sexual problems

Addictive Sexual Disorders: Differential Diagnosis and Treatment
Jennifer P. Schneider, MD, PhD, and Richard Irons, MD

Educational Objectives:
Visualize where addictive sexual disorders fit into the DSM-IV.
Obtain an overview of the spectrum of addictive sexual disorders.
Understand the principles of treatment of sex addiction and have access to resources for recovery.

Introduction: Patients who present with excessive and/or unusual sexual urges or behaviors are often a source of confusion to clinicians. In some cases, the diagnosis appears clear-cut: The young man who has a history of arrests for exposing his genitals to unsuspecting strangers has a paraphilia known as exhibitionism (pp525); a young woman's obsessive, intrusive, and very disturbing sexual thoughts may be one aspect of her obsessive-compulsive disorder (pp417); the 70-year-old nursing home patient who gropes any female staff member who gets within touching distance may be exhibiting a loss of judgment secondary to his Alzheimers disease (pp139); and another hypersexual patient exhibits pressured speech and grandiosity typical of the manic phase of bipolar type I or II psychosis. (pp356)

In a larger number of cases, the etiology is less obvious, and therefore the therapeutic approach is less clear. Some examples are: The computer programmer whose job and marriage suffer because he spends many hours daily viewing internet pornography and communicating online with women who have similar interests; the married woman who has multiple affairs despite her fears that the marriage will end; the gay man who has had thousands of anonymous sexual encounters in restrooms and parks with other menusually without giving any thought to "safe sex" practices until panic sets in after the encounter is over; the clinician who uses his professional practice to engage in sexual encounters with women; and the isolated consumer of home and bookstore pornography whose multiple daily episodes of masturbation have cost him excessive time, money, and injuries to his genitalia.

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To complicate the picture, many people who engage in excessive sexual behavior are also pathologically indulgent in other behaviors and activities.

1. They are most commonly found to have a concurrent substance use disorder, such as alcohol dependence, an impulse control disorder such as pathological gambling, or an eating disorder.

2 The majority of people with cocaine dependence engage in compulsive sexual behavior as part of their cocaine-using lifestyle.

3 Professionals who treat chemical dependency are learning that in order to avoid relapse in chemical use among recovering addicts, all compulsive behaviors must be identified and addressed. Assessment and treatment of addictive sexual behaviors must be an integral part of chemical dependency treatment.

The goal of this article is to help the psychiatrist and the primary care physician to understand the various disease processes underlying excessive sexual behaviors and to understand the various treatment approaches which are helpful. Slide #PP4:16

Differential Diagnosis of Excessive Sexual Behaviors
Common
- Paraphilias
- Sexual disorder NOS
- Impulse control disorder NOS
- Bipolar disorder (I or II)
- Cyclothymic disorder
- Posttraumatic stress disorder
- Adjustment disorder [disturbance of conduct]

Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.
Slide #PP4:17

Differential Diagnosis of Excessive Sexual Behaviors

Infrequent
- Substance-induced anxiety disorder [obsessive-compulsive symptoms]
- Substance-induced mood disorder [manic features]
- Dissociative disorder
- Delusional disorder [erotomania]
- Obsessive-compulsive disorders
- Gender identity disorder
- Delirium, dementia, or other cognitive disorder
Source: Schneider JP, Irons RR. Sexual Addiction Compulsivity. 1996; 3:721.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

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Differential Diagnosis of Addictive Sexual Disorders
The most common types of excessive sexual behaviors can be classified into three Axis I categories: paraphilias, impulse control disorder Not Otherwise Specified (NOS), or sexual disorder NOS. The paraphilias are characterized by recurrent, intense sexual urges, fantasies, or behaviors that involve unusual objects (such as animals or inanimate objects), activities or situations (for example, involving nonconsenting persons, including children, or causing humiliation or suffering). For some individuals, paraphilic fantasies or stimuli are essential for erotic arousal and are always part of sexual activity; in other cases, the paraphilic preferences occur only episodically. In contrast to sexual dysfunctions, which are associated with decreases in sexual functioning, the paraphilias are commonly associated with increases in sexual activity, often with compulsive and/or impulsive features.

While some cases of sexual excess represent impulse-control disorders, many others cannot be classified as either paraphilias or impulse-control disorders. If they cause distress to the person, they can be diagnosed as Sexual Disorder NOS. Many of these cases can be considered as addictive disorders.

The essential features of all substance use disorders are behavioral, consisting of: (1) loss of control
(2) preoccupation, and
(3) continuation despite adverse consequences.

These same criteria can be applied to excessive behaviors such as excessive sexual behaviors, compulsive overeating, and pathological gambling. This analysis suggests that an addiction-sensitive treatment model might be effective in treating disorders of excess involving sex, food, and gambling.

(4) Other psychiatric disorders can also be associated with sexual excesses.

In addition, Axis II characterological disorders (eg, antisocial personality disorder, narcissistic personality disorder) are often contributory, or may be the primary cause of paraphiliac or nonparaphiliac excessive sexual behavior. The frequent and infrequent Diagnostic and Statistical Manual of Mental Disorders Axis I diagnoses associated with sexual excesses are presented in (PP4:16,17).5

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The word "excessive," as used in this article, does not specify a particular quantity, frequency, or type of sexual behavior. Rather, what makes these behaviors addictive disorders is that the patient has expended much time and mental energy in connection with the behavior, and has incurred distressing life consequences as a result of the behavior yet has been unable to stop.

Among 1,000 patients admitted for inpatient treatment of addictive sexual disorders, Carnes2 discerned 10 patterns of behavior, summarized in (PP4:18). Five of the categories covered in (PP4:18) constitute specific DSM-IV paraphilias: voyeuristic sex, exhibitionistic sex, pain exchange (sexual sadism, sexual masochism), some types of intrusive sex (frotteurism), and exploitative sex (pedophilia).

Four of the remaining categories may be correlated with paraphilias as follows:

1. fantasy sex may be associated with paraphiliac urges not acted upon;
2. anonymous sex may be used to permit expression of paraphiliac behavior with decreased risk of consequences; and
3. paying for sex and
4. trading sex are means by which a partner who may permit paraphiliac activities may be purchased.

Whether the specific pattern is diagnosed as paraphiliac or nonparaphiliac, its compulsive nature often leads to a failure of traditional psychotherapeutic techniques to cure it, and success with addiction-based approaches.

Gender Differences
Significant gender differences have been observed in the prevalence of various patterns of addictive sexual behaviors.

(6) Men tend to engage in behavioral excesses that objectify their partners and require little emotional involvement (voyeuristic sex, paying for sex, anonymous sex, and exploitative sex). A trend toward emotional isolation is clear. Women tend to be excessive in behaviors that distort power either by gaining control over others or being a victim (fantasy sex, seductive role sex, trading sex, and pain exchange).

Women sex addicts use sex for power, control, and attention. 6,7

Case 1: A 34-year-old woman from a rigidly religious family married an alcoholic. After 2 years of marriage, she became involved in the first of many extramarital affairs. To avoid detection by her husband, she withdrew from him emotionally and neglected the marital relationship. She recognized that she was not spending enough time with her children, but felt powerless to change. Despite feelings of guilt, she did not seek help until she cheated on her new lover. Slide #PP4:18

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Patterns of Addictive Sexual Behaviors

1. Fantasy sex: Person is obsessed with a sexual fantasy life. Fantasy and obsession are all-consuming.
2. Seductive role sex: Seduction and conquest are the key. Multiple relationships, affairs, and/or unsuccessful serial relationships are present.
3. Anonymous sex: Engaging in sex with anonymous partners, or having one-night stands.
4. Paying for sex: Paying for prostitutes or for sexually explicit phone calls.
5. Trading sex: Receiving money or drugs for sex or using sex as a business.
6. Voyeuristic sex: Visual sex: Use of pornographic pictures in books, magazines, computer, pornographic films, peep-shope. Window-peeping and secret observation. Highly correlated with excessive masturbation, even to the point of injury.
7. Exhibitionistic sex: Exposing oneself in public places or from the home or car; wearing clothes designed to expose.
8. Intrusive sex: Touching others without permission. Use of position or power (eg, religious, professional) to sexually exploit another person.
9. Pain exchange: Causing or receiving pain to enhance sexual pleasure.
10. Exploitative sex: Use of force or vulnerable partner to gain sexual access. Sex with children.

Source: Carnes PJ. Don't Call it Love: Recovery from Sexual Addiction. New York, NY: Bantam Books. 1991;35:42- ­44.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

Multiple Addictions
Addictive disorders tend to coexist. Nicotine dependency, for example, is highly correlated with alcohol dependence. The same is true of sex and drugs. Addictive sexual disorders often coexist with substance-use disorders and are frequently an unrecognized cause of relapse. In an anonymous survey of 75 self-identified sex addicts,9 39% were also recovering from chemical dependency and 32% had an eating disorder. In another study,3 70% of cocaine addicts entering an outpatient treatment program were also found to be engaging in compulsive sex. In Irons and Schneiders8 population of health professionals assessed for sexual impropriety, those with addictive sexual disorders were almost twice as likely to have concurrent chemical dependency (38% prevalence) as those who were not sexually addicted (21%). Thus, the presence of sexual compulsivity was a comorbid marker for chemical dependency.

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Case 2: A 40-year-old physician was actively involved in Alcoholics Anonymous and appeared to be doing well until the day he did not appear at work and was found at home, intoxicated and suicidal. He explained to his therapist that drinking was not the real problemhe had been engaging in anonymous unsafe sex with men in public restrooms, and could not stop. He felt such fear and anguish that his only options seemed to be suicide or drinking; he chose alcohol. Sexual issues had not been addressed during his prior inpatient treatment for alcoholism.10

Professional Sexual Exploitation
Sexual contact between a helping professional (eg, physician, counselor, or minister) and their patients or clients is condemned by professional organizations and licensing bodies, and is considered to be sexual exploitation.

Professionals may be sexually exploitative on the basis of

1. naivety and lack of knowledge of appropriate boundaries,
2. circumstances which for a time increase the professionals vulnerability,
3. the presence of one or more Axis I addictive disorders, or
4. the presence of Axis I mental illness or Axis II character pathology such as antisocial personality disorder. In many cases, the professional has a repetitive pattern of sexual exploitation of clients, and actually has an addictive sexual disorder.

Irons and Schneider reported the results of an intensive inpatient assessment of 137 health care professionals referred because of allegations of personal or professional sexual impropriety. After assessment, half (54%) were found to have a sexual disorder NOS with addictive features (ie, to be sexually addicted). Two thirds (66%) of the entire group were found to have engaged in professional sexual exploitation, and of this subpopulation, two thirds (66%) were sexually addicted. Thus, addictive sexual disorders are a common feature of sex offending by professionals. In addition, 31% of the entire group was incidentally found to be chemically dependenta condition for which many had not previously been treated.

Case 3: A 52-year-old married minister had a long history of sexual involvement with female parishioners who came to him for counseling. His family relationships were distant, because he was often away from home in the evenings "counseling" rather than spending time with his family. After several women came forward with their stories, the minister was fired, evicted from his church-owned house, and publicly humiliated. He resigned from his ministerial duties and changed his profession.

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Table 1: Twelve-Step Program for Sex Addiction
For the Addict
Sexaholics Anonymous (SA). P.O. Box 111910,Nashville, TN 37222-6910, (615) 331-6230

Sex Addicts Anonymous (SAA), P.O. Box 70949, Houston, TX 77270, (713) 869-4902

Sex and Love Addicts Anonymous (SLAA)
P.O. Box 119, New Town Branch, Boston, MA 02258, (617) 332-1845
For the Partner
S-Anon, P.O. Box 111242, Nashville, TN 37222-1242, (615) 833-3152

Codependents of Sex Addicts (CoSA)
9337 B Katy Fwy #142, Houston, TX 77204, (612) 537-6904
For Couples
Recovering Couples Anonymous, P.O. Box 11872, St. Louis, MO 63105, (314) 830-2600

Professionals and interested patients can also write for information to:
National Council on Sexual Addiction and Compulsivity (NCSAC)
1090 S. Northchase Parkway, Suite 200 South, Atlanta, GA 30067, e-mail: ncsac@mindspring.com
website: http://www.ncsac.org

Source: Irons RR, Schneider JP. Addictive sexual disorders. In: Miller NS, ed. Principles and Practice of Addictions in Psychiatry. Philadelphia, Pa: Saunders; 1997:441-457.
Schneider JP, Irons RR. Primary Psychiatry. Vol. 5. No. 4. 1998.

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Treatment
Unlike the goal in treatment of substance use disorders, which is abstinence from use of all psychoactive substances, the therapeutic goal for sex addicts is abstinence only from compulsive sexual behavior. The counselor can help the client identify which sexual behaviors are best avoided. For many sex addicts, masturbation is analogous to the "first drink" which can lead to relapse. Some recovering sex addicts can eventually resume this practice if they restrict their sexual fantasies to "healthy" themes, whereas others must continue to avoid it.

Because sex addicts were often sexually abused as children (83% according to Carnes2), and because they have distorted ideas about sex, they frequently lack information about healthy sexuality. Education about this subject is highly desirable. In the early recovery period, sex addicts and their partners frequently have sexual difficulties, often to a greater degree than during the active addiction phase. Therapists can provide reassurance during this phase. If the compulsive sexual behavior was same-sex, as is surprisingly common even among men who identify themselves as heterosexual,9 therapists can help patients work through issues of sexual identity.

Group therapy is the cornerstone of sex addiction treatment. Shame, a major issue for sex addicts, is often addressed best in group therapy, where other recovering addicts can provide both support and confrontation. Education about sex addiction is a major component of all treatment programs.7,12,13,14

For patients who are suicidal or have other comorbid psychiatric or addictive disorders, or who are unable to recover in an outpatient setting, several inpatient treatment programs are available in the United States. Most are located in hospitals that also treat substance use disorders. Increasingly, treatment programs for substance use disorders are now assessing for the presence of sex addiction and other addictive disorders, and are either treating the problem themselves or referring out for such treatment.

Because a large percentage of people with addictive sexual disorders are also chemically dependent, the initial decision often facing a treatment professional is which addiction to treat first. By the time sex addicts seek help for this disorder, many are already in recovery from their substance dependence. If not regardless of which addiction is primary the drug dependence must be treated first if sex addiction treatment is to succeed.

The 12 steps of Alcoholics Anonymous have been adapted for use in programs for eating disorders, compulsive gambling, sexual addiction, and other addictions. For those with addictive sexual disorders, attendance at a program dealing with sexual addiction is highly recommended. Several fellowships have evolved, which differ primarily in their definitions of "sexual sobriety." Programs modeled after Al-Anon (the mutual-help program for families and friends of alcoholics) are also available, and attendance by spouses of sex addicts can be very helpful both for the spouse and for the relationship. The two major fellowships have no significant differences. Group support can be a powerful tool for overcoming the shame that most sex addicts and their partners feel. For information about the nearest meetings available in the United States and Canada, contact the fellowships listed in Table 1.

In cases of professional sexual exploitation, it is important to have a thorough assessment to determine the cause. Some exploitative professionals have a better prognosis than others for return to professional practice. In contrast to those who exploit primarily as an expression of an Axis II characterological disorder, sexually addicted professionals who have successfully completed comprehensive assessment and primary treatment can often return to work without compromising public health and safety. Irons11 devised a set of proposed contractual provisions for reentry. Such a contract can be part of a binding legal stipulation between the professional and a state professional licensing board and can define a standard of care for potentially impaired health care professionals.

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Conclusion
Addictive sexual disorders have distinct parallels with other addictive disorders. They commonly coexist with substance-related disorders, may themselves have features associated with addiction, and may respond to an addiction model of treatment and therapy. Unrecognized and untreated symptoms of these sexual disorders are significant factors that lead to a return to substance use in substance-related disorders. Compulsive sexual behavior has significantly contributed to the growth of the current epidemic of acquired immunodeficiency syndrome. A more detailed discussion of diagnostic and treatment issues and resources may be found in our chapter in a recently published addiction psychiatry textbook.5

next: Four Perspectives on Sex Problems

References

American Psychiatric Association. Diagnostic and Statistical Manual of Mental Disorders. 4th ed. Washington, DC: American Psychiatric Association. 1994.

Carnes PJ. Don't Call it Love: Recovery from Sexual Addiction. New York, NY: Bantam Books. 1991; 35:42-44.

Washton AM. Cocaine may trigger sexual compulsivity. US J Drug Alcohol Depend. 1989;149:1690-2685.

Schneider J, Irons R. Treatment of gambling, eating, and sex addictions. In: Miller NS, Gold MS, Smith DE, eds. Manual of Therapeutics for Addictions. New York, NY: John Wiley Sons. 1997:225-245.

Irons RR, Schneider JP. Addictive sexual disorders. In: Miller NS, ed. Principles and Practice of Addictions in Psychiatry. Philadelphia, PA: Saunders; 1997:441-457.

Carnes P, Nonemaker D, Skilling N. Gender differences in normal and sexually addicted populations. Am J Prev Psychiatr Neurol. 1991;3:16-23.
Kasl CD. Women, Sex, and Addiction. New York, NY: Ticknor Fields. 1989.

Irons RR, Schneider JP. Sexual addiction: significant factor in sexual exploitation by health care professionals. Sexual Addiction Compulsivity. 1994;1:198-214.

Schneider JP, Schneider BH. Sex, Lies, and Forgiveness: Couples Speak on Healing from Sex Addiction. Center City, Minn: Hazelden Educational Materials; 1991:17.

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Schneider JP. How to recognize the signs of sexual addiction. Postgrad Med. 1991;90:171-182.

Irons RR. Sexually addicted professionals: contractual provisions for re-entry. American Journal of Preventive Psychiatry Neurology. 1991;307:57-59.

Carnes, PJ. Out of the Shadows: Understanding Sexual Addiction. Minneapolis, Minn: CompCare Publications; 1983.

Schneider JP. Back From Betrayal: Recovering From His Affairs. New York, NY: Ballantine;1988.

Earle R, Crow G. Lonely All the Time. New York, NY: Pocket Books;1989.

next: Four Perspectives on Sex Problems

men and sex

Women feel intimacy and closeness when they talk, touch, and share their thoughts and feelings with a loved one. They are usually more interested in intimacy than in sex of and for itself.

A feeling of intimate closeness takes time to develop. Therefore, women want to take their time with a relationship. They want to go through the stages of getting to know the man, becoming friends, touching, kissing, hugging and showing affection. Eventually they get around to sex when they feel closeness and believe they are in love.

If women typically require closeness and intimacy before they experience "good sex," does that mean they can't and won't have sex before they feel intimate? No, it means that sex is often not satisfying, even when orgasm takes place, without that close feeling.

When some women feel pressure to have sex before they are ready, they think, "This man doesn't love me for me. He only loves me for what he can get."

They might even develop resentments toward men in general.

Men, Sex and Feelings

Women are probably even more of a puzzle to men than men are to women. Even though women are important to men, they live in this mysterious other world of menses and babies and rampant emotions and even tears that men can't or don't want to understand.

This man who is notoriously poor at figuring out his own feelings is even worse at figuring out the feelings of a woman. Just deciding what a woman wants from him in general is fraught with danger.

Many men see sex, though, as a way to get close to women, and possibly, even a way to please them. The fact that they are usually wrong, of course, doesn't stop a man from thinking sex can make everything right with his woman. A cure-all of great proportions... "All she needs is a good f___ ," is a common solution to male - female problems for many men.

Very seldom is that what she needs but that is another story...

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"Don't Push Me So Hard For Sex" Women Want Time Before Sex

One young woman told me that she has to have time before sex to get to know and trust a man. She has to see him in different situations, with different people, and talk to him for hours before she will "allow" herself to even consider sex.

She continued, "One guy I dated pushed so hard for sex, that I gave in before I was ready. But that made sex basically unsatisfying. Even though chemistry was there at first, I lost interest sexually. Once I decided he wasn't a good lover, I was ready to move on. We never gave real love a chance."

Another women agreed that time is necessary to feel a real desire for sex. She said, "If a man pushes me to sex too quickly, the relationship rarely gets much further than a few trips to bed. Then they (men) are hurt and can't understand why I don't stay in love with them. They don't get it-I never was in love with them."

Most women agree that men who push for sex before the woman is ready had better be really good in bed. Unfortunately, this is unlikely to happen.

For whatever reason, women are a diverse group in terms of what produces pleasurable sex. It is a rare man that can be a good lover to a woman without a certain amount of experience with that particular woman.

Women can forgive fumbling, partial or non-existent erections, and premature ejaculations when they are in love. They can even call up a certain acting ability in the name of love. But when love has not been given the time it takes to grow for the woman, she often labels the man a poor lover and the relationship is stillborn in the bedroom.

Some women learn to look at sexual-timing incompatibilities with humor. One lady said, "I used to resent being pushed for sex. Now I get amused at all these guys and their gropings. Most of them end up providing me with a few funny stories to tell my girlfriends. I certainly don't fall in love with them, but I don't get mad at them anymore either."

And still others avoid sex. These women feel if they put themselves in the position to get what they want: affection, touching, and cuddling, they will have to do battle not to have sex.

So some women do without desired affection, particularly in the beginning of a relationship, to avoid pressure to have sex.

Why Women and Men Have Different Sex Timeframes

How can women and men have such different timeframes for the beginning of sex in a relationship? Two reasons stand out:

1. Our society teaches females that "nice girls don't." When society has taught this lesson for years, it is hard to suddenly feel sexual, even when hormones start raging in adolescence.
2. And, probably because of the lessons of their youth, women reach their sexual peak in their mid-to-late thirties or even later, rather than when teen-age hormones first kick-in.

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Age is a leveler

As men and women get older, women usually become more interested in sex for the sake of sex, and most men learn to curb some of their sexual impatience, giving closeness and love a chance to flourish. So, for many single men and women, it can be true: love and sex are both more wonderful the second time around.

Without a doubt, the sexual revolution changed the sex scene for women. Fewer virgins at marriage; more women with multiple sex partners; more women having affairs; more women having sex openly, more women opting for sex only rather than marriage, etc.

Some women felt this was a change for the better. Others saw it as unfavorable.

The Changing Sexual Attitudes and Behaviors of Women

Working outside the home also changed women's attitudes toward sex.

The Janus Report on Sexual Behavior by Samuel Janus, Ph.D. and Cynthia Janus, M.D., copyright 1993, had some eye-opening observations along this line. They wrote, "Our study has documented many levels of sexual and social changes for both women and men in the early 1990s, but we acknowledge that women's, not men's, sexual attitudes and behavior have drastically changed within the past two decades.

"The enormous and ongoing change in women's social and sex lives has separated women into entirely different groups."

The Janus' write, "Work-life and a workplace outside the home have given a new focus to many women's lifestyles. The innovations transcend income earned or the nature of the work performed; more significantly, they involve a personal sense of identity that sets these women apart."

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They continued, "In the women-C (career women) and the women-H (homemaker women) groups, we found that we had two distinctly different populations, regarding sex life and life-style in general.

"Women who work part-time outside the home offered responses that were almost always between those of the women-C and women-H groups."

Interesting!

But more interesting still was another observation of The Janus Report, "One of the most striking indications of our data involves the unprecedented levels of agreement between men and women-C (those who work full-time outside of the home), as compared to women-H, who do not work outside of the home at all. New levels of sexual affinity and relatedness can also be observed, in sharp contrast to the stereotypical sexual roles men and women have had assigned to them in the past."

They concluded, "No longer does the man alone decide the mode of sexual gratification; most often, the couple decides together."

The sexual revolution was followed by the reality of Herpes and AIDS and the need for safe sex. Many experts predicted a slow down for sex in general and certainly a slow down for those out in the less-safe singles' world.

Dr. and Dr. Janus found the experts were wrong.

They reported, "Approximately one-quarter of the men (24%) and one-fifth of the women (20%) had much more sex activity. When we combined sex activity."

They continued, "Perhaps not too surprisingly, the homemakers increased their sexual activity more than the career women did (43% versus 37%). We felt justified in assuming that more homemakers than career women were in ongoing monogamous relationships."

Certainly a major sexual change has taken place in American society. Assertiveness regarding the "when, where, and why" of sex rather than passive acquiescence to sex is now a prerogative exercised by many American women.

If the Janus' observations are accurate, much of this sexual change was brought about by women taking jobs outside the home and acquiring a heightened sense of personal identity.

next: Men and Sexual Rejection from Women

You want to look and feel your best. But does this mean you should watch your weight, eat fat-free foods, and count calories? Start by getting the facts on fat and calories, then decide for yourself.

What Are Fat and Calories?

Fats, or lipids, are nutrients in food that your body uses to build nerve tissue (like the brain) and hormones. Your body also uses fat as fuel. If fats that you've eaten aren't burned as energy or used as building blocks, they are stored by the body in fat cells. This is your body's way of thinking ahead: by saving fat for future use, your body plans for times when food might be scarce.

A calorie is a unit of energy that measures how much energy food provides to your body. When some people hear the word calorie, they think calories are a bad thing. But the truth is that everybody needs to have calories. Your body needs calories to function properly.

How Are Calories and Fat Represented on Food Labels?

Food labels list calories by the amount in each serving size. Serving sizes differ from one food to the next, so to figure out how many calories you're eating, you'll need to do three things:

• Look at the serving size.
• See how many calories there are in one serving.
• Multiply the number of calories by the number of servings you're going to eat.

For example, a bag of cookies may list three cookies as a serving size. But if you eat six cookies, you are really eating two servings, not one. To figure out how many calories those two servings contain, you must double the calories in one serving.

When you start looking at food labels, you may be surprised at some of the serving sizes! Food companies want their foods to seem healthier, low in fat, or low in calories, so they may make their serving size smaller than the portion size most people would normally eat.

For example, on the labels of six cold breakfast cereals, the serving size ranges from 1/2 cup to 1 3/4 cups. You would have to more than triple the smallest serving size (1/2 cup) to compare the calories in that cereal with the calories in the cereal with the largest serving size (1 3/4 cups). A bag of corn chips might list five chips as a serving size. But you'd have a hard time finding anyone who would eat only five chips! That's why it's always important to compare serving sizes.

When it comes to fat, labels can say many things. Low fat, reduced fat, light (or lite), and fat free are common terms you're sure to see splashed across food packages. The government has strict rules about the use of two of these phrases: By law, fat-free foods can contain no more than 0.5 grams of fat per serving. Low-fat foods may contain 3 grams of fat or less per serving. Foods marked reduced fat and light (lite) are a little trickier, and you may need to do some supermarket sleuthing.

Light (lite) and reduced-fat foods may still be high in fat. The requirement for a food to be labeled light (lite) is that it must contain 50% less fat or one third fewer calories per serving than the regular version of that food. Foods labeled reduced fat must contain 25% less fat per serving than the regular version. But if the regular version of a particular food was high in fat to begin with, a 25% to 50% reduction may not lower the fat content enough to make it a smart snacking choice. For example, the original version of a brand of peanut butter contains 17 grams of fat and the reduced fat version contains 12 grams. That's still a lot of fat!

And don't expect the label to tell it all. The percentage of fat in a food isn't always listed on the label. But it is easy to calculate. Divide the number of calories from fat by the number of total calories and multiply by 100.

For example, if a 300-calorie food has 60 calories from fat, you divide 60 by 300 and then multiply by 100. The result shows that food gets 20% of its calories from fat.

Knowing how to figure out how many calories you're getting from fat is important. U.S. Dietary Guidelines recommend that no more than 30% of all the calories you eat in a day should come from fat.

4, 4, and . . . 9?

Food calories come from carbohydrates, proteins, and fats. A gram of carbohydrate contains 4 calories. A gram of protein also contains 4 calories. A gram of fat contains 9 calories - more than twice the amount of the other two. That's why a food with the same serving size as another may have far more calories. A high-fat food has many more calories than one low in fat and higher in protein or carbohydrates.

For instance, a 1/2-cup serving of vanilla ice cream contains:

• 178 total calories
• 2 grams of protein (2 grams times 4 calories = 8 calories from protein)
• 12 grams of fat (12 grams times 9 calories = 108 calories, or 61%, from fat)
• 15.5 grams of carbohydrate (15.5 grams times 4 calories = 62 calories from carbohydrate)

Compare this to the same serving size (1/2 cup) of cooked carrots:

• 36 total calories
• 1 gram of protein (1 gram times 4 calories = 4 calories from protein)
• 0 grams of fat (0 grams times 0 calories = 0 calories from fat)
• 8 grams of carbohydrate (8 grams times 4 calories = 32 calories from carbohydrate)

These two examples show what a difference fat makes when it comes to total calories in a food.

But let's face it: who's going to choose a heaping bowl of cooked carrots over luscious ice cream on a hot summer day? It all comes down to making sensible food choices most of the time. According to Debby Demory-Luce, PhD, a dietitian, "The goal is to make trade-offs to balance a higher-fat food with foods that are lower in fat to keep the fat intake at 30% for the day." So if you really want that ice cream, it's OK once in a while - as long as you work in some lower-fat foods, like carrots, that day.

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Are All Types of Fat the Same?

All types of fat have the same amount of calories, but not all fats are created equal - some are more harmful to your health than others. Two of the most harmful fats are saturated fat and trans fat. Both of these fats can increase a person's risk of heart disease - and experts believe that trans fat may carry an even greater health risk than saturated fat.

Saturated and trans fats are solid at room temperature - like butter, shortening, or the fat on meat. Saturated fat comes mostly from animal products, but some tropical oils, like palm kernel oil and coconut oil, also contain saturated fat. Trans fat is also found in whole dairy and meat products. But one of the most common sources of trans fat in today's foods is hydrogenated vegetable oil. Hydrogenated oils are liquid oils that have been changed into a solid form of fat by adding hydrogen. This process allows these fats to keep for a long time without losing their flavor or going bad. Trans fats are often found in packaged baked goods, like cookies, crackers or potato chips. They are also in fried foods like french fries and doughnuts. Because saturated fat and trans fat are tied to heart disease, a gram of one of these fats is worse for a person's health than a gram of unsaturated fat.

Unsaturated fats are liquid at room temperature. Unsaturated fats can be polyunsaturated or monounsaturated. Polyunsaturated fat is found in soybean, corn, sesame and sunflower oils, or fish and fish oil. Monounsaturated fat is found in olives, olive oil or canola oil, most nuts and their oils, and avocados.

Fat and Calories in a Healthy Diet The Food Guide Pyramid shows that fats should be used sparingly. The American Heart Association recommends people get as much of their daily fat intake as possible from unsaturated fats and that they limit saturated fats and trans fats - or at least keep their consumption of these fats to no more than 10% of their daily diet. Saturated fats are listed on food labels. Keeping track of trans fat is also going to be easier - the FDA requires that, by 2006, all food companies list the amount of trans fat in a product on its food label.

With all the talk about fat and tons of low-fat products out there, some teens may decide to completely cut out fat from their diet. Bad idea! Some fat is needed for good health. Fat is necessary for developing bodies, especially during puberty, when the body grows very quickly.

Fats are also needed to absorb certain vitamins that are essential for proper growth. Vitamins A, D, E, and K are known as fat soluble, meaning they can only be absorbed if there is fat in a person's diet. Also, fat cells act as insulation to keep your body warm and make up part of the outer coating that protects your nerve cells. When it comes to foods, a little fat is where it's at - you should never try to stop eating fat completely.

Likewise, you need a certain amount of calories in your diet to fuel your body. In fact, Dr. Demory-Luce doesn't recommend calorie counting (the term for keeping track of the number of calories in everything that you eat) unless a person's doctor has specifically ordered it. "Even for teens who are overweight," she says, "making wise food choices and increasing activity would be more healthy." If you are concerned about your weight, speak to your doctor.

Maintaining a healthy weight means choosing foods that are low in fat and high in complex carbohydrates. Think about which foods you can substitute for those in your diet that are high in sugar, fat, or calories - such as drinking water or skim milk instead of soft drinks or choosing mustard instead of mayonnaise on your sandwich. Other healthy food choices include:

• low-fat or fat-free dairy products
• fresh fruits and vegetables
• whole-grain cereals and breads
• lean meats

Being aware of the amount of fat and calories you eat makes sense, as long as you eat a balanced diet. Establishing sensible eating habits, choosing foods wisely and exercising regularly are the keys to long-term good health.

next: Food Anxiety: Food Shapes Our Identity and Influences How We See the World
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There's a strong link between teen depression and suicide. Teens are much more vulnerable to major depression and bipolar illness.

The majority of suicide attempts and suicide deaths happen among teens with depression. Consider these statistics about teen suicide and teen depression: about 1% of all teens attempts suicide and about 1% of those suicide attempts results in death (that means about 1 in 10,000 teens dies from suicide). But for adolescents who have depressive illnesses, the rates of suicidal thinking and behavior are much higher. Most teens who have depression think about suicide, and between 15% and 30% of teens with serious depression who think about suicide go on to make a suicide attempt.

Keep in mind that most of the time for most teens depression is a passing mood. The sadness, loneliness, grief, and disappointment we all feel at times are normal reactions to some of the struggles of life. With the right support, some resilience, an inner belief that there will be a brighter day, and decent coping skills, most teens can get through the depressed mood that happens occasionally when life throws them a curve ball.

But sometimes depression doesn't lift after a few hours or a few days. Instead it lasts, and it can seem too heavy to bear. When someone has a depressed or sad mood that is intense and lingers almost all day, almost every day for 2 weeks or more, it may be a sign that the person has developed major depression. Major depression, sometimes called clinical depression, is beyond a passing depressed mood - it is the term mental health professionals use for depression that has become an illness in need of treatment. Another form of serious depression is called bipolar disorder, which includes extreme low moods (major depression) as well as extreme high moods (these are called manic episodes).

Though children can experience depression, too, teens are much more vulnerable to major depression and bipolar illness. Hormones and sleep cycles, which both change dramatically during adolescence, have an effect on mood and may partly explain why teens (especially girls) are particularly prone to depression. Believe it or not, as many as 20% of all teens have had depression that's this severe at some point. The good news is that depression is treatable - most teens get better with the right help.It's not hard to see why serious depression and suicide are connected. Serious depression (with both major depression and bipolar illness) involves a long-lasting sad mood that doesn't let up, and a loss of pleasure in things you once enjoyed. It also involves thoughts about death, negative thoughts about oneself, a sense of worthlessness, a sense of hopelessness that things could get better, low energy, and noticeable changes in appetite or sleep.

Depression also distorts a person's viewpoint, allowing them to focus only on their failures and disappointments and to exaggerate these negative things. Depressed thinking can convince someone there is nothing to live for. The loss of pleasure that is part of depression can seem like further evidence that there's nothing good about the present. The hopelessness can make it seem like there will be nothing good in the future; helplessness can make it seem like there's nothing you can do to change things for the better. And the low energy that is part of depression can make every problem (even small ones) seem like too much to handle.

When major depression lifts because a person gets the proper therapy or antidepressant treatment, this distorted thinking is cleared and they can find pleasure, energy, and hope again. But while someone is seriously depressed, suicidal thinking is a real concern. When teens are depressed, they often don't realize that the hopelessness they feel can be relieved and that hurt and despair can be healed.

The National Hopeline Network 1-800-SUICIDE provides access to trained telephone counselors, 24 hours a day, 7 days a week. Or for a crisis center in your area, go here.

next: Suicide Facts - Suicide Statistics
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In January 2000, the American Psychiatric Association revised it guidelines for the treatment of anorexia nervosa and bulimia nervosa. The following summary focuses on psychosocial interventions incorporated into a comprehensive treatment plan that includes nutritional counseling and/or rehabilitation as well as medications. The authors note, in reviewing research on the impact of multi-part psychosocial interventions, that it may not always be possible to identify those components of the treatment plan that contribute to improvements in clinical status.

Anorexia Nervosa

Psychosocial treatment for anorexia nervosa has several goals:

1. to help the patient both understand and cooperate with the comprehensive treatment process;
2. to help the patient understand and, hopefully, change behaviors and underlying attitudes related to their anorexia;
3. to help the patient enhance social and interpersonal functioning; and
4. to help the patient address coexisting mental disorders and conflicts that support dysfunctional eating behaviors.

The first step, obviously, is to establish a therapeutic alliance with the patient. In the initial phase of psychosocial treatment, patients will benefit from empathic understanding and encouragement, education, positive reinforcement for achievements, and enhancement of motivation to recover.

Once the patient is no longer medically compromised and weight gain has commenced, formal psychotherapy may be quite beneficial. It should be noted that:

• No specific form of psychotherapy appears to be a cut above any other in the treatment of anorexia.
• Successful treatments are informed by an appreciation of:
  • psychodynamic conflicts;
  • cognitive development;
  • psychological defenses;
  • the intricacy of family relationships; and
  • the presence of concurrent mental disorders.
• Psychotherapy, in and of itself, in insufficient to treat the medically compromised patient with anorexia.
• Ongoing individual therapy is usually required for a minimum of one year and may, in fact, take between five and six years because of the recalcitrant nature of this condition and the need for continuing support during the recovery process.
• Family therapy and couples therapy are often helpful in addressing both the symptoms of anorexia as well as the relationship problems that may contribute to their maintenance.
• Group therapy is sometimes used adjunctively, but caution must be exercised, since patients may compete to be the "thinnest" or "sickest" group member or become demoralized through witnessing the ongoing difficulties of other group members.

Bulimia Nervosa

Psychosocial treatment for bulimia nervosa may incorporate several goals. These include:

1. reducing or eliminating binge eating and purging behaviors;
2. improving attitudes surrounding the bulimia;
3. minimizing food restriction and increasing food variety;
4. encouraging healthy (but not excessive) patterns of exercise;
5. treating concurrent conditions and clinical features related to the bulimia; and
6. focusing on the developmental issues, identity and body image concerns, gender role expectations, difficulties with sex and/or aggression as well as the regulation of affect, and family issues that may underlie the bulimia.

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According to the Guidelines,

• Interventions should be selected on the basis of a full assessment of the patient and take into consideration the individual's cognitive and emotional development, psychodynamic concerns, cognitive style, concurrent mental disorders, personal preferences, and family circumstances.
• Cognitive behavioral therapy is the approach that has been most extensively studied to date and its utility has been the most consistently substantiated, although many experienced clinicians report that they do not find these techniques to be as effective as the research would suggest.
• Some research indicates that combining antidepressant medication with a cognitive behavioral approach offers the best treatment outcome.
• Controlled trials also support the use of interpersonal psychotherapy in the treatment of bulimia.
• Behavioral techniques, including planned meals and self-monitoring, may also be beneficial, particularly for initial symptom management.
• Clinical reports suggest that psychodynamic constructs, incorporated into individual or group treatment, may help once binge eating and purging are under better control.
• Patients concurrently suffering from anorexia nervosa or a major personality disorder may require continuing therapy.
• Family therapy should be added in whenever feasible, especially when treating adolescents who still live with their parents or older patients whose interactions with their parents continue to be conflicted.

Readers who would like more information on the treatment of these conditions are invited to review the full set of guidelines, cited below.

Source: American Psychiatric Association. (2000). Practice guidelines for the treatment of patients with eating disorders (revision). American Journal of Psychiatry, 157(1), supplement, 1-39.

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Having healthy relationships not only helps to alleviate clinical depression, but also helps to prevent relapse of major depression. Discover why.

"Anything that promotes a sense of isolation often leads to illness and suffering. Anything that promotes a sense of love and intimacy, connection and community, is healing."
Dean Ornish, Love and Survival

One of the great lessons I learned from my episode of clinical depression is that one cannot overcome an illness like major depression (or any dark night of the soul experience) by oneself. The weight of the agony is too immense, even for the strongest-willed individual, to bear alone.

Having healthy relationships not only helps to alleviate depression, but also helps to prevent its recurrence. Isolation, on the other hand, makes one more vulnerable to mental and physical illness.

During my illness, two people close to me, a previous therapist and a fellow student of metaphysics, committed suicide in the midst of similar bouts of depression. The cause of their tragedies, I believe, lies in the words of Spanish philosopher Miguel de Unamuno, who said, "Isolation is the worst possible counsel." My friends had retreated into environments in which they were cut off from family, friends and therapeutic assistance. Fortunately, many people in the Portland area extended themselves to me-the staff and patients at day treatment, my partner Joan, countless friends, and the prayer ministry of LEC. Without them I would not have survived.

It is my belief that the key "ingredient" in my healing was the presence of group energy. I had met and prayed with Mary Morrissey many times; I had prayed with other ministers and members of the prayer team, as well as with my therapist-and still I continued to decline. It wasn't until someone said, "Let's put all of your support people together in one room" that the healing power of prayer became fully activated. The combined prayers and positive thoughts of the group members set up a spiritual energy field through which Divine Love moved and healed my body and soul.

In a recent special aired on National Public Radio, Mike Wallace, William Styron and Art Buchwald spoke candidly about their depressions and about the lifeline of support that developed among them during their episodes. (All three were living on Martha's Vineyard at the time of their ordeals.) In his acknowledgment of Art Buchwald's support, Styron said:

I have to give Art credit. He was the Virgil to our Dante. Because he'd been there [in hell] before, like Virgil. And he really charted the depths, and so it was very, very useful to have Art on the phone, because we needed it. Because this is a new experience for everyone, and it's totally-it's totally terrifying. And you need someone who has been there to give you parameters and an understanding of where you're going.

In my depressive state, I did not have a Buchwald-a brother or sister survivor who had been to hell and back-who could assure me of my future deliverance. What I did have, however, was a committed group of individuals who "kept the high watch" by holding a vision of my healing until it came to pass. And so I learned the lesson that is granted to survivors of emotional and physical trauma: when Divine love heals us, it most often comes through the healing love of other people.

Putting the Power of Support Into Practice

Building a good support network takes time and the process is unique to each person. It means surrounding yourself with people who can validate what you are going though and who can unconditionally accept you. Some of the members of a support system may include:

• family and close friends.

• anallysuch as a counselor, psychologist, psychiatrist, rabbi, minister, priest, 12 step sponsor or friend in whom you can confide.

• group support.Here is where you can gain (and give) help and encouragement from (and to) others who are going through experiences like yours. In a support group, you learn that you are not alone in your suffering, and that there are others who truly understand your pain. To find a depression or anxiety support group in your area, call your local mental health clinic, hospital, the National Alliance for the Mentally Ill (800-950-NAMI) or the Depressive and Related Affective Disorder Association (410-955-4647) or the Depression and Bipolar Support Alliance (DBSA) (800-826-3632).

Other types of group support you may wish to seek out include a 12-step group, a women's group, a men's group, group therapy, a self-help group that focuses on any issue you are dealing with, or a Master Mind group.

In addition to the support of human beings, I want to mention the support of animals, especially domestic pets. The unconditional love that we give to and receive from our animal friends can be as healing as human love. (This is why pets are increasingly brought to hospital wards and nursing homes.) A loving relationship with a cherished pet provides bonding and intimacy that can strengthen one's psychological immune system and help keep depression at bay.

This page was adapted from the book,
"Healing from Depression: 12 Weeks to a Better Mood: A Body, Mind, and Spirit Recovery Program",

by Douglas Bloch, M.A.

next: The Power of Social Support in Coping With Depression
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Parents of children with eating disorders have a difficult and frightening job. Recent research by Pamela Carlton, MD, indicates that they often feel overwhelmed and confused when their critically ill child is hospitalized. They may not understand the severity of the threat to their child's health, and they are often anxious about their own ability to care for their child after discharge.

"Parents are extraordinarily frustrated that they can't get their kid to eat," says Carlton, a staff physician at Lucile Packard Children's Hospital's eating disorders program. "We've found that, although we're taking care of their kids, they're not learning what they can do in the hospital and at home to help their children."

Carlton is spearheading a new effort to teach parents the how and why of the medical, psychiatric and nutritional treatment their child will receive as an inpatient of Lucile Packard Children's Hospital's Comprehensive Eating Disorders Program. The eating disorders staff will also help parents manage their child's condition at home after discharge and will organize weekly support groups for parents of children with eating disorders, a first for the area. The support groups will be led by a social worker and may invite occasional speakers to address common parental questions.

The plan sprang from two focus groups Carlton conducted a year ago, as well as a recent survey of 97 families of Packard Children's Hospital eating disorder inpatients. She asked the parents of children who had been hospitalized for anorexia, bulimia and other eating disorders to list concerns they had about their child's disorder and its treatment.

"What was very interesting to us," says Carlton, "was that hospitalization was the first time the parents realized how sick their kids actually were. We want parents to realize how serious the situation is and why we are taking it seriously. They may think, 'She seemed fine when I brought her into the clinic, so it can't really be that bad.'"

Carlton also found that parents are often confused about the rationale and enactment of their child's treatment plan. Participants of the focus groups were unanimous in their desire to have more information about all aspects of their child's disease and treatment, and both groups asked to stay behind after the session to compare notes with each other about their experiences.

"One thing that really frustrates parents is that they have no idea how to feed their child at home," says Carlton. "They're looking at the nutritional guidelines and asking 'What does this mean? What is a serving?'"

As part of the new education campaign, every parent will receive a binder of information about eating disorders and the types of treatment their child can expect to receive. After reviewing the information, the parents will meet weekly with Carlton for two hours to discuss the material.

Parents will learn, for example, that children who are less than 75 percent of their ideal body weight, or whose hearts beat less than 50 times each minute, have a drastically increased risk of sudden cardiac death even though they may look fine. They will be instructed to watch out for subtle danger signs, including fainting and blue hands or feet, which may signal a medical emergency.

And they will meet Anna, an alternate personality evoked in an essay by a recovering patient describing how it feels to be 'inhabited' by an eating disorder. Finally, the binder includes basic information about food groups and menus for balanced, nutritionally complete meals to feed their child.

In addition to the written information and the weekly question and answer sessions, Carlton hopes to set up a resource room for parents at the eating disorder program's new home at El Camino Hospital. When completed, the room will likely offer educational materials for check-out and computer terminals with lists of suggested reputable websites about eating disorders. Carlton plans to evaluate the effectiveness of the new educational program by surveying parents upon admission and again when their child is discharged. "If their knowledge and comfort levels about eating disorders and their treatment don't increase, then we'll adjust the program to better meet their needs," she says.

next: How Do I Help Someone With an Eating Disorder?
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teenage sex

As teens, many struggle with issues of self esteem - the degree to which we appreciate our own worth and importance. The way we regard ourselves is dependent on many factors, and recognizing them is the first step to overcoming obstacles.

Self-esteem involves how much a person values herself and appreciates her own worth and importance. For example, a teen with healthy self-esteem is able to feel good about her character and her qualities and take pride in her abilities, skills, and accomplishments. Self-esteem is the result of comparing how we'd like to be and what we'd like to accomplish with how we actually see ourselves.

Everyone experiences problems with self-esteem at certain times in their lives - especially teens who are still figuring out who they are and where they fit into the world. How a teen feels about herself can be related to many different factors, such as her environment, her body image, her expectations of herself, and her experiences. For example, if a person has had problems in her family, has had to deal with difficult relationships, or sets unrealistic standards for herself, this can lead to low self-esteem.

Recognizing that you can improve your self-esteem is a great first step in doing so. Learning what can hurt self-esteem and what can build it is also important. Then, with a little effort, a person can really improve the way she feels about herself.

Constant criticism can harm self-esteem - and it doesn't always come from others! Some teens have an "inner critic," a voice inside that seems to find fault with everything they do - and self-esteem obviously has a hard time growing in such an environment. Some people have modeled their inner critic's voice after a critical parent or teacher whose acceptance was important to them. The good news is that this inner critic can be retrained, and because it now belongs to you, you can be the one to decide that the inner critic will only give constructive feedback from now on.

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It may help to pinpoint any unrealistic expectations that may be affecting your self-esteem. Do you wish you were thinner? Smarter? More popular? A better athlete? Although it's easy for teens to feel a little inadequate physically, socially, or intellectually, it's also important to recognize what you can change and what you can't, and to aim for accomplishments rather than perfection. You may wish to be a star athlete, but it may be more realistic to set your sights on improving your game in specific ways this season. If you are thinking about your shortcomings, try to start thinking about other positive aspects of yourself that outweigh them. Maybe you're not the tallest person in your class and maybe you're not class valedictorian, but you're awesome at volleyball or painting or playing the guitar. Remember - each person excels at different things and your talents are constantly developing.

How to Improve Your Self-Esteem

If you want to improve your self-esteem, there are some steps you can take to start empowering yourself:

• Remember that self-esteem involves much more than liking your appearance. Because of rapid changes in growth and appearance, teens often fall into the trap of believing their entire self-esteem hinges on how they look. Don't miss the inner beauty that's more than skin deep in yourself and in others.
• Think about what you're good at and what you enjoy, and build on those abilities. Take pride in new skills you develop and talents you have. Share what you can do with others.
• Exercise! You'll relieve stress, and be healthier and happier.
• Try to stop thinking negative thoughts about yourself. When you catch yourself being too critical, counter it by saying something positive about yourself.
• Take pride in your opinions and ideas - and don't be afraid to voice them.
• Each day, write down three things about yourself that make you happy.
• Set goals. Think about what you'd like to accomplish, then make a plan for how to do it. Stick with your plan and keep track of your progress. If you realize that you're unhappy with something about yourself that you can change, then start today. If it's something you can't change (like your height), then start to work toward loving yourself the way you are.
• Beware the perfectionist! Are you expecting the impossible? It's good to aim high, but your goals for yourself should be within reach.
• Make a contribution. Tutor a classmate who's having trouble, help clean up your neighborhood, participate in a walk-a-thon for a good cause, the list goes on. Feeling like you're making a difference can do wonders to improve self-esteem.
• Have fun - enjoy spending time with the people you care about and doing the things you love.

It's never too late to build or improve self-esteem. In some cases, a teen may need the help of a mental health professional, like a therapist or psychologist, to help heal emotional hurt and build healthy, positive self-esteem. A therapist can help a teen to learn to love herself and realize that her differences make her unique.

So, what's the payoff? Self-esteem plays a role in almost everything you do - teens with high self-esteem do better in school and enjoy it more and find it easier to make friends. They tend to have better relationships with peers and adults, feel happier, find it easier to deal with mistakes, disappointments, and failures, and are more likely to stick with something until they succeed. Improving self-esteem takes work, but the payoff is feeling good about yourself and your accomplishments.

next: Difference Between Sex and Love

"All of us who are happy have the intention of being happy. It seems to me that intention is the key."
- Janet Jantzen

1) Responsibility
2) Deliberate Intent
3) Acceptance
4) Beliefs
5) Gratitude
6) This Moment
7) Honesty
8) Perspective

2) Make Happiness A Deliberate Intention

How often do you base whether you'll be happy or not, on the circumstances and conditions in your life? "When this happens, I'll be happy. When I get this house, car, relationship, job, this problem is solved, have self esteem, get out of this marriage (the list is endless) ... thenI'll be happy."

What if your happiness was...
More important than changing?
More important than getting what you want?
More important than making more money?
More important than being healthy?
More important than having friends?
More important than being respected?
More important than having the right career?
More important than being in a great relationship?

What if you could be happy while pursuing the things you want? Whose to say you can't? Is there any reason you can't experience joy while creating the life you want?

What we focus on becomes larger in our lives. If you focus on feeling happy, you will feel happier. Consider this. If you don't have to use unhappiness to motivate yourself to accomplish something, you could pursue your desires while being happy. You could feel good, right here, right now. It's all about setting the intention to feel good at the top of your list. To understand this more fully, I recommend you read Emotional Options by Mandy Evans.

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One of the surprising and amazing results of deliberately making happiness important in your life, is how much more effective you will be at creating what you want!

next: 8 Ways To Happiness: Acceptance

"Most folks are about as happy as they make up their minds to be."
- Abraham Lincoln

So if happiness is so important to us, and its what everyone seeks, then why aren't there any classes on how to be happy? No society, past or present, has put any emphasis on teaching people to experience what we all yearn for. You'd think with the magnitude of the role happiness plays in our lives, that there would be some type of education on the subject. Ever seen "A Study in Happiness" offered at school? No, of course not.

I've racked my brain trying to figure out why we don't teach people about how to help themselves feel good, and I think it comes down to one reason. Society, as a whole, has some pretty big misconceptions about what it means to be happy. We have passed down from generation to generation the belief that happiness, or unhappiness, can be attributed to external causes. We've been told that other people and the circumstances make us happy or unhappy. That our happiness is outside ourselves. Here's what Richard Evans has to say about happiness and society.

"The Pursuit of Happiness"

There are some fine distinctions to be found in the now immortal phrase, "Life, liberty, and the pursuit of happiness." Life is eternal; liberty, an inalienable right, but with happiness - we are offered only the right to pursue it! We can give a man his liberty but not so his happiness. We can help, but ultimately he has to help himself to happiness. This all men have in common, we are searching for happiness. No one wants to be unhappy; no one deliberately sets out to try to make a muddle of his life.

Among the many misconceptions concerning this thing so much pursued are these: (One) That money makes happiness. False. It may help or it may hinder. Some men have sold their happiness, but no one was ever able to buy it. (Two) That pleasure is the same as happiness. False. You can wear yourself ragged in pursuit of pleasure and still wake up in dull despair. (Three) That fame brings happiness. False. The record eloquently indicates otherwise. (Four) That happiness must be found in far places. False again. We carry it with us.

If there were no reasonable chance of finding happiness, we had just as well ring down the curtain on time and eternity, for happiness is properly the chief business and ultimate aim of life. "Men are, that they might have joy." But there is no point in pursuing it where it never was and never will be found. No one ever over took anything -- including happiness -- by pursuing it on the wrong road. If we want it, we had better look for it where it is."

Since society believes happiness comes from things and events, it's focus is on classes that help you get things and events. The most important lessons are left up to you to sort out. Who am I? What do I believe? How can I be happy?

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next: Using Unhappiness As Motivation