this may possibly be true, it indicates that they may have been selective in their friendships in choosing people who share their addictive behaviour. It is important to treat patients in groups so that they can understand, support and challenge each other. One-to-one therapy is mostly what patients want but it does nothing to counter the psychopathology of denial, in which patients do not believe that they really have this specific problem. They need to be able to see other sufferers so that they can get the essential insight that their own problem is part of their genetic make-up rather than anything to do with the specific events of their childhood or current circumstances.

Some patients who have eating disorders will also have other addictive tendencies beyond the common cross-addictions of work; exercise, shopping and spending that form the "nurturant of self" group. They may also have some characteristics of the "hedonistic" group (alcohol, recreational drugs, prescription drugs, nicotine, caffeine, gambling and risk-taking, sex and love addiction). Other patients may have significant scores on the compulsive helping and relationship addiction questionnaires. Some may have widespread addictive behaviour across all three groups. In our experience of treating over three thousand inpatients over the last seventeen years, we find that the broader the range of addictive tendencies and the higher the scores within each individual addictive outlet, the higher the frequency of relapse.

This is not surprising but it emphasises the need to look at all addictive tendencies right at the start if one is to give these patients the best opportunity of recovery when they first enter treatment. What does interest me is the relative intensity of one addictive outlet compared with others. If all have the same cut-off point of twenty points for clinical significance, it enables patients to see immediately that they are at risk of relapse unless they look at all their significant addictive outlets. Leaving an addictive tendency unattended means that the underlying neurotransmission disease is being ineffectively addressed and will be perpetuated in one form or another, if not through its original addictive outlet. Patients who suffer recurrent relapses inevitably become dispirited - as will their counsellors - and they deserve better than that. Ignoring nicotine addiction - on the grounds that it can be dealt with later - or stimulating a prescription drug addiction by prescribing antidepressants, on the grounds that these drugs help patients to be more functional, is fundamentally misconceived.

The idea that patients should not tackle everything at once dies hard but I believe that cross-addictions are the prime cause of relapse. This is obviously true if one believes that the problem goes primarily with the person rather than with one or another substance. Naturally, addicts of one kind or another will defend their alternative addictive outlets to the hilt - because without them they have to face up to their disturbed thoughts, feelings and behaviour without any of these emotional props. However, they have to live in the real world rather than escape from it. Naturally counsellors who are themselves still smoking cigarettes, or indulging in