Best

In traditional sex therapy, the therapist's role was primarily to present a program of exercises and help clients follow that program to achieve functioning. Therapists offered sex education and worked to improve couples' communication. The therapist was the authority, suggesting techniques, pacing interventions, and monitoring progress. Little attention was paid to how a therapist's style might be influencing the progress of therapy. Working with survivors has taught many sex therapists that their therapeutic style is as important as any intervention.

For many survivors, sex is one of the most difficult areas to address in recovery Just hearing the word "sex," or saying it can bring on a minor panic attack. Survivors can easily unconsciously project feelings toward the offender and the abuse onto the therapist and the sexual counseling. After all, therapists seem invested in survivors being sexual, and the process of therapy strains a survivor's sense of control and protection. This high potential for negative transference needs to be addressed if sex therapy with survivors is to be successful.

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To minimize negative transference, I suggest therapists adopt the following premise: Do the opposite of what happened in the abuse. For instance, because the victim was dominated and disempowered in abuse, it makes sense that therapy should focus on empowering the client and respecting his or her reactions to it. Therapists need to explain techniques and interventions, encouraging clients to exercise choice at all times. Suggestions, not directions or prescriptions, should be given. Rather than admonish clients for their resistances and relapses, therapists should reframe these as inevitable, seek to understand, and work with them.

Because sexual abuse involved a traumatic violation of boundaries, it's important that sex therapists be extremely good at maintaining clear emotional and physical boundaries. Talking about sex can stir up sexual feelings. It's inappropriate to combine sex-focused sessions with touch.

Several years ago, I was appalled when a prominent sex therapist told me how she held and rubbed her female client's hand during a session to demonstrate different stroking techniques for masturbation. Therapy needs to be a safe place physically and psychologically for everyone, at all times.

It's also important for sex therapists not to dominate the content and course of therapy. Personally, I find I'm most effective when I establish a therapeutic relationship with the client in which we're working together. The client sets the pace and direction and presents the content; I provide encouragement, support, guidance, creative ideas, insight, information and resources.

The Value of Change

There is no question that the challenge of treating survivors has revolutionized and improved the practice of sex therapy Personally, I know that the changes I have made in how I perceive and practice sex therapy have made me a better therapist with all of my clients, regardless of whether they were abused. Other sex therapists seem to agree that the practice of sex therapy has become more client centered and respectful of individual needs and differences. Learning about the dynamics of sexual trauma has helped therapists become more aware of the conditions necessary for sex to be positive and life affirming for everyone.

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Endnotes

¹ This is a pseudonym, as are all names in this article.

² For more information on techniques, see The Sexual Healing Journey, HarperCollins, 1991.

³ For a description of these techniques, see William Masters et al., Masters and Johnson on Sex and Human Loving, Little Brown and Co., 1986.

Wendy Maltz, M.S.W., is clinical director of Maltz Counseling Associates. She is the author of the Sexual Healing journey: A Guide for Survivors of Sexual Abuse and Caution: Treating Sexual Abuse Can Be Hazardous to Your Love Life.

next: The Basics of Sex Therapy Homepage

The core symptoms of ADHD predispose adults with ADHD to have difficulties with planning, organizing, and managing time. Here's some help.

Gee Whiz, I Missed It Again: How Can I Improve My Time Management Skills?

Bill told his wife to meet him for lunch, only to discover, after his wife was already at the restaurant, that he had a meeting with his boss. Sandra stayed up all night for two nights in a row finishing a major sales report that was assigned three months ago, and got to the sales meeting late. Peter aimlessly drifts through his day, feeling like he is getting nothing accomplished.

These three adults with ADHD are experiencing significant problems with time management. The core symptoms of ADHD- inattention and poor behavioral inhibition- predispose adults with ADHD to have such difficulties planning, organizing, and managing time. For most busy non-ADHD adults, a key element of effective time management is the use of a day planner. Many of you reading this sentence will lament, "But I have owned hundreds of day planners, calendars, etc., and I can never get myself to use them, if I can even find them." This may be because you went about using a day planner in the wrong way, perhaps trying to bite off more than you could chew all at once.

Forget about these past failures. Wipe them out of your mind. I am going to give you a simple, step-by-step approach for successfully using a day planner and taking charge of time rather than letting time pass you by. The key to this approach is that you take one small step at a time. Continue that step for one or more weeks and become comfortable with it. Only when you have mastered each step should you move onto the next step. Also, make a list of rewards or privileges which you can indulge yourself with for successfully completing each step. These might be special activities or purchases. After you have successfully carried out each step of this program for one week, pick one activity from your list and reward yourself for your efforts.

If you still find that it is too difficult to carry out these steps, ask a spouse or friend to help you. If that is not sufficient, seek out the help of a coach or a therapist, who will help you break tailor this type of program to your special situation.

1. Select a compatible day-planner. At a minimum, a day-planner is a device that includes a calendar, space to write "to-do" lists, and space to write telephone numbers, addresses, and other basic identifying/ reference information. It can be a paper-and-pencil model, as with Franklin Planner or Day Timer brands. It can be a fancy electronic organizer such as a Palm Pilot, or it can be time management software on a laptop or desktop computer. Electronic organizers do have a number of advantage. They are compact; they provide audible reminders that can serve as memory management aides; they can sort, organize, and store more information more efficiently than paper and pencil planners; and they can easily exchange information with office and home computers.

   If you are a gadget-oriented person who learns new technology easily, pick an electronic organizer. If you are not technology oriented, pick a paper and pencil model. Go on an outing to an office supply store and carefully review a number of different types of day planners to see which one you feel most comfortable with. They come in all sizes, shapes, and colors, with different types of daily, weekly, and monthly views. Carefully inspect the different types of daily, weekly, and monthly pages. Do you schedule many appointments on the hour or half-hour? Then, you need a clear daily view. Are you making "to do"lists but not scheduling many appointments? Perhaps you need a weekly view with a lot of space for lists.

2. Find a single, accessible place to keep the day-planner. After selecting a planner, the next step is to start keeping it in a single, accessible location at home and at work, so you will always know where to find it. The location should be clearly visible from a distance, even in a cluttered room or on a messy desk. Convenient locations might be next to the telephone, on a table near the front door, on the desk at the office. If the day-planner has a strap, it might be hung on a hook next to the front door, above the telephone, or together with the car keys. Select a place to keep your day planner at work and at home. Carry to and from work, and practice keeping it in the designated locations for a week.

3. Enter the basics in the day-planner. You are now ready to enter basic information into your day planner. Gather the most common names, addresses, and phone numbers which you use. Enter them into the planner in the alphabetical name/ address section, or in the case an electronic planner, into its memory. Consider what vital information it might be helpful to have in the planner- insurance policy numbers, computer passwords, equipment serial numbers, birthdays and anniversaries, etc., and enter this information.

4. Carry the day-planner at all times. Now that there is some information in your planner, you should carry it with you at all times. Many of my patients tell me that they have carried their planner with them at all times, but they forgot the great idea they thought of while shopping. "At all times" means whenever you leave the car to go into a store or whenever you leave your desk to attend a meeting. Work for several days on carrying your planner with you at all times.

5. Refer to the day-planner regularly. Many adults with ADHD write things in their planners but rarely look at what they wrote, relying instead on memory, with disastrous consequences. Before you can use the planner as a calendar or for "to do" lists, you need to develop the habit of checking it regularly. You should start by checking your planner a minimum of three times per day- once in the morning to plan/review the day's upcoming events, once in the middle of the day to make any mid-course corrections and/ refresh your memory about the remaining day's events, and once in the evening, to plan/ review the next day's events.

   What can you do to help you remember to check your planner? First, if you have an alarm wrist watches or alarms on your electronic planner, set them to go off at regular intervals when you wish to check your planner. Second, you could associate checking your planner with habitual activities that you always do at approximately the same time each day, e.g eating meals, getting dressed in the morning or ready for bed at night, entering or exiting the office, etc. Third, you could leave yourself reminder notes in strategic locations (on the desk in the office, on the mirror in the bathroom, on the dashboard or door handle of the car) to remind you to look at the planner.

   You should practice checking your planner at least three times per day, using the reminder methods outlined above if necessary, for at least one week, before going onto the next step.

6. Use the day-planner as a calendar. You are now ready to learn to use your planner as a calendar. Make a list on scrap paper of all the appointments which you have scheduled at any time in the future. Then, write these appointments in the appropriate time slots on the pages of the planner for the particular days and months. Review the scheduled appointments for that day each time you check the planner. As you go through your day with your planner by your side, write in any additional appointments as soon as you schedule them. Use your planner as a calendar for the next week.

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1. Construct a daily "to-do" list and refer to it often. "To do" lists are lists of things which you need to get done. Only after you experience success using your planner as a calendar should you start making a daily "to do" list. Most planners have a place to put "to do" lists adjoining the calendar for each day. During the first review of your planner in the morning, make a list of everything you need to get done that day. Keep the list relatively short, e.g. 5-8 items, so that you can experience success completing all of the items. State the items in language which clearly tells you the action you need to take. "Buy my wife flowers" would be a more specific item than "Be nice to my wife."

   Examine the list and decide which items you can assign to a particular time during the day. Write these items into your schedule at the designated times. Try to complete them as scheduled. Refer to your list often as you go through your day. Check off any completed items and review the items which remain to be completed.

   At the end of the day, compute the percentage of items on the list that you completed, analyzing the reasons why you did not complete every item. If there are a few unfinished, items move them forward to the next day's list. However, if you have many unfinished items, then you need to consider whether you have unrealistic expectations for how much you can get done. You either must scale back your expectations or find other approaches to getting tasks done (delegate, streamline, eliminate, etc.).

2. Prioritize your "to-do" list and act in accordance with your priorities. Now you are ready to prioritize the items on your daily "to do" list. There are many ways to prioritize a "to do list." You could number all of the items on the list in order of decreasing priorities. Alternatively, you could classify the items into one of three categories: "Essential," "Important," and "Do only if I have extra time." Pick the method that fits your style best. Begin prioritizing your daily "to do" list.

   As you go through your day, carry out the items on your "to do" list in order of decreasing priorities. If you are like most adults with ADHD, you will often be tempted to ignore your priorities. An exhaustive discussion of methods for sticking to your priorities is beyond the scope of this article, but I will give few suggestions. Make sure that you are taking an effective dose of stimulant medication that lasts throughout the day. Set the alarms on your wrist watch, electronic planner, computer task management software, or beeper to go off at regular intervals as a signal to check whether you are on task following your priorities. Use self-talk to help avoid distractions. Train yourself to repeat reminders such as "I have to keep from getting distracted," "I have to stick with my priorities," "Don't switch now, I am almost done,"etc.
   Work on prioritizing your "to do" list and following your priorities for at least two weeks before going onto the next step.

3. Conduct a daily planning session. By the time you have completed the first eight steps, you will be conducting "ad hoc" daily planning sessions when you construct and prioritize your daily "to do" list. It is time to formalize this process as "the daily planning session." Consider the time when you construct and prioritize your lists as your daily planning session. Your goal at this time is to plan the upcoming day's activities and develop a plan of attack to carry them out. In addition to listing priorities and reviewing schedules, the planning session is the time to consider exactly how each task will be accomplished. What materials will be needed? What individuals will have to be consulted? What obstacles are likely to be encountered? How can these obstacles be overcome? You should ask yourself these questions as you prioritize the items on your "to do" list. You want to emerge from the planning session with a mental map to guide you in carrying out the tasks on your list.

   When you have reached this point in the program, congratulate yourself! You have mastered the basic steps to using a day planner to manage time! Continue to follow these steps. As they become habitual, you may want to consider trying the last step, which bridges the gap between short-term and long-term planning, but understand that it is more challenging and may require the assistance of a coach or therapist.

4. Generate a list of long-term goals and break the long-term goals into small, manageable chunks, allocating these chunks to monthly and weekly planning sessions. I can only touch on this briefly here; readers interested in a more detailed discussion of it should consult sources such as Covey (1990). First, you generate a list of all of your long-term goals. These are broad goals which you want to accomplish over many months and years. Then, you take one goal at a time and break it into small chunks or sub-goals which might be accomplished on a monthly basis. You assign one sub-goal to each month of the year. At the beginning of the month, you conduct a monthly planning session, during which you decide how to accomplish the sub-goal over the course of the month. You assign various tasks to each week of the month. At the beginning of each week, you conduct a weekly planning session, during which you decide how to assign aspects of that week's sub-goal to the daily task lists for the entire week. During each daily planning session, you plan the details of the assigned task, which you then carry out that day.

   For example, one of my adult ADHD patients had as his long-term goal to write a historical non-fiction book. He already had much of the factual material which he needed collected. We divided this goal into the following sub-goals which we tentatively assigned to various months of the year: (1) January- make an outline of the book, specifying 10 major chapters and topics; (2) February to November- write the first draft of one chapter during each month; (3) December- review all of the chapters and prepare the book to send to the publisher by the end of the year. At the beginning of January, we further divided the task of making the outline into portions to be done each week; at the beginning of each week, the patient decided when he was going to work on the outline and assigned it to each of his daily task lists. He continued in this manner for the remainder of the year.

Conclusion

I understand that it is easy for me to give you the suggestions given in this article, but hard for you to carry them out. As stated at the outset, you need to develop a list of strong rewards, and give yourself these rewards on a regular basis as you accomplish small steps towards using a day planner effectively. Enlist your spouse, relatives, or friends to praise you as you experience success at each step. You may need to creatively break these steps down into even smaller steps to tailor them to your particular form of procrastination.

If you experience difficulty following this advice, don't give up. Remember that it took a lifetime of ADHD to get to the point that you are at now; it will take more than a short time to start making meaningful changes. Do as many of these steps as you can on your own, then seek the assistance of a friend, a coach, or a therapist to help you complete the process. Good luck!

Ten Steps For Learning To Use a Day- Planner

1. Select a compatible day-planner.
2. Find a single, accessible place to keep your day-planner.
3. Enter basic information into your day-planner.
4. Carry your day-planner at all times.
5. Refer to your day-planner regularly.
6. Use your day-planner as a calendar, writing in appointments and time-locked activities.
7. Construct a daily to-do list and refer to it often.
8. Prioritize your daily to-do list and act in accordance with your priorities.
9. Conduct daily planning sessions.
10. Generate long-term goals. Break your long-term goals into small, manageable chunks, and allocate these chunks to the monthly and weekly task lists and planning sessions.

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next: ADHD Adults: Tips for Making Good Career Choices
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Reference

Covey, S. (1990). The 7 habits of highly effective people. New York: Simon and Schuster.

Dr. Robin is a member of the CH.A.D.D. Professional Advisory Board and a Professor of Psychiatry and Behavioral Neurosciences at Wayne State University in Detroit, Michigan. He also maintains a private practice in Beverly Hills, Michigan.

Re-Printed Attention Magazine (http://www.chadd.org./)

Many times, there are warning signs that someone is seriously depressed and may be thinking about or planning a suicide attempt. Here are some of them:

• pulling away from friends or family and losing the desire to go out
• trouble concentrating or thinking clearly
• changes in eating or sleeping habits
• major changes in appearance (for example, if a normally neat person looks very sloppy - as if they're not taking the usual care of themselves )
• talk about feeling hopeless or feeling guilty
• talk about suicide
• talk about death
• talk about "going away"
• self-destructive behavior (drinking alcohol, taking drugs, or driving too fast, for example)
• no desire to take part in favorite things or activities
• the giving away of favorite possessions (like offering to give away a favorite piece of jewelry, for example)
• suddenly very happy and cheerful moods after being depressed or sad for a long time (this may mean that a person has decided to attempt suicide and feels relieved to have found a "solution")

Don't Blow Off the Warning Signs of Suicide

Paying attention to and responding to these clues can sometimes save a life and prevent a tragedy. Most of the time, teens who are considering suicide are willing to discuss it if someone asks them out of concern and care. Some people (teens and adults) are reluctant to ask teens if they have been thinking about suicide or hurting themselves for fear that, by asking, they may plant the idea of suicide. This is a myth. It is always a good thing to ask and to initiate the conversation with someone you think may be considering suicide.

First, it allows you to get help for the person. Second, just talking about it may help the person to feel less alone, less isolated, more cared about and understood - the opposite of many feelings that may have led to suicidal thinking to begin with. Third, it may give the person an opportunity to consider that there may be another solution.

Sometimes, a specific event, stress, or crisis can trigger suicidal behavior in someone who's at risk. Common triggers are a parent's divorce, a breakup with a boyfriend or girlfriend, or the death of a friend or relative, for example. It's always good to ask a friend who's going through a crisis how they're doing, if they're getting any support, how they're coping, and if they need some more support. There are plenty of adults who can help you or a friend find the support you need. Everyone deserves that support.

Sometimes, teens who make a suicide attempt - or who die as a result of suicide - seem to give no clue beforehand. This can leave loved ones feeling not only grief-stricken but guilty and wondering if they missed something. It is important for family members and friends of those who die by suicide to know that sometimes there is no warning and they should not blame themselves.

next: What Else Puts Teens at Risk for Suicide?
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~ all articles on depression

Perhaps you're wondering how you can tell if you are even relapsing or not. Here's a list of signs to look for. If you, or someone you know is experiencing these signs of an eating disorders relapse, then it's time to get help.

• Thoughts continue to turn back to weight and food.
• Increasing need to be in control over many things.
• Perfectionistic thinking returns or becomes stronger.
• Feelings of needing to escape from stress and problems.
• Feeling hopelessness and/or increasing sadness.
• Increasing belief that you can only be happy if you are thin.
• Increasing belief that you are out of control if you are not on a "diet."
• Dishonesty with treatment coordinators and/or friends and family.
• Looking in mirrors often.
• Weighing yourself more and determining whether today will be good or bad depending on what shows up on the scale.
• Skipping meals, or purging them.
• Avoiding food and/or get-togethers that involve food.
• Increasing need to exercise continually.
• Thoughts of suicide.
• Feeling guilt after eating.
• Feeling the need to isolate yourself from those around you.
• Feeling "fat" even though people say otherwise.

when.you.have.most.of.the.signs.of.an.eating.disorders.relapse

If you are currently going through an eating disorders relapse, sit down and try to figure out how you were feeling before the relapse occurred and what was going on at the time that could have triggered you. Make a plan of how you can deal with the trigger in better ways the next time it comes around. Recognize how you are feeling right now and how you can change those feelings through helpful reactions. Know that you can talk to someone about what is going on in your life, whether it involves the relapse or things that triggered the relapse.

Most importantly, realize that you do not need to be hard on yourself for this relapse! Guilt and beating yourself up for slipping gets you nowhere and is not needed. All beating yourself up over this will do is make you feel bad and will give even more fuel to the eating disorder to use against you. You are not a failure. Recovery from an eating disorder is not meant to be perfect, and you are not meant to be perfect. There is no shame with having an eating disorder or a relapse. I cannot stress enough that when a relapse occurs it does not mean that you have "failed once again," but what it does mean is that there are feelings inside that still need to be dealt with.

When all we wanted was the dream
to have and to hold that precious little thing
like every generation yields
the newborn hope unjaded by their years-Sarah McLachlan

Once again, relapses - they can and will happen during recovery from an eating disorder. This doesn't mean that you shouldn't try at all or that you are a failure if you relapse. Recovery takes a long, long time to reach and it involves dealing with a lot of painful issues that can leave you susceptible to relapsing into old "comforts" like starving or purging. Please, reach out for help if you suspect that you have relapsed or that you are close to doing so, and then recognize what caused you to relapse in the beginning. You deserve help and you deserve to get better, no matter what.

next: Welcome to Triumphant Journey Homepage
~ all peace, love and hope articles
~ eating disorders library
~ all articles on eating disorders

So how do you prevent eating disorder relapses? Realize that a relapse can come on quickly by the smallest trigger, and that not just one trigger can cause a relapse. Anything from stress from school or your family, to coping with something that a friend is going through, to having just talked about a difficult thing that occurred in your life with a therapist can trigger the onset of an eating disorder relapse. Recognize ahead of time the things that could trigger you to a relapse. Here are some things that I've noticed tend to trigger relapses within myself and those who I know:

• Mid-terms and finals at school, or any major exams that are in the near future.
• Increasing pressure from family (especially parents), or problems with them are increasing.
• Going through a painful break-up with a girlfriend or boyfriend, or being rejected.
• Problems with a husband or wife.
• Problems at work.
• A competition in a sport coming up (spec. gymnastics, ballet and/or dance)
• The loss of a friend or family member.
• Having a friend that is going through a rough time.
• Recently talking to a therapist about past trauma (sexual/mental/physical abuse, rape, etc.)
• Just being released from inpatient treatment.
• Being around those that are engrossed with their own eating disorders while you are trying to recover.
• Fear of recovering.
• Believing that you are fully recovered when there are still underlying issues that have not been properly dealt with in a non-destructive way.

These are just some of the things that can trigger an eating disorder relapse. Look at your own life and make your own list ahead of time of things that can trigger you to turn back to trying to starve or purge your problems away. Recognizing ahead of time what can harm you and what you can do to help deal with those problems in a non-self-destructive way when they come.

I really want to point out that many relapses occur when someone has begun talking with a therapist about past traumas like abuse or rape, but that this does not mean that you should not talk about it just because it triggers you. With something as horrific as abuse or rape you must talk about it so that you can learn to move on from it. Otherwise, if you just continue to run from dealing with those issues, they will continue to haunt you and cause pain in your life. The only way to finally relieve yourself of those problems is by dealing with them. If you are talking with your therapist about issues that are triggering, please, please, please let the therapist know that this is very hard for you to talk about and that your other problems, whether they be an eating disorder, depression, self mutilation, OCD, etc., are at high risk of getting worse from talking and finally having to deal with it.

"Loving yourself takes work, patience and hope. Treat yourself like a friend whenever you're about to take a dive..." SushiJunkie

Before an eating disorder relapse it is also helpful to have a list of people and their phone numbers for you to call during the times that you are triggered or when you suspect that you will be triggered. If possible, you might also want to have a sponsor, a person who can keep track of your behaviors and reactions, so that you have someone to warn you ahead of time when it is suspected that you are relapsing. No matter what your head tells you, it really is okay to have extra support during the rough times. You are not weak or greedy. You are, however, going through a rough time and just need some help coping. There is nothing wrong with that!

Sometimes what helps people from relapsing is making a list of things they can do instead of starving or purging. Things like cleaning, playing with an animal, going on the computer, talking with a friend, going camping, listening to your favorite CD, and so on can help.

next: Self-Mutilation: The Truth Behind the Shame
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~ eating disorders library
~ all articles on eating disorders

Explanation of how to request an Assessment of Special Educational Needs for your child with ADHD and the subsequent process.

SEN Code of Practice 2001 Statutory Assessment

Before we start on the process of obtaining a Statutory Assessment of Special Educational Needs, please bare in mind that this information is for England. For Scotland, go to http://www.childrenofscotland.org.uk/ and for The United States please check out the website http://www.wrightslaw.com/

According to the Education Act 1996 Chapter 54 a child has learning difficulties if:

1. he has a significantly greater difficulty in learning than the majority of children his age
2. He has a disability which either prevents or hinders him from making use of educational facilities of a kind generally provided for children of his age in schools, within the area of the local education authority.
3. He is under the age of 5 and is, or would be if special educational provision were not made for him, likely to fall within the above (a) & (b) when of or over that age.

For your information a child includes any person under 19 that is still a registered pupil in his school.

Requesting an assessment

In order to get a Statement of Special Educational Needs there first needs to be a statutory assessment made by the Local Education Authority, more commonly known as the LEA. This can be done ideally with parents and school working together, by the school or by the parent independently.

The special educational needs of the majority of children should be met effectively in mainstream schools through Early Years Action, Early Years Action Plus, School Action and School Action Plus, depending on the age and severity of the problems, without the need for the LEA to make an assessment.

In a small number of cases the LEA will need to make the Statutory Assessment and then consider whether or not to issue a Statement. This involves consideration by the LEA, working co-operatively with parents, schools and if appropriate other agencies involved to determine whether an assessment is needed. Please be aware that if the LEA decides an assessment is needed, this doesn't necessarily mean it will lead to a statement!

Referrals can be made by another agency such as Social Services or the Health Authority; this can happen particularly with children under the age of 5 with complex needs not yet attending school but maybe in an early educational setting

When requesting an assessment the evidence that should be provided by the school should include:

• The views of parents recorded at Early Years Action and Action Plus or School Action and Action Plus.
• The ascertainable views of the child
• Copies of IEP's
• Evidence of progress over time
• Copies of advice where obtained from health services and social services
• Evidence of involvement and views of professionals and relevant specialists outside of the school setting
• Evidence of the extent the school has followed advice provided by professionals and relevant specialists.

A Request by a Parent

Parents may request an assessment under section 328 or 329 of the education act. The LEA must comply unless an assessment has been made within 6 months of the date of the request or if they conclude after examining the evidence that it is not necessary.

Once the request has been made the LEA must decide within 6 weeks whether or not to carry out the assessment and should contact the parents. They must also inform the Head Teacher and obtain any written evidence from the school about the child's learning difficulties and the schools account of any special educational provisions made. The Educational Psychology Service, the designated officer of Social Services department, Health Authority and any other agencies involved must also be informed.

Suggested format for a letter of request:

The letter should be addressed to:-

Additional Educational Needs Manager

Local Education Authority

(Address)

Childs name and Date of Birth

Name of child's school (if of school age)

Dear Sir/Madam

I am writing to request that the LEA carry out a Statutory Statement of Special Educational Needs for my Son/Daughter under Section 323 of the Education Act of 1996 Chapter 54 , as is my right under section 329.

2nd paragraph: enter a description of your child's difficulties, past history, medical diagnosis and anything else relevant.

3rd paragraph: enter the current provisions your child receives, for example Individual Education Plan, helper, portage, outside agencies, speech therapy, physiotherapy, health and social services, one to one support and for how long etc.

4th paragraph: enter detailed account of why you think current provisions are not meeting your child's needs with evidence of lack of progress.

Yours Sincerely

Remember the LEA must take all parental requests seriously and take immediate action.

If a child attends an independent school or is being home educated, a request for an assessment must follow the same procedure.

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What Happens Next?

The LEA before deciding to make an assessment must issue a notice under section 323(1) or 329A (3) of the education act and:

1. Must write to parents giving them notice
2. Must set out for parents the procedures to be followed if an assessment is considered necessary and for subsequently drawing up a statement, if considered necessary.
3. Should explain the precise timing of each stage of the assessment within the overall 6 months time limit, and indicate ways the parent can assist in meeting the time limits, and explaining the exceptions to any.
4. Must tell parents the name of the officer from LEA whom they can contact for any further information needed.
5. Must tell parents of their right to submit written evidence and oral representations as to why their child should be assessed. The LEA must set a time limit for receiving these, which must not be less then 29 days.
6. Parents should be encouraged to respond and submit evidence. Any oral representations should be put into a written summary agreed by both the LEA and parents. Parents should indicate formally if they do not wish to make or add to previous representations so the assessment can start immediately.
7. Must inform parent of local Parent Partnership Services which should provide information about other sources of independent advice.
8. Should ask parents if they want the LEA to consult anyone in addition to those who they must approach for Educational, medical, psychological and social services advice if they proceed.
9. Should tell parents that they can provide any private advice or opinions that they have or can obtain.

This notice must make clear that at this stage the LEA has not made the decision to go ahead with the assessment, but is considering whether to do so or not.

The Decision is No!!

If the decision is made that an assessment is not necessary, the LEA must write to the parents and school explaining the reasons. They should also set out the provisions they consider will meet the child's needs. They should ensure the parent understands the school-based provision and the monitoring and review arrangements. Where parents have requested the assessment under section 328 or 329 or the school has made a request under section 329A, the parents may appeal. LEAs must inform parents of this right to appeal and the time limits.

The Decision is Yes!!

Once it had been decided to go ahead with the assessment, the LEA must seek parental, educational, medical, psychological and social services advice and any other advice they consider appropriate.

Parents must also be informed that, as part of the process, their child may be called for an examination or assessment. If this does happen, the parent must also be informed of their right to be with their child during any interview, test, medical or any other assessment which is being conducted and told of the time, place and purpose of the appointment. They must also be told of the name of an LEA officer who they can contact for further information.

The Next Steps

After receiving all the advice, the LEA must make the decision whether or not to make a statement or amend an existing one. This decision must be made within 10 weeks of serving the notice of assessment.

If it is decided that a statement is necessary, it must draft a proposed statement and send a copy to the parent within 2 weeks along with a copy of any advice received as part of the assessment.

If it is decided it's not necessary for a statement, the LEA must notify the parents and school giving their reasons within 2 weeks. Once again parents must be notified of their right to appeal.

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