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The subjects were encouraged to take an active part in the programme cheap malegra fxt 140mg fast delivery erectile dysfunction diagnosis, they received information about the vicious circle of pain buy malegra fxt 140mg on line impotence lexapro, muscular tension buy cheap malegra fxt 140 mg on line erectile dysfunction quiz, demoralization and about how the programme would improve their sense of self-control over their thoughts, feelings and behaviour. The subjects were taught how to control their responses to pain using progressive muscle relaxation. They were given a home relaxation tape, and were also taught to use imagery techniques and visualization to distract themselves from pain and to further improve their relaxation skills. The subjects were asked to complete coping cards to describe their maladaptive thoughts and adaptive coping thoughts. The groups were used to explain the role of fear, depression, anger and irrational thoughts in pain. The subjects were encouraged to use distraction tech- niques to reduce depression and pain perception. They were encouraged to shift their focus from those activities they could no longer perform to those that they could enjoy. Activity goals were scheduled and pleasant activities were reinforced at subsequent groups. Time 1 to time 2 The results showed significantly different changes between the two groups in all their ratings. Compared with the control group, the subjects who had received cognitive behavioural treatment reported lower pain intensity, lower functional impairment, better daily mood, fewer bodily symptoms, less anxiety, less depression, fewer pain-related bodily symptoms and fewer pain-related sleep disorders. Time 1 to time 2 to time 3 When the results at six-month follow-up were included, again the results showed sig- nificant differences between the two groups on all variables except daily mood and sleep disorders. The role of adherence The subjects in the treatment condition were then divided into those who adhered to the recommended exercise regimen at follow-up (adherers) and those who did not (non-adherers). The results from this analysis indicate that the adherers showed an improvement in pain intensity at follow-up compared with their ratings immediately after the treatment intervention, whilst the non-adherers ratings at follow-up were the same as immediately after the treatment. Conclusion The authors conclude that the study provides support for the use of cognitive– behavioural treatment for chronic pain. The authors also point to the central role of treatment adherence in predicting improvement. They suggest that this effect of adherence indicates that the improvement in pain was a result of the specific treatment factors (i. However, it is possible that the central role for adherence in the present study is similar to that discussed in Chapter 13 in the context of placebos, with treatment adherence itself being a placebo effect. Placebos and pain reduction Placebos have been defined as inert substances that cause symptom relief (see Chapter 13). Beecher (1955) suggested that 30 per cent of chronic pain sufferers experience pain relief after taking placebos. A sham heart bypass operation involved the individual believing that they were going to have a proper operation, being prepared for surgery, being given a general anaesthetic, cut open and then sewed up again without any actual bypass being carried out. The individual therefore believed that they had had an operation and had the scars to prove it. However, the results suggested that angina pain can actually be reduced by a sham operation by comparable levels to an actual operation for angina. This suggests that the expectations of the individual changes their perception of pain, again providing evidence for the role of psychology in pain perception. The psychological treatment of pain includes respondent, cognitive and behavioural methods. These are mostly used in conjunction with pharmacological treatments involving analgesics or anaesthetics. The outcome of such interventions has tradition- ally been assessed in terms of a reduction in pain intensity and pain perception. Recently, however, some researchers have been calling for a shift in focus towards pain acceptance. This methodology encourages the participant to describe their experiences in a way that enables the researcher to derive a factor structure. From their analysis the authors argued that the acceptance of pain involves eight factors. These were taking control, living day-by-day, acknowledging limitations, empowerment, accepting loss of self, a belief that there’s more to life than pain, a philosophy of not fighting battles that can’t be won and spiritual strength. In addition, the authors suggest that these factors reflect three underlying beliefs: (i) the acknowledgment that a cure for pain is unlikely; (ii) a shift of focus away from pain to non pain aspects of life; and (iii) a resistance to any suggestion that pain is a sign of personal weakness. In a further study McCracken and Eccleston (2003) explored the relationship between pain acceptance, coping with pain and a range of pain-related outcomes in 230 chronic pain patients. The results showed that pain acceptance was a better predictor than coping with pain adjustment variables such as pain intensity, disability, depression and anxiety and better work status. The authors of these studies suggest that the extent of pain acceptance may relate to changes in an individual’s sense of self and how their pain has been incorporated into their self- identity. In addition, they argue that the concept of pain acceptance may be an import- ant way forward for pain research, particularly, given the nature of chronic pain. Self-reports Self-report scales of pain rely on the individuals’ own subjective view of their pain level. Describe your pain: no pain, mild pain, moderate pain, severe pain, worst pain) and descriptive questionnaires (e. Some self-report measures also attempt to access the impact that the pain is having upon the individuals’ level of functioning and ask whether the pain influences the individuals’ ability to do daily tasks such as walking, sitting and climbing stairs. Observational assessment Observational assessments attempt to make a more objective assessment of pain and are used when the patients’ own self-reports are considered unreliable or when they are unable to provide them. For example, observational measures would be used for children, some stroke sufferers and some terminally ill patients. Observational measures include an assessment of the pain relief requested and used, pain behaviours (such as limping, grimacing and muscle tension) and time spent sleeping and/or resting. Physiological measures Both self-report measures and observational measures are sometimes regarded as unreliable if a supposedly ‘objective’ measure of pain is required. In particular, self- report measures are open to the bias of the individual in pain and observational measures are open to errors made by the observer. Such measures include an assess- ment of inflammation and measures of sweating, heart rate and skin temperature. However, the relationship between physiological measures and both observational and self-report measures is often contradictory, raising the question ‘Are the indi- vidual and the rater mistaken or are the physiological measurements not measuring pain? However, the gate control theory, developed in the 1960s and 1970s by Melzack and Wall, included psychological factors. As a result, pain was no longer understood as a sensation but as an active perception. Due to this inclusion of psychological factors into pain perception, research has examined the role of factors such as learning, anxiety, fear, catastrophizing, meaning, attention and pain behaviour in either decreasing or exacerbating pain. As psychological factors appeared to have a role to play in eliciting pain perception, multi- disciplinary pain clinics have been set up to use psychological factors in its treatment. Recently, researchers have suggested a role for pain acceptance as a useful outcome measure and some research indicates that acceptance, rather than coping might be a better predictor of adjustment to pain and changes following treatment.

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Zygote Chapter 14: Carrying Life Forward: The Female Reproductive System 225 Think you’ve conquered this process? Fill in the blanks to complete the following sentences: Meiosis produces sperm and ovum cheap 140 mg malegra fxt with mastercard erectile dysfunction drugs without side effects, which contributes to making a 41 order malegra fxt 140 mg on-line erectile dysfunction causes prescription drugs. The number of chromosomes is cut in half during the first meiotic division purchase malegra fxt 140 mg otc erectile dysfunction diabetes permanent, producing gametes that are 45. But that doesn’t mean that sexual intercourse outside that time frame can’t lead to pregnancy. Research indicates that spermatozoa can survive up to seven days inside the uterus and Fallopian tubes. If a sperm is still motile — that is, if it’s still whipping its flagellum tail — when an ovum comes down the tube, it will do what it was made to do and penetrate the ovum’s membrane. When the sperm penetrates the ovum, it releases enzymes that allow it to digest its way into the ovum, leaving its flagellum behind. After that first sperm penetrates, the mem- brane instantly solidifies around the ovum, preventing any other sperm from getting inside. Over the next three to five days, the zygote moves through the Fallopian tube to the uterus, undergoing cleavage (mitotic cell division) along the way: Two cells become four smaller cells, four cells become eight smaller cells, and then those eight cells become a solid 16-cell ball called a morula. After five days of cleavage, the cells form a hollow ball of approximately 32 cells called a blastula, or blasto- cyst. The inner hollow region is called the blastocoele, and the outer-layer cells are called the trophoblast. Within three days of its arrival in the uterine cavity (generally within a week of fertiliza- tion), the blastocyst implants in the endometrium, and some of the blastocyst’s cells — called totipotent embryonic stem cells — organize into an inner cell mass called the embryonic disk, or embryoblast. Over time, the embryonic disk differentiates into the tis- sues of the developing embryo (see Figure 14-4). Cells above the disk form the amniotic cavity, and those below form the gut cavity and two primitive germ layers. The layer near- est the amniotic cavity forms the ectoderm while that nearest the gut cavity forms the endoderm. Between the two layers, additional ectodermal cells develop to form a third layer, the mesoderm. The ectoderm forms skin and nerve tissue; the mesoderm forms bones, cartilage, connective tissue, muscles, and organs; and the endoderm forms the linings of the organs and glands. To keep these terms straight, remember that endo– means “inside or within,” ecto– means “outer or external,” and meso– means “middle. In the fourth week of development, the embryonic disk forms an elongated structure that attaches to the developing placenta by a connecting stalk. A head and jaws form while primitive buds sprout; the buds will develop into arms and legs. During the fifth through seventh weeks, the head grows rapidly and a face begins to form (eyes, nose, and a mouth). After eight weeks of development, the embryo begins to have a more human appearance and is referred to as a fetus. The outer cells of the embryo, together with the endometrium of the uterus, form the placenta, a new internal organ that exists only during pregnancy. The placenta attaches the fetus to the uterine wall, exchanges gases and waste between the maternal and fetal bloodstreams, and secretes hormones to sustain the pregnancy. Chapter 14: Carrying Life Forward: The Female Reproductive System 227 Cleavage 8-cell stage 4-cell stage 2-cell stage Zygote Morula Egg nucleus Sperm nucleus Corpus luteum Sperm cells Blastocyst Maturing follicle Figure 14-4: Beginning of Ovary implantation Egg cell Embryonic develop- Fertilization ment. Now that you’ve refreshed your memory a bit about how babies are made (beyond the birds and bees talks), try the following practice questions: 49. Growing from Fetus to Baby Pregnancy is divided into three periods called trimesters (although many new parents bemoan a postnatal fourth trimester until the baby sleeps through the night). The first 12 weeks of development mark the first trimester, during which organogenesis (organ formation) is established. During the second trimester, all fetal systems continue to develop and rapid growth triples the fetus’s length. The overall growth rate slows in the third trimester, but the fetus gains weight rapidly. At the end of the second month (when the terminology changes from “embryo” to “fetus”), the head remains overly large compared to the developing body, and the limbs are still short. The circulatory (cardiovascular) system supplies blood to all the developing extremities, and even the lungs begin to practice “breathing” amniotic fluid. By the end of the third month, the external genitalia are visible in the male (ultrasound technicians call this a “turtle sign”). The body grows rapidly during the fourth month as legs lengthen, and the skele- ton continues to ossify as joints begin to form. Growth slows during the fifth month, and the legs reach their final fetal propor- tions. Hair grows on the head, and lanugo, a profusion of fine soft hair, covers the skin. The fetus is between 11 and 14 inches long and weighs a bit less than 1 ⁄12 pounds. During the seventh month, skin becomes smoother as the fetus gains subcuta- neous fat tissue. During the eighth month, subcutaneous fat increases, and the fetus shows more baby-like proportions. During the ninth month, the fetus plumps up considerably with additional sub- cutaneous fat. Much of the lanugo is shed, and fingernails extend all the way to the tips of the fingers. The average newborn at the end of the ninth month is 20 inches long and weighs about 7 ⁄12 pounds. The following practice questions deal with the development of the fetus during its 40 weeks in the womb: 59. By the 19th week of gestation Chapter 14: Carrying Life Forward: The Female Reproductive System 229 60. Describe one new fetal development for each month: 3rd month: ________________________________________________________________________ 4th month: ________________________________________________________________________ 5th month: ________________________________________________________________________ 6th month: ________________________________________________________________________ 7th month: ________________________________________________________________________ 8th month: ________________________________________________________________________ 9th month: ________________________________________________________________________ Growing, Changing, and Aging After a baby arrives, the female reproductive system goes into a different form of overdrive. Throughout the pregnancy, the placenta has been producing estrogen and progesterone to sustain the fetus. But after the baby is born, the sudden drop in hor- monal blood levels triggers the pituitary gland to release prolactin, a hormone that stimulates the woman’s mammary glands to secrete milk in a process called lactation. First, however, the glands produce colostrum, a thin, yellowish fluid rich in antibodies and minerals to sustain a newborn. Both colostrum and milk flow from a number of lobes inside the breast through lactiferous ducts that converge on the nipple. Faced with survival after its physical separation from the mother, a neonate must abruptly begin to process food, excrete waste, obtain oxygen, and make circulatory adjustments. Growth during this period is explosive under the stimulation of circulatory growth hormones from the pituitary gland, adrenal steroids, and thyroid hormones. The infant’s deciduous teeth, also called baby or milk teeth, begin to form and erupt through the gums.

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Barrett [N]ursing diagnosis is a static term that is quite inap- (1998) expanded and updated the methodology by propriate for a dynamic system order malegra fxt 140mg line impotence blood pressure. cheap 140 mg malegra fxt mastercard impotence 18 year old. buy malegra fxt 140mg without prescription impotence statistics. Pattern manifestation knowing is Furthermore, nursing diagnoses are particular- the continuous process of apprehending the istic and reductionistic labels describing cause and human and environmental field (Barrett, 1998). The nursing ian position of the nurse, whereas “knowing” process is a stepwise sequential process inconsistent means to recognize the nature, achieve an under- with a nonlinear or pandimensional view of reality. Intervention means tinuous process whereby the nurse assists clients in to “come, appear, or lie between two things” freely choosing—with awareness—ways to partici- (American Heritage Dictionary, 2000, p. The nurse does not gathered from and about the client, family, or com- invest in changing the client in a particular direc- munity—including sensory information, feelings, tion, but rather facilitates and mutually explores thoughts, values, introspective insights, intuitive with the client options and choices and provides in- apprehensions, lab values, and physiological meas- formation and resources so the client can make in- ures—are viewed as “energetic manifestations” formed decisions regarding his or her health and emerging from the human/environmental mutual well-being. Fifth, all pattern infor- not consistent with Rogers’ postulate of pandimen- mation has meaning only when conceptualized and sionality and principles of integrality and helicy. Synopsis and Rather, acausality allows for freedom of choice and synthesis are requisites to unitary knowing. The goal of Synopsis is a process of deliberately viewing to- voluntary mutual patterning is the actualization of gether all aspects of a human experience (Cowling, potentialities for well-being through knowing par- 1997). The constituents for the development of Rogerian prac- human and environmental fields are inseparable. Cowling (1993b, 1997) refined the Thus, any information from the client is also a re- template and proposed that “pattern appreciation” flection of his or her environment. Physiological was a method for unitary knowing in both and other reductionistic measures have new mean- Rogerian nursing research and practice. For preferred the term “appreciation” rather than “as- example, a blood pressure measurement inter- sessment” or “appraisal” because appraisal is associ- preted within a unitary context means the blood ated with evaluation. Appreciation has broader pressure is a manifestation of pattern emerging meaning, which includes “being full aware or sensi- from the entire human/environmental field mutual tive to or realizing; being thankful or grateful for; process rather than being simply a physiological and enjoying or understanding critically or emo- measure. Pattern apprecia- unitary and not particular by reflecting the unitary tion has a potential for deeper understanding. The first constituent for unitary pattern appreci- The sixth constituent in Cowling’s practice ation identifies the human energy field emerging method describes the format for documenting and from the human/environment mutual process as presenting pattern information. Pattern manifestations emerging nursing diagnoses and reporting “assessment data” from the human/environment mutual process are in a format that is particularistic and reductionistic the focus of nursing care. Next, the person’s experi- by dividing the data into categories or parts, the ences, perceptions, and expressions are unitary nurse constructs a “pattern profile. Third, “pattern appreciation rizing the client’s experiences, perceptions, and requires an inclusive perspective of what counts as expression inferred from the pattern appreciation pattern information (energetic manifestations)” process. Cowling (1990, 1993b) also identified additional forms of pattern profiles, in- Pattern manifestation knowing and appreciation cluding single words or phrases and listing pattern is the process of identifying manifestations of information, diagrams, pictures, photographs, or patterning emerging from the human/environmen- metaphors that are meaningful in conveying the tal field mutual process and involves focusing on themes and essence of the pattern information. Verifying manifestations (Barrett, 1988), whereas “apprecia- can occur by sharing the pattern profile with the tion” seeks for a perception of the “full force of pat- client for revision and confirmation. Sharing the pattern profile with the client en- enced, perceived, and expressed is a manifestation hances participation in the planning of care and facilitates the client’s knowing participation in the Pattern is the distinguishing feature of change process (Cowling, 1997). Everything The eighth constituent identifies knowing par- experienced, perceived, and expressed is a ticipation in change as the foundation for health manifestation of patterning. Knowing participation in change is being aware of what one is choosing to do, feeling free to do it, doing it intentionally, and being ac- of patterning. The purpose festation knowing and appreciation, the nurse and of health patterning is to assist clients in knowing client are coequal participants. Ninth, pat- tice, nursing situations are approached and guided tern appreciation incorporates the concepts and by a set of Rogerian-ethical values, a scientific base principles of unitary science, and approaches for for practice, and a commitment to enhance the health patterning are determined by the client. The unitary mism, humor, unity, transformation, and celebra- pattern-based practice method consists of two non- tion intentional in the human/environmental field linear and simultaneous processes: pattern manifes- mutual process (Butcher, 1999b, 2000). The focus of nursing care ing an atmosphere of openness and freedom so guided by Rogers’ nursing science is on recognizing clients can freely participate in the process of manifestations of patterning through pattern mani- knowing participation in change. Compassion includes energetic acts ment/health situation is relevant, various health as- of unconditional love and means (a) recognizing sessment tools, such as the comprehensive holistic the interconnectedness of the nurse and client by assessment tool developed by Dossey, Guzzetta, and being able to fully understand and know the suffer- Keegan (2000), may also be useful in pattern know- ing of another, (b) creating actions designed to ing and appreciation. However, all information transform injustices, and (c) not only grieving in must be interpreted within a unitary context. A another’s sorrow and pain, but also rejoicing in an- unitary context refers to conceptualizing all infor- other’s joy (Butcher, 2002b). All information is in- terconnected, is inseparable from environmental context, unfolds rhythmically and acausally, and re- Pattern manifestation knowing and appre- flects the whole. Data are not divided or under- ciation involves focusing on the experi- stood by dividing information into physical, ences, perceptions, and expressions of a psychological, social, spiritual, or cultural cate- health situation, revealed through a rhyth- gories. From a unitary perspec- perceptions, and expressions of a health situation, tive, what may be labeled as abnormal processes, revealed through a rhythmic flow of communion nursing diagnoses, illness or disease are conceptual- and dialogue. In most situations, the nurse can ini- ized as episodes of discordant rhythms or nonhar- tially ask the client to describe his or her health sit- monic resonancy (Bultemeier, 2002). The dialogue is guided toward A unitary perspective in nursing practice leads focusing on uncovering the client’s experiences, to an appreciation of new kinds of information that perceptions, and expressions related to the health may not be considered within other conceptual ap- situation as a means to reaching a deeper under- proaches to nursing practice. Humans are con- using multiple forms of knowing, including pandi- stantly all-at-once experiencing, perceiving, and mensional modes of awareness (intuition, medita- expressing (Cowling, 1993a). Experience involves tive insights, tacit knowing) throughout the pattern the rawness of living through sensing and being manifestation knowing and appreciation process. Pattern information tion of his or her health situation includes his or concerning time perception, sense of rhythm or her experiences. Perception is making and sense of integrity are relevant indicators of sense of the experience through awareness, appre- human/environment/health potentialities (Madrid hension, observation, and interpreting. A person’s hopes and clients about their concerns, fears, and observations dreams, communication patterns, sleep-rest is a way of apprehending their perceptions. In ipation in change provide important information addition, expressions are any form of information regarding each client’s thoughts and feelings con- that comes forward in the encounter with the cerning a health situation. All expressions are energetic manifestations The nurse can also use a number of pattern ap- of field pattern. In rection of change without attachment to predeter- addition to those mentioned in Part 1, Paletta mined outcomes. The process is mutual in that (1990) developed a tool consistent with Rogerian both the nurse and the client are changed with each science that measures the subjective awareness of encounter, each patterning one another and co- temporal experience. The nurse has no investment in grasp meaning, create a meaningful connection, and changing the client in a particular way. Sharing the pattern pro- tional acceptance, while remaining fully open to the file with the client is a means of validating the rhythm, movement, intensity, and configuration of interpretation of pattern information and may pattern manifestations” (Butcher, 1999a, p. However, a meaning- the client facilitates pattern recognition and also ful connection with the client is facilitated by creat- may enhance the client’s knowing participation in ing a rhythm and flow through the intentional his or her own change process. An increased aware- expression of unconditional love, compassion, and ness of one’s own pattern may offer new insight and empathy. Together, in mutual process, the nurse increase one’s desire to participate in the change and client explore the meanings, images, symbols, process.

Background The original stages of change model describes the following stages: s Precontemplation: not seriously considering quitting in the next six months discount 140 mg malegra fxt fast delivery erectile dysfunction treatment in pune. The model is described as dynamic order 140mg malegra fxt with visa erectile dysfunction doctors jacksonville fl, not linear with individuals moving backwards and forwards across the stages discount 140mg malegra fxt fast delivery erectile dysfunction treatment in lucknow. In this study, the authors categorized those in the con- templation stage as either contemplators (not considering quitting in the next 30 days) and those in the preparation stage (planning to quit in the next 30 days). Methodology Subjects A total of 1466 subjects were recruited for a minimum intervention smok- ing cessation programme from Texas and Rhode Island. The majority of the sub- jects were white, female, had started smoking at about 16 and smoked on average 29 cigarettes a day. Design The subjects completed a set of measures at baseline and were followed up at one and six months. Measures The subjects completed the following set of measures: s Smoking abstinence self-efficacy (DiClemente et al. According to this scale, subjects were defined as precontemplators (n = 166), contemplators (n = 794) and those in the preparation stage (n = 506). Results The results were first analysed to examine baseline difference between the three subject groups. The results showed that those in the preparation stage smoked less, were less addicted, had higher self-efficacy, rated the pros of smoking as less and the costs of smoking as more, had made more prior quitting attempts than the other two groups. The results were then analysed to examine the relationship between stage of change and smoking cessation. At both one and six months, the subjects in the preparation stage had made more quit attempts and were more likely to not be smoking. Conclusion The results provide support for the stages of change model of smoking cessation and suggest that it is a useful tool for predicting successful outcome of any smoking cessation intervention. Clinical interventions: promoting individual change Clinical interventions often take the form of group or individual treatment programmes based in hospitals or universities requiring regular attendance over a 6- or 12-week period. These interventions use a combination of approaches that reflect the different disease and social learning theory models of addiction and are provided for those individuals who seek help. Disease perspectives on cessation Within the most recent disease models of addiction, nicotine and alcohol are seen as addictive and the individual who is addicted is seen as having acquired tolerance and dependency to the substance. For example, nicotine fading procedures encourage smokers to gradually switch to brands of low nicotine cigarettes and gradually to smoke fewer cigarettes. It is believed that when the smoker is ready to completely quit, their addiction to nicotine will be small enough to minimize any withdrawal symptoms. Although there is no evidence to support the effectiveness of nicotine fading on its own, it has been shown to be useful alongside other methods such as relapse prevention (for example, Brown et al. Nicotine replacement procedures also emphasize an individual’s addiction and depend- ency on nicotine. For example, nicotine chewing gum is available over the counter and is used as a way of reducing the withdrawal symptoms experienced following sudden cessation. The chewing gum has been shown to be a useful addition to other behavioural methods, particularly in preventing short-term relapse (Killen et al. More recently, nicotine patches have become available, which only need to be applied once a day in order to provide a steady supply of nicotine into the bloodstream. They do not need to be tasted, although it could be argued that chewing gum satisfies the oral component of smoking. However, whether nicotine replacement procedures are actually compensating for a physiological addiction or whether they are offering a placebo effect via expecting not to need cigarettes is unclear. Treating excessive drinking from a disease perspective involves aiming for total abstinence as there is no suitable substitute for alcohol. Social learning perspectives on cessation Social learning theory emphasizes learning an addictive behaviour through processes such as operant conditioning (rewards and punishments), classical conditioning (associations with internal/external cues), observational learning and cognitions. Therefore, cessation procedures emphasize these processes in attempts to help smokers and excessive drinkers stop their behaviour. These cessation procedures include: aversion therapies, contingency contracting, cue exposure, self-management techniques and multi-perspective cessation clinics: 1 Aversion therapies aim to punish smoking and drinking rather than rewarding it. Early methodologies used crude techniques such as electric shocks whereby each time the individual smoked a puff of a cigarette or drank some alcohol they would receive a mild electric shock. However, this approach was found to be ineffective for both smoking and drinking (e. Wilson 1978), the main reason being that it is difficult to transfer behaviours that have been learnt in the laboratory to the real world. In an attempt to transfer this approach to the real world alcoholics are sometimes given a drug called Antabuse, which induces vomiting whenever alcohol is consumed. This has been shown to be more effective than electric shocks (Lang and Marlatt 1982), but requires the individual to take the drug and also ignores the multitude of reasons behind their drink problem. Imaginal aversion techniques have been used for smokers and encourage the smoker to imagine the negative consequence of smoking, such as being sick (rather than actually experiencing them). However, imaginal techniques seem to add nothing to other behavioural treatments (Lichtenstein and Brown 1983). Smokers are required to sit in a closed room and take a puff every 6 seconds until it becomes so unpleasant they cannot smoke any more. Although there is some evidence to support rapid smoking as a smoking cessation technique, it has obvious side effects, including increased blood carbon monoxide levels and heart rates. Other aversion therapies include focused smoking, which involves smokers concentrating on all the negative experi- ences of smoking and smoke-holding, which involves smokers holding smoke in their mouths for a period of time and again thinking about the unpleasant sensations. Smoke-holding has been shown to be more successful at promoting cessation than focused smoking and it does not have the side effects of rapid smoking (Walker and Franzini 1985). Smokers and drinkers are asked to make a contract with either a therapist, a friend or partner and to establish a set of rewards/punishments, which are contingent on their smoking/drinking cessation. For example, money may be deposited with the therapist and only returned when they have stopped smoking/ drinking for a given period of time. Schwartz (1987) analysed a series of contingency contracting studies for smoking cessation from 1967 to 1985 and concluded that this procedure seems to be success- ful in promoting initial cessation, but once the contract was finished, or the money returned, relapse was high. In a study of alcoholics, 20 severe alcoholics who had been arrested for drunkenness were offered employment, health care, counselling, food and clothing if they remained sober (Miller 1975). The results showed that those with the contracts were arrested less, employed more, and were more often sober according to unannounced blood alcohol checks than those who were given these ‘rewards’ non-contingently. In addition, this perspective is reminiscent of a more punitive moral model of addictions. For example, if an individual always smokes when they drink alcohol, alcohol will become a strong external cue to smoke and vice versa. Cue exposure techniques gradually expose the individual to different cues and encourage them to develop coping strategies to deal with them. This procedure aims to extinguish the response to the cues over time and is opposite to cue avoidance procedures, which encourage individuals not to go to the places where they may feel the urge to smoke or drink. Cue exposure highlights some of the problem with in- patient detoxification approaches to alcoholism whereby the alcoholic is hospitalized for a length of time until they have reduced the alcohol from their system. Such an approach aims to reduce the alcoholic’s physiological need for alcohol by keeping them away from alcohol during their withdrawal symptoms.