Obsessive-Compulsive and Related Disorders.

By David Joel Miller.

Obsessive-Compulsive Related Disorders.

Obsessive-Compulsive and Related Disorders.
Photo courtesy of Pixabay.com

Obsessive-compulsive is a label that is frequently misused. Most people, when they say they are obsessive-compulsive, mean that they have strong preferences for the way they want the thing to be done. In the mental health field, what we mean by Obsessive-Compulsive Related Disorders are a group of disorders which seriously interfere with a person’s relationships, their ability to work, cause them distress, or prevent them from engaging in other important activities.

A personal story about compulsions to illustrate this difference.

I have a preferred breakfast meal. It comes frozen and is relatively inexpensive. Each week when I do the grocery shopping, I buy enough for the following week. I tend to eat this meal every day. Should I end up traveling, or get behind schedule I’m open to eating something else.

Someone with OCD or a related disorder might feel that their failure to eat the required breakfast, could cause their day to be ruined. They might believe, even though they know it is illogical, that their failure to eat the required breakfast, in a specific order, could result in someone starving to death, or harm coming to a family member. These beliefs that their actions or inactions, can cause harm results in an overwhelming compulsion to perform actions.

I have used an extremely exaggerated example here, but I hope you can see the difference between an extremely strong preference and a compulsion. A compulsion is something you feel forced to do even when it makes no sense. It is as if the person with OCD is being controlled by an outside force.

Defining obsessions and compulsions.

Obsessions are persistent, unwanted, and intrusive thoughts, urges, or pictures that you can’t get out of your head. Compulsions are the things people feel required to do to reduce the tension caused by the obsessions. These behaviors are often done a specific number of times. Compulsions may involve inflexible rules which must be obeyed to prevent something bad happening. Some Obsessive-Compulsive Related Disorders involve self-injury, like hair pulling or skin picking, which continues despite efforts reduce or stop the behavior.

Classifying Obsessive-Compulsive Related Disorders.

In the past, Obsessive-Compulsive Related Disorders were scattered throughout the diagnostic manual. Some of these disorders were in the chapter on anxiety; some were mixed in with impulse control disorders, others were under somatoform disorders. A few were not even recognized as mental illnesses in the past. In the most recent DSM-5, these issues were brought together in a single Obsessive-Compulsive and Related Disorders chapter.

Sometimes it’s hard for professionals to diagnose which disorder a person has. It is possible for one person to have several of the Obsessive-Compulsive Related Disorders. Many people with Obsessive-Compulsive Related Disorders also have anxiety disorders, trauma and stressor-related disorders and some form of depression.

OCD leads the Obsessive-Compulsive Related Disorders parade.

Among the Obsessive-Compulsive Related Disorders, the best-known disorder is Obsessive-Compulsive Disorder, a serious mental health issue which is estimated to affect between 1% and 2% of the population worldwide.

Other Obsessive-Compulsive Related Disorders include Body Dysmorphic Disorder, Hoarding Disorder, Trichotillomania, (hair pulling), and excoriation (skin picking). All of these disorders significantly interfere with people’s lives. Symptoms in these disorders recur, despite repeated efforts to control or stop the Obsessive-Compulsive Related Behaviors.

Substances and medications can cause, or induce, Obsessive-Compulsive Related Disorders. Some medical conditions can also cause obsessive-compulsive behaviors. In the DSM-5 they are also seven other conditions lumped together under the heading Other Specified Obsessive-Compulsive Disorders. One of those conditions is Obsessional Jealousy. This is one of the few times jealousy counts as a symptom of a mental health disorder. More on Obsessional Jealousy in a future post.

Treatment for Obsessive-Compulsive Related Disorders.

The primary treatment for Obsessive-Compulsive Disorder (OCD) is exposure and response prevention therapy. While exposure and response prevention therapy has some similarities to systematic desensitization, which is used to treat specific phobias, relatively few therapists are trained in exposure and response prevention therapy.

One resource you may want to consult is the WordPress blog ocdtalk.  http://ocdtalk.wordpress.com/

For more information on Obsessive-Compulsive and Related Disorders see:

Obsessive-Compulsive Related Disorders category

Obsessive-Compulsive Disorder (OCD)

Body Dysmorphic Disorder

Hoarding Disorder

Trichotillomania, (hair pulling)

Excoriation (skin picking)

Obsessive-Compulsive Personality Disorder

David Joel Miller MS is a Licensed Marriage and Family Therapist (LMFT) and a Licensed Professional Clinical Counselor (LPCC.)  Mr. Miller provides supervision for beginning counselors and therapists and teaches at the local college in the Substance Abuse Counseling program.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

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PTSD or Acute Stress?

By David Joel Miller

What’s the difference between PTSD and Acute Stress?

Stressed

Feeling stressed out?
Photo courtesy of Pixabay.com

PTSD, Post-Traumatic Stress Disorder has made the news a lot recently. This is a good thing. More recognition of PTSD should result in more treatment and less suffering from those who have PTSD. Stress caused problems may or may not be from a Trauma.

What hasn’t gotten as much notice and should have, is the role of Acute Stress Disorder in the events that knock people down and cause a lot of suffering. Acute Stress Disorder creates a lot of problems for a lot of people. Reactions to severe stress can cause long-term changes in people’s feelings and behaviors. Many of these changes go unrecognized and untreated. Acute Stress Disorder may be missed more often than it is diagnosed. More on that later in this blog post.

Stress can harm you.

We know stress is a problem a lot of the time, for a lot of people. Outside the field of mental health, there are lots of blog posts and books on stress, what it is and how to deal with it.  I have written posts about stress and managing it for those of you who have too much stress in your life even if it does not get you a diagnoses or disability.

Stress, plain simple stress, can break people down even if they never meet the criteria for a mental illness. Think of stress like this:

Remember those spectacular car crashes at those televised car races? Some of those crashes were the result of car parts (or drivers) under stress. All day, for hundreds of miles that car and that poor car part, ran hard and fast. The stress just kept coming, then suddenly that part breaks, that car goes all which way and the crash occurs.

Stress on people can be like that. Too much stress too long and the person develops mental health problems. Some of those problems need a day off, others become diagnosable illnesses. In the past, we tended to think of stress related disorders like Post-Traumatic Stress Disorder (PTSD) as close cousins to Anxiety. That has started to change.

Beginning soon mental health professionals will begin to use new coding systems. The DSM-5 or the newer ICD codes. In those systems, Stress and Trauma-Related Disorders get their own chapter. While Stressor-Related Disorders can cause anxiety and have some symptoms in common with anxiety disorders they also have some differences.

Trauma- and Stressor-Related Disorders.

From the day you are born till the day you die too much stress can cause you a problem. One key factor in Trauma- and Stressor-Related Disorders is that there has to be a specific thing that happened to you, the stressor. Trauma is the king of all stressors.

So these things do not just suddenly happen for no reason and they are presumably not something you are born with. This fuzzes up the expression that mental illness is a brain disorder, in that the cause of these disorders are things that happen to you.

If life events result in acquiring a mental illness, then events, as in therapy and learning, can be helpful in treating that disorder.  Much of the treatments for stressor-related disorders are cognitive type therapies.

Trauma and Stressor-Related Disorders also can have features that are similar, we might even say overlap, depression, anxiety, obsessive-compulsive and the often overlooked dissociation. Not every other mental illness is caused by stress or trauma. We just need to be aware that sometimes there can be connections. This similarity to other issues results in a lot of stress-related disorders not being diagnosed until years later when the person is severely mentally ill or disabled.

What is Acute Stress Disorder and why is it important?

Acute Stress Disorder has two sets of “symptoms,” the things people experience that are a problem for them and the technical things professionals use to give out the diagnosis.

Some of the things you might experience as a result of having Acute Stress Disorder are also symptoms of other mental health issues or other mental illnesses. There are a variety of diagnoses that someone might get as a result of injuries they sustained due to stress.

These symptoms can impact your life in long-term ways. People may find their personality has changed.

Poor or no sleep is a cause for worry. Poor sleep now, predicts mental health issues down the road. In the aftermath of stressors, many people report that they do not sleep well. Some report bad dreams, nightmares or night terrors. A few days of bad sleep after you are stressed and you should get back to normal. If the sleep disturbance goes on for very long it starts to change your functioning and your life.

Panic attacks are common in the first month after a severe life stressor. The time period of thirty days becomes important when we try to separate Acute Stress Disorder from other problems. This panic attack may first be experienced immediately after a stressful incident and then go on to become Panic Disorder.

If you have been through a severely stressful incident it is not unusual for you to blame yourself for not expecting it, not doing something differently and not being able to prevent it. Rationally you should know that it may not have been possible to prevent what happened, but people commonly experience guilt or even shame over not being able to stop that trauma.

After a trauma, some people report that the happiness or joy has been sucked out of life. They stop caring about themselves or others. They may begin to take risks that they never took before. They drive too fast, gamble, take more sexual risks. Some trauma or stress survivors become angry, bitter and more argumentative. They get in more fights, verbally and physically. It is as if they have changed who they are and they no longer care.

If you knew about the traumatic experience you might understand why the changes in behavior occurred. If that trauma survivor kept the trauma a secret, and many do, you might think this was all bad behavior.

Trauma survivors, even those who do not go on to develop more serious mental health problems, may become confused or think they are losing their minds. They may get tested for or treated for concussions. They could have both a concussion and a longer term mental illness.

After a trauma or a crisis from the buildup of long-term stress, you may find it difficult to go back to places that remind you of the trauma. People become unable to go back to work, visit certain places or they avoid social situations.

How do professionals diagnose Acute Stress Disorder and why is that diagnosis so rare?

The official criteria for Acute Stress disorder are found in the DSM-5 or DSM-4-TR if your agency is still using that one. The DSM’s are published by the APA and you can order the full text from them. Here is my oversimplified plan language version of that criteria. I hope I do not make errors in this explanation.

A warning

Self-diagnosis or diagnosing your family and friends is a risky behavior. If after reading all this you believe you or someone close to you has Acute Stress Disorder, another Trauma- and Stressor-Related Disorder or any other mental health problem, go see a professional and get it checked out. There are treatments available for all of these conditions and there is no need to suffer alone.

There are 5 things the professional needs to look at for Acute Stress Disorder

  1. Did you experience a really bad Traumatic Stressor Recently?

There is a “waiting period” of 3 days. Most people have difficulty for a few days after a serious trauma. Then there is the requirement that the problems you are having must last UP TO 30 days. This is a huge thing for Acute Stress Disorder. If your problems go on more than 30 days the name we call this (diagnostic code) changes to something more long-term like Post-Traumatic Stress Disorder (PTSD.)

The result of this time factor is that a whole lot of people who have this problem do not ever get diagnosed. In outpatient settings, it can take 30 days to get your insurance settled and to get in for an appointment. In hospital settings this diagnoses may be found more often using “strict criteria” but in most other places the results of trauma do not show up till years later and the issues then get called something other than Acute Stress Disorder.

  1. You must have at least 9 of 14 possible symptoms.

This leads to lots of ifs. Depending on who is doing the evaluating some things get counted and not others. Another problem is that trauma victims do not like to talk about their trauma. One symptom is avoiding reminders of the trauma and talking about it again is a reminder. So not having said they have a symptom can rule people out who did, in fact, meet criteria and do have Acute Stress Disorder.

I will not go through all the 14 criteria here, just a few of the big ones.

You can’t get the trauma or stressor out of your head.

This is sometimes called intrusive thoughts. You may also have dreams and things will trigger the memories so much you begin avoiding those emotional triggers. After the 30 days waiting period this may become PTSD.

From now on you are in a bad mood and can’t get out of it.

The happiness and joy get sucked out of your life. You are in a bad mood all the time for no apparent reason. Some people, kids, and men mostly, become irritable, angry and possibly violent. In my view, Acute Stress Disorder and its aftermath are involved in a lot of these unexpected violent incidents.

People may “space out.”

Researchers have noted that zoning out, technically called dissociation, is common, almost universal in the first three days after a trauma. If that dissociation continues after the third day we think it indicates Acute Stress Disorder. After thirty days that dissociation gets diagnosed as something else. I believe that there are more cases of dissociation than get recognized. Some are ignored and some get another name like Psychosis NOS (not otherwise specified.)

Acute Stress Disorder is time limited.

Acute Stress Disorder must last more than three days and less than thirty. Beyond the thirty the name gets changed. Many people try their hardest to cope and do not report symptoms. They can’t work and go on disability for a while until that runs out. Some end up alone and homeless. They get angry, depressed or anxious and their relationships suffer. They develop panic attacks or obsessive-compulsive disorders. Some get other mental illness diagnoses.

Having Acute Stress Disorder really matters.

This disorder, like most things we call mental illness, really makes a difference in people’s lives. It interferes with their ability to work or go to school. Having Acute Stress disorder can interfere with or destroy relationships with family and friends. It causes the people who have it a lot of suffering even when they can’t express how or why they are suffering. It can also damage other important areas of your life, such as religious observances, hobbies and so forth.

Acute Stress Disorder is not something else.

Professionals are continually reminded to avoid putting the wrong label (diagnoses) on things. If you only have these symptoms because of a medical issue or because you are drunk or high when you have the symptoms then we do not say you have Acute Stress Disorder.

This does not mean that people with medical problems or who use drugs can’t get Acute Stress Disorder, we just want to be careful we do not get the diagnosis wrong and count as symptoms things that were not caused by the stressor.

One last thing to consider.

There are two other groups of mental health problems in the Trauma and Stressor-Related Disorder chapter. Attachments Disorders, those problems that begin in very early life and Adjustment Disorders, which are reactions to stress that may not be life-threatening but have a huge impact on your mental health. These groups of life problems, sometimes, they rise to the level of a mental illness or a mental health problem.

I have written elsewhere about how Attachment Disorders and Adjustment Disorders can wreck someone’s life if not attended to. I am out of time and space here to talk about these other groups of Trauma and Stressor-Related Disorders.

Hope this post did not run too long. I do not think I have written a post of this length in the past but this seemed like a topic that needed more space and discussion.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Systematic desensitization – conquering fear.

By David Joel Miller

Anxiety can be a stubborn foe.

Pain, Anxiety, Depression, Stress

Anxiety, Fear, and Stress
Photo courtesy of Flickr (marsmet481)

It is tempting to avoid the things you fear and to find ways to numb those unpleasant feelings. Some people use alcohol or sleeping pills other people use avoidance. But eventually, you have to face that fear or be taken prisoner by your fear.

You can’t get over something you don’t face. Sometimes the only way out of a burning building is through the door that is on fire. To begin with, we won’t ask you to walk through the flames, just to look at the door and see how your fear that it might be on fire on the other side is keeping you a prisoner in that room.

Systematic desensitization reduces the impact of fears.

One way of domesticating the anxiety monster is a technique called systematic desensitization. This is an especially effective technique for taming fears or anxiety when those anxieties are a fear of one very specific thing.

Some of these item fears are so specific we name them Specific Phobias. Meaning you are deathly afraid of one particular thing even if you are never around that thing.

Some of these specific phobias are so terrifying to the people with that particular specific phobia that I can’t even write the word out or they would stop reading. So let’s start with an exaggerated and somewhat humors example of how this specific desensitization could work.

Say there is this person that is deathly afraid of crackers. (The little packaged edible kind.)

If you know who I am talking about here please do not let on. That person’s family laughed at him.  But try as he would he just could not bear to eat at a table where there were crackers. Eventually, this got so bad that I – I mean he – could not eat with his family when they were having soup for fear there would be crackers present.

This fear became progressively worse. Soon eating out was impossible because there might be crackers all around. Eventually, even commercials for crackers or the mention of the word might provoke a panic attack. Something needed to be done.

The cure for cracker or saltines phobia? Systematic desensitization.

So off to the therapist this sufferer from cracker phobia went. Here are the steps in a recovery from cracker phobia.

First, you need to be willing to talk about this fear and develop a scale of fear. Something like if we just talk about that fear I – I mean he – had by referring to this as the fear of “You know what.” That would be a 1 on the fear scale.

Actually using the name “Cracker” that scored a two. To see a picture of some crackers in a magazine that would rate a fear factor of 4. Entering at a restaurant where there might or might not be crackers present, that was a 5. Seeing actual crackers, that would be a 6 and witnessing someone eat one that would rank an 8. To have to physically touch a cracker that would rank a 9. To personally eat a cracker that would rate a 10.

Now having developed our scale we would begin to work our way up the scale all the while with the therapist reassuring the client.

Along the way, the therapist might teach the client some relaxation techniques, deep breathing and so on. The theory here is that you can’t really feel two contradictory feelings at the same time. The more you concentrate on your relaxation the more likely you are for the fear, or anxiety if you prefer, to subside.

So over time, the exposure to the dreaded crackers becomes more and more frequent and closer, all the while practicing the relaxations skills.

At the end of treatment, the goal would be for the client to actually open a package of crackers and to eat one while the counselor watched.

Now neither I nor anyone I know has really suffered from a cracker phobia. This cracker fear has been a long time joke in the family. But I hope this has demonstrated how a counselor could help a client overcome a specific phobia that may sound funny to the client’s family and friends but has been causing the client some very real distress.

What are some of the specific phobias that this method is known to work on? Well the number one fear in America, more severe than the fear of death, is the fear of public speaking. Also up there on the list are phobias to snakes and spiders.

Fear of snakes is no big thing for most city dwellers, but if you needed to live and work outdoors this could be a trial. If you worked at the zoo in the reptile house a fear of snakes could cost you your job.

So whatever your fear or specific phobia there are treatments to help you turn that anxiety or fear control back down to a manageable setting.

Similar to systematic desensitization, at least in my book, is the use of exposure and response prevention. People with Obsessive Compulsive Disorder (OCD) develop rituals or routines that they feel the need to perform to reduce the anxiety. If we can expose the person to the thing that they fear and prevent the ritual, then over time the fear diminishes. Combine some relaxation techniques with the exposure and response prevention and you move close to the systematic desensitization approach.

Best wishes on taming those pesky excessive anxiety and fear monsters.

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.

Perfectionism – good thing or bad thing

By David Joel Miller

Is your perfectionism out of control?

Perfectionism

Perfectionism, that constant striving to do everything just right, has been connected with high accomplishment. Parents often believe the way to get the most out of their children is to push them for ever-increasing goals. Parents may feel their role is to point out their child’s failings to inspire them to do better.

People who aim for perfection set higher goals and may achieve grander things than those who have lower expectations. Does perfectionism really inspire more effort and accomplishment? Or does perfectionism have a dark side?

Perfectionism’s dark side.

Perfectionism has been linked to high worry, fear of failure, eating disorders, depression, obsessive-compulsive disorder and an increased risk of suicide. Perfectionists can suffer unmercifully and they can make those around them miserable also.

Perfectionism, Learned or Genetic?

In this conversation about perfectionism, I am talking about the learned variety. Anything which is learned can be unlearned. There are those whose perfectionist tendencies are a part of Obsessive Compulsive Disorder or Obsessive Compulsive Personality Disorder. These disorders appear to have a physical or genetic basis in addition to any learned component. If you have OCD or OCPD medication and therapy may be helpful in managing your disorder so can other recovery methods.

Perfectionism has mixed results.

Why does this striving for perfection sometimes result in champions and other times in learned hopelessness and failure? The key lies in how the perfectionist was raised and in how they are raising themselves. What were the messages the perfectionist received in childhood from whatever source and how have they gone on to adopt those “need to be perfect” themes?

One way in which setting high standards goes wrong and results in unhealthy perfectionism is when caregivers set high standards but are at the same time disapproving of the child. If the parent’s approval of the child is contingent on success, the only way a child can get that parents love is to always be perfect and win at everything.

After receiving this message for a while the perfectionist internalizes the message “I am what I accomplish, if I don’t do everything perfectly I am no good.” Not only do they believe this message but they repeatedly retell themselves this story.

No matter how hard this child tries it is never enough, a little league championship should have been a World Series win and gold medal should have been the most Gold Medals ever. The target keeps changing and the child internalizes this belief that they will never be good enough and that their self-worth is dependent on never making a mistake.

Homes that produce unhealthy perfectionists are high in control, the parent is in charge of most everything, but they are low in warmth and affection. To win is to be loved. To lose is to face rejection. Perfectionists go on to love or reject themselves based on their successes and failures.

Parental acceptance in children and presumably self-acceptance in adulthood appear to be the best antidotes to perfectionism, self-doubt and excessive worry about mistakes.

If you didn’t get acceptance in childhood or didn’t get as much as you feel you need, begin today to accept yourself. Whatever you do is good enough. This is tough medicine for the perfectionist to swallow. Something about that constant struggle to be perfect reduces anxiety and seems protective at the time until the perfectionist fails at something.

If how you feel about yourself or how others feel about you is dependent not on effort but upon results you are in for a rough ride. Smooth out the road ahead by cutting yourself some slack.

Self-esteem for perfectionists fluctuates widely. When they achieve their goals they feel good about themselves and when they fall short they are overly negative and pessimistic. You should not base your self-esteem on what you win or lose. You are not a better person for being a perfectionist and may, in fact, be a pain to be around.

Parents who over control children and do not allow their child to develop a sense of self-control do not prevent the child from making mistakes. These parents prevent their child from learning how to make choices.

If that happened to you, stop making the same mistake with yourself and start accepting that most things in life do not need to be perfect. The time used to make one thing perfect is time taken away from other things you should do, like being present with your children and not passing the perfectionist disorder on to them.

If you are plagued by perfectionism and it has made you or those around you miserable are you ready to seek help for your perfectionism?

Staying connected with David Joel Miller

Two David Joel Miller Books are available now!

Bumps on the Road of Life. Whether you struggle with anxiety, depression, low motivation, or addiction, you can recover. Bumps on the Road of Life is the story of how people get off track and how to get your life out of the ditch.

Casino Robbery is a novel about a man with PTSD who must cope with his symptoms to solve a mystery and create a new life.

For these and my upcoming books; please visit my Amazon Author Page – David Joel Miller

Want the latest blog posts as they publish? Subscribe to this blog.

Want the latest on news from recoveryland, the field of counseling, my writing projects, speaking and teaching? Please sign up for my newsletter at – Newsletter. I promise not to share your email or to send you spam, and you can unsubscribe at any time.

For more about David Joel Miller and my work in the areas of mental health, substance abuse, and Co-occurring disorders see my Facebook author’s page, davidjoelmillerwriter. A list of books I have read and can recommend is over at Recommended Books. If you are in the Fresno California area, information about my private practice is at counselorfresno.com.