(Practical Resources for the Mental Health Professional) Sharon L. Johnson-Therapist's Guide to Clinical Intervention, Second Edition_ The 1-2-3's of Treatment Planning (Practical Resources for the Me(1).pdf

Therapist's Guide to
Clinical Intervention
The 123's of Treatment Planning
Second Edition
This page intentionally left blank
Therapist's Guide to
Clinical Intervention
The 1—2—3's of Treatment Planning
Second Edition
SHARON L JOHNSON
ACADEMIC PRESS
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03 04 05 06 07 9 8 7 6 5 4 3 2 1
CONTENTS
Introduction xvii
Level of Patient Care and Practice Considerations xix
Decision Tree of Evaluation and Intervention xxi
Levels of Functioning and Treatment Associated Considerations xxii
High-Risk Situations in Practice xxiii
Treatment Plan xxiv
Solution-Focused Approach to Treatment xxv
Case Conceptualization xxvi
Common Axis 1 and Axis 2 Diagnoses xxviii
Chapter i
TREATMENT PLANNING: GOALS, OBJECTIVES,
AND INTERVENTIONS
Disorders Usually First Evident in Infancy, Childhood, or Adolescence 1
Mental Retardation (MR) 1 Pervasive Developmental Disorders (PPD) 5
Disruptive Behavior Disorders 7
Attention Deficit Hyperactivity Disorder (ADHD) Oppositional Defiant Disorder,
Conduct Disorder 7 Separation Anxiety 13 Avoidant Disorder 14
Overanxious Disorder 16 Eating Disorder (EDO) 18
Preventing Weight and Body Image Problems in Children 24
Recommendations for Family Members of Anorexic Individuals 25
Identity Disorder 26
Children 28
Organic Mental Syndromes and Disorders 31
V
Dementia 32
Dementia and Organic Mental Disorders 32
Defining Specific Dementias 34
Psychoactive Substance Abuse Disorders 37
Substance Abuse and/or Dependence 38 Categories of Pharmacological
Intervention 41 Treatment Settings 41
List of Symptoms Leading to Relapse 42
Schizophrenia, Delusional, and Related Psychotic Disorders 45
Thought Disorders 45 Phases of Treatment 49
Treatment Settings 49 Summary of Treatment Recommendations for
Patients with Perceptual Disturbances 49
Mood Disorders 51
Depression 52 Depression Cooccurring with other Illness 56
Mania 58 Children 61
Bipolar Disorder Hypersexuality 62
Antidepressant Medication and other Treatment 63
Additional Treatment Considerations 64
Anxiety Disorders 65
Cycle of AnxietyProvoked Emotional Distress 69
Trauma Response 70
Somatoform Disorders 72
Somatoform Disorders 72 Psychosomatic Illness and Personality Disorder 75
Interpreting Functional Presentations of Symptomology 77
Dissociative Disorders 78
Sexual Disorders 80
Sexual Disorders 80
Adjustment Disorders 81
Impulse Control Disorders 84
Psychological Factors Affecting Physical Condition 86
Psychological Factor Affecting Physical Condition 86
Personality Disorders 88
Avoidant Personality Disorder 89 Compulsive Personality Disorder 90
Dependent Personality Disorder 92 PassiveAggressive Personality Disorder 94
Paranoid Personality Disorder 95 Schizotypal Personality Disorder 97
Schizoid Personality Disorder 98 Histrionic Personality Disorder 99
Narcissistic Personality Disorder 100
Borderline Personality Disorder 101
Physical Factors Affecting Psychological Functioning 104
Stages of Adjustment 105
Vl Contents
Chapter 2
ASSESSING SPECIAL CIRCUMSTANCES
Assessing Special Circumstances 109
CognitiveBehavioral Assessment 109 Depression And Anxiety Screening 111
Depression 111 Anxiety 111
Structured Interview for Depression 112
Cycle of Depression 113
Suicide 115
Suicide Assessment Outline 115 Adolescent Suicide 116 Treatment
Focus and Objectives 117 Depression and Suicide Risk Relapse 118
Dangerousness 119
Dangerousness Assessment Outline 120 Clarifying Risk of Harm 121
Treatment Focus and Objectives 122
Cycle of Phobic Anxiety 124
Obsessional Disorders: An Overview 125
Assessment of Obsessional Disorders (OD) 125
Gravely Disabled 127
Activities of Daily Living 128
Living Situation 129 SelfCare Skills 129 Level of Required
Assistance 129 Care of Environment and Chore Responsibilities 129
Meals 129 Child Care 129 Financial 129 Shopping 129
Transportation 130
Chronic Mental Illness (CMI) 130
General Guidelines for Assessing the Chronic Mentally HI 131
Crisis Evaluation 132
Crisis Intervention 133
Critical Incident Stress Debriefing (CISD) 134 Screening for Survivors 135
Identifying Traumatic Stress 135
Recovering from Traumatic Stress 135 How Does a Traumatic Event
Affect Someone? 136 The Effects of Time 137
Traumatic Stress and Vehicular Accidents 137
Assessment of Phobic Behavior 139
Postpartum Depression and Anxiety 141
Definitions 141 Postpartum Crisis Psychosis 143 How to Break the
Postpartum Cycle 144
Professional Guidelines for Crisis Intervention 145
SelfCare Behaviors 146
Counseling the Individual in a Medical Crisis 147
Treatment Framework and Conceptualization 148
The Central Crisis Issue 149
Dealing with the Challenges of Long Term Illness 151
Working Through the Challenges and Fears Associated with LongTerm Illness 154
Contents Vii
Chronic Pain: Assessment and Intervention 157
Factors Affecting the Experience of Pain 157 Clinical Interview 158
Assessment and Measuring Pain 158
Pain Identification Chart 160
Location and Type of Pain 160
Pain Management Scale 161
Interventions for Chronic Pain 162 Six Stages of Treatment 162
Interventions 162
Somatic Problems: A Brief Review 164
The Patient with Psychosomatic Illness Who has an Underlying
Personality Disorder 165
Eating Disorders Screening Questionnaire 167
The Mood Eating Scale 169
Eating History 169
Eating Disorder Evaluation: Anorexia 170
Eating Disorder Evaluation: Bulimia 172
Adult ADD Screening 174
ADHD Behavioral Review 177
Chemical Dependency Assessment 179
Chemical Dependency Psychological Assessment 182
Withdrawal Symptoms Checklist 185
Psychological 185 Somatic 185
Spousal/Partner Abuse 187
Assessing Spousal/Partner Abuse 187
The Stage Model of Domestic Violence 191
Assessing for Domestic Violence 192
Intervention Categories 193
Counseling Victims of Domestic Violence 194
Objectives 195
Child Abuse and Neglect 195
Prevention 195 Indicators of Abuse 196 Treatment 197
Child Custody Evaluation 198
Guidelines for Psychological Evaluation 198
Ability of the Child to Bond 199
Ability of the Parent to Bond and Other Pertinent Information 199
Child Custody Evaluation Report Outline 200 Parental Behavior 201
Interaction Between ParentChild(Ren) 201 Bonding Study Versus
Custody Evaluation 201
Parental Alienation Syndrome 202
Parental Programming 202 Subtle and Unconscious Influencing 202
Child's Own Scenarios 203 Family Dynamics and Environment/
Situtational Issues 203 Criteria for Establishing Primary Custody 203
Behaviors of the Parents 204 Children 205 Three Categories of
Parental Alienation 206
Viii Contents
Evaluation and Disposition Considerations for Families where Parental
Alieneation Occurs 207
Questions to Ask Children 208 Questions to Ask the Parents 209
Parental Alienation Syndrome Treatment 209
Visitation Rights Report 211
Visitation Rights Report 211
Dispositional Review: Foster Placement; Temporary Placement 211
Dispositional Review Report Outline 212
Psychiatric WorkRelated Disability Evaluation 213
Identifying Information 213 Description of Client at Time
of Interview 213 Descriptions of Client's Current Complaints 213
History of Present Illness 213 Occupational History 214
Past Psychiatric History and Relevant Medical History 214
Family History 214 Developmental History 215 Social History
(Distinguish Prior to Disability, Disability Concurrent, After Injury) 215
Mental Status Exam 215 Review of Medical Record 215
Findings from Psychological Assessment 215 Interviews With
Collateral Sources and Review of Employment or Personnel Records (Compare
Description of Industrial Injury With Clients Description) 216
DSMIV Diagnosis (Multiaxial, Using DSM Criteria and Terminology) 216
Summary and Conclusions 216
Psychological PreEmployment Evaluation 217
Report Outline 217
Compulsory Psychological Evaluation 218
Compulsory Psychological Evaluation 218
Forensic Evaluation 219
Report Outline 220
Competency 220 Competency to Plead and/or Confess 220
Competency to Stand Trial 220 Mental Status at Time of Offense 220
Chapter 3
SKILLBUILDING RESOURCES FOR INCREASING
SOCIAL COMPETENCY
What is Stress? 223
Stress Review 225
Stress Management 226
Early Warning Signs of Stress 228 Stress Signals 228
Stress Busting 229
Effective Management of Stress 229
Critical Problem Solving 229 Assertiveness 230
Conflict Resolution 230 Time Management 230
SelfCare 230
Tips for Stress Management 230
C o n t e n t s IX
Tips to Simplify Life 231
Ten Signs that You Need to Simplify Your Life 232
How to Improve Planning 233
Pain Management 233
Some Examples of Individualized Time Management Options 234
SelfCare Plan 235
How to Get The Most Out of Your Day 236
Emotional IQ 237
Relaxation Exercises 238
Deep Breathing 238 Mental Relaxation 239
Tensing the Muscles 239 Mental Imagery 239 Brief Relaxation 241
Brief Progressive Relaxation 241 Progressive Muscle Relaxation 242
Preparing for the Provocation 244 Confronting the Provocation 245
It's Time to Talk to Yourself 245 A Guide to Meditation 245
Critical Problem Solving 247
Preparing to Learn ProblemSolving Skills 248
Managing Interaction During Problem Solving 248
Developing Good ProblemSolving Skills Equips Individuals To: 248
Stages of Problem Solving (As Therapist Facilitates Skill Development
in Individual): 248 Steps for Problem Solving 249
Problem Solving Diagram 249
Assignment 1 250
Sample Problems 250
Assignment 2 250
Assignment 3 251
Risks 252
Components of Effective Communication 253
"I" Statements 253 Active Listening 253 Reflection 254
Nonverbal Communication Checklist 255
Improving Communication Skills 256
How You Present Yourself: Body Language 256 How You Say It: Quality
of Voice 256 Effective Listening 257
Assertive Communication 257
Assertiveness Inventory 258
Nonverbal Communication 260
Developing Assertiveness 261
Nonverbal Assertive Behavior 261
Personal Bill of Rights 262
Assertiveness 262
The Steps of Positive Assertiveness 263 Practicing Assertive Responses 263
Ten Steps for Giving Feedback 264
Saying "No" 264
To Overcome Guilt in Saying "No" 264 Review for Yourself the
Consequences of Saying "Yes" 265
Accepting "No" for An Answer 265
X Contents
Ten Ways of Responding to Aggression 265
The Communication of Difficult Feelings 266
How You Can Deal with Uncomfortable Feelings 266
Writing 267
Areas of Potential Conflict 268
List of Potential Conflicts 268
List of Feeling Words 269
Pleasant Feelings 269
Difficult/Unpleasant Feelings 269
Time Management 270
Four Central Steps to Effective Time Management 270 How to Start Your
Time Management Program 270
Some Examples of Individualized Time Management Options 271
Decision Making 272
Steps for Decision Making 272
Goal Development 273
Steps for Developing Goals 273
Setting Priorities 274
Steps for Setting Priorities 274
Rational Thinking: SelfTalk, Thought Stopping, and Reframing 274
SelfTalk 274 Thought Stopping 276 Reframing 277
Thinking Distortions 278
Realistic SelfTalk 279
Practice Reframing How You Interpret Situations 281
Defense Mechanisms 282
Defense Mechanism Definitions 283
Anger Management 283
Seven Steps of Taking Responsibility 284
Understanding Anger 285
Handling Anger 286
General Principles Regarding Anger 286
Understanding Your Experience of Anger 286
Recognizing the Stages of Anger 287 Decrease the Intensity of Anger 287
Barriers to Expressing Anger 288 Inappropriate Expression of Anger:
Violence and Rage 288 Penalties for Not Expressing Anger 288
Ways to Deal with Anger 289
Ten Steps for Letting Go of Anger 289
Preventing Violence in the Workplace 289
Negative Work Environment 290 The Dangerous Employee 290
Bully in the Workplace 291 Workplace Violence 291
How to Handle Angry People 295
What Management Can Do to Minimize Employee Stress 296
Adjusting/Adapting 298
Life Changes 298 Developmental Perspective 299
Contents XI
Learning History 300
Losses/Opportunities 301
What is Meant by Resolving Grief/Loss? 301 Why Are People Not Prepared
to Deal with Loss? 301 What Are the Myths of Dealing with Loss? 302
How Do You Know You Are Ready? 302 Finding the Solution: The Five
Stages of Recovering From Loss 302 How You Deal with Loss 302
Other Ways? 302
Grief Cycle 303
Definition: The Natural Emotional Response to the Loss of a Cherished Idea,
Person, or Thing 303
Grief 304
Never Happened 304 Bargaining 305 Depression 305
Acceptance 306
History of Loss Graph 307
Example 307
Relationship Graph 307
Example 307
Is Life What You Make It? 308
Journal Writing 308
Steps 14 308 Steps 515 309
Developing and Utilizing Social Supports 310
Characteristics of a Supportive Relationship 310
How to Build and Keep a Support System 312
Recognizing the Stages of Depression 313
Decreasing the Intensity of Depression 313
Managing Depression 314
The Causes of Depression 314
Depression Symptom Checklist 315
Surviving the Holiday Blues 317
Utilizing Your Support System 318
Examples 318
The Power of Positive Attitude 318
SelfMonitoring Checklist 319
Management Behaviors 319
Daily Activity Schedule 322
Confronting and Understanding Suicide 323
Hopelessness and Despair 323
Depression 324
Phone Numbers 324
Feeling Overwhelmed and Desperate 325
Feeling like Your Life is Out of Control 326
Guilt 327
Loneliness 329
Chemical Imbalance 329
Xll Contents
Low SelfEsteem 330
The SelfEsteem Review 332
Ten SelfEsteem Boosters 333
Affirmations for Building SelfEsteem 334
SelfNurturing: A Component of SelfEsteem 334
Characteristics of Low SelfEsteem 336
Characteristics of High SelfEsteem 338
What Motivates Me? 339
Standing Up to Shyness 339
Socializing 340
Bad Memories and Fear 341
Seasonal Anniversary of Losses 342
Fatigue or Sleep Deprivation 344
What is Panic Anxiety? 344
Symptoms 345 Treatment 345
PostTraumatic Stress Disorder (PTSD) 346
Managing Anxiety 347
What Do You Do 349
Survey of Stress Symptoms 350
Psychological Symptoms 350 Physical Symptoms 350
Estimate Your Stress Level 350
How Your Body Reacts to Stress and Anxiety 351
Managing Stress 351
25 Ways to Relieve Anxiety 352
Plan of Action for Dealing with Anxiety 353
Relapse—Symptom Reoccurrence 354
Intervening in the Relapse Cycle 355
Warning Signs of Relapse 356
Systematic Desensitization 357
The Ten Steps of Systematic Desensitization 357
What is Dementia? 358
Symptoms 358 Conditions Causing Reversible Symptoms 358
Conditions Causing Dementia That Are Not Reversible 359 Diagonosis 359
Understanding Schizophrenia 359
Symptoms and Perceptual Disturbance 360 Potential for Violence 360
Suicide 360 What Causes Schizophrenia 360
Ten Warning Signs of Alzheimer's Disease 362
Caregiving of Elderly Parents 363
Common Problems Experienced by Caregivers 365
Effective Coping Strategies for the Caretaker 365
Tips for the Caretaker 366 Advice for others Close to the Situation 366
Ten Warning Signs of Caregiver Stress 366
Sleep Disorders 367
Contents XIII
Ten Tips for Better Sleep 368
Health Inventory 370
Assessing Lifestyle and Health 371
Assuming the Patient Role: The Benefits of Being Sick 372
Improving Your Health 373
Heart Disease and Depression 375
Facts on Depression and Heart Disease Offered by The National
Institute of Health 375 Benefits of Depression Treatment 375
Depression Is Often Undiagnosed and Untreated 375
Effective Treatment for Depression 376
Eating History 376
How to Stop Using Food as a Coping Mechanism 377
Preventing Body Weight and Body Image Problems in Children 378
Obsession with Weight 378 Obesity and SelfEsteem 379
What Parents Can Do 379
Guidelines to Follow if Someone You Know Has An Eating Disorder 379
Dealing with Fear 380
Guidelines for Family Members/Significant Others of Alcoholic/Chemically
Dependent Individuals 381
Detaching with Love Versus Controlling 382
The Enabler—The Companion to the Dysfunctional/Substance
Abusing Person 383
Substance Abuse/Dependence Personal Evaluation 385
List of Symptoms Leading to Relapse 386
What is Codependency? 387
The Classic Situation 388
Some Characteristics of Codependence 388
Suggested Diagnostic Criteria for Codependence 389
How Does Codependency Work? 390
The Rules of Codependency 391 How Codependency Affects
One's Life 391 Symptom/Effect in Children of Codependents 392
What Can You Do 392 Stages of Recovery 392
Characteristics of Adult Children of Alcoholics 393
Guidelines for Completing Your First Step Toward Emotional Health 394
Relationship Questionnaire 396
Healthy Adult Relationships: Being a Couple 396
Special Circumstances 397
How to Predict the Potentially Violent Relationship 397
Domestic Violence : Safety Planning 399
Most Important to Remember 399 Document the Abuse 399
Find A Safe Place to Go 399 Create a Safe Room in Your Home 400
Have Money and Keys 400 Create a File with Your Important
Documents 400 Pack a Suitcase 401
Know When and How to Leave 401
Why Victims of Domestic Violence Struggle with Leaving 401
Improved Coping Skills for Happier Couples 402
Evaluate the Problem 402 Problem Resolution 403
XIV Contents
Couple's Conflict: Rules for Fighting Fair 403
Parenting a Healthy Family 406
Creating Effective Family Rules 406 Effective Coparenting 406
Maintain the Parent Role 407 Be An Active Parent 407
A Healthy Family Means All of Its Members are Involved 407
Encourage Communication 407
Guiding Your Child to Appropriately Express Anger 408
The Family Meeting 409
Guidelines 409 Developing Positive SelfEsteem in Children
and Adolescents 410
Understanding and Dealing with Life Crises of Childhood 411
What Is a Crisis? 411
What Happens During a Crisis 412
Crisis Resolution 413
What Do You Need to Do to Help a Child 413
Your Child's Mental Health 415
Warning Signs of Teen Mental Health Problems 416
Talking to Children 417
Rules for Listening 418 Rules for Problem Solving and Expressing Your
Thoughts and Feelings to Children 418 Do's 419 Don'ts 419
Guidelines for Discipline that Develops Responsibility 419
Helpful Hints 420 Steps in Applying Logical Consequences 420
Surviving Divorce 420
Physical Stress 421 Emotional Stress 421 SelfCare 421
Successful Stepfamilies 422
Honor 422 Validation 422 Respect 422 Responsibility 422
Communication 423 Discipline 423 ParentCentered Structure 423
Helping Children Cope with Scheduling Changes 423
Is Your Behavior in the Best Interest of Your Children? 425
The Rules of Politeness 426
SelfMonitoring 426
Questions to Ask Yourself 426
Goal Setting 427
Accomplishments 428
Strengths 428
Resources 429
Ten Rules for Emotional Health 429
Chapter 4
PROFESSIONAL PRACTICE FORMS, CLINICAL FORMS,
BUSINESS FORMS
Case Formulation 435
General Consult Information 435
General Clinical Evaluation 436
Contents XV
Treatment Plan 439
Mental Status Exam 442
Contents of Examination 442
Initial Case Assessment 447
Initial Evaluation 449
Brief Mental Health Evaluation Review 451
Life History Questionnaire 454
Adult Psychosocial 463
Family History 464 Drug and Alcohol Abuse 465
Educational History 465 Employment History 465
Socialization Skills 465
Summary 466
Treatment Plans and Recommendations 466
Child/Adolescent Psychosocial 467
Identifying Information 467
Parent's Questionnaire 475
Question 475
SelfAssessment 477
Brief Medical History 478
Illnesses and Medical Problems 479
Medical Review Consult Request for Primary Care Physician of an Eating
Disorder (EDO) Patient 480
Substance Use and Psychosocial Questionnaire 481
Treatment History 482 Family History 483
Social History 483 Medical Problems 484
Chemical Dependency Psychosocial Assessment 485
Initial Evaluation Consultation Note to Primary Care Physician 488
Brief Consultation Note to Physician 490
Outpatient Treatment Progress Report 491
Progress Note for Individual with Anxiety and/or Depression 494
Clinical Notes 496
Disability/Worker's Compensation 498
Social Security Evaluation, Medical Source Statement, Psychiatric/
Psychological 499
Worker's Compensation Attending Therapist's Report 500
Progress 500 Treatment 500
Work Status 500 Disability Status 500
Brief Psychiatric Evaluation for Industrial Injury 502
Brief Level of Functioning Review for Industrial Injury 505
Outline for Diagnostic Summary 509
Diagnostic Summary 509
Discharge Summary 511
Patient Registration 515
XVI Contents
Insured/Responsible Party Information 515 Office Billing and
Insurance Policy 515
Contract for Services Without Using Insurance 517
Fee Agreement for Deposition and Court Appearance 517
Limits on Patient Confidentiality 519
Release of Information 519
Treatment Contract 520
Contract for Group Therapy 521
Release for the Evaluation and Treatment of a Minor 522
Authorization for the Release or Exchange of Information 522
Client Messages 523
Affidavit of the Custodian of Mental Health Records to Accompany
Copy of Records 524
Referral for Psychological 525
Psychiatric History 525
Release to Return to Work or School 527
Notice of Discharge for Noncompliance of Treatment 528
Duty to Warn 529
Missed Appointment 530
Receipt 531
Receipt 532
Balance Statement 533
Client Satisfaction Survey 534
Form for Checking Out Audiotapes, Videotapes and Books 536
Quality Assurance Review 537
Initial Assessment 537 Progress Notes 537
Bibliography 539
Index 553
Contents XVlI
INTRODUCTION
THIS second edition, like the first, is intended to serve as a comprehensive resource tool.

Because of the positive response to the organization of the original text, the format
has remained the same. The Therapist's Guide to Clinical Intervention is divided into four
sections: Treatment Planning, Special Assessment, SkillBuilding Resources, and Clinical/
Business Forms. The handbook concept has evolved and expanded, building on the strong
foundation of the first edition. Upon review of the current literature, it was unnecessary to
alter or delete any of the information contained in the original text. Instead, information
viewed as increasing the resourcefulness of the text has been added. In addition to being
a timemanagement tool, helping the therapist to meet the increasing demands of documen
tation requirements and the expectation of therapeutic effectiveness in identifying and
resolving current problems with the brief mental health treatment benefit of managed care,
the format supports improved case conceptualization of individualized treatment planning.
Since the publication of the first edition of the Therapist's Guide to Clinical Intervention,
the prevalence of managed care in the marketplace has increased and the challenge of max
imizing effectiveness has increased with it. Managed care companies and consumers alike
expect to be informed of the expected number of sessions necessary to resolve the present
ing issue(s) and for the therapist to collaterally communicate with the primary care physi
cian and the physician prescribing psychotropic medications. It is a casemanagement role
not sought after by therapists, but bestowed upon them. As a result, additional time and
added responsibility are integrated into one's professional practice, again reflecting the
importance of adequate documentation. The solutionoriented standard of practice has con
tinued to flourish. The fiscal agenda of the managed care company is clear. What has become
more surprising is that many consumers also are seeking brief therapy in association with
clearly defined goals. Therefore, in many cases, both the consumer of services and the con
tractor of services are depending on the therapist to provide refined diagnostic skills, concise
treatment planning with defined goals and objectives, crisis intervention, case management
with collateral contacts, contracting with the client for various reasons, and discharge plan
ning that is well documented and research supported. The Therapist's Guide to Clinical
Intervention facilitates the ease of accomplishing these expectations by combining the afore
mentioned significant aspects of practice. All of this is provided in a single resource, which
saves a tremendous amount of time that would be required to review the number of texts
necessary to amass a commensurate amount of information.
To review the format for those familiar with the first edition and introduce this format to
those who are new to the Therapist's Guide to Clinical Intervention, we will provide a brief
summary on the four sections of the text. The first part of the book is an outline of cognitive
behavioral treatment planning. This organization of goals and objectives associated with
specific, identified problems supports thoroughness in developing an effective intervention
xix
formulation that is individualized to each client. Each diagnosis or diagnostic category
has a brief summary highlighting the salient diagnostic features. The treatment planning sec
tion was designed to be userfriendly and to save time. There is a list of central goals derived
from identified diagnostic symptoms and the associated treatment objectives for reaching
those goals from a cognitivebehavioral perspective. It goes without saying that not all
individuals or diagnoses are amenable to brief therapy interventions. However, cognitive
behavioral interventions can still be very useful in the limited time frame for developing
appropriate structure and facilitating stabilization. Often the brief intervention will be used
as a time for initiating necessary longerterm treatment or making a referral to an appropri
ate therapeutic group or psychoeducational group.
The second part of the book offers a framework for assessing special circumstances, such
as those involving a danger to self, danger to others, the gravely disabled, spousal abuse/
domestic violence, and so forth. Additionally, this section offers numerous report outlines
for various assessments with a brief explanation of their intended use. The assessment out
lines provide a thorough, wellorganized approach resulting in the clinical clarity necessary
for immediate intervention, appropriate referrals, and treatment planning.
The third part of the book offers skillbuilding resources for increasing client competency.
The information in this section is to be used as an educational resource and as homework
related to various issues and needs presented by clients. This information is designed to sup
port cognitivebehavioral therapeutic interventions, to facilitate the client's increased under
standing of problematic issues, and to serve as a conduit for clients to acknowledge and
accept their responsibility for further personal growth and selfmanagement. Skillbuilding
resources, whether offered verbally or given in written form, promotes the use of client moti
vation between sessions, enhancing goaldirected thoughts and behaviors.
The fourth part of the book offers a continuum of clinical/business forms. The develop
ment of forms is extremely time consuming. Some of the forms have only minor variations
due to their specificity, and in some cases they simply offer the therapist the option of choos
ing a format that better suits his or her professional needs. Many of the forms can be uti
lized as is, directly from the text. However, if there is a need for modification to suit specific
or special needs associated with one's practice beyond what is presented, having the basic
framework of such forms continues to offer a substantial timesaving advantage.
This text is a compilation of the most frequently needed and useful information for the
timeconscious therapist in a general clinical practice. To obtain thorough utilization of the
resources provided in this text, familiarize yourself with all of its contents. This will expe
dite the use of the most practical aspects of this resource to suit your general needs and
apprise you of the remaining contents, which may be helpful to you under other, more spe
cific circumstances. While the breadth of the information contained in this book is substan
tial, each user of this text must consider her or his own expertise in providing any services.
Professional and ethical guidelines require that any therapist providing clinical services be
competent and have appropriate education, training, supervision, and experience. This
would include a professional ability to determine which individuals and conditions are
amenable to brief therapy and under what circumstances. There also needs to be knowledge
of current scientific and professional standards of practice and familiarity with associated
legal standards and procedures. Additionally, it is the responsibility of the provider of psy
chological services to have a thorough appreciation and understanding of the influence of
ethnic and cultural differences in one's case conceptualization and treatment, and to see that
such sensitivity is always utilized.
xx
Level of Patient Care and
Practice Considerations
Levels of Functioning and Associated Treatment Considerations
Level of functioning Treatment goalsa Focus of treatment Possible treatment modalities
1. Patient demonstrates adaptive Increase Self efficacy Didactic/educational Groups

functioning with minimal Knowledge Education Community/church based support groups
tono symptomology Understanding Prevention Therapeutic classes/groups focused on
Problem Solving developmental Issues
Choices/Alternatives Recommended reading
2. Patient demonstrates mildto Cognitive restructing Decrease symptomology Individual therapy
moderate symptomology which Behavior Modification Self care Conjoint therapy
interferes with adaptive Improve coping Family therapy
functioning Improve problem solving and Group therapy dealing with specific
management of life stressors issues and/or long term support
3. Patient demonstrates moderate Improve daily functioning Stabilization Urgent care
symptomology and selfmanagement Daily activity schedule Intensive outpatient (OP)
warranting higher Productive/pleasurable activities Reinitiate outpatient treatment with
level of care Symptom management possible increased frequency
Development and utilization of Medication evaluation/monitoring
social supports Therapeutic/educational groups
Case management
4. Patient demonstrates Monitor and provide Stabilization Increased OP therapy contact
severe symptomology safe environment All aspects of patient's life and Urgent care
Danger to self environment (family, social, Intensive outpatient
Danger to others medical, occupational, recreational) Partial hospitalization
Grave disability Decrease symptomology 23hour unit
Psychopharmacology Inpatient treatment
Monitoring Safely maintained in structural/monitored
Improve judgement, insight, impulse control setting with adequate social support
Home health intervention
Reinitiate individual treatment when adequately stabilized
5. Patient demonstrating Provide safe environment Stabilization Increased OP therapy contact

acute symptomology and rapid stabilization Decreased symptomology Urgent care
Psychopharmacology Intensive OP
Monitoring 23hour unit
Partial hospitalization
Support group
Medication monitoring
Case management
6. Patient demonstrating acute Provide safe environment Psychopharmacology Inpatient treatment
symptomology with Protection of patient Monitoring 23hour unit
difficulty stabilizing Protection of others Urgent care
Partial hospitalization
Intensive OP
Individual therapy
Support group
Medication monitoring
Case management
a
Treatment goals are cumulative, i.e., a patient at a functioning level of 6 with acute symptomology may include treatment goals of previous, less acute levels, as symptomology decreases and level
of functioning increases.
HIGHRISK SITUATIONS IN PRACTICE
You can substantially reduce or eliminate risk in the following situations by giving heed to
the track record of liability insurance companies. To gain perspective in these issues, plan to
take a Risk Management Continuing Education course when available in your area.
1. Child Custody Cases

2. Interest Charges
3. Service Charges
4. Patients Who Restrict Your Style of Practice (e.g., Do Not Want You To Take
Notes)
5. Release of Information without a Signed Form—To Anyone
6. Collection Agencies
7. Answering Service
8. Interns or Psychological Assistants to Supervise
9. Patient Abandonment
10. Dual Roles
11. HighRisk Patients, Such As Borderline Patients, Narcissistic Patients, or
Multiple Personality Patients
12. Repressed Memory Patients or Analysis
13. High Debt for Delayed Payment
14. Appearance of a Group Practice without Group Insurance
15. Sexual Impropriety
16. Evaluations with Significant Consequence
17. Over or Under Diagnoses for Secondary Purposes
18. Failure to Keep Session Notes
Printed by permission from Allan Hedberg, Ph.D.
xxv
The Treatment Plan formulation serves as the guide for developing goals and for monitor
ing progress. It is developed specifically to meet the assessed needs of an individual. The
Treatment Plan is composed of goals and objectives, which are the focus of treatment.
The following is an example of how to use the treatment planning information to quickly
devise a clear Treatment Plan. Listed in the example are five identified treatment goals and
the corresponding objectives.
A 12yearold boy is referred for treatment because of behavioral problems. He is diagnosed
as having an Oppositional Defiant Disorder.
TREATMENT PLAN
Goals and Goal 1
Parent Education
Objectives
Objectives
A. Explore how family is affected, how they respond, contributing factors such as
developmental influences, prognosis, and community resource information
B. Parent Effectiveness Training Limit seeting, natural consequences, positive
reinforcement, etc.
Goal 2
Develop Appropriate Social Skills
Objectives
A. Role model appropriate behaviors/responses for various situations
B. Identify manipulative and exploitive interaction along with underlying
intention. Reinforce how to get needs met appropriately.
C. Identify behaviors which allow one person to feel close and comfortable to
another person
Goal3
Improved Communication Skills
Objectives
A. Teach assertive communication
B. Encourage appropriate expression of thoughts and feelings
C. Role model and practice verbal/nonverbal communication responses for various
situations
Goal 4
Improved Self-Respect and Responsibility
Objectives
A. Have person define the terms of selfrespect and responsibility, and compare
these definitions to their behavior
B. Have person identify how they are affected by the behavior of others and how
others are affected negatively by their behavior
C. Work with parents to clarify rules, expectations, choices, and consequences
GoalS
Improved Insight
Objectives
A. Increase understanding of relationship between behaviors and consequences
B. Increase understanding of the thoughts/feelings underlying choices they make
C. Facilitate problem solving appropriate alternative responses to substitute for
negative choice
xxvi
SOLUTIONFOCUSED APPROACH TO TREATMENT
1. Meet people where they are psychologically and emotionally
A. Listen
B. Validate
C. Reflect
2. Reframe
A. When necessary/helpful
B. To facilitate the ability to see alternatives/new possibilities
C. "Planting seeds"
3. Clarify
A. Clear descriptions of feelings
B. Clear descriptions of situations and associated responses
C. Patterns (relationship between thoughts, feelings, and behaviors)
D. What are they motivated to work on or change?
4. Develop realistic expectations and limitations
A. Establish appropriate/obtainable goals
B. Identify markers of progress
5. Evaluate the response and outcome of prior crises
A. What/who was helpful?
B. What does the person think was a turning point?
C. What did the person learn?
6. Facilitate development of problem solving and decision making
A. Teach basic skills (Johnson, 1997)
7. Develop a plan of action
A. Requires specifics which can be broken down
B. Mutually agreed upon plan/goals
C. Integrate empirically supported treatments
D. Selfmonitoring
8. Homework
A. Designed to continue treatment progress
B. Facilitate personal growth and recovery
9. Follow up
A. Follow up on homework assignment to clarify
1. What did or did not work
2. Motivation
3. Associated increased awareness and associated choices
10. Reinforce efforts and encourage continued growth
A. Reinforce efforts throughout the course of treatment
xxvn
*HIPAA: Health Insurance Portability and Accountability Act. Protecting the privacy of patient's health information.
XXV111
XXIX
COMMON AXIS 1 AND AXIS 2 DIAGNOSES
Depressive Disorders Adjustment Disorders

Dysthymia 30040 with depressed mood 30900
Depression, NOS 31100 with anxiety 30924
Major Depression, Single Episode: with mixed anxiety and depressed mood 30928
Mild 29621 with disturbance of conduct 30930
Moderate 29622 with mixed disturbance of emotions and conduct 30940
Severe without psychotic features 29623 unspecified 30990
In partial remission 29625
Anxiety Disorders
Unspecified 29620
Panic, without agoraphobia 30001
Major Depression. Recurrent Episode:
Panic, with agoraphobia 30021
Mild 29631
Agoraphobia without panic 30022
Moderate 29632
Specific Phobia 30029
Severe without psychotic features 29633
Social Phobia 30023
In partial remission 29635
ObsessiveCompulsive Disorder 30030
Unspecified 29630
PTSD 30981
Acute Stress Disorder 30830
AttentionDeficit and Disruptive Behavior Disorders
Generalized Anxiety Disorder 30002
AttentionDeficit/Hyperactivity Disorder:
Anxiety Disorder NOS 30000
Combined or hyperactiveimplosive types 31401
Predominantly inattentive type 31400 V Codes
ADHD NOS 31490 Relational Problem 16190
Conduct Disorder 31280 ParentChild Relational Problem 16120
Oppositional Defiant Disorder 31381 Partner Relational Problem, Abuse of Adult 16110
Disruptive Behavior Disorder NOS 31290 Sibling Relational Problem 16180
Relational Problem NOS 16281
Personality Disorders
Abuse or Neglect of Child 16121
Paranoid 30100
Noncompliance with Treatment 11581
Schizoid 30120
Malingering 16520
Borderline 30183
Adult Antisocial Behavior 17101
Histrionic 30150
Child/ Adolescent Antisocial Behavior 17102
Narcissistic 30181
Religious or Phase of Life Problems 16289
Avoidant 30182
Bereavement 16282
Dependent 30160
Academic Problem 16230
ObsessiveCompulsive 30140
Occupational Problem 16220
NOS 30190
Acculturation Problem 16240
Eating Disorders Substance Use
Anorexia Nervosa 30710 Alcohol Dependence 30390
Bulimia Nervosa 30751 Alcohol Abuse 30500
Eating Disorder NOS 30750 Cocaine Dependence 30420
Cocaine Abuse 30560
Others Cannabis Dependence 30430
Psychological Factors Affect on med card 316 Cannabis Abuse 30520
Medication Induced Disorder 995.2 Opioid Dependence 30400
Noncompliance with Treatment v!5.81 Opioid Abuse 30550
No Diagnosis on Axis I v71.09
Diagnosis defined on Axis I 799.9 Impulse Control Disorders
No Diagnosis on Axis II v71.09 Impulse Control Disorder NOS 31230
Diagnosis defined on Axis II 799.9 Intermittent Explosive Disorder 31234
XXX
Chapter 1
Treatment Planning. Goals,

Objectives, and Interventions
DISORDERS USUALLY FIRST EVIDENT IN INFANCY,
CHILDHOOD, OR ADOLESCENCE
MENTAL RETARDATION (MR)
Mental retardation is characterized by intellectual functioning being below average (IQ of
70 or below) with concurrent impairments in adaptive functioning, which includes social
skills, communication, daily living skills, ageappropriate independent behavior, and social
responsibility. There are four degrees of severity in impairment: mild, moderate, severe, and
profound.
A medical exam, neurological exam, or evaluation by a neuropsychologist is important
to rule out organicity, vision/hearing deficits and to determine the origin of the present
ing problems. With the information yielded from such exams, a thorough individualized
program can be developed and implemented. An individualized treatment and educational
plan addresses the individual needs along with the identification of intelligence level
and strengths for the facilitated development of the highest level of functioning for that
individual.
Goals 1. Establish developmentally appropriate daily living skills

2. Develop basic problemsolving skills
3. Decrease social isolation and increase personal competence
1
4. Develop social skills
5. Support and educate parents on management issues
Treatment Focus 1. Daily Living Skills (waking by alarm, dressing, hygiene/personal care, finances,

and Objectives taking the bus, etc.)
A. Realistic expectations and limitations
B. Repetition of behaviors
C. Modeling of desired behaviors
D. Breaking down behaviors into stepwise sequence (shaping)
E. Positive feedback and reinforcement
2. Impaired Problem Solving
A. Roleplay solutions to various situations
B. Develop a hierarchy of responses for potential problem/crisis (enlist help
of caretaker, parents, neighbor, or other known party who is responsible
and inform them as to how to contact the police, EMT, or fire
department, etc.)
C. Practice desired responses
D. Focus on efforts and accomplishments
E. Positive feedback and reinforcement
3. Social Isolation
A. Appropriate educational setting
1. Most communities have a vocational rehabilitation program and
volunteer bureau to offer jobs in the community related to their level of
functioning
B. Special Olympics, or community sporting activities
C. Programmed social activities
D. Camps for the MR
E. Contact local association for mentally retarded persons for community
resources
F. If older, evaluate for vocational training, living arrangement away from family,
which includes social agenda (independent living or group home), if low
functioning, a day treatment program may be helpful
4. Impaired Social Skills
A. Realistic expectations and limitations
B. Teach appropriate social skills (developmental, age appropriate)
1. Collaboration
2. Cooperation
3. Follow rules
4. Etiquette/manners
C. Games that practice social skills
D. Roleplay
E. Practice/repetition
F. Focus on efforts and accomplishments
G. Positive feedback and reinforcement
5. Family Intervention/Education
A. Educate regarding realistic expectations and limitations
B. Review options and alternatives to various difficulties
2 1. Treatment Planning. Goals, Objectives, and Interventions

C. Identify and work through feelings of loss, guilt, shame, and anger; it is not
uncommon for parents/families of severely, handicapped children to feel resentment
toward the child, who may be disruptive to the family
D. Facilitate other children in family to deal with their feelings or concerns
E. Encourage acceptance of reality
F. Encourage identification and utilization of community support organizations and
other associated resources
G. Teach parents behaviormodification techniques
Additional During Assessment

Considerations 1. If there is adequate verbal skills, utilize open ended questions
2. Clarify with concrete, simple, tightly structured interview questions
3. Be careful to accurately assess for a rich fantasy life versus a diagnosis of psychosis
4. Be sensitive to depression and low selfesteem as clinical issues
Levels of mental retardation by Intelligence Test Range

Mild mental retardation 5055 to approximately 70
Moderate mental retardation 3540 to 5055
Severe mental retardation 2025 to 3540
Profound mental retardation below 2025
Behavior Competency Expectations Associated with Degree of Mental

Retardation (Marsh & Barclay, 1989)
Mild
Preschool (05) Able to develop social and communication skills. The minimal sensorymotor
retardation may not be evident until later.
School age (618) Academic proficiency up to 6th grade level. Able to take the lead to social
conformity.
Moderate
Preschool Able to talk/learn to communicate. Poor social awareness. Adequate motor skills. Benefits
from selfhelp skill training with supervision.
School age Able to benefit from social and occupational skill training. Not likely to advance beyond
2nd grade level. Some independence in familiar setting.
Severe
Preschool Poor language development. Minimal language skill/little communication. Unlikely to
benefit from selfhelp training.
School age Able to learn to talk/communicate. Training beneficial for basic selfhelp skills. Benefits
from systematic habit training.
Profound
Preschool Minimal capacity in sensorymotor functioning. Requires intense care.
School age Some evidence of motor development. May respond to very limited range of training in
selfskill development.
The most common intrauterine causes of mental retardation are the following:
1. Fetal alcohol syndrome (FAS)
2. Asphyxia (from maternal hypertension, toxemia, placenta previa)
3. Intrauterine infections
4. Rubella
5. Toxoplasmosis (often from cats)

The most common prenatal causes of mental retardation are the following:
1. Meningitis
2. Encephalitis
3. Head trauma
4. Anoxia
Dual Diagnosis Jacobson (1982a, 1982b) surveyed retarded children from infancy to adolescence and found

that 9.8% had significant psychiatric impairment, which was categorized into four areas
(developmentally
based on features and severity:
disabled with
psychiatric
1. Cognitive
disorder)
A. Major thought disorder
B. Hallucinations
C. Delusions
2. Affective
A. Significant depression
B. Dysphoric affect
3. Minor behavioral problems (these problems are on a continuum
to major problems)
A. Hyperactivity
B. Tantrums
C. Stereotypies
D. Verbal abusiveness
E. Substance abuse
4. Major behavioral problems
A. Physical aggression/assault
B. Property destruction
C. Coercive sexual behavior
D. Selfinjurious behavior
Parents and siblings must be evaluated in association with their own risk for significant dif

ficulties (may or may not be related to mentally retarded child in the family system). The
family system may lack cohesiveness and harmony.
Parents Increased risk for depression

Decreased satisfaction in parenting
Potential for negative attitude toward retarded child
Marital stress
Increased social isolation
Siblings Behavioral problems

Feelings of guilt/anger
Psuedoadult responsibilities (loss of their childhood)
4 1. Treatment Planning Goals, Objectives, and Interventions

PERVASIVE DEVELOPMENTAL DISORDERS (PDD)
Pervasive Developmental Disorder is defined by a withdrawal of the child into a separate,
selfcreated fantasy world. The course of this disorder is chronic and often persists into
adulthood. It is characterized by such features of impairments as these:
1. Reciprocal Social Interaction: not aware of others' feelings, doesn't imitate,

doesn't seek comfort at times of distress, and impairment in ability to make
peer relationships.
2. Impaired Communication: abnormal speech productivity, abnormal form or
content of speech, and impaired initiating or sustaining conversation despite
adequate speech.
3. Restricted Repertoire of Activities and Interests: stereotyped body movements,
marked distress over trivial changes, and restricted range of interests.
A medical exam to rule out physical problems such as hearing or vision impairments should
be performed prior to the assignment of this diagnosis. PDD show severe qualitative abnor
malities that aren't normal for any age in comparison to mental retardation, which demon
strates general delays and the person behaves as if he/she is passing through an earlier stage
of normal development. However, MR may coexist with PDD.
Goals 1. Child will not harm self

2. Child will demonstrate trust in his/her caretaker
3. Shaping child's behavior toward improved social interaction
4. Child will demonstrate increased selfawareness
5. Child will develop appropriate means of verbal and nonverbal communication
for expressing his/her needs
6. Support and educate parents regarding behavioral management
Treatment Focus 1. Risk of SelfHarm

and Objectives A. Intervene when child demonstrates selfinjurious behaviors
B. Determine precipitators of selfinjurious behaviors (such as increased tension in
environment or increased anxiety)
C. Make efforts to assure, comfort, or give appropriate structure to child during
distressful incidents to foster feelings of security and trust
D. Offer onetoone interaction to facilitate focus and foster trust
E. Use safety helmet and mitts if necessary
2. Lack of Trust
A. Consistency in environment and interactional objects (e.g., toys, etc.) fosters
security and familiarity
B. Consistency in caretaker to develop familiarity and trust
C. Consistency in caretaker responses to behavior to facilitate development of
boundaries and expectations; behavioral reinforcement
D. Caretaker must be realistic about limitations and expectations. Prepare caretaker to
proceed at a slow pace and to not impose his/her own wants and desires of progress
on the child who will have to move at his/her own slow pace.

E. Proceed in treatment plan with the lowest level of desired interaction to initiate
positive behavioral change. Lowlevel behaviors could include eye contact, facial
expression, or other nonverbal behaviors. Development of these types of behaviors
require onetoone interaction.
F. Keep environmental stimuli at a minimum to reduce feelings of threat or being
overwhelmed
3. Dysfunctional Social Interaction
A. Requires objectives 1 and 2 to be in practice
B. Support and reinforce child's attempts to interact, with consistent guidance toward
goal behaviors
C. Consistently restate communication attempts to clarify and encourage appropriate
and meaningful communication that is understandable (be careful to not alter the
intended communication, just clarify it)
4. Identity Disturbance
A. Utilize activities that facilitate recognition of individuality. Begin with basic
daily activities of dressing and mealtime, such as difference in appearance and
choices.
B. Increase selfawareness and selfknowledge. This can be initially facilitated by
having the child learn and say the name of the caretaker and then his/her own name
and learning the names of his/her own body parts. These types of activities can be
done through media such as drawing, pictures, or music.
C. Reinforce boundaries and individuality
5. Impaired Communication
A. Consistently make efforts to clarify intent/need associated with communication
B. Caretaker consistency will facilitate increased understanding of child's
communication patterns
C. When clarifying communication, be eye to eye with child to focus on the
communication in connection with the issue of need being presented by the child
6. Parental Intervention/Education
A. Educate regarding realistic understanding of expectations and limitations
B. Identify and work through feelings of loss, guilt, shame, and anger
C. Facilitate other children in the family to deal with their feelings and concerns
D. Encourage acceptance of reality
E. Encourage identification and utilization of community support organizations and
other associated resources
F. Identify additional support and respite care
G. Teach parents specific behavioral management techniques to fit their needs, such as
how to solve practical problems (within family, between child/school, family/school,
and with other services), how to celebrate progress and how to establish reinforcers
H. Recognize that parents may be at increased risk for depression or stressrelated
illnesses
Some conditions produce PDD symptoms, therefore, if a formal diagnosis has not previously
been assigned, the following information should be given to the parents and appropriate
referral considerations be communicated to the primary care physician.
Medical 1. History

Assessment 2. Examination
3. Rule out associated medical conditions (pica and associated lead intoxication)
6 i. Treatment Planning: Goals, Objectives, and Interventions

4. Visual/audiology exams
5. Neurological assessment important to evaluate for seizures
6. Genetic screening
7. Language/communication assessment, such as articulation/oral motor skills and
receptive/expressive skills
Developmental 1. Preschool

Stage A. Early intervention
B. Parental education and training
C. Some eligibility of services
2. School age
A. Increased eligibility for services (public, social, educational)
B. Continued education and support of parents, including a focus on problem solving
skills and behavior management
3. Adolescence
A. Expanding eligibility for services by focusing on adaptive skills development,
prevocational skills, and vocational programming/education
B. Clinical clarification of strengths/weaknesses as related to vocational training
C. When possible include adolescent in treatment planning
D. Monitor for development of comorbid diagnoses such as depression or
seizures
4. Adult
A. Identification of community resources
B. Support in planning longterm care, including employment, residential care, social
support/activities, and family support
DISRUPTIVE BEHAVIOR DISORDERS
ATTENTION DEFICIT HYPERACTIVITY DISORDER
(ADHD) OPPOSITIONAL DEFIANT DISORDER
CONDUCT DISORDER
There is somewhat of a continuum and overlap between manifestations of Attention Deficit
Hyperactivity Disorder, Oppositional Defiant Disorder, and Conduct Disorder. ADHD may
be an underlying issue in both Oppositional Defiant Disorder and Conduct Disorder. A care
ful assessment taking this into consideration will allow the therapist to rule out the ADHD
diagnosis in these instances. Because of the commonality in behavioral symptomology, the
treatment focus and objectives will be offered as a single section to draw from based on the
needs of the case.
ADHD children are at risk for delinquent behaviors because they do not consistently
demonstrate behaviors that will naturally elicit positive reinforcement. Instead they tend
to receive negative feedback from their peers and adults. In an effort to fit in with a peer
group, they may find acceptance with children/adolescents that have obvious behavioral
problems. Generally, there is behavioral evidence of difficulties associated with ADHD in all
settings (home, work, school, social), and symptoms are usually worse in situations requir
ing sustained attention. Although the excessive motor activity characterizing ADHD often
subsides prior to adolescence, the attention deficit frequently persists.
In cases where ADHD is suspected, first refer to a physician for a medical exam to rule out
endocrine problems or allergies and to address the issue of medication. Rule out mood disor
ders and abuse. In cases where Oppositional Defiant Disorder or Conduct Disorder is a poten
tial diagnosis, rule out substance abuse, sexual abuse, physical/emotional abuse, and ADHD.
Goals 1. Assess for referral for medication evaluation

2. Enhance parent education regarding familial and clinical aspects of the
disorder and behavioral management
3. Collateral cooperation in behavioral management with teaching staff
4. Develop responsible behavior and selfrespect
5. Develop appropriate social skills
6. Improve communication
7. Decrease defensiveness
8. Improve selfesteem
9. Improve coping
10. Problem solving
11. Improve insight
12. Impulse control
13. Anger management
14. Eliminate potential for violence
Treatment Focus 1. Evaluate for Referral for Medication Evaluation

and Objectives A. If parents have a negative or resistant response to medication, direct them to some
appropriate reading material and suggest that they meet with a physician
specializing in this disorder before they make a decision
2. Parent Education
A. Overview giving the defining criteria of the specific disorder, explore how the family
is affected and how they respond, etiology, developmental influences, prognosis, a
selection of reading materials and information on a community support group, if
available
B. Parent effectiveness training. Training to include parenting skills in behavioral
modification, contingency planning, positive reinforcement, appropriate limit setting
and consequences, encouraging selfesteem, disciplining in a manner that fosters the
development of responsibility and respect for others. Consistency is imperative to
successful behavioral change and management.
C. Dysfunctional family dynamics
1. Explore and identify family roles
2. Identify modification and changes of person's role in family
3. Identify the various roles played by family members and the identified patient,
and modify or change as needed in accordance with appropriate family
dynamics and behavior
4. Facilitate improved communication
5. Clarify differences between being a parent and a child in the family system,
along with role expectation
6. Explore the necessity of out of home placement if parents are unable to
effectively manage and support behavior change or are actual facilitators of
antisocial behaviors. Depending on severity of behaviors, it may require
placement for monitoring to prevent risk of harm to self or others
8 1. Treatment P l a n n i n g . G o a l s , Objectives, and Interventions
3. Teachers
A. Define classroom rules and expectation regularly
B. Break down goals into manageable time frames depending on the task. Time
frames could be 15 minutes, 30 minutes, one hour, a day, or a month. Be
encouraging by providing frequent feedback. Break tasks into small steps.
C. Give choices whenever possible
D. Provide short exercise breaks between work periods
E. Use a time to encourage staying on task. If these students finish a task before the
allotted time, reinforce their behavior
F. Facilitate the development of social skills
G. Encourage specific behaviors
H. Develop contracts when appropriate. It will also help parents reinforce the teacher's
program
I. Develop a secret signal that can be used to remind students to stay on task, which
will avoid embarrassment and low selfesteem
J. Facilitate the development of selfmonitoring so that students can pace themselves
and stay on task, as well as selfreinforce for progress
K. Structure the environment to reduce distracting stimuli
L. Separate these students from peers who may be encouraging inappropriate behavior
M. Highlight or underline important information
N. Use a variety of highinterest modes to communicate effectively (auditory, visual,
handson, etc.)
O. Position these students close to resources/sources of information
P. Consistency is imperative
Q. Work collaterally with all professionals to develop an individualized cognitive
behavioral program
4. Lack of SelfRespect and Responsibility
A. Have person define these terms accurately (may need support or use of external
resources) and compare the working definitions to his/her behavior as well as
developing appropriate behavioral changes
B. Facilitate the concept of choices related to consequences, and acceptance of
consequences as taking responsibility for one's own actions
C. Have these children identify how they are affected by the behavior of others and
how others are affected negatively by their behaviors. Clarify that they only have
control over their own behaviors.
D. Work with parents to clarify rules, expectations, choices, and consequences
5. Dysfunctional Social Interaction
A. Rolemodel appropriate behaviors/responses for a variety of situations and
circumstances. Provide situations or vignettes to learn from.
B. Provide positive feedback and constructive education about their interaction
C. Identify manipulative or exploitive interaction. Explore intention behind interaction
and give information and reinforcement on how to get needs met appropriately.
D. Focus on the positive demonstrations of interaction over negative ones when
reinforcing behavioral change
E. Have person identify reasons for inability to form close interpersonal relationships
to increase awareness and to develop choices for change
F. Have person identify behaviors that allow one person to feel close or comfortable
with another person versus distancing behaviors
6. Impaired Communication Skills
A. Teach assertive communication skills
B. Encourage appropriate expression of thoughts and feelings

C. Rolemodel and practice communication responses (verbal and nonverbal) for
various situations and circumstances
D. Positive feedback and reinforcement
7. Defensive Behaviors
A. Increase awareness for defensive tendencies by defining with examples and
encouraging the individual to identify similar behaviors of his/her own
B. In a nonthreatening way, explore with these individuals any past feedback that they
have been given from others about how others perceive them and what contributes
to that perception
C. Focus on positives attributions to encourage positive selfesteem
D. Encourage acceptance of responsibility for one's own behavior
E. Have person identify the relationship between feelings of inadequacy and
defensiveness
F. Positive feedback and reinforcement
8. Low SelfEsteem
A. Through a positive therapeutic relationship, be accepting, respectful, and ask them
often what their views are about issues, affirming the importance of what they have
to offer
B. Support and encourage appropriate risk taking toward desired goals
C. Encourage their participation in problem solving
D. Reframe mistakes in an effort toward change as an opportunity to learn more and
benefit from experiences. Encourage taking responsibility for one's own mistakes.
E. Encourage selfcare behaviors: grooming/hygiene, exercise, no use of substances,
good nutrition, engaging in appropriate pleasurable activities
F. Identify selfimprovement activities; behavioral change, education, growth
experiences
G. Identify and develop healthy, appropriate values
H. Identify strengths and develop a form of daily affirmations for reinforcing positive
selfimage
I. Identify desired changes. Be sensitive, realistic, and supportive in development of
shaping changes.
J. Facilitate assertive communication and assertive body language
K. Educate about the destructiveness of negative selftalk
L. Create opportunities for person to show his/her abilities
M. Notice examples of ability and point them out. Build on strengths.
N. Positively reinforce their efforts and accomplishments
9. Ineffective Coping
A. Provide appropriate physical activity to decrease body tension and offer a positive
choice with a sense of wellbeing
B. Set limits on manipulative behavior and give appropriate consequences
C. Facilitate change in coping by not participating in arguing, debating, excessive
explaining, rationalizing, or bargaining with the person
D. Running away
1. Identify the nature and extent of running away
2. Clarify and interpret the dynamics of running away
3. Work through the identified dynamics
4. Facilitate the individual to identify the signs of impending runaway
behavior
5. Facilitate identification and implementation of alternative solutions to
running away

E. Lying
1. Identify the nature and extent of lying
2. Confront lying behavior. Assert the importance of behavior matching what is
verbalized
3. Clarify and interpret the dynamics of lying
4. Work through the dynamics of lying
5. Facilitate the development of a behavioral management program for lying.
Monitor accurate reporting of information, and encourage the person to make
amends to those lied to whenever possible.
F. Focus on positive coping efforts
G. Encourage honest, appropriate, and direct expression of emotions
H. Facilitate the development of being able to delay gratification without resorting to
manipulative or actingout behaviors
I. Have person verbalize alternative, socially acceptable coping skills
10. Ineffective Problem Solving
A. Encourage the identification of causes of problems and influencing factors
B. Encourage the person to identify needs and goals. Facilitate, with the individual's
input, the objectives, expected outcomes, and prioritization of issues
C. Encourage the exploration of alternative solutions
D. Provide opportunities for practicing problemsolving behavior
E. Explore goals, and problemsolve how to reach goals
11. Poor Insight
A. Increase understanding of relationship between behaviors and consequences
B. Increase understanding of the thoughts/feelings underlying choices made
C. Facilitate problem solving appropriate alternative responses to substitute for
negative choices
12. Poor Impulse Control
A. Increase awareness, and give positive feedback when the person is able to
demonstrate control
B. Explore alternative ways to express feelings
C. Facilitate the identification of particular behaviors that are causing problems
D. Facilitate identification of methods to delay response and encourage thinking
through of various responses with associated consequences
13. Poor Anger Management
A. Identify antecedents and consequences of angry outbursts
B. Facilitate understanding of anger within the normal range of emotions and
appropriate responses to feelings of anger
C. Identify issues of anger from the past and facilitate resolution or letting go
D. Identify the difference between anger and rage
E. Identify affect of anger on close, intimate relationships
F. Identify role of anger as a coping mechanism or manipulation
G. Facilitate the taking of responsibility for feelings and expressions of anger
H. Problemsolve current issues of anger to resolve conflicts
I. Positive feedback and reinforcement for efforts and accomplishments
14. Potential for Violence
A. Assess for signs and symptoms of acting out
B. Maintain a safe distance and talk in a calm voice
C. Provide a safe, nonthreatening environment with a minimum of aversive stimulation
Disruptive Behavior Disorders I 1

D. Use verbal communication and alternative stress and anger releasers to prevent
violent acting out
E. Anger management
1. Identify the nature, extent, and precipitants of the aggressive behavior (i.e., is
the behavior defensive, etc.)
2. Facilitate identification and increased awareness of the escalators of aggressive
behavior
3. Clarify and interpret the dynamics of aggressive impulses and behavior
4. Work through the dynamics of aggression
F. Reinforce the use of the skills that the person has developed
G. Have the person discuss alternative ways of expressing their emotion
appropriately to avoid negative consequences
H. Encourage the individual to verbalize the wish or need to be aggressive rather
than to act on the impulse
I. If the person demonstrates the tolerance of intervention, provide a recreational
outlet for aggressive impulses
J. Facilitate the individual to implement alternative actions to aggressive
behavior
K. At a later time when the threat of acting out has passed, help the person to benefit
from the experience by reviewing the circumstances, choices, and different points
of possible intervention and what would have been helpful reinforce the person's
problemsolving efforts
Additional Regarding culturally diverse and innercity dwellers, it is imperative to obtain information
on the family and neighborhood:
Considerations
1. Inquire about the possibility of lead intoxication and malnutrition

2. Ask about parental abuse of substances and antisocial behavior/personality
disorder (including family members and peer reference group)
3. In the culturally diverse, assess the level of cultural tolerance for certain
behaviors
4. Determine if their environment demands physical strength and aggression as
survival factors
5. What is the impact of social/economic pressures on lying, truancy,
stealing, early substance abuse, sexual behavior, inconsistent/absent parental
figures (i.e., single parent who works and is not available), and their
values/beliefs
Disorders of behavior are treated with a focus on behavioral interventions. Therefore,
therapy is has these features:
1. Highly structured
2. Moderate in supportiveness (some attention to past patterns/difficulties)
3. May include modalities of individual, family, and selfhelp groups
4. Physical examination with minimal use of medication (not a substitute for
modifying inappropriate behavior)
5. Brief duration of treatment
12 i.Treatment Planning: G o a l s , Objectives, and Interventions

Many children diagnosed with Attention Deficit Disorder (ADD), ADHD, or other behav
ioral disorders may actually be manic depressive. Bipolar Disorder in children
1. May strike as early as age 7
2. May be prone to rapid cycling
3. May go untreated for years
Similarities between hyperactivity and mania in children are that the children are
1. Excessively active
2. Irritable
3. Easily distracted
However, children with Bipolar Disorder also exhibit
1. Elated mood
2. Inappropriate giggliness
3. Grandiosity
4. Flights of ideas
5. Racing thoughts
6. Decreased need for sleep
SEPARATION ANXIETY
The most prominent feature of this disorder is excessive anxiety concerning separation from
those to whom the child is attached. Additional symptoms includes irrational fears, night
mares, emotional conflicts, and refusal to attend school. Explore the presence of domestic
issues that are related to or are exacerbating the child's emotional and behavioral problems.
Goals 1. Support and educate parents regarding ageappropriate separation issues

2. Identify and resolve the events precipitating the anxiety
3. Decreased worrying
4. Consistent school attendance
5. Resolution of the emotional conflict
6. Foster cooperative efforts with school personnel to effectively manage
behavior
Treatment Focus 1. Educating Parents Regarding AgeAppropriate Emotional Separation

and Objectives 2. Exploring Precipitating Events Such as Recent Losses, Stressors, and Changes
A. Explore the issues of substance abuse in the home or other contributors of
instability
B. Explore parental conflict and spousal abuse issues
C. Explore possible nightmares or fears associated with separation
D. Explore the fear of being alone

3. Excessive Worrying
A. Explore fears related to concerns—rational and irrational
B. Deal with issues related to rational fears and problemsolve more adaptive
coping responses
C. Confront irrational fears and beliefs
4. Refusal to Attend School
A. Child needs to attend school
1. Contact school to prepare the staff for the situation
2. Parents and teachers to be consistent with a mutual understanding of the plan
to manage the child
5. Difficulty Dealing with Emotional Conflict
A. Play therapy to identify and work through issues
B. Relaxation training (with reaffirming messages such as "mommy is at work, but
will be home at ..., Everything is the way it is supposed to be ...")
C. Keeping a journal for venting feelings and for problem solving
D. Encourage appropriate behavior; do not focus on negative behavior
E. Explore presence of physical symptoms associated with anticipation of separation.
Facilitate development of management skills to decrease symptoms.
F Positive feedback and reinforcement
6. Teacher
A. Inform teacher of difficulties that child is experiencing
B. Coordinate consistency between efforts of school personnel and parents in being
supportive to the child
While separation anxiety is seen as a normal response in young children, when it inter

feres with ageappropriate tasks (school attendance, peer interaction, daily activities etc.), it
needs to be dealt with.
Additional For children residing in innercity settings there may be legitimate issues of safety associated

with high crime rates. Parents may be reluctant to let their children go outside and play with
Considerations out adult supervision, feeling anxious and unsafe themselves. Therefore, the parent's level of
anxiety and coping must be carefully evaluated. If there is an instance of actual harm or
abrupt separation from a caretaking figure, a child's anxiety may increase.
Note that a diagnosis of anxiety disorder is only appropriate when a child's fear, anxiety,
worries are persistent and unrealistic.
AVOIDANT DISORDER
The central feature of this disorder is the excessive negative reaction to unfamiliar people.
Additional features include heightened anxiety and low selfesteem. These children desire
warm and satisfying relationships with familiar people, but their severe reaction to unfamil
iar people interferes with social functioning.
Goals 1. Correct irrational thinking

3. Facilitate selfmanagement through identification of personal
goals and objectives
4. Improve coping

5. Decrease avoidance
6. Decrease anxiety
7. Improve peer relationships
Treatment Focus 1. Explore Fears and Irrational Beliefs

and Objectives A. Challenge irrational thoughts with reality
understand fear
normalize fear
manage fear
B. Substitute irrational thoughts with rational thoughts
C. Encourage appropriate risk taking (plugging in some guaranteed successes)
2. Low SelfEsteem
A. Identify strengths and accomplishments
B. Create opportunities to demonstrate strengths
C. Encourage expression of thoughts and feelings on problemsolving issues
D. Be accepting and respectful
E. Facilitate development of assertive communication
3. Lacks Appropriate Goals
A. Identify strengths and interests
B. Break down objectives to goal into manageable steps
C. Focus on efforts and accomplishments
A. Facilitate identification of feelings
B. Encourage appropriate venting of feelings
C. Set limits on avoidant behaviors while encouraging effective coping
behaviors
D. Explore alternatives for dealing with avoidance to specific situations
E. Practice effective solutions such as homework designed to help individuals face
their fears and test cognitions (for example, gradually increasing exposure to
feared stimulus)
F. Focus on efforts and accomplishments
G. Positive feedback and reinforcement
5. Avoidant Behavior
B. Teach appropriate social skills
C. Roleplay responses to variety of social situations
D. Systematic desensitization
1. Develop hierarchy of increasing anxietyprovoking situations to facilitate feelings
of being in control
2. In vivo desensitization may work faster for some individuals then imaginal
desensitization
E. Positive feedback and reinforcement for efforts and accomplishments
6. Increased Anxiety
A. Identify relationship between anxiety and behavior

B. Teach relaxation techniques
1. Deep breathing
2. Progressive muscle relaxation
3. Visual imagery
7. Improve Peer Relationships
1. Encourage participation in activity where additional benefit is time shared with
peers who have the same interest
2. Encourage participation in engaging situations or activities that offer distraction,
thereby increasing mastery over anxiety while in the company of peers
3. Parents may have to be more accomodating and lack demonstrations of distress
associated with accomodating
Additional 1. Assess parental response to new people and situations

Considerations A. Modeling
B. Level of anxiety
2. Assess
A. Parental encouragement/reassurance of appropriate risktaking behavior
B. Resolution to distressing situations—learning/increased awareness versus
appropriate distrust
3. Work with parents to help them understand their child's behavioral and
emotional reactions and the role they can play in modification
OVERANXIOUS DISORDER
This disorder is characterized by irrational anxiety where there is no identifiable situation
linked to the fear. Symptoms include worry about the future, low selfesteem (selfconfidence),
inability to effectively cope, need for reassurance, and somatic complaints. This child is pre
occupied with irrational thoughts.
Goals 1. Correct irrational thinking

2. Improve coping
4. Decrease anxiety
5. Family education and intervention
6. Collateral contact with school personnel
Treatment Focus 1. Irrational Beliefs

and Objectives A. Rule out trauma/abuse
B. Explore parental experience of the world (e.g., mother may be over anxious,
therefore the world is a dangerous place)
C. Challenge irrational thoughts with reality
D. Encourage appropriate risk taking
B. Encourage appropriate venting of feelings
C. Identify effective solutions to anxietyprovoking situations

D. Practice positive thinking and effective behaviors in a variety of situations
E. Focus on efforts and accomplishments
3. Elevated Anxiety
A. Teach relaxation techniques
2. Deep breathing
3. Visualization that creates a feeling of calm, reassurance, and safety
B. Challenge irrational beliefs and behavior
C. Facilitate development of appropriate substitute selfstatements and behaviors for
irrational ones
D. Create mastery experiences. They may need to broken down into successive
approximations.
4. Low SelfEsteem
A. Support and encourage appropriate risktaking behavior
B. Encourage participation in problem solving
C. Reframe mistakes in an effort toward change and an opportunity to learn more
D. Identify desired areas of change
E. Identify strengths and develop daily affirmations for reinforcing positive selfimage
F. Facilitate development of assertive communication
G. Create opportunities for person to demonstrate strengths/desired changes
H. Feedback and positive reinforcement for efforts and changes
5. Family Intervention/Education
A. Refer to primary care physician for a physical examination if somatic complaints
are present to rule out any organic basis for complaints
B. Explore what they may be doing to reinforce the beliefs and behaviors
C. Explore possibility of parental overconcern on child as a deflective response to
avoid their own relationship issues, or is this the only method they have for
joining?
D. Strengthen the relationship with siblings, if present
E. Facilitate appropriate parental focus on the child's behaviors
F. Educate parents regarding needs for emotional availability, limits/boundaries,
encouragement, and positive reinforcement
6. School
A. Work with school toward mastery behavior versus concern for anxious behavior
B. Reinforce for efforts and accomplishments
According to Peterson and BrownleeDuffeck (1989)
1. Fears and anxieties of family members constitute a factor in whether or not to

treat the fears and anxieties of a child
2. In the vast majority of cases of child anxiety, there is a positive correlation
between parental anxiety and child anxiety
3. This correlation between parental and child anxiety demonstrates stronger lies
for younger children than older children
Child anxiety is more common among children from lower socioeconomic strata than
those from higher economic strata

EATING DISORDER (EDO)
Due to the overlap in symptoms and the blending of features from more than one diagnosis
of Eating Disorder, the goals and objectives will be presented as one section instead of sep
arated according to the specific diagnosis.
The central features of Anorexia are refusal to maintain adequate body weight, distorted
body image, fear of becoming fat, amenorrhea, eating/food rituals, and excessive exercise.
An anorectic may experience feelings of power associated with restricting food.
The central features of Bulimia include recurrent episodes of binge eating and purging, the
use of laxatives/diuretics, efforts to diet/fast, and an excess concern with body shape and
weight. The bingepurge cycle is initiated by binge eating. This provides relief because the
individual ceases to dwell on anything except the food and how to get it down. This behav
ior replaces all other thoughts, behaviors, and feelings. The purging is initiated to "undo"
the consequences of binging. When the bingepurge cycle is over, the bulimic briefly regains
control with associated feelings of competence and increased selfesteem. There are no
longer any feelings of guilt for having eaten so many calories. The person is on a high or
numbed out, feeling relaxed and drained by the behavior.
Due to the relationship of EDO behaviors to physical etiology and consequences, it is
important to refer the person to a physician initially (and monitoring if necessary) to rule
out the presence of organic problems such as those associated to the endocrine system, gas
trointestinal complications, cancer, hypothalamus brain tumor, electrolyte imbalance, assess
ing the need for hospitalization, etc.
When working with individuals diagnosed with an EDO, be aware of the possibility of a
general problem with impulse control. Compulsive behaviors can be oriented around steal
ing, sex, selfdestructive behaviors, and substance abuse. It is not uncommon for individuals
diagnosed with an EDO to trade compulsions (even the EDO behaviors) when they are in
treatment and are making efforts to alter their behaviors. Be alert to the comorbidity of
mood disorder and personality disorder with these individuals, with the associated compli
cations to the clinical picture.
Goals 1. Medical stability

2. Assess for referral for medication evaluation
3. Improve coping
4. Facilitate appropriate autonomy
5. Improve body image
6. Improve rational thinking
7. Improve interpersonal relating
10. Identify feeling states
11. Differentiate between internal sensations and emotional states
12. Family intervention
13. Selfmonitoring
14. Assess psychiatric status and safety
Treatment Focus 1. Inadequate Nutrition

and Objectives A. Evaluation by physician/dietitian to determine adequate fluid intake and number
of calories required for adequate nutrition and realistic weight. These profes
sionals will have to monitor the medical side of the disorder. For the therapist to
become involved, serious complications must arise in the therapeutic relationship.
18 1. Treatment Planning: Goals, Objectives, and Interventions

As adequate nutrition and normal eating patterns are established, begin to explore
with the person the emotions associated with his/her behavior.
In instances in which intervention has taken place early and the weight loss is
not extreme, it may be adequate to do dietary education: the nutritional needs of
the body, the effects of starvation, what purpose(s) the illness serves, and
contracting for stabilization of weight and normalizing eating patterns. If these
limits are transgressed, refer for medical intervention.
If 15% of body weight is lost, refer to physician for monitoring. If the weight loss is
25% or below, hospitalization is necessary. In considering the issues of hospitalization
the following factors play a role: (1) how quickly the weight is lost (rapid weight loss
is more dangerous), (2) the person's weight prior to weight loss (an obese person has
a better tolerance to weight loss), (3) the person's physical condition, as determined
by the physician (potassium deficiency, dehydration, hypothermia, low blood pressure,
cardiac irregularities, etc.), and (4) the presence of starvation symptoms (cognitive
deficits, delayed visual tracking, reduced metabolic rate, fatigue etc.).
B. Rapid weight fluctuation. This is rarely a problem so extreme to be lifethreatening.
With severe engagement of the bulimic bingepurge cycle, there can be electrolyte
imbalance and dehydration. Additional physical complications are hair loss,
pimples, esophageal tears, gastric ruptures, and cardiac arrhythmias.
Ask directly about behaviors of restriction, binging, purging, and laxative/
diuretic use.
2. Assess for Referral for Medication Evaluation
A. Presence of mood disturbance (depression/anxiety)
B. Potential benefit of psychotropic medication for EDO symptoms
A. Identify person's anger or other feelings associated with loss of control of his/her
eating pattern
B. Explore family dynamics. Facilitate the recognition that maladaptive behaviors are
related to emotional problems due to family functioning/structure
C. Explore fears that interfere with effective coping
D. Explore history of sexual abuse, physical abuse, emotional abuse, neglect
E. Identify problem situations and develop alternative responses
F. Identify manipulative responses
G. Encourage honest, appropriate expression of emotions
H. Identify eating rituals and the role they play
I. Identify the fears associated with stopping the purging behavior
J. Identify the reasons to choose not to binge and purge
K. Identify what the bulimics behaviors protect the individual from
L. Assertive communication
M. Relaxation training
2. Visualization
3. Meditation
4. Difficulty with Autonomy
A. Teach response options to increase choice and feelings of responsibility
B. Encourage increased confidence and selfesteem
C. Encourage selfcare and being good to oneself
D. Explore ways to identify and work through underlying fears
E. Encourage appropriate risk taking
E Reframe mistakes as opportunities for learning and encourage related problem
solving

G. Encourage appropriate separation from family
H. Resolve developmental fears
I. Encourage the person's collaboration and input in treatment
J. Identify confusion
1. Separate selfacceptance from performance and the evaluation of others
2. Encourage the validation of the person's own thoughts and feelings
3. Explore the meaning of weight
4. Facilitate accurate perception of self
5. Through positive feedback, help these individuals to accept themselves as
they are
5. Distorted Body Image
A. Develop realistic expectations
B. Explore relationships and the belief of needing to be a certain way to maintain
the relationship
C. Encourage appropriate grieving for loss of central focus of preoccupation with
body and food
D. Increase awareness and expression through guided imagery and art
6. Irrational Thinking (EDO Thinking)
A. Negative self talk, all or nothing thinking, overgeneralizations, and perfectionistic
should statement
B. Confronting fear of weight
C. Replacing negative thoughts with realistic and constructive thoughts
7. Impaired Interpersonal Relations
A. Identify trust and honesty issues in relationships
B. Identify fear of "being found out" and of being rejected
C. Encourage appropriate risktaking behavior in developing relationships
D. Assertive communication
8. Dysfunctional communication
B. Encourage appropriate ventilation of thoughts and feelings
C. Model and roleplay appropriate responses to various situations
9. Low SelfEsteem
A. Explore ways to change faulty selfperceptions
B. Encourage these person's to develop trust in themselves and their abilities
C. Encourage their participation in problem solving
D. Encourage selfcare behaviors and positive selftalk
E. Create opportunities for success
F. Identify strengths and develop daily affirmations for reinforcing a positive selfimage
G. Identify personal growth activities
H. Promote feelings of control within the environment through participation and
independent decision making
I. Positively reinforce their efforts and successes
10. Identify Feeling States
A. Explore ways for these individuals to separate and maintain their own emotions
from the emotions of others
B. Facilitate accurate identification and acknowledgment of feelings
C. Assist person in dealing effectively with feelings

D. Facilitate understanding of feelings such as despair and guilt
E. Encourage daily journal entry related to feelings identification
11. Differentiation between Internal Sensations and Emotional States
A. Explore eating patterns in relationship to denial of feelings, sexuality, fears,
concerns, selfcomforting, approval, and so on
B. Facilitate development of acknowledging hunger and eating in response to
internal hunger cues
C. Identify ritualistic behaviors and substitute appropriate eating patterns
12. Family Therapy
A. Approach family in a nonblaming manner
B. Assume that families have done their best (rule/out)
C. Assume that families want to help (rule/out)
D. Recognize that families are tired and stressed
E. Facilitate ageappropriate separation
F. Identify person's role in the family
G. Identify how family maintains the dysfunctional behavioral/emotional patterns
H. Identify the role of the family in recovery
I. Identify community resources
1. Referral to group therapy and/or selfhelp groups
Physical Signs of Poor Nutrition and Inadequate SelfCare
Nutrient deficiency or Signs associated with poor nutrition or

Body areas other cause of problem other cause
Hair Protein Lack of natural shine: hair dull and dry; thin and

sparse; hair fine; color changes easily plucked
Face Protein, calories, niacin, Skin color loss; skin dark over cheeks and under

zinc, riboflavin, Vit. B6, eyes; lumpiness or flakiness of skin on nose and
Essential Fats (A, D, E & K) mouth; scaling of skin around nostrils
Eyes Vitamin A Dryness of eye membranes; night blindness
Lips Riboflavin, vit. B, folate Redness and swelling of mouth or lips, especially at

corners of mouth
Tongue Riboflavin, niacin Swelling; scarlet and raw tongue; magenta color;

swollen sores
Teeth Fluoride, sugar Missing or erupting abnormally; gray or black spots;

cavities
Gums Vitamin C "Spongy" and bleed easily; recession of gums
Glands Iodine, protein Thyroid enlargement; parotid (cheeks) enlargement
Skin Protein, niacin, zinc, Dryness; sandpaper feel of skin; red swollen

vit. B6, C, and K, essential pigmentation of exposed areas; excessive lightness
fats (A, D, E, and K) or darkness; black and blue marks due to skin
bleeding; lack of fat under the skin
Muscles Protein, calories Lack of muscles in temporal area, hand between

thumb and index finger and calf muscles;
Thiamin Pain in calves; weak thighs

13. SelfMonitoring/Relapse Prevention
A. Identify "red flag" patterns of behavior
B. Identify resources and support system
C. Encourage regular review of their program for recovery
D. Journal Writing
1. Expressing thoughts and feelings honestly; venting, clarification, and use for
problem solving
2. Record keeping of food consumption, vomiting, purging, and laxative use
3. Encourage identification of behavioral patterns and related emotional states
4. Facilitate identification of the kinds of thinking that leads to trouble
5. To provide a more objective record of changes that do or do not occur
E. Maintain increased awareness for the role of negative emotional states in relapse
F. Planning for followup with various professionals
14. Assessing Psychiatric Status and Safety
A. Suicidality
B. Mood/anxiety disorders
C. Substance use/dependence
D. Obsessive Compulsive Disorder/Symptoms
E. Personality Disorders
F. Post Traumatic Stress Disorder (PTSD)
Additional If an eating disorder is suspected of an individual from a culturally diverse group, it is impor

tant to determine the eating behavior and dietary habits that are culturally acceptable, the
Considerations
acculturation issues negatively impacting the individual, and the person's internal struggle with
adjustment. The individual's efforts of personal growth and success in a new culture may cre
ate significant cognitive dissonance as well as family pressure, disappointment, or alienation.
Possible Signs and Symptoms of Anorexia Nervosa, Bulimia Nervosa, and Compulsive

Overeating (Age 13 to Adult)
Physical symptoms Psychological symptoms
Anorexia Nervosa Skin rashes Perfectionist expectations

Blueness in extremities Avoidance of relationships
Poor circulation Preoccupation with weight
Fainting spells History of sexual abuse/assault
Anemia Euphoria
Chronic low body weight Sense of omnipotence
Irregular thyroid Views self as "fat"
Postpubertal absence of menses Overly compliant
Decreased gastric emptying Highly motivated
Water retention Ritualized behaviors
Bulimia Nervosa Swollen glands Impulsive behaviors

Susceptibility to infections Intense attachments
Irregular heart rate Preoccupation with weight
Persistent acne Alcoholic parent(s)
Menstrual irregularity Depression
Frequent diarrhea or constipation Suicidal thoughts
Water retention Poor selfesteem
Dental erosion Extreme sense of guilt
Ipecac poisoning Mood swings
Aspiration pneumonia History of excessive exercise
(Continues)

Possible Signs and Symptoms of Anorexia Nervosa, Bulimia Nervosa, and Compulsive
Overeating (Age 13 to Adult) (Continued)
Physical symptoms Psychological symptoms
Compulsive Overeating Shortness of breath Compulsive behavior

Frequent constipation Dependent attachments
Irritable bowel syndrome Preoccupation with weight
Elevated blood sugar Alcoholic parent(s)
Water retention Depression
Nausea Suicidal thoughts
Sleep disturbance Distorted perception of body
Weight fluctuation Sense of inadequacy
Joint inflammation History of frequent dieting
In addition to forwarding a letter that outlines recommendations for treatment, include this

laboratory assessment chart for patients with Eating Disorders when a consultation note is
sent to primary care physicians. It will offer them information on assessment in a manner in
which they are familiar.
A dental examination should also be performed. In younger patients it is generally useful
to assess growth, sexual development, and general physical development. A standard pedi
atric growth chart is useful for identifying patients who have failed to gain adequate and
expected weight or who have experienced growth retardation.
The American Psychiatric Society recommends the following laboratory assessments for
patients with eating disorders:
1. Consider the following assessments for all patients with eating disorders;
A. Basic analyses
1. Blood chemistry studies
a. Serum electrolyte levels
b. Blood urea nitrogen (BUN) levels
c. Creatinine level
d. Thyroid function
2. Complete blood count (CBC)
3. Urinalysis
2. Consider for malnourished and severely symptomatic patients
A. Additional analyses
1. Blood chemistry studies
a. Calcium level
b. Magnesium level
c. Phosphorus level
d. Liver function
2. Electrocardiogram
3. Consider for those patients who have been underweight for more than
six months
A. Osteopenia and osteoporosis assessments
1. Dualenergy Xray Absorptiometry (DEXA)
2. Estradiol level
3. Testosterone level (male)
4. The following are nonroutine assessment procedures
A. Consider only for specific unusual indications

B. Possible indicator of persistent or recurrent vomiting
1. Serum amylase level
C. For persistent amenorrhea at normal weight
1. Luteinizing hormone (LH) and follicle stimulating hormone (FSH) levels
D. For ventricular enlargement correlated with degree of malnutrition
1. Brain magnetic resonance imaging (MRI)
2. Computerized tomography (CT)
E. For blood
1. Stool
PREVENTING WEIGHT AND BODY IMAGE PROBLEMS

IN CHILDREN
Increased stress, everpresent media, convenience food and soda, and decreased physical
activity have led to an overconcern about physical appearance with decreased tolerance for
all the normal variations in body types and an epidemic of obesity in children. Children are
becoming more concerned about their weight and body image at an earlier age (as early as
6 to 9 years old). However, children who are obese do not necessarily have lower selfesteem
than nonobese children.
Obesity among children has now become a health concern that can make some medical
issues worse and lead to others (such as diabetes, joint problems, hypertension, premature
onset on periods and irregular periods, etc.). Both genetic and environmental factors affect
a child's potential for obesity. Therefore, it may be important to change both you and your
child to change some habits. Consult with your family physician or nutritional specialist,
attend nutrition classes, and educate yourself by reading about how to eat healthfully.
Continuously bringing up exercise and dieting to children and adolescents can create con
flicts, resistance, and negative selfesteem. Therefore, problemsolve what changes you will
make that sets the tone for nutrition and exercise. Your children will learn from you. Be a
more active family. Make activity fun and an important part of your lifestyle.
Obsession with While being obsess is not necessarily related directly to lower selfesteem there is still
warranted concern
Weight
1. Peer cruelty
2. Parental focus on weight
Feelings of inadequacy
Potential precursor to eating disorders
3. Media continuously portraying cultural perception of thin as attractive
Obesity and 1. Obesity is not always related to the lowering of selfesteem

SelfEsteem 2. Selfesteem is more likely to be associated with the following:
How family members respond to weight issues
Social experiences
Development of effective coping skills
What Parents 1. Set a healthy example

Can Do Physical activity
Nutrition

Not being negatively judgmental about different body types; children develop adult
perceptions of attractiveness as early as age 7
2. Make sure that children know and feel they are loved regardless of their
weight
Do not focus on their weight
Focus on spending time with them
Focus on teaching them effective lifemanagement skills
RECOMMENDATIONS FOR FAMILY MEMBERS OF
ANOREXIC INDIVIDUALS
1. With child/adolescent anorexics, demand less decision making from the

anorexic. Offer fewer choices, less responsibility. For example, they should
not decide what the family eats for dinner or where to go for vacation.
2. With child/adolescent anorexics, in conflicts about decisions, parents
should not withdraw out of fear that their child/adolescent will become
increasingly ill.
3. Seek to maintain a supportive, confident posture that is calming yet assertive.
Do not be controlling.
4. Express honest affection, both verbally and physically.
5. Develop communication/discussion on personal issues rather than on food
and weight.
6. Do not demand weight gain or put down the individual for having anorexia.
7. Do not blame. Avoid statements like "Your illness is ruining the family." This
person is not responsible for family functioning.
8. Do not emotionally abandon or avoid the anorexic family member. Remain
emotionally available and supportive. Utilize clear boundaries.
9. Once the individual is involved in treatment, do not become directly involved
with the weight issues. If you see a change in the individual's appearance,
contact the therapist or other pertinent professional such as the person's
physician and dietitian.
10. Do not demand that they eat with you, and do not allow their eating problem
to dominate the family's eating schedule or use of the kitchen. Be consistent.
11. For child/adolescent anorexics, do not allow them to shop or to cook for the
family. This puts them in a nurturing role and allows them to deny their own
needs for food by feeding others.
12. Increase giving and receiving of both caring and support within the family.
Develop clear boundaries, and allow each person to be responsible for
themselves and setting their own goals.

IDENTITY DISORDER
This disorder is characterized by confusion related to goals, career, friendships, sexual ori
entation, religion, and morality. The individual experiences distress over his/her inability to
clarify and integrate these factors into a selfassured, goaldirected sense of self.
Goals 1. Development of personal goals

2. Responsible behavior
3. Improve communication skills
5. Identify and resolve related family issues
Treatment Focus 1. Lack of Goals

and Objectives A. Identify strengths and areas of interest
B. Encourage appropriate risk taking
C. Encourage selfexploration through specific boundaries (individual desires, pleasing
self versus pleasing someone else, etc.)
D. Development of realistic expectations and limitations
E. Identify fear and anxiety associated with decision making, which interferes with
following through on decisions
F. Refer for vocational counseling
2. Difficulty Taking Responsibility
A. Discourage parental rescuing
B. Support appropriate management of anxiety
C. Encourage appropriate separation and individuation
D. Encourage appropriate risk taking
E. Identify strengths
F. Focus on positives and reinforce trying new things
3. Dysfunctional Communication Skills
B. Encourage ventilation of thoughts and feelings
C. Keep a journal for venting thoughts and feelings, clarification of issues, identifying
dysfunctional patterns, and problem solving
4. Low SelfEsteem
A. Be accepting, respectful, and encourage expression of person's beliefs and feelings
B. Reinforce the trying of new things, and focus on how it felt
C. Teach assertive communication
D. Identify strengths and accomplishments
E. Encourage focusing on strengths and accomplishments
F. Identify desired areas of change and problemsolve the necessary objectives to meet
the defined goals
G. Encourage and positively reinforce appropriate independent functioning
H. Facilitate selfmonitoring of efforts toward desired goals
5. Dysfunctional Familial Interacting
A. Identify issues of overcontrol or underinvolvement
1. Educate and validate regarding impact of such interaction
2. Encourage person to take responsibility

3. Encourage separation and individuation
4. Educate parents on parenting style and teach effective parenting skills
5. Encourage parents to not rescue or to be aware of detachment and alter
6. Develop realistic expectations and limitations of family for person
7. Identify and encourage appropriate parental interaction
B. Facilitate selfparenting techniques for the person
1. Use affirmative and reassuring selftalk
2. Eliminate irrational, selfcritical selftalk
3. Facilitate the experience of learning from mistakes as part of life versus inaction
out of fear of making mistakes
4. Encourage thorough review of family experience to facilitate identification of
areas of change to increase awareness and to break dysfunctional family patterns
in the person's own future family
6. Sexual orientation
Medication and talk therapy do not alter homosexuality or transsexual crossgender
identification. However, talk therapy can be useful in alleviating emotional problems
associated with the individual's social experience, relationship with the self, and
the experience within their family. Referral for medication evaluation would be
based on the same premise of other similar referrals (to eliminate/alleviate/stabilize
symptomology).

When working with children and adolescents, a myriad of special issues need to be consid
ered in the assessment, treatment planning, and treatment phases of intervening. A brief and
general summary of the biopsychosocial issues to be considered may be quickly reviewed by
using the following mnemonic:
CHILDREN
C cultural/gender issues
coping mechanisms
conflicts in marital relationship
H hyperactivity (ADHD)
health issues (chronic/acute)
I information releases for all professionals interacting with child/adolescent
injuries, head trauma (recent fall/physical trauma)
identity issues
intellectual function
L learning disabilities, learning styles (auditory, visual etc.)
low selfesteem
limitations (physical, mental, psychological, parental/family, etc.)
D drug abuse
defiant and oppositional behaviors
deficient mental capacity
R relationship issues (family, peers, educators, other significant people in
child's life)
resources and resourcefulness
religious/spiritual beliefs
E emotional disturbances and management (emotional/psychological
functioning)
educational issues (academic performance, truancy, compliance with rules)
experimenting sexually/fears or concerns/promiscuity
expectations of life and life goals
empathy and understanding of others
eyes and ears (verify that hearing and vision have been checked)
N nutrition/eating disorders
neglect or other abuse issues
The following three pages offer a summary on the theories of
1. Kohlberg's stages of moral development

2. Erikson's stages of psychosocial development
3. Freud's stages of psychosexual development

Kohlberg's theory of moral development is most often cited. This theory is conceptually
founded on the premise that stages of moral development occur in a distinct sequence, in
which each stage builds on the previous one and is more cognitively complex.
Kohlberg's Stages of Moral Development
Level 1 Preconventional Morality

(Ages 4–10)
Stage 1: PunishmentObedience Orientation
Moral judgment based on a desire to avoid punishment.
Stage 2: InstrumentalRelativist Orientation
Individual is motivated by a desire to satisfy own needs.
Level 2 Conventional Morality

(Ages 10–13)
Stage 3: "Good Boy/Nice Girl" Orientation
Individual motivated by a desire to avoid disapproval or dislike of others.
Stage 4: Law and Order Orientation
Moral judgments based on a desire to avoid censure by a legitimate authority.
Level 3 Postconventional Morality

(Adolescence to adulthood; not reached by most adults)
Stage 5: Legalistic Orientation
Individual concerned with maintaining the respect of equals and the community, maintaining
social order, and obeying democratically determined laws.
Stage 6: Universal Ethical Principles Orientation
Individual's own conscience is the only criterion of moral conduct.
Erikson's stages of psychosocial development stress social factors in personality develop
ment and are characterized by a psychosocial crisis that represents a conflict between the
developing individual and society. Erikson viewed development as a process that continues
throughout the course of one's life span.
Erikson's Stages of Psychosocial Development
Stage/age Conflict Significant relations Favourable outcome
OralSensory Trust versus Primary caretaker Trust and optimism

(0–12 mos.) mistrust
Muscularanal Autonomy versus Parents Selfassertion, selfcontrol,

(1236 mos.) shame feelings of adequacy
Locomotorgenital Initiative versus Family Sense of initiative,

(3–6 yrs.) guilt purpose, and direction
Latency Industry versus School, Productivity and competence in

( 6 – 2 yrs.) inferiority neighborhood physical, intellectual, and social skills
Adolescence Ego identity versus Peers, leadership Integrated image of oneself

role confusion models as a unique person
Early adulthood Intimacy versus Partners in Ability to form close personal

isolation friendship, relationships and make career
sex, etc. commitments
Middle adulthood Generativity versus Shared labor and Concern for future

stagnation household generations
Maturity Integrity versus Humankind Sense of satisfaction with one's

despair life; ability to face death
without despair
Children 29
Freud's constructs of psychosocial development are biological in nature and are based on
the inevitable unfolding of different stages in which particular behaviors occur. Abnormal
development takes place as a trauma is experienced in early childhood that prevents the flow
of libidinal energy through the various stages. If this happens, development is said to be
fixated at a particular stage, rendering the individual more vulnerable to crisis later in life.
A conflict occurs with each stage. There is a corresponding adult character pattern with each
stage.
Freud's Stages of Psychosexual Development
Stage/age Source of satisfaction Primary conflict Personality outcome
Oral (0–12 mos.) Mouth (sucking, Weaning Fixation produces

biting, chewing) dependence, passivity,
gullibility, sarcasm, or
orally focused habits
(smoking, nailbiting,
eating, etc.).
Anal (13 yrs.) Anal region Toilet training Fixation produces anal

(expulsion and retentiveness (stinginess,
retention of selfishness, obsessive
feces) compulsive behavior)
or anal expulsiveness
(cruelty, destructiveness,
messiness).
Phallic (3–6 yrs. Genitals Oedipus/Electra Successful conflict resolution

(masturbation) complex produces identification
with the samesex parent
and development of the
superego. Fixation may
produce a phallic character
(sexual exploitation of
others).
Latency (6–12 yrs.) During this stage, the
emphasis is on the
development of social
skills rather than sexuality.
Genital (12+ yrs.) Genitals (sexual Sexuality becomes focused in

intercourse) mature, genital love and
adult sexual satisfaction.

ORGANIC MENTAL SYNDROMES
AND DISORDERS
The various Organic Mental Syndromes and Disorders are manifested in disturbances of cog

nitive, behavioral, and personality changes. When presented with the symptoms of Dementia
and Organic Mental Disorders assessment is crucial in determining the origin of symptom
presentation. Just with the symptoms of hallucinations and delusions, the clinician must take
into consideration organicity, psychosis, depression with psychotic features, and substance
abuse or drug reaction (which can happen easily with the elderly). Substance abuse or drug
reaction will be the easiest to clarify because of lab results and history and change in symptom
presentation as the person detoxes. Therefore, for the initial refinement in diagnosis the fol
lowing general comparisons are helpful:
Organicity Depression Psychosis
History of failing memory Difficulty concentrating History of personality disturbance

Disorientation for time More precise onset Auditory hallucination/delusions
Perseverations Low motivation Disoriented to people and place
Visual/olfactory Selfcritical Perseveration of bizarre thoughts
hallucinations
Neurological signs Mood congruent hallucinations Mood inappropriate
Worse at night Vegetative symptoms (sleep/
appetite)
Depression can lead to symptoms that may appear to be Dementia. However, depression can
also be the response to early signs of Dementia. To clarify whether you are dealing with
Dementia or Pseudodementia, the following guidelines may be helpful:
Dementia Pseudodementia
Age is nonspecific Elderly > 60
Onset is vague (over months or years) More precise onset (days or weeks)
Slow course, worse at night Rapid, uneven course (not worse at night)
Dysphasia, agnosia, apraxia Sadness, somatic symptoms of depression
Increased cognitive impairment Increased impairment in personality features in
—Memory —Confidence
—Disoriented to time/date —Interests
Mental status—keeps making same mistakes —Drive
Behavior and affect congruent with degree Incongruent mood/affect
of impaired though processes and affect Selfdeprecating
Cooperative but frustrated Cooperative effects poor
Responses to questions confabulated Response to questions a pathetic, "I don't know'
Response to funny/sad situations is Little or not response to sad or funny situations
normal/exaggerated
Neuroevaluations abnormal (CT, EEG) Neuroevaluations normal (CT, EEG)
While the diagnostic generalities fit the elderly population, there are differences that warrant

clarification because of the impact on treatment plan formulation and care. Those present
ing with dementia exhibit a broad range of cognitive impairments, behavioral symptoms and
mood changes. Thus, necessitating an individualized and multimodel treatment plan. Since
dementia is often progressive, and in conjunction with its evolution is the emergence of
new issues to address, the clinican must closely monitor for changes, and whenever possible
predict impending change for the individual and/or their family. The following mnemonic
provides a useful overview for diagnostic consideration.
Organic Mental Syndromes and Disorders 31

DEMENTIA
D drug interaction
E emotional disturbances/current crises or losses
M metabolic/endocrine problems such as diabetes or thyroid
dysfunction
E eyes and ears
N nutritional deficiencies
T tumor or trauma
I infection/brain abscess
A arteriosclerosis or other arterisclerotic problems
This mnemonic (Perry et al., 1985) can be utilized while doing a mental status exam and
making a thorough diagnostic assessment to rule out reversible dementia such as depression,
anemia, hypothyroidism, alcoholic dementia, and so on. Refer for a complete physical which
includes a recommendation for a neurological exam, drug screen, endocrine panel, a neu
ropsychological testing if appropriate.
A family session can be used to educate family members and encourage their consulting
with the physician on the case. This will be helpful for increasing their understanding of the
medical situation, prognosis, indications, and contraindications of treatment. They need to
be educated on how to manage perceptual disturbances and disruptive behaviors, and the
importance of medication compliance and signs of toxicity.
DEMENTIA AND ORGANIC MENTAL DISORDERS
Dementia may have various origins. However, the symptomatology does not vary other than
for nuances of case individuality and the progression of deterioration. Like Dementia, many
of the Organic Mental Disorders (OMD) demonstrate evident symptoms through cognitive,
behavioral, and personality changes. There may also be evidence of depression, delirium, or
delusions. The dysfunction of OMDs tends to be chronic in that the related physical disor
ders attributed to these changes are progressive, except in some cases of psychoactive sub
stanceinduced OMDs.
The level of functioning must be thoroughly assessed for treatment planning, which
includes placement if necessary, and has not been addressed.
Goals 1. Refer for medical evaluation

2. Stabilization and thought processes are intact
3. Note that person will demonstrate improved reality testing or accept
explanation/reality testing from others
4. Improve selfcare
5. Decrease social isolation
7. Person will not experience physical injury
8. Person will not harm self or others
9. Reduce stress of caregiver
32 t. Treatment Planning Goals, Objectives, and Interventions

Treatment Focus 1. Refer for immediate medical examination to rule out drug interactions,
and Objectives metabolic or endocrine problems, problems with hearing or vision, presence of
tumor, infections, and so on, which could be contributing to the symptom
presentation. Additionally medical treatments are available for cognitive
symptoms, which offer modest benefit to some. However, the side effects may
be difficult to tolerate.
2. Altered Thought Processes
A. Assist in reality testing. Encourage person to interrupt thoughts which are not
reality based.
B. Instruct caretaker on facilitating person's orientation to time, place, person, and
situation
C. Discourage pattern stabilization of false ideas by talking to the person about real
people and situations
D. Offer simple explanations when necessary, and talk slowly and face to face to
increase effective communication
E. Reinforce accurate reality testing with positive feedback
3. SensoryPerceptual Changes
A. Decrease environmental stimuli
B. Assist in reality testing
C. Discourage pattern stabilization of false ideas by talking to the person about real
people and situations
D. Provide reassurance for increased feelings of security
E. Instruct caretaker on facilitating reality testing when person demonstrates
inaccurate sensory perception
4. Inadequate SelfCare
A. Encourage daily independent living skills
1. Bathing
2. Cleaning hair, cutting when necessary, and styled appropriately
3. Brushing teeth
4. Dressing adequately and appropriately
5. Cleaning self adequately after using bathroom, and wash their hands
5. Social Isolation
A. Supportive psychotherapy in early stages of dementia to address issues of loss
B. Reminiscence therapy
C. Stimulation oriented treatment
1. Recreational activity
2. Art therapy
3. Pet therapy
6. Low SelfEsteem
A. Encourage honest expression of feelings loss related to deterioration in
functioning
B. Encourage all levels of communication, and selfcare
C. Problemsolve ways of dealing with cognitive deficits (making labels large and easy
to read, signs identifying rooms, etc.)
D. Focus on abilities and accomplishments
E. Reinforce accurate reality testing with positive feedback
Dementia 33
7. Risk for Injury
A. Assess
1. Psychosis
2. Disorientation
3. Wanders off
4. Agitation unmanageable
5. Excessive hyperactivity
6. Muscular weakness
7. Seizures
'Agitation and psychosis are a common presentation in individuals with dementia. If these

symptoms are present, a through evaluation to determine what may underlie the
disturbance is recommended.
B. Precautions
1. Caretaker to remain in close proximity for monitoring, check frequently
2. Objects/furniture in room should be placed with function and safety in mind
3. Remove potentially harmful objects
4. Padding of certain objects may be necessary
5. Educate caregiver on safety and management issues
8. Risk of Violence
A. Assess level of agitation, thought processes, and behaviors indicative of possible
episode of violent acting outing potentially directed toward self or others
B. Keep environmental stimuli to a minimum, and remove all dangerous objects
C. Encourage caregiver to maintain a calm manner
D. Gently correct distortions of reality
E. Evaluate need for higher level of care
9. Caregiver Stress
A. Encourage appropriate expression of feelings such as anger and depression
B. Identify ways to effectively deal with emotions
C. Identify feelings of stress and loss in relationship to the person they are taking
care of
D. Identify family conflict related to issues of care
E. Identify how their own lives have been interrupted/interfered with by caregiver role
E Develop rotations of time off to take care of own needs and have time to themselves
G. Refer to community support group focusing on caregiver situation
DEFINING SPECIFIC DEMENTIAS
1. Alzheimer's Disease: Dimension with an insideous onset, gradual progression,
with initial memory deficits. After several years, aphasia, apraxia and agnosia
as well as deficits in executive function follows.
*Executive function: High level decision making, performing multiple step tasks, etc.
Alzheimer's subtypes: with delirium, with delusions, with depressed mood and
uncomplicated

2. Multiinfarct (vascular) Dementia: The consequence of one or more strokes
negatively impacting cognitive functioning. Onset is abrupt and pattern of
cognitive deficits depends on the region of the brain affected.
3. Dementia associated with Parkinson's Disease: This dementia is demonstrated
by a slow progression. Also associated with Parkinson's is a high prevalence of
depression and psychosis.
4. Dementia associated with Lewy Body Disease: Clinically similar to
Alzheimer's. However, onset is earlier with a faster evolution. There is a
prominence of psychotic symptoms and sensitivity to antipsychotic
symptoms.
5. Dementia associated with Pick's Disease (and other frontal lobe dementias):
Early stages of dementia characterized by changes in personality, executive
function, deterioration of social skills, emotional blunting, behavioral
disinhibition, and prominent language abnormalities.
6. Others
a. Dementia associated with Huntington's chorea
b. Dementia associated with CreutzfeldtJakob Disease
c. Dementia associated with structural lesions (brain tumor, subdural hematoma, head
trauma, HIV nutritional deficiencies, endocrine conditions
According to the American Psychiatric Association (2002), the following are underlying con
ditions commonly associated with delirium:
A. Central nervous system disorder
1. Head trauma
2. Seizures
3. Postictal state
4. Vascular disease
5. Degenerative disease
B. Metabolic disorder
1. Renal failure
2. Hepatic failure
3. Anemia
4. Hypoxia
5. Hypoglycemia
6. Thiamine deficiency
7. Endocrinopathy
8. Fluid/electrolyte imbalance
9. Acidbase imbalance
C. Cardiopulmonary disorder
1. Myocardial infarction
2. Congestive heart failure
3. Cardiac arrhythmia
4. Shock
5. Respiratory failure
Dementia 35
D. Systemic illness
1. Substance intoxication or withdrawal
2. Infection
3. Neoplasm
4. Severe trauma
5. Sensory deprivation
6. Temperature dysregulation
7. Postoperative state
According to the American Psychiatric Association (2000), the following are substances that

can cause delirium through intoxication or withdrawal:
A. Drugs of abuse
1. Alcohol
2. Amphetamines
3. Cannabis
4. Cocaine
5. Hallucinogens
6. Inhalants
7. Opioids
8. Phenylcyclidine
9. Sedatives
10. Hypnotics
11. Others
B. Medications
1. Anesthetics
2. Analgesics
3. Antiasthmatic agents
4. Anticonvulsants
5. Antihistamines
6. Antihypertensives
7. Cardiovascular meds
8. Antimicrobials
9. Antiparkinsonians
10. Corticosteroids
11. Gastrointestinal meds
12. Muscle relaxants
13. Immunosuppressive agents
14. Lithium
15. Psychotropic agents with anticholinergic properties
C. Toxins
1. Antocholinesterase
2. Organophosphate insecticides
3. Carbon monoxide
4. Carbon dioxide
5. Volatile organic substances such as fuel or solvents
36 i. Treatment Planning Goals, Objectives, and Interventions

PSYCHOACTIVE SUBSTANCE ABUSE DISORDERS
This diagnostic section is identified by personality, mood, and behavioral changes associated
with the use of substances. These changes are manifested by impairments in the following
areas of functioning: social, emotional, psychological, occupational, and physical. Instead of
using the terms tolerance and withdrawal to describe substance dependence it may be more
helpful to conceptualize "addiction" by the following criteria:
1. Obsessivecompulsive behavior with the substance
2. Loss of control, manifested by the person being unable to reliably predict
starting and stopping his/her use of the substance
3. Continued use despite the negative consequences associated with substance use
There are four pathways of use:
1. Oral—absorption in the bloodstream

2. Injection—IV use
3. Snorting—absorbed through the nasal membrane
4. Inhaling—absorbing through the lung
Brown's (1985) developmental model for the stages of recovery offer's a conceptual frame

work for identifying where an individual is in his/her recovery so that the developmentally
appropriate interventions can be made. The stages are as follows:
1. Drinking. The internal and external conflicts of addiction lead the individual

to a point of loathing, fear, selfhatred, losses, and other consequences. The
individual hits bottom.
2. Transition. The individual makes a shift from using to not using. If the
individual does not fully accept and believe that he/she is addicted, the person
may slip back and forth between stage 1 and 2. At this stage, work with the
resistance as much as possible. Without a constant focus on the substance, the
individual is enticed back into the belief that he/she can control use and may
initiate the cycle of use once more.
3. Early recovery. The individual begins social integration by interacting with others
without the use of a substance. With continued abstinence the person begins to
recover some of his/her losses with a return to work, family relationships, and other
adjustments. This is a period of new experiences for the individual, which requires
the support of others. The individual benefits from participation in a 12 Step group.
4. Late recovery or ongoing recovery. This is the developmental stage of recovery
where the more typical psychotherapeutic issues are evident. During this
period, there is a move from the selfcentered view of the world to a view in
which the individual exists in relation to others.
Recovery is not a linear process. It is the up, down, and sideways flow of interaction between
all of the experiences. This includes new ideas, new behaviors, new belief system, and the
shaping of a new identity integrating the culmination of where the individual has been and
where he/she is. This foundation of integrating experience one day at a time is what will take
the individual to tomorrow.
SUBSTANCE ABUSE AND/OR DEPENDENCE
Goals 1. Complete assessment with appropriate referrals
2. Encourage abstinence
3. Break through denial
4. Support cognitive restructuring
5. Improve behavioral selfcontrol
6. Develop refusal skills
7. Improve social skills
9. Improve coping skills
10. Improve problemsolving skills
12. Support and educate family
Treatment Focus 1. Thorough Assessment for Referral and Treatment

and Objectives A. Evaluate substance use (how much, how often, substances of choice, family history,
patterns of use, prior treatment, level of impairment in major life areas, inability to
control use, etc.)
B. Refer for general physical examination and consultation with primary care
physician. Refer for specific assessment of physiological impairment if warranted
by history.
C. Referrals (assuming detox is not an issue or is completed)
1. If unable to remain in recovery, refer to residential program
2. Outpatient chemical dependency program
3. 12step meetings or other supportive groups and programs
D. Evaluate cognitive deficit
1. Establish baseline assess of fund of knowledge, take into consideration level of
education and level of development
2. Identify strengths and weaknesses
E. Inadequate nutrition
1. Facilitate identification of prior eating patterns
2. Develop and establish eating three balanced meals a day
2. Abstinence
A. Individual has made a commitment to abstain from substance use
B. Individual is participating in an outpatient program
C. Individual has worked with therapist to develop own program for abstinence
recovery
3. Denial
A. Convey an attitude that is not rejecting or judgmental
B. Confront denial with reality of use and education to correct misconceptions
C. Identify the relationship between substance use and personal problems
D. Do not accept or ignore the use of other defense mechanisms to avoid reality

E. Encourage person to take responsibility for choices and associated consequences
F. Provide positive feedback and reinforcement for insight and taking responsibility
4. Negative/Irrational Thinking
A. Educate regarding positive selftalk to challenge negative selfstatements and
negative selffulfilling prophecy
B. Identify differences in statements prefaced as "can," "can't," "will," and "wont't"
C. Seek clarification "Does my style of thinking help or hinder me?"
D. Challenge beliefs with factual information
E. Accurately reflect reality to individual
5. Lack of SelfControl
A. Facilitate individual's analysis of substance use patterns and monitoring
1. Identify situations, people, emotions, and beliefs associated with substance use
2. Monitor currently or through recollection of past behaviors
3. Facilitate preparation for anticipated difficult situations and planning strategies
either to avoid or cope with these situations (strategies should be both cognitive
and behavioral)
4. Encourage active participation in group affiliation and other selfcare behaviors
5. Build in "reminder" statements or affirmations about the individual's
commitment to abstinence
B. Facilitate development of assertive communication
C. Offer relaxation training with positive selfstatements attached
D. Increase repertoire of coping skills through modeling, rehearsal, and homework
assignments
6. Lack of Refusal Skills
A. Goal is to develop the skills needed to refuse substances, refuse invitations to
participate in activities or be in the company of others associated with substance
abuse
B. Specific tasks to develop to strengthen refusal skills
1. Asking for help
2. Honestly expressing thoughts and feelings
3. Confronting and dealing with fear(s)
4. Standing up for their rights
5. How to deal with being left out
6. How to deal with group pressure and persuasion
7. Ineffective Social Skills
A. Teach social skills through role modeling, rehearsal, and role playing
B. Teach effective communication
1. Nonverbal communication such as positioning, eye contact, and personal space
2. Verbal communication
a. Initiating conversation
b. Reflecting
c. Giving and accepting compliments
d. Using "I" statements
e. Dealing with criticism or teasing
f. Assertive communication
C. Develop and utilize social supports
D. Forming close and intimate relationships
1. Steps of getting to know someone
2. Disclosure (how much/what/how soon)
Psycboactive Substance Abuse Disorders 39

3. Setting limits and boundaries
4. How to be close to someone and not lose focus on your goals
5. Establish trusting relationship reciprocating respect by keeping appointments,
being honest, etc.
a. Facilitate person to clarify the impact that substance abuse/dependence has
had on their significant relationships, financial implications, work, physical
health, and social supports/interaction or peer reference group
b. Once these issues are identified, facilitate insight, understanding, and the
development of choices in dealing with these various situations
8. Ineffective Communication
A. Assertive communication. Educate using comparisons of assertive communication
to aggressivepassive/aggressivepassive. Use vignettes and roleplay.
B. Facilitate awareness for inappropriate behaviors and verbal expressions as
ineffective attempts to communicate
C. Identify feelings behind inappropriate behavioral and emotional expressions and
facilitate problem solving
D. Use "I" statement to avoid blaming and manipulation
E. Use vignettes, role modeling, rehearsal, and role play for developing
communication skills
B. Encourage appropriate ventilation of feelings
C. Set limits on manipulative behavior (be consistent)
D. Facilitate development of appropriate and acceptable social behaviors
E. Educate person regarding the effects of substance use on social, psychological, and
physiological functioning
F. Explore alternatives for dealing with stressful situations. Problemsolve
appropriate responses instead of substance use.
G. Facilitate the development of a selfcare plan that outlines resources, skills to use
in various situations, daily structure, red flags to regression, and so on
H. Encourage person to take responsibility for choices and associated consequences
I. Positive feedback for independent and effective problem solving
A. Teach problemsolving skills
B. Develop some sample problems and give homework to practice new skills on
C. Identify secondary gains which inhibits progress toward change
11. Low SelfEsteem
A. Be accepting and respectful of person
B. Identify strengths and accomplishments
C. Encourage a focus on strengths and accomplishments
D. Facilitate identification of past failures and reframe with a perspective of how the
person can benefit and learn from previous experiences
E. Identify desired areas of change and facilitate problem solving the necessary
objectives to meet the defined goals
F. Facilitate selfmonitoring of efforts toward desired goals
G. Encourage and positively reinforce appropriate independent functioning
H. Facilitate development of assertive communication
I. Facilitate clarification of boundaries and appropriate limit setting in
relationships

12. Dysfunctional Family Interaction
A. Evaluate how family has been affected by behavior of this person (fear, isolation,
shame, economic consequences, guilt, feeling responsible for the behavior of
others)
B. Explore how family may help sustain or reinforce this dysfunctional behavior
C. Teach communication skills
D. Refer family members to appropriate 12Step groups, other community resources,
or therapy. Decrease isolation.
CATEGORIES OF PHARMACOLOGICAL INTERVENTION

1. Medications to treat intoxication and withdrawal states
2. Medications to decrease the reinforcing effects of abused substances
3. Medications that discourage substance abuse by
A. Inducing unpleasant consequences through drugdrug interaction
B. Coupling substance use with an unpleasant drug induced condition
4. Agonist substitution therapy
5. Medications to treat comorbid psychiatric conditions
TREATMENT SETTINGS
As in all cases, individuals should be treated in the least restrictive setting that provides
safety and effectiveness. General treatment settings include the following:
1. Hospitalization
A. Danger to self, others, gravely disabled
B. There has been an overdose
C. There is risk of severe/medically complicated withdrawal
D. Comorbid medical condition(s) prohibits a safe outpatient detox
E. Psychiatric comorbidity impairs ability to comply and benefit from a lower level
of care
2. Residential treatment facility
A. Does not meet criteria for hospitalization
B. Lacks adequate social and vocational skills to maintain abstinence
C. Lacks of social support
3. Partial hospitalization
A. Requires intensive care but is able to abstain
B. Requires a transitional level of care following discharge from inpatient care when
risk of relapse remains relatively high
C. Lacks sufficient motivation to continue in treatment
D. Requires a high level of support (for those returning to highrisk environments).
There has not been a positive response to intensive outpatient
4. Outpatient Programs
A. Clinical conditions/environmental circumstances do not require intensive care
"Duration of treatment is individualized to the specific needs of the person in treatment

and may last from several months to several years.

LIST OF SYMPTOMS LEADING TO RELAPSE
1. Exhaustion: Allowing yourself to become overly tired. Not following through

on selfcare behaviors of adequate rest, good nutrition, and regular exercise.
Good physical health is a component of emotional health. How you feel will
be reflected in your thinking and judgment.
2. Dishonesty: It begins with a pattern of small, unnecessary lies with those you
interact with in family, social, and at work. This is soon followed by lying to
yourself or rationalizing and making excuses for avoiding working your
program.
3. Impatience: Things are not happening fast enough for you. Or others are not
doing what you want them to do or what you think they should do.
4. Argumentative: Arguing small insignificant points, which indicates a need to
always be right. This is sometimes seen as developing an excuse to drink.
5. Depression: Overwhelming and unaccountable despair may occur in cycle. If it
does, talk about it and deal with it. You are responsible for taking care of
yourself.
6. Frustration: With people and because things may not be going your way.
Remind yourself intermittently that things are not always going to be the way
that you want them.
7. Selfpity: Feeling like a victim, refusing to acknowledge that you have choices
and are responsible for your own life and the quality of it.
8. Cockiness: "Got it made" compulsive behavior is no longer a problem. Start
putting self in situations where there are temptations to prove to others that
you don't have a problem.
9. Complacency: Not working your program with the commitment that you
started with. Having a little fear is a good thing. More relapses occur when
things are going well than when not.
10. Expecting too much from others: "I've changed, why hasn't everyone else
changed too?" You can only control yourself. It would be great if other
people changed their selfdestructive behaviors, but that is their problem. You
have your own problems to monitor and deal with. You cannot expect others
to change their lifestyle just because you have.
11. Letting up on discipline: Daily inventory, positive affirmations, 12Step
meetings, meditation, prayer, therapy. This can come from complacency and
boredom. Because you cannot afford to be bored with your program, take
responsibility—talk about it and problem solve it. The cost of relapse is too
great. Sometimes you must accept that you have to do some things that are
the routine for a clean and sober life.
12. The use of moodaltering chemicals: You may feel the need or desire to get
away from things by drinking, popping a few pills, and soon, and your
physician may participate in the thinking that you will be responsible and not
abuse the medication. This is the most subtle way to enter relapse. Take
responsibility for your life and the choices that you make.

Common Drugs of Abuse
Pharmaceutical Psychological Physical Methods Symptoms Withdrawal

Type of drug or street name dependence dependence Tolerance of use of use syndrome
Stimulant/uppers
Amphetamines Benzedrine Swallowed Increased Apathy, long
Amphetamines Dexadrine pill/capsule activity and periods of sleep,
Dextroamphetamine Peppills, toot or injected alertness irritability,
Methamphetamine Xtops, Meth into veins euphoria depression
Crystal, Ice High Moderate Yes snorted dilated pupils
Cocaine Bennies, Dexie to High injected disorientation
Uppers, Speed smoked increased
heart rate and
*BP insomnia,
loss of
appetite.
Paranoia,
Nicotine smoke hallucinations
snuff anxiety
chew convulsions
Caffeine Swallowed pill/
capsule or
beverages
Depressants/downers
Barbiturates Phenobarbital, High High Swallowed in Slurred speech, Anxiety, insomnia
Sedative Seconal, Tuinal pill or capsule disorientation, tremors,
Quaalude, Soper High High Yes form, or drunken delirium,
Hypnotics Barbs, Yellow injected into behavior, convulsions,
Jackets, Red veins drowsiness, possible death
Devils, Blue Devils impaired
Tranquilizers Librium, Valium, judgment
Equanil, Miltown Moderate Moderate
Alcohol Beer, Wine, Spirits High High
Opium Paregoric (O) High High Swallowed in Euphoria, Watery eyes,
Morphine (M) Hard Stuff High High Yes pill or liquid drowsy runny nose,
Codeine School Boy Moderate Moderate form, injected respiratory yawning, loss of
Heroin H, Horse, Smack High High into veins or depression appetite,
smoked constricted irritibility
pupils, nausea tremors, panic
chills, sweating
cramps, nausea
(Continues)
44
Common Drugs of Abuse (Continued)
Pharmaceutical Psychological Physical Methods Symptoms Withdrawal

Type of drug or street name dependence dependence Tolerance of use of use syndrome
Hallucinogens
Marijuana (Hashish) Pot, Grass, Possible Possible Smoked, Illusions,
Joint Reefer inhaled, or hallucinations,
eaten poor perception
LSD Acid, Lucy in Possible No Yes Injected or of time and
the Sky with swallowed in distance
Diamonds tablets sugar slurred vision
PCP Peace Pill, Possible No cubes confusion,
Angel Dust dilated pupils,
Psilocybin Magic Mushrooms Possible No mood swing
Inhalants/solvents
Gasoline Trash Drugs Inhaled or sniffed Disorientation, Restlessness,
Taluene Inhalants often with use slurred speech, anxiety
Acetone of paper or dizziness, irritability
Cleaning fluids Moderate No Yes plastic bag nausea, poor
Airplane cements or rag motor control
Nitrous Oxide Laughing Gas Moderate No Yes Inhaled or sniffed Lightheaded
Nitrites
Amyl Poppers, Locker Moderate No Yes Inhaled or sniffed Slowed thought,
Butyl Room Rush, from gauze/ headache
Snappers ampules
*BP—Blood pressure.
SCHIZOPHRENIA, DELUSIONAL, AND RELATED
PSYCHOTIC DISORDERS
Individuals diagnosed with a thought disorder can exhibit symptoms ranging from mild to
bizarre delusions and hallucinations. Symptomatology indicative of psychoticism includes
alteration in content of thought, alteration in the organization of thought, and disturbance of
sensory input. Additional features include disturbance of mood, affect, sense of identity, voli
tion, psychomotor behavior, and difficulty maintaining satisfactory interpersonal relations.
The goal of treatment is usually not to cure the individual but to improve the quality of life.
THOUGHT DISORDERS
Goals 1. Ensure that person will not harm self or others
2. Provide safe environment
3. Refer for medication evaluation
4. Encourage stabilization with decreased/elimination of perceptual disturbances
6. Improve selfmanagement skills (grooming/hygiene, sleep cycle, etc.)
7. Improve sleep pattern
11. Family intervention
12. Medication compliance
13. Educate person and significant others on side effects of medication
Treatment Focus 1. Evaluate for risk to self or others (psychotic thinking, rage reactions, pacing,

and Objectives overt aggressive acts, hostile and threatening verbalizations, irritability, agitation,
perceives environment as threatening, selfdestructive or suicidal acts, etc.)
A. Keep environmental stimuli low
B. Monitor closely
C. Remove dangerous objects from environment
D. Redirect physical acting out through physical exercise to decrease tension
E. Medicate as directed/prescribed
F. Call for crisis team or police of necessary to transport to psychiatric facility
2. Evaluate Environmental Safety
A. Determine if person demonstrates adequate level of cooperativity
B. Evaluate adequacy of social support
C. Adjust level of care if necessary
1. Day treatment program/partial hospitalization
2. Inpatient settingopen unit
3. Inpatient settingclosed unit
3. Refer for Medication Evaluation
A. If this is an initial evaluation and symptoms of perceptual disturbances are
identified, refer for a medication evaluation
S c h i z o p h r e n i a , D e l u s i o n a l , and Related Psychotic Disorders 45

B. If this has been an ongoing case and the person is experiencing an exacerbation of
symptoms, their functioning has deteriorated, or there are any other signs of
decompensation, refer them to their prescribing physician. Additionally, consult
with physician yourself to ensure optimal case management.
4. SensoryPerceptual Disturbance
A. Identify the nature and etiology of delusions
B. Rule out the presence of concomitant medical conditions as etiology of delusions
C. Look for signs of person withdrawing into self
D. Keep stress and anxiety at a minimum and educate regarding the relationship
between stress and anxiety to perceptual disturbance
E. Increase awareness for patterns of talking or laughing to self
F. Monitor for disorientation and disordered thought sequencing
G. Confront distortions and misinterpretations with reality testing, and encourage
person to define and test reality
H. Intervene early to correct reality if person is experiencing perceptual or sensory
distortions
I. Distract the person away from the perceptual disturbance by engaging him/her in
another direction of thinking or activity
J. Skill development for stress and anxiety management
1. Using progressive muscle relaxation
2. Listening to soft music
3. Walking or other appropriate activity
4. Utilizing support from others
A. Facilitate identification of stressors contributing to increased anxiety and agitation,
which result in disorientation of person
B. Be honest and open about what is or will be taking place so as to decrease
suspiciousness and to increase trust
C. Confront distorted thinking, facilitate reality testing
D. Encourage consistency in environment
E. Encourage verbalization of feelings
F. Facilitate appropriate problem solving
G. Encourage medication compliance
H. Educate family to be supportive of appropriate responses, consistency in
environment, medication compliance, emotional management, minimal stimuli,
necessity for honesty and following through on promises, and so on
I. Facilitate person's ability to adequately and effective appraise situations and to
respond appropriately
J. Encourage and facilitate appropriate interaction and cooperation
6. Grooming and Hygiene
A. Encourage daily independent living skills
1. Bathing
2. Cleaning hair, cutting when necessary, and styling appropriately
3. Brushing teeth
4. Dressing adequately and appropriately
5. Cleaning self adequately after using the bathroom and washing hands
B. Encourage appropriate independent efforts
C. Rolemodel and encourage the practice of appropriate behavior
D. Offer positive reinforcement for efforts and accomplishments of independent
living skills

7. Sleep Disturbance
A. Log sleeping pattern to develop treatment plan
B. Use sedative antipsychotic medications at night (if prescribed)
C. Clarify if fears or anxiety play a role in difficulty falling to sleep
D. Develop a pattern for winding down and offer methods to promote sleep
1. Warm soothing bath or shower
2. Light snack
3. Warm milk or herbal tea
E. Discourage daytime sleeping
F. Encourage exercise during the day
G. Use relaxation techniques
H. Use soft music or nature sounds
I. Limit caffeine intake
8. Low SelfEsteem
A. Reinforce accurate reality testing with positive feedback
B. Encourage assertive communication
C. Problemsolve through modeling and roleplay ways to deal with typical problems
encountered by the person in their environment, when interacting in society, and
in peer situations
D. Encourage and positively reinforce selfcare behaviors
9. Social Isolation
A. Educate, rolemodel, and practice appropriate social skills
B. Brief, frequent social contacts to facilitate familiarity
C. Accepting attitude to facilitate trust and feelings of selfworth
D. Offer patience and support to increase feelings of security
E. Encourage respect of personal space
F. Initiate the development and understanding of social cues
G. Identify feelings or circumstances that contribute to desire or need to withdraw
and isolate
H. Refer person to appropriate social gatherings/groups to practice appropriate social
behaviors
A. Encourage person to stay on task with one topic
B. Encourage appropriate, intermittent eye contact
C. Clarify communication (I don't understand..., Do you mean...?, etc.)
D. Help person understand how his/her behavior and verbal expression are
interpreted and act to distance or alienate the person from others
E. Encourage efforts and accomplishments with positive reinforcement
F. Facilitate person's ability to recognize disorganized thinking
G. Facilitate person's ability to recognize impaired communication
11. Dysfunctional Family Interaction
A. Identify how family is affected by person's behavior
B. Identify behaviors of family members that prevent appropriate progress or
behavioral management
C. Educate family regarding appropriate management of behaviors, the impact of
conflict, impact from level of environmental stimuli, importance of medication
compliance, reality testing, and how to respond to selfinjurious or aggressive
behavior. Encourage family to speak with physician and pharmacist regarding
the side effects of the medications, the issue of monitoring side effects, and
Schizophrenia, D e l u s i o n a l , and Related Psychotic Disorders 47

how to respond to the various side effects. Refer person to medmonitoring
group if available.
12. Support Medication Compliance
A. Educate person regarding role of medication in functioning
B. Support and reinforce medication compliance as a selfcare behavior
13. General Side Effects of Medication
A. Antipsychotic medication
1. Nausea
2. Sedation
3. Skin Rash
4. Orthostatic hypotension
5. Photosensitivity
6. Anticholinergic Effects
a. Dry mouth
b. Constipation
c. Blurred vision
d. Urinary retention
7. Extrapyramidal symptoms (EPS)
a. Pseudoparkinsonism (shuffling gait, tremor, drooling)
b. Akinesia (muscle weakness)
c. Dystonia (involuntary muscular movements of face neck and
extremities)
d. Akathisia (continuous restlessness)
8. Hormonal Effects
a. Weight gain
b. Amenorrhea
c. Decreased libido
d. Retrograde ejaculation
e. Gynecomastia (excessive development of the breasts in males)
9. Reduced seizure threshold
10. Agranulocytosis (monitor CBC and symptoms of fever, sore throat, malaise)
11. Tardive Dyskinesia (bizarre tongue and facial movements)
12. Neuroleptic Malignant Syndrome (NMS) (monitor fever, severe parkinsonian
rigidity, tachycardia, blood pressure fluctuation, and fast deterioration of
mental status to stupor and coma)
B. Antiparkinsonian medication
1. Nausea
2. Sedation
3. Intensifies psychosis
5. Anticholinergic symptoms
a. Dry mouth
b. Constipation
c. Urinary retention
d. Paralytic ileus (monitor absent bowel sounds, abdominal distention,
vomiting, nausea, epigastric pain)
e. Blurred vision
If the person reports having any side effects from the medication, initiate an immediate
consult with the prescribing physician and encourage the person to do so as well.

PHASES OF TREATMENT
1. Acute phase
A. Goal is to facilitate the alleviation/decrease of acute symptoms in conjunction with
improved functioning
2. Stabilization phase
A. Goal is to minimize stress and provide adequate support in decreasing the
possibility of relapse
B. Adapt/adjust to life in community
C. Facilitate continued reduction of symptoms while maximizing management and
coping
3. Stable phase
A. Ensure maintaining/improving level of functioning and quality of life
B. The effective treatment of schizophrenic symptoms
C. Monitor for adverse treatment effects
TREATMENT SETTINGS
1. Hospitalization
A. Provide safe, structured, supervised environment and decrease stress on patients as
well as their family members
B. Potential harm to self, others, highly disorganized as a result of
delusions/hallucinations or gravely disabled/unable to care for himself/
herself
1. Longterm hospitalization with emphasis on highly structured behavioral
techniques
2. Day hospitalization (crisis unit)
a. This setting offers less disruption to an individual's life, less restrictive
environment, and the avoidance of stigma attached to psychiatric
hospitalization
b. Brief overnight stays in inpatient units should be available when there is
evidence of exacerbation of symptoms (decompensation)
a. This setting benefits the marginally adjusted individual (stabilization to
stable range)
b. The goals are to provide structure, support, prevent relapse, and improve
social functioning
2. Supportive Housing
A. Transitional halfway house
B. Longterm group residence
C. Intensive care/crisis community residences
D. Foster care
E. Board and care homes
F. Nursing homes
SUMMARY OF TREATMENT RECOMMENDATIONS FOR
PATIENTS WITH PERCEPTUAL DISTURBANCES
For disorders involving loss of contact with reality, the following summary creates a useful
overview of areas to consider. Prior to proceeding, be sure to review the specific disorder's
diagnostic criteria because of the broad variations in this section.
Schizophrenia, Delusional, and Related Psychotic Disorders 49

1. Diagnosis
A. Schizophrenia
B. Brief reactive psychosis
C. Delusional disorder
D. Schizoaffective disorder
E. Dissociative disorders
F. Organic mental syndromes and disorders
"Psuedohallucinations
2. Objectives
A. Alleviate/eliminate symptoms
B. Restore contact with reality
C. Maximize emotional/behavioral adjustment disorders
D. Improve coping
E. Prevent relapse
E Educate family
G. Support family
1. Appropriate referral
a. Emotional support
b. Problem solving
c. Community programs
3. Assessment
A. Medical: to clarify diagnostic picture, substance use
B. Neurological: intellectual level, level of functioning
C. Psychological
4. Treatment team
A. Medical (PCP, psychiatrist, neurologist)
B. Psychological (family therapy, individual therapy, group therapy)
C. Rehabilitation therapist
5. Location
A. Inpatient
B. Residential
C. Outpatient
Person intensely experiences something as real

'Psuedohallucinations:
fantasized reactions Intellectually knows it is not real
For example, presence of depersonalization/outofbody experience
6. Interventions
A. Medication; monitor closely to limit side effects
B. Level of care required
1. Inpatient
2. Residential
3. Outpatient

C. Modality
1. Behavior therapy
a. Improve coping
b. Manage stress
c. Improve socialization/utilization of resources
2. Family therapy
a. Education
b. Support
c. Adjustment
3. Psychodynamic therapy
a. Multiple personality disorder
4. Group therapy
a. Rehabilitation counseling
b. Occupational therapy
c. Socialization
d. Respite care
7. Prognosis
A. Varies based on disorder
1. Excellent for brief reactive psychosis
2. Good for psychogenic amnesia
3. Fair for multiple personality disorder/schizophrenia
4. Poor for some organic mental disorders
While therapy typically plays a secondary role in the treatment of most organic disorders, it
can be an important adjunct to medical treatment. This is particularly true in the early/mind
stages of primary degenerative dementia, multiinfarct dementia, an so on. It can serve to do
the following:
1. Encourage active/independent living as long as possible

2. Focus on behavioralcognitive adjustments
3. Facilitate compensation for changes in capacity by building on coping
mechanisms
4. Assist in the management of negative affective states and destructive impulses
Adapted from L. Seligman (1990). Selective effective treatment.

San Francisco: JoseyBass.
MOOD DISORDERS
Mood disorders are divided into Depressive Disorders and Bipolar Disorders. The defining

feature of Bipolar Disorder is the experience of one or more manic or hypomanic episodes.
This section will deal more simply with the objects and goals related to depressive symptoms
and the objectives and goals related to manic symptoms.
According to the DSM IV (1994), the central feature of mood disorders is disturbance
of mood—manic or depressive. The range of the mood disorders include the following:
Major Depression, Dysthymia, Seasonal Affective Disorder, Mania, Hypomania, Bipolar,
and Cyclothymia.
Mood Disorders 51
DEPRESSION
Goals 1. Assess danger to self and others
2. Provide safe environment
3. Assess need for medication evaluation referral
6. Develop and encourage utilization of support system
7. Resolve issues of loss
9. Cognitive restructuring
10. Improve eating patterns
11. Improve sleep patterns
12. Develop depression management program
13. Educate regarding medication compliance
Treatment Focus 1. Suicide Risk Assessment

and Objectives A. Thoughts of killing self, or persistent death wish
B. Plan
C. Means to carry out the plan
D. Feelings of hopelessness
E. Past history of suicide attempts, or someone close to them that has attempted or
committed suicide
F. Recent losses
G. Substance abuse
H. Poor impulse control
I. Poor judgment
During the interview it may be possible to decrease the level of emotional distress by vali

dating the difficulty that the person is experiencing and encouraging him/her to vent feelings
and intentions of suicide. Talking about these issues, which have resulted in such despair and
hopelessness, may not only decrease the level of distress, but may create some opportunity
for intervention. As the person talks about his/her thoughts of suicide, he/she can be facili
tated to begin to understand what a significant impact his/her suicide would have on family,
friends, and others. Offering clients validation and reassurance may increase their ambiva
lence. If there is evidence of adequate social support and cooperation, a shortterm verbal
contract with a coinciding written contract can offer some structure for dealing with self
destructive impulses.
If the person has resources and does not intend to commit suicide, but is vulnerable,
consider increasing the frequency or duration of outpatients contacts for a brief period of
time, an intensive outpatient program, or partial hospitalization. If the person is not cur
rently being prescribed antidepressant medication, he/she should be referred for a medica
tion evaluation.
If the person is not able to make any assurances that he/she does not intend to commit
suicide, then hospitalization is necessary. Initially, approach the person about voluntary
admission to a psychiatric facility. If the person is unwilling to voluntarily admit himself/her
self, then an involuntary admission process will ensue. Providing a safe environment with
monitoring and support is imperative.
While danger to self is often the critical clinical dilemma requiring immediate attention
and intervention, it is also important to assess and rule out any homicidal thoughts and

intentions that place others in a position of potential harm. If an assessment reveals the
intention to harm another person, the appropriate clinical interventions and legal issue of
the duty to warn must be dealt with immediately.
2. Provide Safe Environment

A. Evaluate whether person is demonstrating adequate cooperation (removal of
firearms, medications, etc. that person may have considered for selfharm/suicide)
B. Evaluate adequacy of social support
C. Adjust level of care if necessary
1. Urgent care. Flexible time for meeting, along with extended meeting time to
allow the person to ventilate their emotions and initiate problem solving.
3. Inpatientopen unit
4. Inpatientclosed unit
3. Referral Assessment for Medication Evaluation
A. If this is an initial assessment and a history of depression is given that has clearly
affected quality of life and functioning, refer for a medication evaluation
B. If this has been an ongoing case and acute depressive symptoms are present that are
interfering with level of functioning, refer for medication evaluation
C. Assess for mood congruent psychotic features. They can be present and not
identified. If positive, convey information to prescribing physician.
A. Define the problem(s)
B. Brainstorm all plausible solutions
C. Identify the outcomes in relation to the various solutions
D. Make a decision that appears to best fit the demands of the problem situation
E. Prepare the person for the possibility that the solution may not work out as
planned; therefore, have a contingency plan
5. Dysfunctional Coping
A. Help person recognize that he/she can only do one thing at a time
B. Teach person relaxation skills to use if feeling overwhelmed
C. Facilitate prioritizing issues that person must deal with
D. Facilitate clarification of boundaries, especially related to issues of pleasing others
versus selfcare
E. Rule out secondary gains
F. Helplessness
1. Encourage taking responsibility and making decisions
2. Include the person when setting goals
3. Provide positive feedback for decision making
4. Facilitate development of realistic goals, limitations, and expectations
5. Identify areas of life and selfcare in which the person has control, as well as
those areas where the person lacks control
6. Encourage expression of feelings related to areas of life outside person's control
and explore how to let it go
6. Ineffective Development or Utilization of Resources and Social Supports
A. Resist desire to withdraw and isolate
B. Identify positive social/emotional supports that the person has have been avoiding
C. Make commitment to utilize resources and supports in some way every day
D. Educate regarding role of isolation in maintaining depression
Mood Disorders 53
E. Evaluate impaired social interaction
1. Convey acceptance and positive regard in creating a safe, nonjudgmental
environment
2. Identify people in the person's life and activities that were previously found
pleasurable
3. Encourage utilization of support system
4. Encourage appropriate risk taking
5. Teach assertive communication
6. Give direct, nonjudgmental feedback regarding interaction with others
7. Offer alternative responses for dealing effectively with stressprovoking
situations
8. Social skills training in how to approach others and participate in conversation
9. Roleplay and practice social skills for reinforcement and to increase insight for
how the person is perceived by others
10. Daily structure to include social interaction
7. Dysfunctional Grieving
A. Evaluate stage of grief that person is experiencing
B. Demonstrate care and empathy
C. Determine if the person has numerous unresolved losses
D. Encourage expression of feelings
E. Use the empty chair technique or have the person write a letter to someone he/she
has lost, which may provoke the resolution process
E Educate person on stages of grief and normalize appropriate feelings such as anger
and guilt
G. Support person in letting go of his/her idealized perception so that the person can
accept the positive and negative aspects of his/her object of loss
H. Positively reinforce adaptive coping with experiences of loss (taking into
consideration ethnic and social differences)
I. Refer to a grief group
J. Explore the issue of spirituality and spiritual support
8. Low SelfEsteem
A. Focus on strengths and accomplishments
B. Avoid focus on past failures
C. Reframe failures or negative experiences as normal part of learning process
D. Identify a areas of desired change and objectives to meet those goals
E. Encourage independent effort and accepting responsibility
E Teach assertive communication and appropriate setting of limits and boundaries
H. Teach effective communication techniques by using "I" statements, not making
assumptions, asking for clarification, and so on
I. Offer positive reinforcement for tasks performed independently
9. Distorted Thinking
A. Identify the influence of negativism on depression and educate regarding positive
selftalk
B. Seek clarification when the information communicated appears distorted
C. Reinforce realitybased thinking
D. Facilitate development of intervention techniques such as increased awareness with
conscious choice of what to focus on (positive thoughts), thought stopping, and
compartmentalizing
E. Facilitate person's clarification of rational versus irrational thinking

10. Eating Disturbance
A. Evaluate eating pattern and fluid intake
B. Educate regarding importance of good nutrition for energy and clear thinking
A. Evaluate sleep pattern and overall amount of sleep
B. Encourage appropriate and adequate sleep cycle
C. Discourage daytime napping
D. Avoid caffeine and other stimulants
E. Perform relaxation exercises or listen to relaxing music before sleep
E Daily aerobic exercising such as walking
G. Administer sedative medications in the evening instead of other times during
the day
H. Suggest activities such as warm bath, massage, herbal tea, light snack, and so on,
which promote sleep
12. Difficulty Consistently Managing Depression: This requires a thorough review
of lifestyle. Managing depression requires a commitment by the person to take
responsibility for improving his/her quality of life. (Refer to skill building
section.)
A. The components of a selfcare plan to manage depression include the following:
1. Structured daily activities
2. Development and utilization of social supports
3. Positive attitude and identification of the positive things in one's life
4. Awareness
5. Regular aerobic exercise
6. Eating nutritionally
7. Living in accordance with one's own value system
13. Educate Person (And Family If Appropriate) on Medication Issues
A. Emphasize the importance of compliance. Encourage patient to clarify potential
side effects including those that require immediate attention.
B. Recommend that patients familiarize themselves with any restrictions related to
medication use
C. Refer person to clarify medication issues with his/her physician and pharmacist
D. Educate regarding chemical imbalance related to depression
E. Educate regarding role of decompensation related to lack of medication
compliance
F Possible Side Effects of Antidepressant Medication
1. Sedation
2. Anticholinergic Effects
a. Dry mouth
b. Constipation
c. Blurred vision
d. Urinary retention
4. Tachycardia/arrhythmia
5. Photosensitivity
6. Decrease in seizure threshold
7. Hypertensive crisis (monitor for symptoms such as palpitations, nausea,
vomiting, sweating, chest pain, severe occipital headache, fever, increased blood
pressure, coma)
Mood Disorders 55
8. Weight loss or gain
9. Priapism
If the person reports having any side effects from the medication, consult with the pre
scribing physician immediately and encourage the person to do the same.
If the individual has a diagnosis of seasonal affective disorder, be sensitive to the issue of
light treatment to alleviate their depression.
G. Since a therapist is likely to have significantly more contact with an

individual in treatment who is being prescribed psychotropic medication
than the prescribing physician, it is imperative to monitor the patient
response to medication and communicate salient information to the prescribing
physician
1. At least moderate improvement should be achieved in six to eight weeks
2. Monitor for presence of side effects (especially those that require immediate
attention)
H. Risk factors for recurrence of major depressive episode
1. History of multiple episodes of major depression
2. Evidence of dysthymic symptoms following recovery from an episode of major
depression
3. Comorbid nonaffective psychiatric diagnosis
4. Presence of chronic medical disorder
I. Clinical features that influence the treatment plan
1. Crisis issues
2. Psychotic features
3. Substance abuse
4. Comorbid axis I or axis II disorders
5. Major depression related to cognitive dysfunction (psuedodementia)
6. Dysthymia
7. Severe/complicated grief reaction
8. Seasonal major depressive disorder
J. Atypical major depressive disorder features (defined by reversal of vegetative
symptoms)
1. Increased sleep versus decreased sleep
2. Increased appetite versus decreased appetite
3. Weight gain versus weight loss
4. Marked mood reactivity
5. Sensitivity to emotional rejection
6. Phobic symptoms
7. Extreme fatigue with heaviness of extremities
K. If there is little to no symptomatic response by four to six weeks
1. Assess compliance
2. Reassess diagnosis
3. Reassess adequacy of treatment
DEPRESSION COOCCURING WITH OTHER ILLNESS
The cooccurance of depression with other medical, psychiatric, and substance abuse disor
ders should always be considered. Awareness and treatment can improve overall health and
decrease suffering. A thorough assessment and accurate diagnosis are imperative.
56 t. Treatment Planning. Goals, Objectives, and Interventions

According to the National Institute of Mental Health
1. Depression is a common, serious, and costly illness that affects 1 in 10 adults in

the United States
2. It costs the United States $30 to 45 billion per year
3. It causes impairment, suffering, and disruption of all areas of a person's life
4. Two out of three people suffering from depression do not seek treatment
5. Common interventions include therapy, antidepressant medication, or both
6. Most people can be effectively treated for depression
7. Depression can cooccur with medical, psychiatric and substance abuse
disorders:
A. The presence of both illnesses is frequently unrecognized
B. This may lead to serious and unnecessary consequences for the person/
family
Cooccurance with 1. An estimation of 5 to 10% of primary care patients have depression

Medical Illness 2. An estimation of 10 to 14% of medical patients have depression
3. Depressed feelings can be a normal response to many medical illnesses
4. Research has shown that major depression (clinical depression) occurs in
A. 40 to 65% of patients who have had a myocardial infarction (MI). They may also
have a shorter life expectancy than nondepressed MI patients
B. Approximately 25% of cancer patients
C. 10 to 27% of poststroke patients
"Failure to recognize and treat cooccurring depression may result in increased impairment
and decreased improvement in the medical disorder.
Cooccurance with 1. There is a 13% cooccurance with panic disorder; in approximately 25% of

Psychiatric these patients the panic disorder preceded the depressive disorder
2. 50 to 75% of those with eating disorders have a lifetime history of major
Disorders
depression
'Detection of depression can result in clarifying the primary diagnosis and lead to more

effective treatment and improved outcome.
Cooccurance with 1. Substance abuse disorders frequently coexist with depression

Substance Abuse 2. 32% of individuals with depression experience a substance abuse disorder
Disorders 3. 27% of those with major depression experience substance abuse disorder
4. 56% of those with bipolar disorder experience a substance abuse disorder
"Substance abuse must be discontinued so that a clear diagnosis can be made and the

appropriate treatment given. Treatment for depression may be necessary if it continues
when the substance abuse problem ends.
Mood Disorders 57
MANIA
Goals 1. Provide safe environment
2. Eliminate danger to self or others
3. Stabilization and medication compliance
4. Thought processes intact
5. Eliminate perceptual disturbances
6. Improve social interaction/decrease isolation
8. Improve selfmanagement
9. Improve sleep pattern
10. Educate regarding medication issues and general side effects
Treatment Focus 1. Risk for Injury

and Objectives A. Assess
1. Destructive acting out behavior
2. Extreme hyper activity
3. Extreme agitation
4. Selfinjurious behavior
5. Loud, and escalating aggressiveness
6. Threatening behavior
B. If person lacks control and is a danger to himself/herself or others, hospitalization
is necessary. Hospitalization provides a safe environment, monitoring, and an
opportunity to stabilize medication. Depending on the level of mania, the
person's admission to a psychiatric facility will be voluntary or involuntary
(5150)
C. Keep environmental stimuli at a minimum
D. Remove hazardous objects
E. Physical activity such as walking to discharge energy
F. Medication compliance as prescribed
2. Risk for Violence (Directed Toward Self or Others)
A. Assess
1. Extreme hyperactivity
2. Suspiciousness or paranoid ideation
3. Hostility, threatening harm to self or others
4. Rageful
5. Aggressive body language or aggressive acts of behavior
6. Provoking behavior (challenging, trying to start fights)
7. Hallucinations or delusions
8. Possesses the means to harm (gun, knife, etc.)
9. Bragging about prior incidence of abuse to self or others
B. Keep environmental stimuli or a minimum
C. Monitor closely
D. Remove all potentially dangerous objects
E. Physical exercise to decrease tension
F. Maintain calm attitude with person and do not challenge
G. Medication compliance as prescribed

As with risk for injury or danger to self or others, hospitalization may be necessary during
a manic phase if symptoms are escalating and unmanageable.
3. Medication Noncompliance

A. As person's functioning improves, educate regarding importance of medication
compliance and relationship between decompensation and lack of medication
compliance. Medication is clearly the primary mode of treatment for Mania/
Bipolar Disorder. Medication compliance is imperative to symptom management.
"If a risk factor for poor outcome is present in 50% of patients (history of
nonadherence), it is vital that clinicians are encouraged to ask proactively about
problems with adherence and create an atmosphere where such issues can be
discussed openly" (Pope, 2002). Research by Rasgon et al. (2002) suggests that
women with Bipolar Disorder may be more depressed and experience more frequent
mood changes than men.
4. Altered Thought Processes
A. Do not argue with person or challenge him/her
B. Communicate acceptance of the person's need for the false belief, but let him/her
know that you do not share the delusion
C. Use clarification techniques of communication (Would you please explain...?
Do you mean...? I don't understand....)
D. Offer positive reinforcement for accurate reality testing
E. Reinforce and focus on reality by talking about real events
F. Facilitate development of intervention techniques such as thought stopping, slowing
things down, and requesting the support of others in reality testing
A. Evaluate for hallucination or delusional thinking
B. Let the person know that you do not share the perception. Point out that although
what he/she hears or sees seems real to the individual, you do not hear or see what
the person does.
C. Facilitate understanding between increased anxiety and reality distortions
D. Distract the person with involvement in an interpersonal activity and do reality
testing
E. Intervene when early signs of perceptual disturbances are evident
F. Help person recognize perceptual disturbances with repeated patterns and how to
intervene
G. Offer positive reinforcement for efforts and maintenance of accurate reality testing
6. Impaired Social Interaction
A. Increased awareness for how other people interpret varying forms of behavior and
communication
B. Rolemodel and practice appropriate responding to social situations
C. Encourage acceptance of responsibility for own behavior versus projecting
responsibility onto others
D. Encourage recognition of manipulative behaviors
E. Set limits and boundaries. Be consistent. Do not argue, bargain, or try to reason.
Just restate the limit.
F. Positive reinforcement for recognition and accepting responsibility for own
behavior
G. Positive reinforcement for appropriate behaviors
H. Facilitate appropriate ways to deal with feelings
I. Facilitate understanding of consequences for inappropriate behaviors
Mood Disorders 59
J. Identify and focus on positive aspects of the person
K. Refer to a support group for bipolar disorder
7. Low SelfEsteem
A. Validate person's experience. Identify negative impact that disorder has had on the
person's life.
1. Explore what issues he/she controls versus issues involving lack of control
2. Identify difficulty that person has in accepting the reality of the disorder and as
a result not accepting himself/herself
B. Facilitate identification of strengths
C. Identify areas of realistic desirable change and break it down into manageable
steps
D. Encourage assertive communication
E. Offer person simple methods of achievement
F. Positive feedback and reinforcement for efforts and achievements
8. Improved SelfManagement
A. Increaseawareness of mood changes and how to more effectively manage
B. Increase understanding of developmental deviations and delays caused by chronic
mental illness (CMI)
C. Confront and deal with the stigmatization associated with mental illness
D. Challenge fear of recurrent episodes and associated inhibition of normal
psychosocial functioning
E. Problemsolve interpersonal difficulties
F. Confront and develop appropriate resources to effectively deal with marriage,
family, childbearing, and parenting issues
G. Improved understanding and development of effective interventions to deal with
emotional, social, and legal problems
A. Monitor sleep patterns
B. Reduce stimulation, provide a quiet environment
C. Provide structured schedule of activities, which includes quiet time or
time for naps
D. Monitor activity level
E. Increase identification and awareness for fatigue
F. Avoid caffeine or other stimulants
G. Administer sedative medications, as prescribed, at bedtime
H. Provide cues and methods to promote sleep such as relaxation, soft music, warm
bath, and so on
10. Education on Medication Issues
A. Person and his/her family should be educated about the disorder and management
of the features of the disorder, and they possess a thorough understanding of
medication issues
B. Refer the person and family to the prescribing physician and pharmacist for
clarification of medication issues
C. Educate regarding the chemical imbalance relationship of mania
D. Educate regarding the issue of decompensation and the lack of medication
compliance
E. General Side Effects of Medication
1. Dry mouth, thirst
2. Dizziness, drowsiness

3. Headache
4. Hypotension
5. Pulse irregularities, arrhythmia
6. Nausea, vomiting
7. Fine hand tremors
8. Weight gain
If the person reports having any side effects from the medication, consult the prescribing

physician immediately and encourage the person to do the same.
Individual therapy is an extremely beneficial adjunctive treatment to medication for indi
viduals diagnosed with Mania/Bipolar Disorder. It is used to help individuals recover from
the symptoms of their disorder, restore normal mood, repair relationship damage, repair
career damage, and establish selfmonitoring. Therapy is, of course, not attempted during a
manic phase, which requires medical/medication stabilization. Family therapy and education
are also important to help/support family members in their understanding of the nature of
the illness and treatment.
CHILDREN
Bipolar Disorder appears to be more severe in children. Geller et al. (2002) reported that
Bipolar Disorder in young children is synonymous with the most severe experiences of bipo
lar disorder in adults. In adults, the typical Bipolar experience where involves episodes of
either mania or depression that lasts a few months with relatively normal episodes of func
tioning. However, mania in children has been found to be a more severe, chronic course of
illness. The report states that many children experience both depression and mania at the
same time and may remain ill for years, enduring multiple daily highs and lows without inter
vening periods of relative normalcy. In a study of 89 subjects with childhood onset of mania,
77 had comorbid ADHD and 67 had comorbid Oppositional Defiant/Conduct Disorder.
Psychiatric management (PM) is an ongoing process with bipolar disorder. PM helps to min
imize the negative consequence of unstable mood states by facilitating adaptive responding
1. Interpersonally/socially
2. Professionally
3. Academically
4. Occupationally
5. Financially
Regarding ultra rapid cycling, refer for general medical evaluation
1. With particular focus on thyroid function

2. Comorbid substance abuse
3. Other general medical conditions
Psychosocial variables include the following:
A. Crosscultural issues
1. Culture may influence experience and communication of symptoms (as with all
mental health issues)
Mood Disorders 61
2. Culture may influence under diagnosis/misdiagnosis/delayed diagnosis
3. There may be a differential response to antidepressant medications among ethnic
groups
B. Environment
1. During manic phase, a calm routine environment is helpful
2. Manic individuals may need room to pace and exercise
3. The individual may benefit from the support of someone in his/her environment
who has been educated about realistic expectations and safety associated with
mania
C. Stressors
1. Psychosocial stressors may be associated with the precipitation of mania
2. Many episodes of mania have no identifiable psychosocial stressor and as the illness
progresses, episodes appear to occur spontaneously
3. May be helpful for individuals with bipolar and their families to work with their
therapist to develop an understanding of unique associations to stressful events and
the onset of symptoms
BIPOLAR DISORDER HYPERSEXUALITY
For individuals with Bipolar Disorder, the extreme behaviors associated with mania can be

devastating. While there is a listing of potential extreme behaviors in the DSM indicative of
manic episodes, the review of one of those behaviors serves to highlight the damaging results.
Hypersexuality is defined as an increased need or compulsion for sexual gratification. A per
son may be reluctant to expose his/her experience of hypersexuality in treatment because of
the associated immense feelings of shame. With the decreased inhibition associated with
hypersexuality, individuals find themself engaging in sexual behaviors that they may consider
"deviant or forbidden" and that results in feelings of shame. For some, the frequency of their
compulsion is at an addictive level. In addition to feelings of shame, hypersexuality can
destroy a marriage or a committed relationship and increase the risk of sexually transmitted
diseases.
Regarding the issue of the broad patterns of sexual addiction behavior, the Mayo Clinic
defines sexual addiction as a loss of control with the focus on compulsion: "compulsive sex
ual behavior refers to spending inordinate amounts of time in sexual related activity, to the
point that one neglects important social, occupational, or recreational activities in favor of
sexual behavior." According to the National Council on Sexual Addiction and Compulsivity
addiction is characterized as "loss of the ability to choose freely whether to stop or to con
tinue... continuation of the behavior despite adverse consequences, such as loss of health,
job, marriage, or freedom... obsession with the activity."
Examples of the specific behaviors that are common to those who struggle with hyper
sexuality's compulsive and reckless behaviors include the following:
1. Fantasy sex
2. Fetishes
3. Inappropriate sexual touching
4. Sexual abuse and sexual assault
5. Compulsive masturbation
6. Compulsive sex with prostitutes
7. Masochism

8. Patronizing sexoriented establishments
9. Voyeurism
10. Exhibitionism
The range of consequences associated with hypersexuality include the following:
1. Shame
2. Low selfesteem
3. Fear
4. Financial distress (cost of prostitutes/phone sex and items or activities in
sexoriented establishments)
5. Destruction of relationships
6. Health risk, loss of job (pornography on the computer, inappropriate
behavior, etc.)
While evaluating and treating someone with Bipolar Disorder, the aforementioned infor

mation should clarify the importance of fully understanding the manic experience of the
individual because of the potential deepseated emotional damage resulting from extreme
personally unacceptable behavior. Education and validation are important interventions.
ANTIDEPRESSANT MEDICATION AND
OTHER TREATMENT
Everyone views the treatment choices for depression in his or her own individual manner.
Some individuals prefer an initial treatment modality for mild Major Depression to be anti
depressant medication, while others will prioritize therapy as the initial treatment. There will
be some who obtain the desired response in accordance with their treatment choice. Often
an individual may be treated most effectively by combining these modalities, especially when
there is a history of depression. A referral for antidepressant medication should be provided
for those with moderate to severe major depression. If an individual presents with a major
depression with psychotic features he/she is likely to be treated with an antidepressant and
antipsychotic medication unless ElectroConvulsive Therapy has been planned. For those
with difficulttotreat depression ECT, a stimulant or thyroid supplement is reviewed for
potential effectiveness in a given case.
According to the American Psychiatric Association, the following guidelines should be
considered in the treatment of major depressive disorder:
1. Should a specific effective psychotherapy be provided?

A. Mild to moderate depression: preferred as primary treatment or as combination
with medication
B. Moderate to severe depression: in combination with medication or ECT if
psychosocial issues are prevalent and/or //preferred
2. Should medication be provided?
A. Mild depression: if preferred as primary treatment
Antidepressant Medication and Other Treatment 63

B. Moderate to severe depression: with or without a specific effective psychotherapy
unless ECT has be planned
C. Psychotic depression: combination of antipsychotic and antidepressant medication
unless ECT has been planned
3. Should medication and a specific effective psychotherapy be provided in
combination?
A. Mild depression
1. If combination treatment is preferred
2. When there is a history of partial response to a single treatment modality
3. When poor compliance is an issue
B. Moderate to severe depression
1. When there is presence of
a. Prominent psychosocial issues
b. Significant interpersonal problems
c. Personality disorder
d. Poor compliance
4. Should ECT be provided?
A. Chronic, moderate to severe depression
B. With or without specific psychotherapy based on patient preference
C. Severe depression in combination with any of the following:
1. Psychotic features
2. Patient preference
3. Previous preferred response
4. Need of rapid antidepressant response
5. Intolerance of medication
As an individual is receiving any of these treatment modalities in solo or in combination,

continue to assess improvement/recovery and review for other treatment considerations.
ADDITIONAL TREATMENT CONSIDERATIONS
1. Treatment of Depression in the Elderly. This complex and challenging clinical

dilemma is related to the high degree of comorbidity with medical disorders.
Some of the complications that confound treatment of depressive disorders in
the elderly are as follows:
A. Nonpsychotropic medications may cause depression, alter blood levels of
antidepressant medications, and increase the side effects of antidepressant
medication.
B. Concurrent psychiatric conditions may result in depression, require the use of
different medications, and reduce the response to antidepressant medication.
C. Concurrent medical illnesses may cause biological depression, reduce the
effectiveness of antidepressant medication, and change the metabolic rate of
antidepressant medications.
D. Complications related to stageoflife issues include metabolic slowing, which
requires lower dosing levels, fixed income with limited resources available to them,
issues of loss, dependency and role reversal with children, social isolation, and
illness.

2. Treatment of Depression in Children. Children and adolescents may not
demonstrate the manifestations of depressions as the symptoms readily
recognized in adults. Depression in this population is often masked by acting
out or behavioral problems. A careful and thorough diagnostic assessment is
extremely important because of the high risk of suicide in troubled adolescents.
If depression is diagnosed and psychotropic medication is prescribed it is
crucial to monitor medication compliance.
3. Coexisting Disorders and Conditions. Diagnostic clarification. Unless the person
has a long standing history of depression (Dysthymia), it is the general standard
of practice to treat the coexisting disorders and conditions first. If the depression
remains then the depressive disorder is clearly diagnosed and treated. Possible
associated disorders and conditions include substance abuse, side effects of other
medications, the result of medical conditions, other psychiatric conditions such
as anxiety disorders, and medical conditions such as menopause.
4. Coexistence of Depression and Anxiety. A person may experience a depressive
disorder that is accompanied by symptoms of anxiety. However, the symptoms
of anxiety may not fully meet the criteria necessary for a diagnosis of an
anxiety disorder. The reverse may also be true. A person may have an anxiety
disorder accompanied by symptoms of depression. In this situation it is possible
that the depressive symptoms are not sufficient to meet the criteria for the
diagnosis of a depressive disorder.
ANXIETY DISORDERS
The category of Anxiety Disorders includes diagnoses of Panic Disorder, Agoraphobia,
Phobias, ObsessiveCompulsive Disorder, PostTraumatic Stress Disorder, and Generalized
Anxiety.
The central features of these disorders include anxiety, fear, emotional distress, selfdefeating
cognitive and behavioral rituals, distressing physical symptoms evoked by intense distress
and body tension, sleep and appetite disturbance, feeling out of control, and experiencing
difficulty effectively coping.
ANXIETY DISORDERS
Goals 1. Assess for need for medication evaluation referral
2. Identify source of anxiety and fears
5. Improve selfcare skills
6. Improve feelings of control
10. Improve stressmanagement skills
11. Family education
12. Educate regarding side effects of medication
Treatment Focus 1. Assess for Referral for Medication Evaluation. Patients with heightened
and Objectives anxiety, withdrawal, lack of sleep, obsessive thoughts, and compulsive
behaviors may benefit from the use of psychotropic medications. If there is
comorbidity of depression, convey this information to the referred physician.
2. Feelings of Anxiety and Fear
A. Validate person's emotional experience
B. Identify factors contributing to anxiety
C. Problemsolve factors contributing to anxiety
1. What is the problem?
2. Brainstorm various choices for dealing with the problem if it is within the
person's control
3. Make a decision and follow through. Have a contingency plan.
4. If it is out of the person's control, encourage the person to let go of it
D. Explore methods of managing anxiety
1. Relaxation techniques, including deep breathing
2. Distracting, pleasurable activities
3. Exercise
4. Meditation
5. Positive selftalk
E. Assess medication for effectiveness and for adverse side effects
F. Educate regarding signs of escalating anxiety and various techniques for
interrupting the progression of these symptoms (refer to section on Managing
Anxiety). Also explore possible physical etiology of exacerbation of anxiety.
G. Fear
1. Explore the source of the fear
2. Clarify the reality of the fear base. Encourage venting of feelings of fear. If the
fear is irrational, the person must accept the reality of the situation before any
changes can occur
3. Develop alternative coping strategies with the active participation of the
person
4. Encourage the person to make hi/her own choices and to be prepared with a
contingency plan
5. Use systematic desensitization to eliminate fear with gradual exposure to the
feared object or situation (exposure can be real or through visual imagery)
6. Use implosion therapy where exposure to the feared object or situation is not
gradual but direct (referred to as "flooding")
7. Educate person regarding role of internal, selftalk to feelings of fear, and
develop appropriate counter statements
H. Manage obsessive thoughts and compulsive behaviors
1. Patients with obsessive thoughts should be encouraged to engage in reality
testing and to redirect themselves into productive and distracting activity
2. Patients with compulsive behavior should develop a stepwise reduction in the
repetition of ritual behaviors (medication can be very helpful for managing OCD)
A. Identify factors that escalate anxiety and contribute to difficulty coping
B. Identify ritualistic patterns of behaviors
C. Educate regarding the relationship between emotions and dysfunctional/compulsive
behavior
D. Develop daily structure of activities

E. Gradually decrease time allotted for compulsive ritualistic behaviors, utilizing daily
structure of activities that acts to substitute more adaptive behaviors
F. Positive feedback and reinforcement for effort and change to shape behavior
G. Teach techniques that interrupt dysfunctional thoughts and behaviors, such as
relaxation techniques, meditation, thought stopping, exercise, positive selftalk,
visual imagery, and so on
H. Facilitate shaping of social interaction to decrease avoidant behavior
B. Develop some realistic sample problems and give homework to practice new
skills
C. Identify secondary gains that inhibit progress toward change
5. SelfCare Deficiency
A. Support person to independently fulfill daily grooming and hygiene tasks
B. Adequate nutrition
C. Regular exercise
D. Engaging in activities and being with people, all of which contribute to feelings of
wellbeing
E. Use of positive selftalk and affirmations
E Positive feedback and reinforce efforts and accomplishments
G. Time management
H. Prioritize demands/ tasks
I. Develop and utilize support system
6. Feels Lack of Control over Life
A. Break down simple behaviors and necessary tasks into manageable steps
B. Provide choices that are in their control
C. Support development of realistic goals and objectives
D. Encourage participation in activities in which the person will experience success
and achievement
E. Facilitate development of problemsolving skills
F. Facilitate shaping of social interaction to decrease avoidant behavior
A. Assertive communication
B. Anger management
C. Roleplay, rehearse, and problemsolve appropriate response choices in various
situations
E. Learn to say no, avoid manipulation, set limits and boundaries
8. Irrational Thinking/Beliefs
A. Identify negative statements the person makes to themself
B. Identify the connection between anxiety and selftalk
C. Develop appropriate, realitybased counterstatements and substitute them for the
negative ones
D. Keep a daily record of dysfunctional thoughts to increase awareness of frequency
and impact on emotional state
E. Disrupt dysfunctional thoughts by increasing awareness for internal selftalk,
distracting oneself through relaxation, exercise, or other positive activity, and using
thought stopping
E Irrational Beliefs
1. Identify false beliefs (brought from childhood, integrated parental statements)
2. Challenge mistaken beliefs with rational counterstatements
3. Identify effect that irrational beliefs have on emotions, relationship with self
and others, and choices the person makes
G. SelfDefeating Beliefs/Behaviors That Perpetuate Anxiety
1. Identify needs or tendencies that predispose the person to anxiety
a. Need to control
b. Perfectionistic
c. People pleaser with strong need for approval
d. Ignoring signs of stress
e. Selfcritical
f. Perpetual victim role
g. Pessimistic, catastrophizes
h. Chronic worrier
9. Low SelfEsteem
A. Selfcare
1. Identifying needs
2. Setting appropriate limits and boundaries
3. Seeking a safe, stable environment
B. Identify realistic goals, expectations, and limitations
C. Identify external factors that negatively affect selfesteem
D. Overcome negative attitudes toward self
E. Address issues of physical wellbeing (exercise and nutrition) and positive
body image
E Assertive communication
G. Identify feelings that have been ignored or denied
H. Positive selftalk, affirmations
I. Focus on efforts and accomplishments
J. Positive feedback and reinforcement
10. Ineffective Stress Management
A. Facilitate development of stress management techniques
1. Deep breathing
3. Visual imagery/meditation
4. Time management
5. Selfcare
11. Educate Person/Family
A. Facilitate increased understanding of etiology, course of treatment, and the family
role in treatment. Medical exam to rule out any physical etiology.
B. Encourage person's participation in treatment planning
C. Educate regarding the nervous system and explain that it is impossible to feel
relaxed and anxious at the same time. Therefore, mastery of stress management
techniques such as progressive muscle relaxation works to slowly intervene and
diminish the symptoms of anxiety.
D. Educate regarding the use of medication, how it works, the side effects, and the
need to make the prescribing physician aware of the person's reaction/responses to
the medication for monitoring (the anxious person may need the reassurance from
the physician about the medication and how to use it on more than one occasion).
Some antianxiety medications exacerbate depressed mood.

12. General Side Effects of Medication
A. Physical and psychological dependence
B. May escalate symptoms of depression
C. Drowsiness
D. Nausea/vomiting
E. Orthostatic hypotension
E Dry mouth
G. Blood dyscrasias—if there is easy bruising, sore throat, fever, malaise, or unusual
bleeding, report these symptoms immediately to the physician
If the person reports having any side effects to the medication, consult the prescribing physi
cian immediately and encourage the person to do the same. For individuals who suffer from
an Anxiety Disorder, internal dialogue, interpretation of their experience, and feeling/belief
that something negative is about to happen or will happen significantly affect their ability to
effectively cope. Their cognitive distortions act, in part, as a set up for a selffulfilling
prophecy. That is what makes them difficult to treat. They believe that their fears have been
validated by their experiences. However, it is actually their negative thinking and distorted
beliefs that are keeping them stuck. If they can be supported to adhere to a program of cogni
tivebehavioral interventions, they are likely to experience a dramatic change in their level of
distress. This requires a trusting therapeutic relationship so that the person feels confident of
your support and knowledge.
One thing all anxiety disorders share is the behavioral and emotional manifestations of
avoidance. These individuals experience thoughts, beliefs, and internal dialogue (selftalk),
which perpetuates a cycle of emotional distress. The person wants to participate but experi
ences fears, cognitive distortions and emotional distress, which escalates and eventually leads
to avoidance in order to escape the distress. In other words, their functional performance is
compromised by their interpretation, distorted thoughts, and negative selftalk as it pertains
to relational and environmental interaction.
CYCLE OF ANXIETYPROVOKED EMOTIONAL DISTRESS
Cycle oj AnxietyProvoked Emotional Distress 69

It is evident that unless cognitivebehavioral changes are made, the cycle of anxiety if self
perpetuating.
1. Functional impairment
A. Sometimes a patient is more focused on the panic attacks themselves than on such
issues as avoidance, which significantly impacts his/her daily life (these issues
become of secondary importance)
B. It is important to determine how the individual defines a desired/satisfactory
outcome, which influences motivation/compliance
C. If the defined quality of life is not at an adequate functioning level, the individual
should be encouraged to be more realistic
2. Monitoring progress
A. While there is often an initial positive response in the control of panic attacks,
subthreshold panic attacks may continue necessitating further treatment
B. The feat that attacks may occur in the future often continue when panic attacks
cease
C. It is not uncommon to experience a panic attack after a period of no panic attacks
1. Predict this possibility for patients
2. Use as a monitoring tool to rule out the resumption of a poor selfcare routine
(i.e., increased stress/expanded demands, no exercise, lack of sleep, lack of
progressive muscle relaxation)
D. Be aware of comorbid issues of depression and substance abuse
E. Be alert to emergent depression
3. Improving treatment compliance
A. The anxiety associated/produced by treatment may result in noncompliance
1. Fear side effects of medication (therefore, fear of taking medication)
2. Sensitive to somatic sensations
B. Treatment must be sensitive, supportive, honest, reassuring, and, whenever possible,
predictive of what to expect (to reinforce choice/control and to validate)
* Anxiety disorders demonstrate a higher than average rate of suicide attempts (Weissman
et al, 1989).
TRAUMA RESPONSE
The sequential responses to trauma include the following stage: stressful event, outcry,
denial, intrusion, working through, and resolution. Sometimes an individual will bypass
the outcry stage and proceed from the traumatic event to denial. Corresponding to the stages
of sequential responding are normal reactions or intensification/pathological reactions.
Intensifications result when the normal reaction is unusually intense or prolonged.
1. Traumatic/Stressful Event
A. Normal emotional response: anxiety, fear, sadness, distress
*If normal response is unusually intense or prolonged, the result is a pathological
response.
B. Pathological response: overwhelmed, confused, dazed
70 l. Treatment Planning. Goals, Objectives, and Interventions

2. Outcry
A. Normal emotional response: anxiety, guilt, anger, rage, shame, protest

response.
B. Pathological response: panic, exhaustion, dissociative symptoms, psychotic

symptoms
3. Denial
A. Normal emotional response: minimizing, hypersomnia, anhedonia, depression,
suppression, repression, obsession, fatigue/lethargy, denial

response.
B. Pathological response: maladaptive avoidance, withdrawal, substance abuse,

suicidality, fugue state, amnesia, rigid thinking, psychic numbing, sleep dysfunction,
massive denial of initial trauma or current problems, somatization (headaches,
fatigue, bowel problems/cramps, exacerbation of asthma, etc.)
4. Intrusion
A. Normal emotional response: anxiety, somatosizing, decreased concentration and
attention, insomnia, dysphoria
B. Pathological response: flooded states, hypervigilance, exaggerated startle response,
psuedohallucination, illusions, obsession, impaired concentration and attention,
sleep/dream disturbance, emotional lability, preoccupation with the event,
confusion, fight or flight activation (diarrhea, nausea, sweating, tremors, feelings of
being on edge), compulsive reenactments of trauma, impaired functioning
5. Working through
A. Normal emotional response: find meaning in experience, grieve, personal
growth
*If working through is blocked, the result is a pathological response.
B. Pathological response: frozen states or psychosomatic reaction, anxiety/depression

syndromes
6. Resolution
A. Normal response: return to preevent level of functioning, psychological/personal
growth/integration
*If not achieved the result is a pathological response.
B. Pathological response: Inability to work/act/feel, personality change, generalized
anxiety, dysthymia
Adapted from J.S. Maxmen and N.G. Ward (1995). Modified from M.J. Horowitz (1985).
Cycle of AnxietyProvoked Emotional Distress 7\

SOMATOFORM DISORDERS
The central feature of this disorder is the presence of physical symptoms with a lack of
demonstrable organic findings as a basis for the symptoms. With this circumstance, there is
a strong presumption of a link to psychological factors or conflicts being translated into
physical symptoms.
SOMATOFORM DISORDERS
Goals 1. Improve coping skills
2. Rule out cognitive deficits and educate
3. Increase awareness for relationship between emotional
functioning and physical symptoms
4. Improve body image
5. Improve selfcare
6. Decrease or eliminate perceptual disturbances
7. Improved selfesteem
8. Stress management
Treatment Focus 1. Ineffective Coping

and Objectives A. Confront irrational beliefs. Consult with physician regarding treatment, lab test,
and so on to rule out the possibility of an organic etiology
B. Identify the extent of somatization
C. Identify other impairments that may be manifesting as somatizations
D. Recognize and validate that the symptoms are experienced as real by the person,
but confront the associated cognitive distortion that may precipitate, exacerbate, or
maintain the symptoms
E. In the beginning, while developing the therapeutic relationship, gratify the person's
dependency needs to develop trust and decrease possibility of symptom escalation
F. Identify primary and secondary gains of symptomatology experienced by the person
G. Utilize identified primary and secondary gains to facilitate appropriate problem
solving with person
H. Gradually decrease focus and time spent on physical symptoms to discourage pattern
of dysfunctional behaviors. Set limits in a stepwise progression if necessary to decrease
focus on symptomatology, and be consistent in not discussing physical symptoms
I. Encourage venting of anxieties and fears
J. Facilitate increased awareness and identification for the relationship between stress
and symptoms development or symptom exacerbation
K. Inform patient that development of any new symptoms should be relayed to
physician to rule out organic etiology
L. Identify ways to intervene in dysfunctional pattern of symptomatology in order to
avoid resorting to physical symptoms as a coping mechanism
M. Facilitate identification of how interpersonal relationships are affected by person's
behavior
N. Teach relaxation techniques
2. Visualization
3. Meditation

O. Positive feedback and reinforcement for demonstrating effective, adaptive
coping
2. Lack of Knowledge or Cognitive Deficits
A. Evaluate person's knowledge of relationship between psychological functioning and
physical functioning
B. Encourage the person to keep a journal that focuses on psychological functioning
(anxiety/stress/fears) to facilitate increased awareness and understanding of
mindbody relationship
C. Assess level of anxiety (which negatively affects learning) and motivation to
learn
D. Consult with physician regarding the results of treatment and tests. Explain to
person the reason or purpose of all procedures and the results.
E. Encourage venting of fears and anxiety
F. Facilitate identification of primary and secondary gains so that person can
understand dysfunctional attempts to get needs met and manipulative
behaviors
G. Identify methods in which the person can get needs met appropriately, such as
assertive communication
3. Lack of Awareness for Relationship between Emotional Functioning and
Physical Symptoms
A. Consult with physician regarding treatment, lab test, and so on to rule out
possibility of organic etiology
B. Recognize and validate that the pain is experienced as real by the person
C. Identify the factors that precipitate the pain
D. Encourage the involvement in activities that help distract the person from
symptoms
E. Identify unresolved emotional and psychological issues
F. Facilitate increased awareness and identification for relationship between anxiety
and symptoms
G. Identify alternative means of dealing with stress
H. Identify ways of intervening to prevent escalation of symptoms, such as the
following:
1. Relaxation
2. Guided imagery
3. Breathing exercises
4. Massage
5. Physical exercise
I. Positive feedback and reinforcement for demonstrating effective, adaptive coping
4. Body Image Disturbance
A. Identify misconceptions and distortions in body image
B. Decrease focus on distorted perception, as focus is increased on adaptive coping
and positive selfcare
C. Facilitate grieving for feelings of loss if person has experienced bodily changes
D. Facilitate selfcare behaviors
E. Encourage person to strengthen selfesteem
5. Ineffective SelfCare
A. Consult with physician regarding disabilities and impairment, and collaborate in
developing adequate and effective selfcare behaviors
B. Encourage independent fulfillment of daily activities related to hygiene, grooming,
and other selfcare behaviors (have patient write out a chart of daily behaviors)
C. Be accepting of these individuals—the symptoms that they experience are real to
them. Assure them with information from the physician regarding their abilities and
what activities they can safely participate in
A. Consult with physician regarding treatment, lab tests, and so on to rule out
possibility of organic etiology. Perform regular mental status exam for ongoing
assessment.
B. Identify primary and secondary gains that symptoms provide for the person
C. Facilitate the person following through on independent daily activities for
selfcare
D. Decrease focus on disturbances, as support and focus is increased on effective,
adaptive behaviors
E. Set limits and be consistent regarding manipulation with disabilities
F. Reinforce with reality testing
G. Encourage venting of fears and anxiety
H. Teach assertive communication to increase appropriate means of getting
needs met
I. Facilitate identification of effective coping tools for dealing with stressful
situations
J. Facilitate development and utilization of support system
K. Positive feedback and reinforcement for efforts and accomplishments
7. Low SelfEsteem
A. Facilitate identification of strengths
B. Focus on efforts and accomplishments
C. Teach and encourage assertive communication
D. Replace negative thinking with positive selftalk
E. Encourage taking responsibility for one's own choices and behaviors
F. Positive feedback and reinforcement for efforts and accomplishments
A. Relaxation techniques
B. Time management
C. Selfcare behaviors
* Certain medical conditions mimic somatization disorders and need to be ruled out.

Examples of such medical disorders include those which present vague, multiple, and
confusing symptoms.
1. Multiple sclerosis

2. Systemic lupus erythematusus
3. Porphyria
4. Hyperparathyroidism
Also, women represent the majority of SomatizationDisorder diagnosis. Be careful in assess
ment. Do not allow this information to serve as a bias leading to an incorrect diagnosis.

PSYCHOSOMATIC ILLNESS AND PERSONALITY DISORDER
The patient with psychosomatic illness that has an underlying personality disorder requires
a sophisticated level of clinical expertise. Consider the following issues:
1. Psychosomatic symptoms associated with an underlying personality disorder
present a significant challenge to the therapist. In this case, psychosomatic
patients may demonstrate impulsedominated modes of functioning utilizing
defenses such as the following:
A. Denial/splitting
B. Magical thinking
C. Feeling omnipotence
D. Demands of perfection versus worthlessness (extremes)
E. Displacement/projection/projective identification
F. Masochistic perfectionism
G. Fantasized parental relationships (i.e., conflictfree motherchild
relationship)
2. Psychosomatic families demonstrate a parental psychosocial profile that can be
reviewed for problem solving diagnostically and in the treatment planning
approach. The acronym for this system review is PRISES:
P perfectionism
R repression of emotion
I infantilizing decision making
S organ system choice
E exhibitionistic parental sexual/toilet activity
S unconscious selection of the child
A. Perfectionismemphasis on the following:
1. Good behavior
2. Social conformity
3. Exemplary childhood/adolescent developmental performance
"Results in indirect communication and separation attempts.
B. Repression of emotionscaused by the following:

1. Parental hypermorality (evidenced by)
a. Strict emotional control in front of children
b. Aggressive behavior of children not allowed (in general aggression
denied)
c. Downplay/maximizing of successes
d. Mother deferred to as moral authority
*Rigid internalization of good/bad (without rational review and growth in belief

system).
C. Infantilizing decisionmaking control
1. Everything had to represent a noble purpose
a. Major home activity was intellectual discussion
b. Scholarly reading
c. Independent activity/assertiveness led to consequences of humiliation
* Resulting in inability to make decisions with attempts to get others (therapist) to make

decisions for them.
D. Organsystem choice
1. Development of psychosomatic symptoms
a. Ulcerative colitis
b. Anorexia
c. Asthma
d. Headaches/migraines
e. Skin diseases
E. Exhibitionistic parental sexual/toilet behavior
1. Significance denied (evidenced by)
a. Lack of privacy (bathroom/bedroom doors unlocked/left open)
b. Witnessing f parental intercourse
* Parental exhibitionism coupled with hypermorality and prudishness resulting in

inhibition in normal sexual development.
F. Selection of one child (unconscious selection)

1. Treated differently than siblings
a. Used as a confidant
b. Infantialized (babied)
c. Total devotion to selected child to the exclusion of spouse/siblings
*Lack of individuality, poor boundaries, and passiveaggressive traits.
Adapted from Wilson and Mintz (1989).
Othmer and DeSouza (1985) developed a brief screening test (mnemonic of Somatization

Disorder Besets Ladies and Vexes Physicians) based on their research, which determined that
the presence of any two out of seven specific symptoms accurately predicted the correct soma
tization disorder in 8090% of screened cases. Their work was adapted by Maxmen and Ward
(1995). Each word of the mnemonic is associated with a specific symptoms and organ system.
Somatization Shortness of breath Respiratory

Disorder Dysmenorrhea Female reproduction
Besets Burning in sex organs Psychosexual
Ladies Jump in throat Pseudoneurological
And Amnesia Pseudoneurological
Vexes Vomiting Gastrointestinal
Physicians Painful extremities Skeletal muscle
The following questions are used to assess the presence of seven symptoms in the screening

test for Somatization disorder.
S. Have you ever had trouble breathing?

D. Have you ever had frequent trouble with menstrual cramps?

B. Have you ever had burning sensations in your sexual organs, mouth, or
rectum?
L. Have you ever had difficulties swallowing or had an uncomfortable lump in
your throat that stayed with you for at least an hour?
A. Have you ever found that you could not remember what you had been doing
for hours or for days at a time? (If yes, did this happen even though you had
not been using any substances?)
V. Have you ever had trouble with frequent vomiting?
P. Have you ever had frequent pain in your fingers or toes?
If two or more of these seven questions are answered affirmatively, this screening is
considered positive. A positive screen simply means that the individual might have a soma
tization disorder. To confirm the diagnosis, the individual will need to meet the DSMIV
criteria for somatization disorder.
INTERPRETING FUNCTIONAL PRESENTATION OF
SYMPTOMOLOGY: MALINGERING, FACTITIOUS
DISORDER, AND SOMATOFORM DISORDER
1. Malingering
A. Physical symptoms intentional
B. False of exaggerated symptoms
C. Motivated by external incentives
1. Avoidance driven (legitimate appearance of an excuse)
2. Benefit driven (some gain associated with symptoms presentation)
* Partial malingering is a combination of definable organic pathology and unconscious

psychopathology along with conscious exaggeration of symptoms. Goals include the
following:
a. Relief from work
b. Relief from family responsibility
c. Financial gain
2. Factitious disorder
A. Physical/psychological symptoms intentional
B. Goal is to assume patient role ("sick role")
1. To obtain sympathy or be nurtured
2. External/financial incentives are absent
C. Does not preclude the coexistence of true physical/psychological symptoms
3. Somatoform disorder
A. Physical symptoms not intentional
B. No diagnosable medical condition to account for physical symptoms
1. Conversion disorder
a. Symptoms not intentionally produced
b. Affect, voluntary motor or sensory
c. Suggests neurological involvement
d. Undelrying psychological/emotional functioning factors associated, including
depression or anxiety manifested as .psuedopsychological and symptoms that
help resolve a personal conflict
e. External/financial incentives absent (not financially motivated)
2. Somatization/pain disorder
a. Chronic pain central focus (more than six months)
b. Somatic symptoms are out of proportion to objective findings
c. Psychological factors associated
d. Characterized by depression, dysfunction, drugs, dependency, diagnostic
dilemma, duration, and dramatization of symptoms
e. Selfsustaining, selfreinforcing, and selfgenerating
f. Pain behavior is maladaptive, resulting in despair, alienation from family and
society, loss of job, isolation, invalidism, and suicidal ideation
g. Financial gain rarely present
3. Hypochondriasis
a. Excessive preoccupation with bodily sensations
b. Preoccupation/fear of having a serious disease (despite assurances to the
contrary)
c. Misinterpretation of body symptoms
DISSOCIATIVE DISORDERS
The central feature of dissociative disorders is a disturbance in the integration of identity,
memory, or consciousness. Selected mental contents are removed or dissociated from con
scious experiences; however, they continue to produce motor or sensory effects. The distur
bance may have a sudden or gradual onset and may be temporary or chronic in its course.
Depending on the mode of disturbance (identity, memory, or consciousness), the individual's
life experience is affected in different ways. Conceptually, the course of treatment is to
improve coping, maintain reality, and establish normal integrative functions.
DISSOCIATIVE DISORDERS
Goals 1. Thought processes intact
2. Maintain a sense of reality
4. Stress management
5. Personality integration
Treatment Focus 1. Altered Thought Processes

and Objectives A. In addition to assessing the person directly, gather information form family and
significant others, which acts to broadly define the person (life, experiences,
pleasurable activities, likes/dislikes, favorite music, places the person find
relaxing, etc.)
B. Expose person to positive past experiences and pleasurable activities
C. Slowly elicit personal information from the person to prevent flooding, which could
cause regression
D. As person allows memories to surface, engage the person in activities to stimulate
the forthcoming memories such as photographs, talking about a significant person
from the past, and the role that various other people have played in the person's life
E. Encourage the person to talk about situations that have posed significant stress
F. Facilitate the person to verbalize stressful situations and to explore the feelings
associated with those situations
G. Facilitate increased awareness and understanding of all the factors that have
contributed to the dissociative process

H. Facilitate identification of specific conflicts that are unresolved
I. Develop possible solution to the unresolved conflicts
J. Be supportive and offer positive feedback and reinforcement for the courage to
work through these issues
2. Sensory/Perceptual Distortion
A. Identify the nature, extent, and possible precipitants of the dissociative states
B. Obtain a collaborative history of the nature and extent of the dissociative states
from family/friends
C. Educate the person regarding depersonalization experience, behaviors, and the
purpose they generally serve for the person (or did serve originally)
D. Be supportive and encouraging when the person is experiencing depersonalization
E. Validate feelings of fear and anxiety related to depersonalization experience
F. Educate the person regarding the relationship between severe anxiety and stress to
the depersonalization experience
G. Explore past experiences such as trauma and abuse
H. Encourage the identification and working through of feelings associated with these
situations
I. Identify effective and adaptive responses to severe anxiety and stress
J. Encourage practice of these new adaptive behaviors. This may be initiated through
modeling and roleplay.
K. Facilitate the person's ability to separate past from present to more effectively cope
with the traumatic memories and feelings
A. Be supportive and reassuring
B. Identify situations that precipitate severe anxiety
C. Facilitate appropriate problemsolving in order to intervene and prevent escalation
of anxiety and to develop more adaptive coping in response to anxiety
D. Explore feelings that the person experiences in response to stressful situations
E. Consider using environmental manipulation to improve coping
F. Whenever possible, encourage maintenance of some from of employment as long as
possible
G. Facilitate understanding that the emotion experienced is acceptable and often
predictable in times of stress
H. As the person develops improved coping abilities, encourage him/her to identify the
underlying source(s) of chronic anxiety
I. Encourage identification of past coping strategies and determine if the response was
adaptive or maladaptive
J. Develop a plan of action for effective, adaptive coping to predictable future
stressors
K. Explore with the person the benefits and consequences of alternative adaptive
coping strategies
L. Identify community resources that can be utilized to increase the person's support
system as he/she makes efforts to effectively manage
M. Facilitate identification of how the person's life has been affected by the trauma
N. Offer positive feedback and reinforcement for efforts and accomplishments
A. Relaxation techniques
B. Time management
C. Selfcare (exercise, nutrition, utilization of resources, etc.)
D. Educate regarding role of negative selftalk
5. Identity Disturbance
A. Develop a trusting therapeutic relationship. With a multiple personality, this means
a trusting relationship with the original personality as well as the subpersonalities.
B. Educate person about multiple personality disorder in order to increase his/her
understanding of subpersonalities
C. Facilitate identification of the need of each subpersonality, the role they have played
in psychic survival
D. Facilitate identification of the need that each subpersonality serves in the personal
identity of the person
E. Facilitate identification of the relationship between stress and personality change
F. Facilitate identification of the stressful situations that precipitate a transition from
one personality to another
G. Decrease fear and defensiveness by facilitating subpersonalities to understand that
integration will not lead to their destruction, but to a unified personality within the
individual
H. Facilitate understanding that therapy will be a longterm process, which is often
arduous and difficult
I. Be supportive and reassuring
SEXUAL DISORDERS
For the purpose of this text, the group for Sexual Disorders described as paraphilias are not
considered. This discussion does consider the sexual dysfunctions characterized by inhibi
tions in sexual desire or the psychophysiologic changes associated with the sexual response
cycle. Once the diagnosis and underlying factors have been identified, if the issues require
more than counseling, problem solving life of relationship issues, or adjustment and resolu
tion that do not alleviate the sexual dysfunction, it is then ethical and appropriate to refer
to a certified sex therapist.
SEXUAL DISORDERS
Goals 1. Clarify origin of disorder
2. Make appropriate referrals (physician, certified sex therapist, etc.)
3. Create a baseline for monitoring change
4. Promote education and treatment of emotional and psychological problems
Treatment Focus 1. Assess for Predisposing Factors

and Objectives A. Review current medications that person is taking. Chronic alcohol and cocaine use
have been associated with sexual disorders. Prescription medications that have been
implicated include antidepressants, anxiolytics, antipsychotics, anticonvulsants,
antihypertensives, cholinergic blockers, and antihistamines.
B. Assess psychosocial factors. These factors are wide ranging and encompass age
of experiences, developmental implications, beliefs systems, interpersonal issues,
trauma or pain, and cultural conditioning. These factors may include shame,
guilt, fear, anxiety, depression, disgust, resentment, anger toward partner, stress,
fatigue, fear of pregnancy, ambivalence, fear of commitment, disease phobia,
childhood sexual assault/abuse, moralistic upbringing with negative messages
about sexual contact and sexual organs or rigid religiosity, moral prohibition, or
inhibition.
80 l. Treatment Planning: Goals, Objectives, and Interventions

C. Consult with physician and refer for medical evaluation. Organic etiologies include
the decreased estrogen levels associated with menopause, endometriosis, pelvic
infections, tumors, cysts, penile infections, urinary tract infections, prostate
problems, damage of irritation or the sexual organs, low levels of testosterone,
diabetes, arteriosclerosis, temporal lobe epilepsy, multiple sclerosis, blood pressure,
medication reactions, substance abuse, and Parkinson's disease. Pelvic surgery,
genitourinary surgery, and spinal cord injuries may also be associated with sexual
dysfunction.
2. Assess for Appropriate Referrals
A. Refer to physician to rule out organic etiology
B. Refer to other pertinent specialists such as a certified sex therapist if such expertise
is needed
3. Establish Baseline Information of Sexual Dysfunction Experience
A. Time frame associated with onset of dysfunction
B. Persistent or recurrent (lifelong, acquired, generalized, situational, with or without
masturbations, with or without partner, due to psychological or combined factors)
1. Frequency
2. Setting
3. Duration
4. Level of subjective distress
5. Effects in other areas of function
C. Does not occur exclusively during the course of another axis I disorder (major
depression, substance abuse, etc.)
D. Life situation/stress level
E. Causes marked stress or selfesteem/interpersonal difficulty
E Clarify and interpret the dynamics of sexual dysfunction
G. Work through the dynamics of sexual dysfunction
H. Relationship issues
I. Medical issues/medication
J. Mood and emotion
K. Misinformation or lack of knowledge
L. Sexual history
M. Belief system
4. Lack of Understanding Regarding Dysfunctional Sexual Issues
A. Educate person regarding the potential for change in satisfaction through various
interventions (medical, behavior, psychological)
B. Identify emotional responses to sex and intimacy
C. Explore how sensitive and caring the individual's partner is to the person's needs
D. Determine whether the individual has ever experienced sex as pleasurable or
experienced orgasm
E. Identify the individual's goals, how to incorporate the partner in treatment, and
invest the partner as a support and agent of change
ADJUSTMENT DISORDERS
The hallmark of this disorder is a maladaptive reaction to an identifiable stressor(s). The
stressor may be single or multiple. The severity of the reaction cannot be extrapolated from
the intensity of the stressor. Instead, the reaction is a function of the vulnerability and cop
ing mechanisms of the individual.
ADJUSTMENT DISORDERS
Goals 1. Alleviate emotional, psychological, or behavioral distress
4. Improve adjustment
7. Improve social interaction
8. Develop social supports
Treatment Focus 1. Mood Disturbance

and Objectives ^* Educate regarding relationship between mood and adjusting
B. Identify predisposition/history of emotional response to stressors
C. Review methods of coping in similar situations
D. Reduce stimuli to decrease agitation/anxiety
E. Develop appropriate daily structure
F. Identify precipitating factors that exacerbate mood disturbance
G. Educate regarding importance of good nutrition
H. Regular physical exercise to release tension and decrease fatigue
I. Journal writing to vent thoughts and feelings and to clarify and facilitate
problem solving
A. Encourage appropriate venting of thoughts and feelings
B. Identify physical activities that provide for a healthy outlet for negative feelings
C. Encourage independent functioning
D. Facilitate identification of factors that person has some control over and initiate
problem solving. Also identify factors that person has no control over and initiate
letting go.
E. Increase awareness for person's response to feelings of powerlessness (victim role,
manipulation of others, helplessness, etc.)
F. Positive feedback and reinforcement toward improved coping
3. Impaired Problem Solving
A. Facilitate identification of the issues
B. Facilitate development of alternative ways to manage or resolve issues
C. Facilitate individual to take action, being aware of the consequences and alternative
choices should they be necessary
4. Impaired Adjustment
A. Have person describe his/her functioning prior to the change
B. Have the person describe his/her "normal functioning"
C. Encourage venting of thoughts and feelings associated with change or loss
D. Encourage independent functioning
E. Facilitate problem solving about how the person is going to incorporate the change
or loss as a life experience
82 {.Treatment Planning. Goals, Objectives, and Interventions

F. Identify problems associated with the change or loss
G. Utilize modeling and role playing to prepare person to follow through on dealing
with difficult areas
H. Refer the person to appropriate community resources
B. Selfcare (exercise, nutrition, utilization of resources)
C. Educate regarding role of negative selftalk
6. Low SelfEsteem
A. Be accepting and nonjudgmental toward person
B. Facilitate identification of realistic expectations (goals) and limitations
C. Facilitate identification of person's assets/strengths
D. Facilitate identification of areas of desired change and develop a problemsolving
framework that person can utilize in working toward those goals
E. Encourage and support the person in confronting areas of difficulty
F. Discourage repetition of negative thoughts
G. Encourage taking responsibility for choices and behaviors
H. Facilitate increased selfawareness
1. Journal writing
2. Exploration of thoughts and feelings
I. Facilitate selfacceptance
1. Identify personal beliefs and value system
2. Encourage objectivity and positive regard to the self versus rejecting. Educate the
person about the impact of negative selftalk on selfesteem.
J. Focus on the positive; reframe failures as opportunities to learn
K. Positive feedback and reinforcement
A. Facilitate increased awareness of behavioral responses in relationship and how
others experience and interpret the individual's behavior
B. Identify ineffective and inappropriate attempt to get needs met, such as
manipulative, angry, or exploitative behavior
C. Identify appropriate verbal and behavioral responses
D. Rolemodel and practice appropriate verbal and behavioral responses for a variety
of anticipated situations
E. Utilize resources
8. Lacks Social Support
A. Educate and support regarding the development of an appropriate and adequate
support system
The primary goal of treatment is to facilitate the patient in returning to the precrisis level

of functioning. The secondary goal is to capitalize on the emotional turmoil of the crisis to
change preexisting maladaptive patterns into more useful and selfsatisfying ways of
responding to the environment. Overall, therapy is supportive in nature, focusing on an
individual's strengths in an effort to help individuals adapt and cope effectively with
stressors.
Medication might be utilized as a shortterm intervention in adjustment reaction when
there is a clear target symptom, such as acute anxiety or insomnia, which might impede
recovery or impair functioning if not treated.
IMPULSE CONTROL DISORDERS
The central feature of impulse control disorders is the failure to resist an impulse, drive, or

temptation that is harmful to the person or to others. Even though there is an increasing
sense of tension prior to the act, the act may or may not be premeditated. Additionally, there
may or may not be an awareness for resistance to the impulse.
All impulse control disorders have the following pattern in common:
Failure to resist impulse Increasing sense of tension/arousal

Gratification/release Regret/guilt
Goals IMPULSE CONTROL DISORDERS
1. Eliminate danger to others
2. Eliminate danger to self
4. Improved stressmanagement skills
6. Relapse prevention
Treatment Focus 1. Risk for Violence Toward Others

and Objectives A. Reduce environmental stimuli
B. Clarify positive regard toward the person, but stress that aggressive behaviors are
unacceptable
C. Remove all potentially dangerous objects
D. Facilitate identification of the underlying source(s) of anger
E. Remain calm when there is inappropriate behavior to support person in containing
impulses
F. Encourage use of physical exercise to relieve physical tension
G. Facilitate recognition of warning signs of increasing tension
I. Facilitate identification of choices
J. Clarify the connection between behavior and consequences
K. Positive feedback and reinforcement
2. Risk for SelfDestructive Behavior
A. Assess
1. Mental status
2. History of selfdestructive behaviors
3. Recent crisis, loss
4. Substance abuse
5. Plan
6. Means
7. Quality of support system

B. Provide safe environment, and intervene to stop selfdestructive behaviors (remove
dangerous objects, monitor, etc; the person may require hospitalization)
C. Facilitate identification of environmental or emotional triggers associated with self
destructive impulse
D. Facilitate person to identify areas of desired change
E. Develop a plan for behavior modifications to reach goals of desired behavior change
F. Encourage appropriate venting of thoughts and feelings
G. Avoid focus and reinforcement of negative behaviors
H. Focus on efforts and accomplishments
I. Positive feedback and reinforcement
A. Increase awareness and insight of their behaviors
B. Facilitate clarification of rules, values—right and wrong
C. Encourage the person to take responsibility
D. Confront denial related to behaviors/choices
E. Facilitate development of understanding the relationship of behaviors to consequences
F. Explore and clarify the person's desire and motivation to become a productive
member of society
G. Clarify for person socially acceptable behaviors versus nonsocially acceptable behaviors
H. Facilitate increased sensitivity to others
I. Facilitate increased awareness for how others experience the person and how they
interpret the person's behaviors
J. Clarify that it is the person but rather the person's behavior that is unacceptable
K. Facilitate increasing ability to delay gratification
L. Rolemodel and practice acceptable behaviors with the person over a range of situations
M. Positive feedback and reinforcement for efforts and accomplishments
5. Low SelfEsteem
A. Focus on strengths and accomplishments
B. Avoid focus on past failures (unless utilized in a positive manner to facilitate
hopefulness and the learning of new behaviors)
C. Identify areas of desired change and objectives to meet those goals
D. Encourage independent effort and accepting responsibility
E. Teach assertive communication and appropriate setting of limits and boundaries
6. Relapse Prevention
A. Selfmonitoring
B. Reframe regression issues as an opportunity for taking responsibility to follow the
person's program for behavioral change
C. Journal writing to monitor progress and any other changes in behavior
D. Participation in community groups or utilization of other supportive resources
It is necessary to delineate separate characteristics and clarify commonality among the dis
orders of impulse control in order to determine the course of treatment. These individuals do

not often present for treatment of their own volition. As per the DSMIV, the most notable
disorders of impulse control include the following:
1. Pathological gambling

A. Parents tend to show a pattern of alcoholism/gambling
B. They are unable to resist the impulse to gamble
C. Gambling disrupts family/vocation/personal endeavors
D. At least three of the following have occurred:
1. Arrest for forgery/fraud
2. Default on debt
3. Interpersonal difficulties
4. Borrowing money illegally
5. Absenteeism
6. Exploiting others for help
2. Kleptomania
A. Pattern of being unable to resist the impulse to steal, even with items of no
immediate use or monetary value
B. Increasing sense of tension before acting
C. No planning or assistance from others
3. Pyromania
A. Pattern of behavior to resist impulse to set fires
B. Increasing sense of tension before acting
C. An experience of intense pleasure/release at time of committing the act
D. No motivation such as political action/monetary gain involved
4. Intermittent explosive disorder (rare—more often used as an excuse for self
permission to behave badly)
A. Several discrete episodes of extremely aggressive acts or destruction of property
B. Act is grossly out of proportion to precipitating social or psychological stressors
C. No impulsivity or aggressiveness between episodes
D. No specific organic disorder associated (such as a brain tumor)
PSYCHOLOGICAL FACTORS AFFECTING
PHYSICAL CONDITION
When initially assessing an individual, particularly if physical symptoms are present, note if

there appears to be a significant relationship between the individual's coping mechanisms
and the physical complaint(s). This information will be helpful in treatment planning if the
primary care physician clarifies that there is not organic basis for the symptom presentation
or that the physical symptoms are exacerbated by the individual's coping mechanisms.
PSYCHOLOGICAL FACTOR AFFECTING

PHYSICAL CONDITION
Goals 1. Educate and increase awareness
2. Promote appropriate adjustment to changes

Treatment Focus 1. Lack of Sufficient Information

and Objectives A. Consult with physician regarding tests that have been made and their results
B. Explore feelings of fear and anxiety related to physical functioning. Unless
contraindicated, the person should be given the information related to his/her state
of health and treatment issues.
C. Educate person regarding the mindbody connection. How they think, believe, and
interpret things will have an impact on how they experience something.
D. Encourage venting of thoughts and feelings
E. Facilitate development of questions that the person can use with the physician to
clarify his/her own understanding and to clarify with the physician if there is any
symptomatology that would be important for the person to monitor and to report
to the physician
F. Recommend that the person keep a journal to vent thoughts and feelings, to
clarify, and problemsolve issues. It may help the person identify dysfunctional
patterns.
G. Recommend that the person keep a daily log of appearance, duration, and density
of physical symptoms
H. Increase awareness and understanding for the relationship between emotional
distress and exacerbation of symptomatology
I. Facilitate identification of primary and secondary gains. The person must identify
needs that are being met through sick role to develop more appropriate and
effective methods for fulfilling these needs.
J. Facilitate development of assertive communication so that the person can express
self honestly and effectively
K. Facilitate development of stressmanagement skills
2. Change in SelfPerception and Role Due to Physical Functioning
A. Consult with physician to understand the extent of change in physical functioning,
if the problem is progressive, or if there is expected progress to be made with return
to prior level of functioning
1. Necessary for appropriate treatment planning
B. Encourage venting of thoughts and feelings associated with physical functioning
C. Facilitate identification of stressors that negatively influence functioning
D. Facilitate increased awareness for the relationship between physical symptoms and
emotional functioning
E. Facilitate identification of maladaptive responses
F. Facilitate identification of family's response to the situation and its affect on the
person
G. Encourage family participation as necessary in treatment. Educate them regarding
prognosis, identify dysfunctional patterns, and in enlisting their support
H. Facilitate development of appropriate responses to situations
I. Model and roleplay appropriate responses with the person
J. Facilitate identification of desired changes that the person would like to make
K. Positive feedback and reinforcement for efforts and accomplishments
A. Consult with physician to obtain thorough picture of what the person has
experienced and what the prognosis is
Psychological Factors Affecting Physical Condition 87

B. Facilitate identification of goals
C. Facilitate development of problemsolving skills
D. Encourage the person to take appropriate risks and challenge irrational thinking
E. Encourage the person to take responsibility by making decisions, following through,
and being prepared with a contingency plan
F. Encourage venting of thoughts and feelings (such as powerlessness and lack of
control, appearance, etc. associated with physical contion)
G. Facilitate identification of how the person can maintain a feeling of control
H. Facilitate increased awareness for the relationship between physical symptoms and
emotional functioning
I. Facilitate increased awareness for learned behavior and secondary gains
J. Facilitate increased awareness for primary or secondary gains that may be present
K. Refer the person to appropriate community resources
L. Journal writing to increase awareness and selfmonitor positive efforts
M. Positive feedback and reinforcement for efforts and accomplishments
3. Deep breathing
C. Educate regarding the role of negative selftalk
5. Low SelfEsteem
A. Facilitate identification of realistic goals
B. Facilitate identification of strengths
C. Minimize focus on physical symptoms
D. Focus on strengths, positives, efforts, and accomplishments
E. Facilitate development of problemsolving skills
F. Facilitate identification of appropriate responses to variety of situations to increase
feelings of ability and capability
G. Break down goals into manageable steps. If the person experiences difficulty, work
with him/her to break down steps of change further. Prepare the person that this is
an expected experience in behavior modification and that no step is too small.
H. Promote feelings of control by encouraging the person to participate in decision
making regarding treatment planning
PERSONALITY DISORDERS
A person may meet the criteria for more than one personality disorder. Additionally, there is
an overlap in the diagnostic criteria of various personality disorders. Because a person suf
fering as Axis I crisis may demonstrate personality disorder features during the period of that
crisis does not warrant the diagnosis of a personality disorder. A diagnosis of personality dis
order is only given when enduring personality traits are inflexible and maladaptive and cause
significant impairment in how the individual interacts with the environment.
Due to the nature of personality disorders (enduring and pervasive maladaptive behav
iors), psychodynamic treatment, in conjunction with resultsoriented brief therapy interven
tions and skills development, offers optimal results toward behavioral change.

AVOIDANT PERSONALITY DISORDER
Goals 1. Decrease resistance to beneficial intervention/change
2. Develop goals
4. Decrease avoidant behavior
5. Resolve issues of loss
8. Decrease sensitivity
Treatment Focus 1. Therapeutic Resistance

and Objectives A. Establish a trusting therapeutic relationship
B. Do not engage the person in clinical issues too quickly
C. Do not pressure the person with expectations
2. Lack of Goals
A. Develop appropriate goals for personal growth and behavioral change
A. Facilitate identification of fears (rejection, etc.) and feeling that the environment is
unsafe
B. Educate regarding effect of anxiety in avoidant behavior
C. Facilitate identification of realistic expectations regarding changes in avoidant
behavior
D. Develop a slowpaced stepwise progression of social interaction
E. Facilitate identification of fear of rejection and hypersensitivity. Increase awareness
of alternative ways of viewing the responses of others versus personalizing.
F. Refer to group therapy to increase awareness for and practice dealing with
hypersensitivity
G. Facilitate small steps toward calculated risks for social/personal gratification
H. Positive feedback and reinforcement for efforts and accomplishments
4. Avoidance of People and Situations
A. Systematic desensitization/flooding
B. Teach assertive communication
1. Roleplay and model effective, honest responses/behaviors
C. Break down desired behavioral changes into manageable steps
D. Be supportive, focusing on positives
5. Issues of Loss
A. Facilitate identification of feelings of loneliness, being an outsider, and so forth
B. Identify behaviors that contribute to isolation and aloneness
C. Facilitate resolution of losses through venting of feelings, closure on issues where
appropriate, problem solving, and behavioral changes
A. Establish a trusting relationship, reciprocating respect by keeping appointments,
being honest, genuine, and so on within the therapeutic frame
B. Facilitate identification of feelings
C. Encourage appropriate ventilation of feelings
D. Explore alternatives for dealing with stressful situations instead of avoidance
E. Identify goals for desired changes, and break down each goal into manageable steps
for shaping new behaviors
F. Educate regarding role of negative selftalk
G. Teach relaxation techniques
3. Time management
7. Distorted Beliefs
A. Challenge irrational thoughts, statements, and attributions
B. Reframe beliefs and situations to provide rational, believable alternatives
C. Paradoxical interventions
1. Prescribing avoidant behaviors. This intervention can sometimes be used to slow
down avoidant responding by circumscribing and limiting avoidant patterns of
behavior by assigning specific avoidant behaviors.
2. Prescribing rejections. To fulfill this intervention, seek situations that are
predictable and under control.
8. Overly Sensitive
A. Facilitate increased awareness for acute sensitivity
1. Difficult for the person to benefit from the feedback from others because it is
viewed as criticism and disapproval
2. Interferes with others feeling comfortable with being honest with the person,
fearing the person's negative response
B. Roleplay social situations to decrease fear/anxiety
C. Initiate person to speak honestly about themselves
D. Explore issues of selfacceptance
E. Refer to group therapy to facilitate increased awareness for acute sensitivity and
desensitization
9. Low SelfEsteem
A. Be accepting and respectful to person
B. Identify and focus on strengths and accomplishments
C. Facilitate selfmonitoring of efforts toward desired goals
D. Facilitate development of assertive communication
E. Encourage and positively reinforce efforts and accomplishments
These individuals want affection, but not as much as they fear rejection. The slightest dis
approval or critique is misconstrued as derogatory. They may ingratiate themself to others
in an effort to prevent rejection. A friendly, gentle and reassuring approach is essential in
developing a beneficial therapeutic relationship with someone who is hypersensitive to
potential rejection and has low selfesteem.
COMPULSIVE PERSONALITY DISORDER

Goals 1. Assess for referrals
2. Develop goals
3. Decrease perfectionism

4. Decrease ritual behaviors
5. Decrease obsessive, ruminative thoughts
6. Increase functional, constructive behavior
Treatment Focus 1. Assess Regarding Appropriate Referrals

and Objectives A. For medication evaluation
B. OCD group or other appropriate community resources (for developing increased
awareness for maladaptive coping mechanisms and for reinforcing of positive
efforts and change)
2. Lack of Goals
A. Facilitate development of appropriate goals for personal growth and behavioral
change
B. Facilitate understanding and acceptance that therapy can be a long, slow process
when dealing with such issues. Avoid power struggles. These individuals can be
highly resistant to change and have difficulty dealing with issues of power and
authority.
3. Perfectionism
A. Facilitate identification of feelings and tendency to minimize feelings
B. Facilitate venting of feelings
C. Explore issues of control and frustration associated with perfectionism
4. Compulsive Rituals
A. Identify the nature and extent of compulsions
B. Identify the internal and external triggers for compulstions
C. Facilitate the individual in learning to interrupt the compulsions and to substitute
with appropriate behavior
D. Identify the dynamic of the compulsions
E. Work through the dynamics of the compulsions
F. Systematic desensitization of increase tolerance for associated anxiety
G. Explore unacceptable thoughts and intense feelings that are not expressed
H. Explore fear associated with expression of feelings and thoughts
I. Facilitate use of behavioral journal
1. To develop baseline
2. To develop a reasonable program for decreasing the frequency of ritual
behaviors
3. Reinforce focus on positives and accomplishments
5. Obsessive Ruminations
A. Identify the nature and extent of obsessions
B. Identify the internal and external triggers for obsessions
C. Facilitate the individual in learning to interrupt the obsessions and substitute with
rational thinking
D. Identify the dynamics of the obsessions
E. Work through dynamics of the obsessions
F. Encourage decision making
G. Confront irrational thinking with reality
H. Facilitate rational, positive selftalk
I. Facilitate the use of thought stopping
J. Encourage making of choice of distract self from ruminative thoughts by utilizing
physical activity or other activities.
K. Explore relationship of the obsessive thoughts and compulsive behaviors
L. Maintain focus of treatment on the person's feelings (because these individuals tend
to intellectually defend against threatening feelings)
6. Ineffective Use of Time
A. Facilitate increased awareness for how obsessions and compulsions interfere in
normal daily functioning
1. Facilitate identification of losses, activities the person does not have time to
participate in or fears that prevent participation in otherwise desirable activities
2. Develop daily structure of activities
3. Person to make support system aware of his/her goals and how the support
system can help in efforts toward change
4. Capitalize on positive affect experienced when the person breaks the OCD and
pattern such as improved selfesteem, enjoyment of life, and feelings of control
over his/her life
B. Teach anger management
C. Roleplay and rehearse, problemsolving appropriate responses to a variety of
situations
D. Learn to say no, avoid manipulation, set limits and boundaries
8. Low SelfEsteem
A. Identify realistic goals, expectations, and limitations
B. Identify factors that negatively affect selfesteem
C. Overcome negative feelings toward the self
D. Assertive communication
E. Positive selftalk and affirmations
F. Identify feelings that have been ignored or denied
C. Focus on efforts and accomplishments
Compulsives are a difficult population to treat. Their obsessiveness can paralyze attempts of

clinical progress. They often want complete explanations of what will happen during
the evaluation and course of treatment. Additionally, they often lack insight to initiate
change because their thinking is highly concrete. Progress is measured in terms of behavioral
change.
DEPENDENT PERSONALITY DISORDER
Goals 1. Increase independent beahvior
2. Develop goals
3. Improve decisionmaking skills
6. Promote cognitive restructuring
92 i. Treatment Planning. Goals, Objectives, and Interventions

7. Decrease sensitivity
Treatment Focus 1. Dependent behavior

and Objectives A. Be careful to not push person before the person is ready for change
B. Identify fears associated with independent behaviors
C. Identify how dependent behaviors limit the person in getting needs met and/or
participating in chosen interests
D. Identify how dependent behaviors communicate a mixed or incorrect message to
others
E. Facilitate identification of own competence and selfworth
F. Clarify that seeking autonomy will not be harmful to others
2. Lack of Goals
change
3. Difficulty Making Decisions
A. Teach decisionmaking skills
B. Teach problemsolving skills
C. Facilitate decrease in selfcritical behavior/internal dialogue (selftalk)
B. Roleplay and model assertive communication
C. Positive feedback and reinforcement for efforts and accomplishments
A. Expose the person to anxietyprovoking situations
B. Develop situations that program person for success in accomplishing simple tasks
that normally elicit stress/anxiety
C. Educate regarding the influence on negative selftalk on stress
D. Facilitate development of positive selftalk
E. Educate the person regarding the stages of relations, which include loss and how to
cope with it
F. Facilitate identification of persons' fear of being alone
1. Problemsolve constructive time along for brief periods
2. Positive feedback and reinforcement for efforts and accomplishments
3. Identify irrational thinking behind fear of being alone
G. Teach relaxation techniques
3. Time management
6. Distorted Thinking
A. Challenge irrational beliefs, and offer plausible substitute statement
B. Facilitate clarification when the information communicated appears
distorted
C. Reframe situations previously viewed as negative as an opportunity for change and
growth when appropriate
D. Facilitate person's clarification of rational versus irrational thinking
E. Reinforce realitybased thinking
7. Overly Sensitive
A. Facilitate increased awareness for difficulty that the person has accepting feedback
from others and in viewing it as critical or disapproving
B. Increase understanding for the effect of being overly sensitive in the context of a
relationship and how it limits honest communication
C. Facilitate identification of fear of abandonment and how this fear affects person
and how they relate to others
8. Low SelfEsteem
A. Identify and focus on positives and accomplishments
B. Identify goals and break them down into manageable steps so that the person can
see progress and feel positive about it
C. Facilitate development of assertive communication
D. Positive feedback and reinforcement for efforts and accomplishments
E. Facilitate identification of the person's own competence and selfworth
It is not unusual for individuals with Dependent Personality Disorder to call their therapist

constantly clarifying appointments and asking advice or seeking guidance. Clear limits estab
lished at the onset of treatment regarding the regularity of appointments and therapist avail
ability are necessary.
PASSIVEAGGRESSIVE PERSONALITY DISORDER
Goals 1. Decrease procrastination
2. Develop goals
4. Increase positive emotional/behavioral responding
7. Effective communication
Treatment Focus 1. Procrastination

and Objectives A. Facilitate identification of dysfunctional behavioral patterns (e.g., works slow,
complains, forgets, pessimistic)
B. Facilitate improved time management
1. Increase awareness and productivity. These individuals often do not reach goals
because of selfdefeating behavior.
C. Increase awareness for frequent power struggles with authority figures
2. Lack of Goals
change
3. Distorted Thinking and Beliefs
A. Identify thinking/beliefs that interfere with the person taking responsibility for
his/her behavior
B. Identify, clarify, and interpret the dynamics of the passiveaggressive
behavior
C. Work through the dynamics of passiveaggressive behavior
D. Identify blaming (the problem lies with someone else)

E. Encourage the person to keep a journal
1. To clarify irrational logic and dysfunctional responding
2. To clarify possibility of unrealistic expectations
F. Positive reinforcement and feedback for efforts and accomplishments
4. Negative Emotional and Behavioral Responses
A. Facilitate increased awareness for negative responding associated with situations
that the person does not like (acting out)
1. Identify efforts of manipulation and avoidance
2. Facilitate drawing out of covert aggression
B. Confront veiled threats and efforts of manipulation and direct them back to the
person in terms of what he/she has to gain by such actions
C. Educate regarding how limiting such behavior is
D. Facilitate problem solving for rational, appropriate responses to various situations
that will improve relationships for the person and allow him/her to feel good
E. Facilitate increased awareness and understanding for how such responding affects
selfesteem
A. Social skills training
1. Roleplay appropriate and cooperative behaviors
B. Explore the use of manipulative behavior or other means that the person uses to get
what he/she wants
C. Facilitate acknowledgement that behavioral problems negatively affect one's social
interaction and the outcome
D. Teach assertive communication
E. Facilitate increased awareness for how negative responding has limited developing
mature, appropriate responses
6. Low SelfEsteem
A. Be accepting and respectful to the person
B. Identify strengths and focus on accomplishment
1. Facilitate recognition of the sense of relief associated with completed tasks, and
point out how much more positive things will proceed for the person in his/her
environment with increased cooperation
C. Facilitate selfmonitoring toward desired goals with a focus on the positives
D. Facilitate the development of assertive communication
B. Roleplay and model appropriate communication
PARANOID PERSONALITY DISORDER

Goals 1. Decrease treatment resistance
2. Develop goals
3. Decrease paranoid thinking
5. Manage anger
6. Decrease fear with supportive therapeutic relationship
Treatment Focus 1. Treatment Resistance

and Objectives A. Develop a trusting therapeutic relationship
B. Explain purpose for a cooperative effort
2. Lack of Goals
A. Facilitate development of appropriate goals for personal growth and behavioral change
3. Distorted Paranoid Thinking
A. Identify the nature and extent of paranoia
B. Facilitate the individual's development of awareness for the presence of paranoia
C. Explore thoughts and feelings
1. Identify that person expects to be used or exploited
2. Identify personal impact/losses for being unable to trust
3. Identify that the person is always looking for hidden meaning/conspiracy
D. Be careful to avoid any ambiguity in communication with this person
E. Medication compliance
1. Suspiciousness. Encourage the person to ask questions and read literature on
medication
2. Prepare the person for the various side effects that he/she may experience
F. Facilitate increased awareness for inability to relax. Work with person to develop
plausible alternatives for relaxing (and clarify benefit).
A. Determine range of paranoid thinking (i.e., within normal limits—paranoid)
B. Educate and roleplay regarding appropriate limits and boundaries within various
relationships
C. Educate regarding appropriate level of disclosure in various relationships
D. Problemsolve with person about how to deal with paranoid thinking in a social
context
E. Facilitate increased awareness for restricted affect
5. Underlying Anger
A. Encourage venting of underlying anger/jealousy
B. Validate feelings of anger/jealousy
C. Increase person's awareness for role he/she plays in situation's and support his/her
in taking responsibility for that behavior
D. Facilitate person recognizing that withholding of anger is not in his/her best interest
1. Teach anger management
2. Roleplay the appropriate expression of feelings
3. Teach other constructive methods for dealing with anger and frustration
(exercising, finding a trustworthy person to vent to, journal writing with a
problemsolving component)
6. Fear and Lack of Support
A. Supportive psychotherapy
B. Be clear, respectful, hones, open

C. Challenge denial and projection in a supportive manner
D. Empathize with the person's difficult life experience, while encouraging him/her to
take responsibility
E. Facilitate increased awareness for relationship ambivalence
F. Facilitate increased awareness for the projection of the person's own unacceptable
thoughts
G. Facilitate increased awareness of how the person's distorted perspective interferes in
his/her life
H. Facilitate increased awareness for overinvolvement in fantasy and private belief
system
I. Through problem solving with person, develop minimally threatening situations for
practice and programmed success
J. Positive feedback and reinforcement for efforts and accomplishments
7. Low SelfEsteem
A. Be accepting and respectful to the person
B. Identify and focus on strengths and accomplishments
C. Facilitate selfmonitoring efforts toward desired goals
These individuals rarely present for treatment on their own simply because they do not
perceive weakness or faults in themselves. They tend to be guarded in sharing personal infor
mation. The central goal of treatment is to minimize the distrust of the therapist and the
therapy process. With regard to almost all issues, the paranoid expects the worst but feels
assured in being given all the details beforehand. Therefore, it is imperative to give ade
quately detailed and accurate information.
SCHIZOTYPAL PERSONALITY DISORDER
2. Develop goals
4. Decrease isolation

and Objectives A. Explain purpose of therapy intervention
B. Explain that the person is at risk for premature termination from therapy because
of difficulty trusting the therapist and others
C. Assess disordered thinking
2. Lack of Goals
A. Identify what the person wants and needs
B. Develop and utilize resources that support efforts toward identified goals
A. Facilitate increased awareness for overinvolvement in fantasy and private belief
system
B. Increase awareness for odd and eccentric behavior
C. Increase awareness for how others experience the person
D. Roleplay various social situations to demonstrate appropriate and effective
responses
4. Social Isolation
A. Problemsolve ways to decrease isolation with a minimal amount of distress
B. Participation in regular activities to facilitate development of comfort level with
familiarity
C. Refer to appropriate group or other social interaction to provide opportunity for
practice
6. Low SelfEsteem
A. Identify and focus on strengths and accomplishments
C. Identify goals and break them down into manageable steps for programmed success
Schizophrenia should always be considered in those under the age of 35. If there is a clear
diagnosis, continue to monitor for decompensation
1. They may become transiently psychotic under stress
2. The condition may evolve into schizophrenia
3. They may develop fanatic beliefs
Medication (antipsychotics) may be beneficial in alleviating some of the intense anxiety and

cognitive symptoms (such as odd speech and unusual perceptual experiences). Therefore,
consider the referral for a medication evaluation.
SCHIZOID PERSONALITY DISORDER
2. Develop goals

and Objectives A. Explain purpose of therapy
B. Encourage the person to discuss mixed feelings about participating in therapy
2. Lack of Goals
A. Facilitate development of appropriate goals
B. Assess disordered thinking

3. Ineffective Social Interaction
A. Increase awareness for how others experience the person (cold, detached)
B. Roleplay appropriate and effective responses for various social situations
C. Facilitate increased awareness for emotional experience in relating to others
D. Facilitate identification for consequences of cold, aloof responding to others
4. Social Isolation
A. Facilitate identification of the person's experience
B. Facilitate development of goals. They must be realistic and broken down into
manageable steps.
C. Communicate respect for the person's need for privacy
6. Low SelfEsteem
Because social isolation is such a prominent feature with this disorder, these individuals are

not likely to seek treatment. Most schizoids would lack both the bright and the motivation
for therapy and likely experience the intioning of therapy as too threatening.
HISTRIONIC PERSONALITY DISORDER
Goals 1. Goal development
2. Appropriate affect and expression of emotion
3. Appropriate social behavior
4. Appropriate emphasis on appearance

and Objectives A. Facilitate development of appropriate goals
B. Refer to appropriate group to facilitate clarification of goals as well as efforts
toward progress
2. Inappropriate Affect
A. Facilitate increased awareness for exaggerated emotional display
B. Facilitate increased awareness for seductive behavior
C. Explore need for attention and excitement
D. Facilitate increased awareness for how emotional overreaction affects his/her
relationships
E. Encourage anger management
F. Promote clarification of feelings and appropriate, congruent expression
G. Encourage person to take responsibility for the consequences of his/her actions
3. Dramatized Social Interaction
A. Facilitate increased awareness for inappropriate social responding and the effect
that it has on others in the person's relationships
B. Roleplay appropriate responses to various social situations
C. Facilitate identification of particular areas of difficulty the person experiences in
expressing himselMierself (e.g., how does the person respond when he/she feels ignored)
D. Increase awareness for manipulative behavior
E. Be supportive and empathic toward person's emotional/social difficulties
G. Increase awareness and improve accuracy in selfimage (inflated/distorted)
H. Address provocative attentionseeking behavior
4. Overemphasis on Appearance
A. Facilitate identification of distorted beliefs and overinvestment in appearance
B. Increased awareness and understanding of lack of congruence between looking
good on the outside and internal emptiness/lack of fulfillment
C. Facilitate identification of fears associated with aging, which will affect appearance
D. Facilitate identification on lack of development of internal resources because the
person's energy is consistently used to "look good," whether by physical
appearance or by collecting things
E. Facilitate increased awareness for selfcentered actions to gain immediate satisfaction
B. Encourage the person to keep a journal to increase awareness for honesty, self
centeredness, and tendency toward shallowness
C. Roleplay and model appropriate, assertive communication
D. Facilitate increased understanding for shifting emotions, inappropriate
exaggerations, and the need to be the center of attention, which are communicated
to others. Explore the impact that this has on the person getting needs met and
having fulfilling relationships.
6. Low SelfEsteem
B. Facilitate the development of goals
C. Facilitate selfmonitoring of efforts toward desired goals
D. Facilitate the development of assertive communication
Since histrionics think in terms of impression not fact, trying to get detailed information dur

ing the interview process becomes an arduous task.
NARCISSISTIC PERSONALITY DISORDER
Goals 1. Develop goals
2. Increase sensitivity toward others
4. Increase selfawareness

Treatment Focus 1. Lack of Goals for Personal Growth and Development
and Objectives A. Facilitate development of appropriate goals
B. Break down goals into reasonable steps
C. Identify and problemsolve factors that previously inhibited reaching goals
D. Develop realistic expectations and limitations (these individuals often feel
inadequate and helpless when they fail to meet unrealistic goals)
2. Lack of Sensitivity Toward Others
A. Encourage the person to put himself/herself in the place of others to increase
understanding
B. Encourage the person to appropriately express how he/she feels when people are
insensitive to the person's needs
B. Develop sample problems to practice new skills on
C. Facilitate increased awareness of how feelings of entitlement interfere with
appropriate, effective problem solving
D. Identify secondary gains that inhibit progress toward change
E. Improve coping by increasing awareness for the power struggle between the
person's intense need to be admired by an individual he/she views as important and,
at the same time, feeling rage at being disappointed by that person
4. Lacks SelfAwareness
A. Encourage journal writing to identify thoughts, feelings, and behaviors
B. Encourage honest selfevaluations
C. Facilitate increased awareness for how these individuals' constant seeking of love,
admiration, and attention from others impedes them taking responsibility for
themselves and learning to fill their sense of emptiness on their own
D. Facilitate insight into feelings of inadequacy and vulnerability
5. Low SelfEsteem
B. Facilitate selfmonitoring of efforts toward desired goals
C. Facilitate development of assertive communication
D. Facilitate development, and support maintenance of realistic concept of the
individual's own selfworth
If this individual presents for treatment, it is not likely associated with insight about the need

for taking responsibility and making necessary changes. Instead, it is likely due to depres
sion, pressure from a partner, adjustment/loss, or is associated with a medical condition.
When a therapist exposes these individuals' issues of grandiosity/selfimportance, it should
be done in a gentle way with guidance into a proper perspective. Otherwise it will illicit
strong resentment. Their selfcenteredness is a shield of protection that when fractured
exposes insecurity.
BORDERLINE PERSONALITY DISORDER
Goals 1. Goal development
2. Appropriate expression of emotions

3. Increase awareness for intensity in relationships
4. Decrease selfdestructive behaviors
5. Decrease manipulative behavior
6. Clarify boundaries

and Objectives A. Facilitate development of appropriate goals for personal growth and behavioral
change
B. Facilitate development of realistic expectations and limitations
2. Inappropriate Expression of Emotions
A. Facilitate increased awareness for inappropriate, exaggerated expression of
emotions (emotional instability)
B. Facilitate increased awareness for how inappropriate emotional expression impacts
relationships
C. Facilitate increased awareness for how inappropriate emotional expression impacts
person getting their needs met
D. Facilitate increased awareness for how inappropriate emotional expression impacts
selfesteem
3. Inappropriate Behavior and Lack of Awareness
A. Facilitate increased awareness regarding appropriate behavior
B. Facilitate increased awareness for how inappropriate behavior impacts relationships
C. Facilitate increased awareness for how inappropriate behavior interferes with
getting needs met
D. Facilitate increased awareness for how inappropriate behavior impacts selfesteem
E. Role play and model appropriate behavioral responses
4. SelfDestructive Behavior
A. Facilitate increased awareness for pattern of being easily overwhelmed by anger and
frustration which often results in impulsive, manipulative and/or selfdestructive
behavior
1. Anger management
2. Encourage appropriate expression of feelings and thoughts
B. SelfMutilation
1. Identify the nature and extent of selfmutilating behavior
2. Assess the seriousness of the behavior(s) and provide a safe environment when
necessary
3. Clarify and interpret the dynamics of the behavior
4. Work through the dynamics of selfmutilation
5. Encourage venting of thoughts and feelings associated with the behavior
6. Facilitate development of appropriate alternatives for dealing with unpleasant
affective states that precipitate selfmutilation behavior
C. Facilitate development of appropriate communication
D. Facilitate clarification of wants and needs and how to appropriately get them met
E. Clarify wants and needs to be met by the individual versus those to be met in a
relationship

F. Develop appropriate alternatives of behavioral responses
G. Facilitate recognition of how selfdefeating and selfdestructive behaviors keep
person from getting their needs met
H. Facilitate increased awareness and understanding of the underlying meaning of
selfdestructive behaviors
5. Manipulative Behavior
A. Increase awareness of use of manipulative behavior
B. Increase awareness for goal behind manipulative behavior and the positives and
negatives associated with it
C. Facilitate awareness of benefits associated with eliminating manipulative behavior
D. Role play and model appropriate and inappropriate behaviors for clarification and
to broaden repertoire of appropriate behaviors
6. Lack of Appropriate Boundaries
A. Facilitate increased awareness for person's lack of boundaries
B. Facilitate increased awareness of relationship difficulties associated with lack of
boundaries
C. Facilitate increased awareness for fear of abandonment and role this plays in poor
boundaries, as well as other inappropriate behaviors and inappropriate expression
of emotion (all issues of appropriate boundaries in interpersonal interaction)
D. Facilitate increased awareness for selfdefeating relationship difficulties such as:
1. Unstable and intense relating
2. Idealization and devaluation
3. Manipulation
B. Facilitate awareness for inappropriate behaviors and verbal expressions as
ineffective attempts to communicate
C. Identify feelings behind inappropriate behavioral and emotional expressions and
facilitate problem solving with person for appropriate changes to accomplish
their goal
D. Role play and model assertive communication
8. Low SelfEsteem
B. Facilitate selfmonitoring of efforts toward desired goals
C. Facilitate development of appropriate behavior and verbal communication
This disorder tends to run in families and has a high rate of association to mood disorders.

A majority of borderlines have a history of physical, sexual, or emotional abuse by their
caregivers who at times were also adequate in their care and were even nurturing. The result
is loving and hating the caregiver in a vacillating manner (all good or all bad).
While splitting may be a normal and healthy defense in 18 to 36monthold toddlers,
when the mind is able to handle greater complexity, developmental adjustment facilitates
the good, bad dichotomy diversity and is recognized and managed in the ambiguous shades
of gray in which good and bad exist. Borderlines do not accomplish this developmental
adjustment.

PHYSICAL FACTORS AFFECTING PSYCHOLOGICAL
FUNCTIONING
The following is an example of how a person's emotional and psychological functioning are

affected by a health issue.
1. Vignette
An individual is referred for therapy by the person's primary care physician. While the
person has been experiencing various symptoms for some time, the individual has
recently been diagnosed with multiple sclerosis (MS). For some, a diagnosis of MS
being presented months or even years after the onset of symptoms is a relief from the
standpoint that the person now knows what is wrong. For others, this diagnosis is a
terrible shock.
2. Symptoms of MS possibly experienced prior to diagnosis
A. Weakness
B. Fatigue
C. Low selfworth (associated with the decreased productivity from fatigue)
D. Depression
E. Impaired memory
F. Difficulty concentrating
3. Common reactions to being given the diagnosis of a chronic illness
A. Disbelief
B. Fear
C. Anger
D. Depression
E. Guilt
F. Fear of losing control over one's life
G. Grieving (Grieving losses in functioning as part of adjustment)
H. Denial
4. Central emotional crisis issues associated with a medical crisis
A. Control
B. Selfimage
C. Dependency
D. Stigma
E. Abandonment/rejection
F. Anger
G. Isolation/withdrawal
H. Death
*Refer to information on crisis counseling.
Additionally, some fears associated with a longterm illness where there is decompensa

tion over time include fear of pain, imposed changes in lifestyle, alteration of social patterns,
and fear of the future. The impact of such a significant crisis is stressful to clarify, speak
about, and, initially, to problemsolve how to deal with imposed changes in the level of phys
ical and cognitive functioning as the illness progresses.

STAGES OF ADJUSTMENT
Adjusting to MS is an ongoing process that evolves over a period of time (which varies
among individuals). Some people proceed through cycles of progression and remission, oth
ers decompensate with little remission, and yet others may remain in remitted states for a
very long period of time. Initially, if there is little evidence of disability, the individual may
not experience denial because he or she is not currently confronted with changes in func
tioning. Evidence of psychological stress and efforts to cope may be evidenced as follows:
1. Denial is a normal defense reaction in not wanting to accept and acknowledge

such stressful information. Denial is easily validated with a remission of
symptoms ("I don't really have MS").
2. Resistance to letting "this illness" control one's life is an action based response
against the illness. While this may be a positive demonstration of will, it may
also be an unrealistic expectation of personal control, which could lead to
significant depression if the individual is confronted with the reality that he/she
cannot conquer the illness (i.e., symptom presentation and decompensation).
3. Affirmation is the acknowledgement that the diagnosis is real.
This allows the individual to open up, process, and develop resources. It also
facilitates a reevaluation of life priorities.
4. Acceptance is the realistic recognition of what the diagnosis means and coming
to terms with it.
5. Personal growth is the silver lining in the cloud—responding to a difficult crisis
with the attitude that with every experience in life there is the opportunity to
grow and continue to evolve in new ways. There may be more appreciation for
life in general and genuine gratitude for the things that are "right" in one's life.
There is an unfortunate history of nonintegrated treatment between practioners of physical

health and mental health. As a result, there is often negligence in acknowledging and edu
cating patients regarding the emotional and psychological impact associated with various
medical disorders and disease states. The following table presents a brief review used to
highlight this significant relationship. Such information, when shared with a patient, acts to
validate one's experience and leads to appropriate problem solving and interventions.
Medical Causes of Psychiatric Illness
Depression
mood Anxiety Personality
Medical Problem disorders disorders change Psychosis Dementia
Adrenal insufficiency
Aids
Altitude sickness
Amyotrophic lateral
sclerosis
Antidiuretic hormone
Inappropriate secretion
(Continues)
Physical Factors Affecting Psychological Functioning 105

Medical Causes of Psychiatric Illness (Continued)
Depression
Medical Problem disorders disorders change Psychosis Dementia
Brain abscess Range of cognitive symptoms
Brain tumor
Cancer
Cardiac arrhythmias
Cerebrovascular accident
COPD (Chronic obstructive
pulmonary disease)
Congestive heart failure
Cryptococcosis
Cushing's syndrome
Deafness Paranoid ideation
Diabetes mellitus
Epilepsy
Fibromyaglia
Head trauma Mood swings
Herpes encephalitis
Homocystinuria
Huntington's disease
Hyperparathyroidism
Hypoparathyroidism Paranoid ideation
Hypothyroidism
Kidney failure
Klinefelter's syndrome
Liver failure
Lyme disease
Meniere's disease
Menopause
Migraine
Mitral valve prolapse
Multiple sclerosis Cognitive impairment
Myasthenia gravis
(Continues)
106 i. Treatment Planning: Goals, O b j e c t i v e s , and I n t e r v e n t i o n s

Medical Causes of Psychiatric Illness (Continued)
Depression
Medical problem disorders disorders change Psychosis Dementia
Neurocultaneous disorders
Parkinson disease
Phemochromocytoma
Pneumonia
Pernicious anemia
Porphyria
Postoperative states
Premenstrual syndrome
Prion disease
Progressive supranuclear Labile mood

palsy
Protein energy malnutrition Cognitive change / Occassional
Pulmonary throembolism
Rheumatoid arthritis Rate
Sickelcell disease Substance dependence
Sleep apnea
Syphilis
Systematic infection
Systematic lupus erythematos
Thiamine deficiency Amnesia
Wilson's disease Cognitive disorder
Physical Factors Affecting Psychological Functioning 10/

Chapter 22
Assessing Special Circumstances
ASSESSING SPECIAL CIRCUMSTANCES
This section begins with the special assessment circumstances of risk of suicide (danger to
self), dangerousness (danger to others), and gravely disabled. These constitute three of the
most difficult and challenging situations with which the therapist will be presented. They
require careful assessment, treatment considerations regarding level of care and providing a
safe environment, legal issues, and often a family intervention. Additionally, this section
addresses many other important situations in which the therapist may be engaged clinically
to assess, provide evaluative reports, and/or to make appropriate interventions, referrals,
and recommendations.
Guidelines for assessment provide the framework from which the therapist can establish
a reasonable evaluation from a perspective of standard of care. For example, while there is
no fail safe method of establishing the issue of risk of violence, using standard assessment
criteria in combination with clinical judgment and issues of immediate management offers
numerous points of intervening, thereby decreasing risk and increasing safety.
When providing any of the aforementioned services there are guidelines of education,
training, supervision, and experience which are necessary.
COGNITIVEBEHAVIORAL ASSESSMENT
It may not be possible to assess all of the following during the initial assessment. The
assessment process continues throughout the course of treatment. The cognitivebehavioral
assessment has a general educational element and helps to focus the individual on internal
and external variables that may not have appeared relevant to the problem.
109
Outline of the 1. Succinct description of the presenting problem
Interview 2. Development of the problem
A. Behavior(s)
B. Cognition(s)
C. Affective response(s)
D. Physiological reaction(s)
E. To each of these, answer
1. What
2. When
3. Where
4. How often
5. With whom
6. Degree of distress
7. Degree of disruption
3. Contextual variables or modulating variables
A. Situation(s)
B. Behavior(s)
C. Cognition(s)
D. Affective response(s)
E. Interpersonal response(s)
E Physiological response(s)
4. Maintaining factors
A. Situation!s)
B. Behavior (s)
C. Cognition(s)
D. Affective response(s)
E. Interpersonal(s)
E Physiological response(s)
5. Coping
A. History of responses to difficulty situations
B. Current resources
1. Interpersonal
2. Community
6. Psychiatric history
7. Medical history
8. Previous treatment
A. General course of treatment
B. How responded
C. What was helpful
9. Beliefs and interpretations associated with
presenting issue
10. Mental status
11. Psychosocial factors
A. Family/social relationships
B. Psychosexual development
C. Occupation
110 2. Assessing Special Circumstances

D. Personal interests/leisure activities
E. Adjustment/accommodation
DEPRESSION AND ANXIETY SCREENING

While a complete clinical evaluation is necessary to establish a diagnosis of depression or
anxiety, a simple screening instrument serves a useful purpose to do the following:
1. Clarify symptom presentation

2. Explore the history of symptoms
3. Explore treatment history
4. Educate the patient regarding treatment choices
5. Make appropriate referrals
DEPRESSION
Criteria for Major Five or more of the following symptoms have been present during the same twoweek period
and represent a change from previous functioning. At least one of the symptoms is depressed
Depressive Episode
mood or loss of interest/pleasure.
1. Fatigue or loss of energy
2. Feelings of worthlessness
3. Diminished interest/pleasure in all/almost
all activities
4. Recurrent thoughts of death or suicide or
suicide attempts
5. Significant weight loss or weight gain
6. Insomnia or increased need for sleep
7. Inability to concentrate
8. Depressed mood most of the day
9. Agitation or lethargy
ANXIETY
Many individuals with persistent anxiety present with somatic symptoms as well. For these
individuals, consider a diagnosis of generalized anxiety disorder.
Generalized anxiety disorder is described as excessive anxiety and worry that occurs more
days than not for a period of at least six months. The individual experiences difficulty
controlling the excessive worry. Anxiety and worry are associated with three or more of the
following symptoms.
1. Feelings of restlessness/onedge/keyedup

2. Easily fatigued
3. Difficulty concentrating/maintaining attention
4. Irritability/low frustration tolerance
5. Muscle tension
6. Sleep disturbance
Assessing Special Circumstances 111

STRUCTURED INTERVIEW FOR DEPRESSION
When depression has been identified as the presenting or underlying issue, the next task is to

clarify the nature of the depression and its severity so that appropriate treatment (including
referrals for medication evaluation/hospitalization) can ensue.
1. Current level of functioning

A. Symptoms
B. Relationship
C. Work/school
D. Home
E. Negative/selfdefeating thoughts
F. Onset of depression
G. Development of depression
H. Context of depression
* Collaborate with individual to develop a problem list from their perspective.
I. Mental status

1. Mood
2. Affect
3. Memory
4. Processes
5. Perceptual disturbances
6. Judgment
7. Insight
8. Impulse control
2. Define treatment goals
A. Collaborative
B. Willingness
3. Educate
A. Regarding cycle of negative thinking and depression cycle
B. Possibilities of change, offering hope
C. Importance of selfcare
4. Homework/feedback
A. Do reinforce movement toward treatment goals
B. Awareness
C. Selfresponsibility
D. Preventative strategies developed
5. Prepare for selfmonitoring
A. What to look for
B. What process to use (journals, selfrespect, survey, pre and post test
instrument, etc.)

CYCLE OF DEPRESSION
Early life
experiences
1
Assumptions
Experiences that
validate the formation of
negative or dysfunctional
assumptions
Activation of
assumptions
Learned/rehearsed
automatic negative Symptoms
thoughts of depression
Sleep disturbance
Cycle of depression
Appetite disturbance
Somatic
Fatigue
Decreased libido
Withdrawal
Social isolation
Behavioral
Fearfulness
Lack of activity
Suicidal ideation
— Cognitive Irrational thinking
Rumination
Selfcritical
Despair
Sadness/loss
Affective Low selfesteem
Helpless
Worthlessness
Guilt
Lack of pleasure in
normally pleasurable
1
— Motivational activities
Decreased drive
Procrastination
Adapted from A. Beck, Model of Depression (1967,1976)
Cycle of Depression 113

Subjective Patient Review of Self Awareness and Presenting Problems
Name: Date:
Please fill out the following by checking the correct space that applies.
None or Some A good Most or

a little of of the part of all of
the time time the time the time
I feel downhearted and blue.
I enjoy my time alone.
I have crying spells or feel like having them.
I have trouble sleeping at night.
I eat as much as I used to.
I enjoy sex.
I notice that I am losing weight.
I have trouble with constipation.
My heart beats faster than usual.
I get tired for no reason.
My mind is as clear as it used to be.
I find it easy to do the things I used to do.
I am restless and cannot keep still.
I feel hopeful about the future.
I am more irritable than usual.
I find it easy to make decisions.
I feel that I am useful and needed.
My life is pretty full.
I feel that others would be better off if I were dead.
I still enjoy the things I used to do.
I spend time with friends.
Describe your personality.
What problem are you seeking help for?

SUICIDE
Assessing selfdestructive threats, gestures, and suicide potential refers to the degree of
probability that a person may harm or attempt to kill themselves in the immediate or near
future.
Suicidal impulse and suicidal behaviors constitute a response by a person whose coping
mechanisms have failed. They are often desperate and feel ashamed. If the person has
attempted suicide a medical evaluation and issues of medical stability supersede a clinical
interview. Be calm and caring in your approach, establishing a setting conductive to eliciting
the necessary information. Be reassuring in letting the person know how you plan to proceed
regarding referral for medical evaluation if needed, and that you want to talk to them in
order to understand what has been happening in their life which brought them to the point
of suicidal intent and suicidal behavior.
SUICIDE ASSESSMENT OUTLINE
1. Assessing suicidal ideation
A. Ask directly if they have thoughts of suicide
B. Are the thoughts pervasive or intermittent with a definite relationship to a
given situation
C. Do they have a plan; if so, how extensive is their plan
D. Lethality of the means/method defined
E. Is there access to the identified means
2. Suicide attempt
A. Immediate referral for a medical evaluation for medical stability if method of
attempt warrants it
1. Means, location, collaborator, rescuer, number of attempts
2. Thoroughness of plan and its implementation
3. Note signs of impairment and physical harm
4. Level of treatment required
* Intention, plan, method, means, lethality, and prior attempts
3. Risk factors

A. Intention and history
1. recent/prior attempts or gestures
2. direct or indirect communication of intent
3. extensiveness of plan
4. lethality of means
5. access to means
6. family history of suicidal behaviors
B. Demographics
1. age (teens, middle age, and elderly are at highest risk)
2. gender (males more often succeed at suicide attempts because of the lethality of
means, but females make more attempts)
3. homosexuals (additional stressors/lack of social supports)
4. race (white)
5. marital status (separated, widowed, divorced)
Suicide 115
6. social support (lack of support system, living alone)
7. employment status (unemployed, change in status or performance)
C. Emotional functioning
1. diagnosis (major depression, recovery from recent depression, schizophrenia,
alcoholism, bipolar disorder, borderline personality disorder)
2. auditory hallucination commanding death (bizarre methods may also indicate
psychosis)
3. recent loss or anniversary of a loss
4. fantasy to reunite with a dead loved one
5. stresses (chronic or associated with recent changes)
6. poor coping ability
7. degree of hopelessness or despair
D. Behavioral patterns
1. isolation
2. impulsivity
3. rigid
E. Physical condition
1. chronic insomnia
2. chronic pain
3. progressive illness
4. recent childbirth
While many of these factors appear to be of a general nature it is the clustering of these fac
tors which contribute to the person's mood, belief system, and coping ability that may lead
to the risk of suicide.
ADOLESCENT SUICIDE
Behavioral and Social Clues
1. Heavy drug use
2. Change in academic performance
3. Recent loss of a love object, or impending loss
4. Pregnancy
5. Homosexuality (additional stressors/lack of social support)
6. Running away
7. Prior suicide attempts or family history of suicide
8. Intense anger
9. Preoccupation with the violent death of another person
10. Impulsivity
11. Learning disability
12. Ineffective coping
13. Lack of resources and feelings of alienation
14. Hopelessness, depression
15. Risktaking behaviors (playing in traffic, intentional reckless driving, etc.)
16. Loss of support system
17. Recent move, change in school
116 2. Assessing Special C i r c u m s t a n c e s

18. Loss of family status (family member leaves or is removed from the home,
change in economic level of family)
19. Feeling anonymous and unimportant
20. Peer group activity associated with issue of death
In assessing adolescents, the symptoms of depression may not be indicated as directly as
when assessing an adult. This is referred to as masked depression. Masked depression can
be described in two ways:
1. Classic: Somatic complaints take the place of the general criteria of depression.

There are chronic complaints of headaches, backaches, and stomach ache.
2. Behavioral: Evidenced by acting out behaviors such as substance abuse,
promiscuity, shoplifting. These are all representations of ways of converting
affective state interpreted as boredom into something exciting. Young people
are sometimes ineffective in expression depression. Therefore, they translate it
into something else and project it outward, finding boredom in school, peers,
and family. The use of substances may be an attempt to cope with emotional
distress, lack of identity, or boredom. They may see the world as boring and
unfulfilling. Males tend to act out more aggressively in their environments.
TREATMENT FOCUS AND OBJECTIVES

The type of intervention is based on efforts to problem solve and provide a safe environment
for the suicidal person.
1. Outpatient Therapy and Management: Utilized when the risk of suicide is

low, the precipitating crisis is no longer present, there is an adequate support
system, and the person contracts that they will contact the therapist if they are
unable to cope. Least restrictive and appropriate means of intervention are
always utilized.
2. Hospitalization: Utilized if the person is at high risk for suicide, lacks adequate
social supports, lacks adequate impulse control, is intoxicated or psychotic. For
the benefit of the person, initially pursue the least restrictive course of a
voluntary admission. If they are unwilling and the criteria are present an
involuntary admission is warranted which will necessitate an evaluation by the
appropriately designated persons/facility in your area.
3. Techniques
A. Alleviate the person's isolation by recommending that they stay with family or
friends
B. Facilitate the removal of weapons or other means of a suicide attempt from their
environment. Deal with issues of substances (abuse) if necessary
C. Support the development and utilization of a support system, or the reestablishment
of their support system
D. Facilitate the appropriate expression of anger or other feelings which are
contributing to selfdestructive impulses
E. Validate the person's experience of the crisis, but also identify their ambivalence and
the fact that suicide is a permanent solution to a temporary problem
Suicide 117
F. Refer for medication evaluation making sure that the physician is aware of the
person's suicidal ideation/impulses
G. Educate the person regarding the impact that a lack of sleep has on effectively
coping, and reassure them that the depression can be managed or eliminated
H. Identify irrational, negative beliefs. Help the person recognize that the associated
negative selftalk contributes to keeping them in a state of hopelessness. Facilitate
the identification of alternatives to the difficulties that they are currently
experiencing
I. Do not verbally or nonverbally express shock or horror
J. Do not emphasize how much they have upset other people
K. Do not offer psychological or moral edicts of suicide
L. Explore with person what they hoped to accomplish by suicide
M. Identify life issues which have contributed to person's emotional state
N. Discuss the fact that suicide is a permanent solution
O. Review resources and relationships (family, friends, family physician, clergy,
employer, police, emergency response team, therapist, community support groups,
12step groups, emergency room, psychiatric hospital)
P. Be reassuring and supportive
Q. Facilitate improved problem solving and coping
R. Facilitate development of a selfcare program
1. Daily structure
2. Inclusion of pleasurable activities
3. Resources/support system (including therapy and medication compliance)
4. Identify crisis/potential crisis situations and plausible choices for coping
5. Identify warning signs (selfmonitoring) that indicate that the person is not
utilizing their selfcare plan, medication difficulties, etc.
6. Regular aerobic exercise and good nutrition
DEPRESSION AND SUICIDE RISK RELAPSE

Suicide does not begin with the selfdestructive gesture. It begins with feelings of isolation,
hopelessness, sleep disturbance, inability to cope, and other symptoms related to change,
loss, or impulse control. Warning signs that serve as a potential red flag that there is an
impending crisis include:
1. A general feeling that things are not going well. A pervasive negative outlook.

They feel that life is not worth living and they cannot manage daytoday
activities.
2. Denial. A belief that they lack control over their life. Tendency to blame other
people or situations for how they feel. As a result of not dealing with what they
are experiencing, there is a tendency toward decompensation.
3. Attempts to help others while disregarding the priority of selfcare. They
become involved in other people's issues and avoid dealing with their own.
4. Defensiveness. Taking the position that they are doing fine and do not need the
help of other people, resources, or medication.
5. Old behavior that the person has changed because of its negative role
emotionally begins to surface. This could be looking at pictures or listening to
songs that make them sad, reading old love letters, etc.
6. Focus on negatives. The person focuses on the view rather than the positive
view of things, which increases feelings of helplessness.

7. Impulsive behaviors. The person begins to make rash decisions and
participates in risktaking behavior. Decisions are often made under stress and
without thinking through choices and consequences.
8. Isolation and withdrawl continues. The person makes up excuses and avoids
socializing and utilizing other resources.
9. Physical symptoms begin to appear such as appetite disturbance, sleep
disturbance, fatigue, headaches, etc.
10. The person does not maintain their daily schedule, finding it difficult to get
everything done as they previously had been able to do.
11. Hopelessness. The person feels that nothing will ever improve, that everything
is a mess, and that life is not worth living.
12. The person is often confused and irritated. This low frustration tolerance
affects all areas of life.
13. Breaking relations and associations. The person disengages from their support
system. They may not feel the energy to participate or may believe that
anything will make a difference.
14. Energy level is diminished. The person does little or nothing, spends their time
daydreaming, and does not follow through on tasks.
15. Lack of sleep or poor sleep patterns begin to negatively impact their ability to
effectively cope.
16. Depression becomes more severe in intensity and chronic. As a result, quality
of life and relationships are significantly affected.
17. The person begins to miss therapy appointments. Selfcare and treatment are a
low priority.
18. The person expresses a dissatisfaction with life, immersed in a negative
perspective of everything going on around them.
19. The person takes on the victim role which fosters helplessness and hopelessness.
20. Having thoughts of death or a "death wish." They do not want to kill
themselves, but they want to escape their pain and see death as a state of not
feeling the pain.
21. The person gets their life in order by making a will, giving things away, or
saying goodbye as they emotionally detach.
22. The person appears to be doing much better following a depressive episode,
which gives them enough energy to attempt suicide.
23. Feeling overwhelmed and unable to cope. Not able to adequately problem
solve situations that normally would not present any difficulty.
24. Thoughts of suicide begin, and the person starts thinking about methods of
suicide.
25. The person begins to demonstrate selfdestructive patterns of behavior.
DANGEROUSNESS
The role of the mental health professional in assessing the potential for violence is to pre

vent injury and to provide the necessary care to people who are acting out violently or on
Dangerousness 119
the verge of losing control. The imminent concern of violent behavior is the potential harm
of one person by another.
Violence itself is not a diagnosable mental disorder or illness, but rather the symptom of
an underlying disorder and problems with impulse control. It is important to not discount
or disregard the signs of potential violence. Instead, it provides a crisis situation which
requires effective control before further interventions can be made.
The central priority of dealing with the potentially violent person is to insure the safety
of the person, other individuals within close proximity, and your own safety. If the person
assumes an aggressive and hostile position, steps must immediately be taken to maintain a
safe environment. Often these people are fearful of losing control over their violent impulses,
and as a result, are defending against feelings of helplessness, or have learned intimidation
serves as a method of perceived control when in emotional distress. The immediate goal in
intervening is to help the person regain control over their aggressive impulses.
DANGEROUSNESS ASSESSMENT OUTLINE
1. Assess thoughts of violence
A. Ask directly if they have thoughts of harming another person
B. Are the thoughts pervasive or transient (venting without intent) in relationship to a
response to a given situation
C. Do they have a plan, if so, how extensive is their plan
D. What are the means to be used in harming someone
E. Do they have access to the planned means/method
2. Do they have a history of violent behavior (have they ever seriously harmed
another person)
3. Does the person wish to be helped to manage the aggressive impulses
4. If you are in the process of interviewing someone with a history of violent
behavior be alert to signs of agitation and losing control:
If it is determined that the person is at risk to harm another person,
immediate steps need to be taken. If they demonstrate some semblance of being
reasonable aside from their aggressive impulse toward another person focus on
their ambivalence and talk with them about voluntary admission to a hospital
to gain control over the impulses and to learn appropriate means of dealing
with their feelings. If there is concern that such a discussion would only
escalate a person who is already demonstrating significant agitation then
contact the police for transport to a hospital.
Remember: Having thoughts of wanting to harm someone and having the
intention of acting on them are two different issues. If threats with intent to
harm are present there is a duty to contact the police and the intended victim
so that precautions can be taken.
5. Risk Factors
A. Intention and History
1. specific plan for injuring or killing someone
2. access or possession of the intended weapon of use
3. history of previous acts of violence
4. history of homicidal threats
5. recent incident of provocation
6. conduct disorder behavior in childhood/antisocial adult behavior
7. victim of child abuse

B. Demographics
1. gender (males are at higher risk to act out aggressive impulses)
2. low socioeconomic status (increased frustrations, general feelings of lack of
control in life, aggressive environment or survival issues)
3. social support (lack of support system)
4. overt stressors (marital conflict, unemployment)
C. Emotional Functioning
1. diagnosis (depression with agitation, drug/alcohol intoxication or withdrawal,
delirium, mania, paranoid or catatonic schizophrenia, temporal lobe epilepsy,
antisocial personality disorder, paranoid personality disorder)
D. Behavioral Patterns
1. poor impulse control
2. extreme lability of affect
3. excessive aggressiveness
4. easily agitated and signs of tension
5. loud or abusive speech
6. bizarre behavior or verbalization
CLARIFYING RISK OF HARM
Current Risk Factors
Suicidality None Ideation Plan Intent w/o means Intent w/means
Homicidality None Ideation Plan Intent w/o means Intent w/means
If risk of suicidality or homicidality exists, client is able to contract to not harm:

Self Others
Impulse control Sufficient Moderate Minimal Inconsistent Explosive
Medical risks None Present If present, explain:
Substance abuse None Abuse Dependence Unstable remission

Stable remission
If substance abuse exists, specify substance, quantity, date of last use, ability to abstain, and

prior CD treatment:
Does significant substance abuse or dependence exist in client's living

situation? Yes No
Current physical abuse, sexual abuse, and/or child/elder neglect? Yes No
If yes, client is: Victim Perpetrator Both Neither, but abuse exists in

family
Does abuse involve a child and/or elder? Yes No Legally

reported? Yes No
Specifies
Datigerousness 121
Risk History
Explain any significant history of suicidal and/or homicidal behavior, problems with impulse
control, substance abuse, and/or medical risks that may affect client's current level of risk or
may impair client's functioning.
Functional Impairments (As applicable, explain how the symptoms affect daily functioning

or place the client at risk.)
Please rate severity of impairment. 1=Mild 2=Moderate 3= Severe
Area Severity Description
Job/school
Relationships
Other
Disability? None Medical Mental health
* Claiming workers' comp? Yes No
Currrent Medications None Psychiatric Medical No information
Specify dosage, frequency, and compliance:
Prescribed by: Psychiartist Other physician

1. Outpatient Setting
A. Have a prior plan worked out with office staff for intervening with reinforcement of
security guards or police if escalation is a concern
B. Establish a nonthreatening setting for the interview. Do not turn your back to the
person, be aware of personal space, and position yourself close to the door in case
an exit for safety is necessary
C. Provide supportive feedback, reflecting to them that you recognize that they are
upset. Encourage them to talk about what is wrong
D. Set firm and consistent limits on violent behavior, and encourage the person to
verbally express what they are feeling instead of acting on the aggressive impulses
E. Establish a collaborative environment, being respectful to the person
F. Be reassuring, calm, and if necessary assist in reality testing
G. Refer for medication evaluation
H. Identify personal and community resources
I. Encourage them to take responsibility and emphasize appropriate choices
J. Clarify the connection between actions and consequences
K. Initiate counseling on anger management or refer to a community group focusing on
anger management
L. Teach assertive communication
M. Encourage appropriate physical exercise to discharge body tension

N. Positive reinforcement for efforts and accomplishments
O. Maintain keen awareness for your own reaction to the person
P. End the interview if there are signs of increasing agitation. Inform the person that
you sense the difficulty that they are experiencing in maintaining selfcontrol
2. Inpatient setting
If the person is hospitalized the appropriate intervention selection will be based
on the person's level of agitation and their ability to selfmonitor and to
respond appropriately. The basic goal is to provide a safe environment.
A. Give supportive feedback, and encourage appropriate ventilation and expression of
feelings
B. Maintain personal safety behaviors at all times (don't turn your back on the person,
position yourself close to the door, leave the door open, maintain adequate distance)
C. Set clear and consistent limits. Educate the person about what is expected of them
and how they will benefit by cooperation and collaboration
D. Provide them with appropriate structure to discharge body tension
E. Set physical limits on violent behaviors when verbal limits are not sufficient. Call for
help immediately if there are signs of escalation with impending violent behavior. As
attending you must assume a role of leadership to assure the staff and the person
that you are prepared to take charge and direct the necessary step to insure safety of
the person, unit peers, and staff. If possible, offer the person choices of selfrestraint
for regaining control. If necessary seclude the person, and if warranted use
restraints. At the very least the person should spend some time in the quiet room
which is free of objects and easy to monitor, until they have time to regain
composure and take responsibility for their behavior and be able to offer plausible
alternatives for dealing with feelings of agitation or hostility. Consult with the
treatment team psychiatrist regarding medication if person is unable to calm down
and remains in an agitated state
F. Provide education on assertive communication
G. Provide education on anger management
H. Provide education regarding the relationship between behavior and consequences
I. Encourage the person to take responsibility for their behaviors
J. Positive reinforcement for efforts and accomplishments
Dangerousness 123
CYCLE OF PHOBIC ANXIETY
Behavioral
Stress Reaction Thoughts
Subjective experience
Avoidance
Irrational/distortions
Cries for help
Negative selftalk
Isolation
Physiological Fear of loosing control
Selfdefeating
Nervous System/ behaviors
Adrenal Activity Feelings
Palpitations Helpless
Sweating Overwhelmed
Insomnia Fearful
Abdominal distress Vulnerable
Agitated/onedge
Dizziness/lightheaded
Decreased libido
Situational triggers
Physiological
Nervous system/
adrenal activity
Palpitations
Feelings Sweating
Low selfesteem Insomnia
Fearful Abdominal distress
Helplessness Agitated/onedge
Increased vulnerability Dizziness/lightheaded
(especially to feared Behavioral Decreased libido
object or situation)
Thoughts Avoidance
Withdrawal
Subjective experience
Decreased activity
Irrational/distortions
Decreased use of resources
Negative selftalk
Selfdefeating behaviors
Decreased selfconfidence
This vicious cycle of symptoms and reactions mirror each other and validate or reinforce the selffulfilling
prophecy of expectations of the phobic individual. This cycle maintains and perpetuates fearbased
symptoms and reactions (symptomreaction list is not exhaustive—It is a sample list which can/should be individualized).

OBSESSIONAL DISORDERS: AN OVERVIEW
Defined as unwanted and intrusive thoughts/images and
impulses associated with attempts to neutralize the emotional discomfort
Triggering Stimuli
Provokes obsession
accompanied by
Feelings of discomfort,
Anxiety, Urge to neutralize + Often takes the form of
content compulsive behavior
Personally repugnant . Ascending to stereotyped
topics such as pattern or idiosyncratic rules
Contamination Associated with temporary anxiety
Physical violence relief or expectation that, had ritualizing
Death not been carried out, anxiety would
Accidental harm have increased
Sex Can include changes in mental
Religion activity such as:
Orderliness Choosing to think differently in
I response to obsessional thoughts
? Avoidance behavior (avoiding
Behavioral responses situations that could trigger
Urge to prevent obsessional thoughts)
Attempts to prevent Sometimes accompanied by resistance to
perform the compulsive behavior
When calm, the individual usually can objectively regard his/her obsessional

thought and compulsive behaviors as senseless or excessive (at least to some degree).
ASSESSMENT OF OBSESSIONAL DISORDERS (OD)
1. Presenting problem
A. General description
1. Recent and specific examples
2. Description of situational trigger (nighttime, leaving the
house, etc.)
2. Detailed cognitive, behavioral, physiological analysis
A. Cognitive
1. Form of obsession(s): thoughts/images/impulses
2. Content of obsessions
3. Cognitions that trigger obsessions
4. Neutralizing
5. Avoidance
6. Perceived resistance to obsessions
7. Senseless/excessive ruminations
B. Emotional
1. Mood changes associated with obsessions
a. Anxiety
b. Depression
Assessment of Obsessional Disorders (OD) 125

c. Other forms of distress
d. Mood change before/after obsession
C. Behavioral
1. Triggers for obsessional thinking
2. Avoidance
a. Of situations in which obsessional thoughts
might occur
b. As an effort to control occurrence of obsessive
thoughts
3. Rituals
4. Requesting reassurance
5. Requesting others carry out tasks associated with their
obsessions
D. Physiological
1. Triggers
2. Changes associated with obsessions/compulsions
3. History of obsessional disorder
A. Development of problem
1. Obsessions
2. Neutralizing
3. Avoidance
B. Negative impact on
1. Intimacy/sex
2. Personal growth and goals
3. Work
4. Social interactions/functioning
5. Domestic role and functioning
6. Significant relationships
A. Patterns
B. Dynamics
C. Negative impact
7. Benefits/costs associated with change
4. Monitoring
A. For additional information
B. For change
C. Selfmonitoring/reporting
D. Questionnaire/survey/tests
1. Maudsley ObsessiveCompulsive Inventory
2. Compulsive Activity Checklist
3. Beck Depression Inventory
4. Beck Anxiety Inventory
5. Others
5. Observation by others
A. Significant other
B. Relatives
C. Friends
D. Invivo home visits

GRAVELY DISABLED
The gravely disabled individual is unable to provide for their basic necessities of food, cloth
ing, and shelter. The gravely disabled state may be due to:
1. confusion
2. hallucinations
3. delusional thinking
4. impaired reality testing
5. psychomotor agitation
6. lack of motivation
7. memory impairment
8. impaired judgment
9. undersocialization
Some behavioral indicators of being gravely disabled include:
1. unable to dress self

2. incontinent (without responsibly dealing with it)
3. not eating/drinking
4. deterioration of hygiene
5. inability to maintain medical regime
6. unable to provide residence for self
1. Inadequate Hygiene (Teach basic hygiene and activities of daily living [ADL])
A. Person to seek assistance with bowel/bladder function
B. Person will bathe/shower on their own
C. Person will brush teeth, comb hair, shave, and dress appropriately daily
2. Uncooperative
A. Person will be able to verbalize/demonstrate acceptance of daily assistance
B. Person will comply with medication/medical regimen
C. Person will accept assistance with living arrangement
D. Person will accept longterm assistance
3. Inadequate Nutrition/Fluids
A. Person will drink an adequate intake of fluids to maintain hydration
B. Person will eat a balanced diet
4. Family Nonsupportive or Lacks Understanding Intervention
A. Family education regarding person's prognosis and necessary support/structure
B. Community support group
Gravely Disabled 127

5. Inadequate Coping
A. Consequences of noncompliance with medication
B. Selfcare management
C. Facilitate problem solving and conflict resolution for practical situations that the
person is likely to encounter
D. Facilitate development of adequate social skills
1. provide opportunities for social interaction
2. model and role play appropriate social behaviors
E. Facilitate development of management of anger and frustration
F. Teach relaxation training
G. Identify leisure skills
6. Improve Inability to Manage and Improve Judgment
A. Evaluate for conservatorship
7. Inadequate/Inappropriate Living Arrangement
A. Consider placement
1. Board and care facility
2. Planned senior citizen community with therapeutic and medical care
a. must ask permission of spouse for participation in appropriate adult
activities
b. social isolation
c. reluctance of a spouse (offender) to allow spouse to be seen alone
d. history of child abuse
e. behavior problems in children
ACTIVITIES OF DAILY LIVING
In evaluating competency as it pertains to selfcare and selfsufficiency there are standard
behavioral issues to be assessed. This is a general review of Activities of Daily Living (ADLs)
which need to be adapted to ageappropriate criteria when making an assessment.
LIVING SITUATION
Assessing the living situation encompasses the level of support needed in any given living
situation/environment.
1. Does the individual live independently in their own home or apartment.

2. Do they reside with family members or other individuals, Board and Care
Facility, Custodial Care Facility, Residential Drug Treatment Facility, Nursing
Home, Skilled Care Facility, etc.
A. Do they live there independently or require the care/support/monitoring of those
with whom they reside.
3. Do they utilize community support services such as "meals on wheels," home
health services, someone hired to care for them, etc.
4. Do they attend school, Sheltered Workshop, Day Treatment, Day Activities
Center, Social Club, Rehabilitation/Training Program

SELFCARE SKILLS
Assessing the level of knowledge of basic needs such as food, clothing, hygiene, grooming,
compliance with treatment issues.
1. Feeds self appropriately, adequately

2. Bathes regularly, shaving if necessary, deodorant, hair cut/combed
3. Dresses self appropriately, buys clothes, does laundry
4. Medication and treatment compliance
LEVEL OF REQUIRED ASSISTANCE

Assessing the level of ability of assistance required.
1. Incapable or unable to provide sufficiently for some of own selfcare needs

2. Limited by physical or mental condition
3. Can only carry out simple tasks
4. Can only carry out simple tasks under the supervision or direction of others
5. Can initiate and complete tasks without being reminded, assisted, or prompted
by others
State if ADLs are done by another individual for this person and to what degree assistance

is required.
CARE OF ENVIRONMENT AND CHORE RESPONSIBILITIES
1. Individual takes care of all basic housecleaning tasks and yard tasks.
2. The quality of care in these tasks are: functional, neat, clean, (un)cluttered,
(dis) organized, completion, done in an orderly manner.
MEALS
Eats fast food, carryout, junk foods, snacks, prepared foods, sandwiches, simple cooking,
boils/fries, full menu, able to use all kitchen appliances, coordinates all aspects of a meal.
CHILD CARE
Assess for neglect, abuse, people living in household and their contact to the child, leaves
child alone, issues related to entertainment, teaches ageappropriate information/tasks,
appropriately advocates for child.
FINANCIAL
Assess ability to count, make change, recognition of coins and paper currency. Is able to
write checks, deposit checks/currency, able to do routine banking procedures, demonstrates
ability to spend and save appropriately, effectively manages financial resources.
SHOPPING
Assess ability to shop for personal toiletries, clothing, food, etc.
A c t i v i t i e s of Daily Living 129

TRANSPORTATION
Assess ability to effectively available modes of transportation and to plan for necessary
scheduling.
CHRONIC MENTAL ILLNESS (CMI)
This population can be described as individuals with disabling chronic conditions who are

unable to sustain an adequate range of functional independent skills. Historically, most of
the clinical focus has been on those diagnosed as schizophrenic. There is no question of the
value of behavioral treatment in conjunction with the sensitive use of maintenance medica
tion for many individuals. There is additional benefit in including the significant people in
their life for reinforcement of targeted behavior change or management. This population is
observed as socially deteriorating, demonstrating poor hygiene and lack of selfcare, slow
speech and motor response, high rate of shouting, living in various residential settings
(family home, board and care, various institutional environments, etc.), and they are often
homeless, delusional, and periodically violent in some cases. Many have an inability to par
ticipate in and maintain normal social interaction.
Clinically, their symptoms are classified as "positive" (for example, auditory hallucinations)
or "negative" (for example, poverty of affect and apathetic). These behavioral deficits and
excesses do not demonstrate correlation between individuals. Additional clinical descriptors
associated with causation of symptomology include the following:
1. Premorbid deficits are the symptoms or difficulties experienced before the

psychiatric illness existed, such as social stability and academic/vocational
stability. The significant importance of this history is that it often has a
predictive function in the final outcome or level of functioning of the individual
with CMI.
2. Primary deficits are those that directly emerge as the fundamental nature of the
disorder. It is these deficits that result in a diagnosis.
3. Secondary deficits are those experienced as a consequence of the illness or the
adverse personal reactions that continue even when primary deficits are managed
or eliminated—for example, property damage that results in lost opportunities
for the individuals and possibly others as well (such as a wrecked car).
4. Institutional deficits are those that can be identified as the consequence of being
institutionalized.
5. latrogenic deficits are the side effects of longterm medication use.
6. Pain deficit is experienced as an increased threshold for pain, or the individual
may not present symptoms or illnesses to be treated medically, which is related
to CMI individuals having a higher level of morbidity than the general
population.
Therapists working with CMI recognize the importance of stimulation level in the individ

ual's environment. Too much stimulation is agitating and can contribute to decompensation,
while too little stimulation produces higher levels of social withdrawal and general apathy.
When there is motivation and effort, appropriately include those with CMI in treatment
planning outlining goals and objectives which relate to perceived needs. Offer direct inquiry
into personal desires of improvement and offer or work with them to develop appropriate
and helpful means of achievement. Encourage and facilitate as much social responsibility and

opportunity as possible. As with all treatment, the lowest level of clinical intrusiveness should
be applied along with adequate support. When the treatment plan has been established, there
is the added clinical responsibility to educate and teach those involved in the direct care as
to their role and skill development for interaction with the identified individual.
GENERAL GUIDELINES FOR ASSESSING THE
CHRONIC MENTALLY III
1. General interview and demographic information
2. Current behavior
A. Remaining skills/assets
B. Deficits/losses
C. Deviation/oddities/excesses
3. Past behavior
A. Identified in prior treatment (hospital/outpatient)
B. Selfreports
C. Collateral reports
D. Antecedents of episodes of decompensation (people, place, situation, timing)
4. Potential target problems (those identified for treatment)
A. Substance abuse
B. Sexually exploited (poor judgment, etc.)
C. Medical treatment
5. The use of rating scales
A. Standard measures (for general behavior/psychiatric rating)
6. Time sampling
A. Observation at predetermined intervals
B. Observation in specific environments/situations
7. Identifying community resources
A. Applicable for unique needs of individuals
B. Specific groups which encourage positive maintenance and desired changes
8. Changing sensitive treatment goals
A. Checklist for specific steps of change
B. Update goals as needed
9. Developing brief treatment planning
A. When working with a motivated individual (avoid overwhelming them)
B. When working with collateral contacts such as family members or other care givers
10. Treatment team
A. Consult as needed
In general, the results would be the development of the following:
1. A cognitivebehavioral program

2. Individualized treatment planning
3. Treatment in the context of larger groups
4. Treatment in the context of smaller groups (individuals with their families)
Chronic Mental Illness (CMI) 131

CRISIS EVALUATION
The crisis evaluation is utilized when urgent care is required or there is the presentation of

acute symptomology during the course of an initial interview. The areas of evaluation
includes the following:
1. Tentative diagnosis
A. Multiaxial
B. Underlying the current acute symptomolgy
2. Identification of other potential diagnoses to be ruled out (R/O)
A. Multiaxial
B. Influencing/contributing factors to acute symptomology
C. Shortterm treatment
D. Implications for longterm treatment
E. What diagnostic issues are longer term regarding being confirmed/disconfirmed
during the course of treatment?
3. Biopsychosocial factors that play a role in the current and longterm symptom
presentation, including ethnic and cultural issues.
4. Patient's participation in current and future treatment. Consider the following:
A. Abilities/limitations (current/long term)
B. Willingness
C. Motivation
D. Cooperativity
5. Crisis issues presenting risk (voluntary/involuntary inpatient admission)
A. Danger to self
1. Precautions to take (safety, legal, ethical)
2. Hospital admission
3. Shortterm/longterm interventions/treatment
B. Danger to others
2. Hospital admission
C. Gravely disabled (safety, legal, ethical)
1. Precautions to take
2. Hospitalization
D. Violence/abuse (child, spousal/partner/elder/dependent adult)
2. Hospitalization
3. Shotterm/longterm interventions/treatment
6. Disposition
Immediate placement and treatment for necessary level of care and expected
level of transition during course of treatment
7. Consideration and recommendation associated with discharge planning
8. Follow up

CRISIS INTERVENTION
When a person experiences an unexpected traumatic experience, an intervention is most
beneficial when it follows the event as closely as possible. A discussion about what happened
and the associated response facilitates working through and resolving the crisis experience.
The personal response to a traumatic crisis includes emotional, psychological, physical, and
behavioral factors, and the response pattern varies among individuals.
The individual response pattern is a function of the following:
1. Past experiences and how the person has coped
2. Access and utilization of a support system
3. Emotional health at the time of the crisis
4. Physical health at the time of the crisis
5. Beliefs
6. Attitudes
7. Values
8. How others/society respond to the individual and the event that the person
experienced.
Here are some of the more common responses:
Emotional Mental Physical Behavioral
anxiety confusion fatigue angry outbursts

fear forgetfulness exhaustion increased substance use
agitation difficulty gastrointestinal isolation
irritability concentrating problems withdrawal
anger distractibility respiratory restless
guilt intrusive thoughts problems interpersonal problems
grief/loss flashbacks headaches appetite disturbance
vulnerability nightmares twitching sleep disturbance
fragility obsessing sweating change in libido
disbelief hypervigilance dizziness easily agitated
In an effort to decrease the intensity of the emotional and psychological response, decrease
physiological arousal, and facilitate resolution of the crisis with a return to previous level
of functioning, discussion of the traumatic experience should be initiated as soon as possi
ble following the crisis. Early intervention will prevent the development of PTSD for some
individuals. Be careful to not overstimulate the individual and add to the experience of
trauma.
1. Listen carefully and pay close attention to the responses of

these individuals (detachment, agitation, emotional reactiveness,
flashbacks, etc.)
2. Decrease physiological arousal
3. Facilitate appropriate support(s)
4. Normalize their responses to crises
Crisis Intervention 133

5. Educate them about the range of responses to crises, with care to avoid the
following:
A. Compounding social stigmatization of those with more symptoms
B. Creating feelings of guilt for experiencing fewer symptoms
than others
C. Using confusing jargon/language not used by the general
public
D. Overpathologizing and focusing on disability
6. Assure them that their response is temporary
7. Let them know that there is not a specific time frame in which to recover
from a crisis. However, if they engage in selfcare behaviors, healing is likely
to be expedited.
8. Foster resilience and recovery
9. Assess for substance abuse
10. Follow up
When providing psychological interventions to those recently traumatized and experienc

ing acute stress or individuals with PTSD validated treatment elements include direct
therapeutic exposure and cognitive restructuring. Early cognitivebehavioral interventions
include the following techniques:
1. Deep breathing
3. Imaginal and invivo exposure therapy
4. Regular physical activity
5. Positive daily structure with reinforcers
6. Utilization of resources
7. Journaling
8. Selfmonitoring
CRITICAL INCIDENT STRESS DEBRIEFING (CISD)
Mitchell and Everly (2000) have suggested a sevenphase structured group discussion, which
is provided within 10 days of a crisis (110 days). The purpose is to alleviate acute symp
toms, assess for need of resources and followup, and provide a sense of closure to the cri
sis experience. The phases are as follows:
1. Introduction and guidelines for participation

2. Discussion of relevant facts
3. Discussion of thoughts
4. Discussion of reactions/emotions
5. Discussion of developing symptoms
6. Education about responses and coping strategies
7. Reentry
A. Summarize
B. Discuss additional available resources

SCREENING FOR SURVIVORS
The Institute of Medicine (IOM) offers screening program guidelines. Visit these two websites
to access such information:
http://books.nap.edu/books/0309068371/html/index.html
http://www.quic.gov/report/toc.htm
IDENTIFYING TRAUMATIC STRESS
Be aware of the following warning signs for traumatic stress:
1. Recurring thoughts about the event (intrusive thoughts)

2. Recurring nightmares about the event
3. Sleep disturbance/appetite disturbance
4. Acting or feeling as if traumatic event is recurring, changes in appetite
5. Experience of anxiety and fear, especially when exposed to event reminiscent
of trauma
6. Being on edge
7. Hypervigilant
8. Feeling depressed/sad
9. Low energy/fatigue
10. Memory difficulty, including difficulty in remembering aspects of the trauma
11. Difficulty with attention and concentration, unable to focus on work tasks or
daily activities
12. Difficulty making decisions
13. Low frustration tolerance, easily agitated, angry or resentful
14. Feeling numb and withdrawn
15. Feeling disconnected or different from others
16. Mood swings, crying without provocation, feeling a sense of despair and
hopelessness
17. Restricted range of affect
18. Sense of foreshortened future
19. Feeling overly fearful and protective of the safety of loved ones
20. Avoidant behavior (avoiding people, places or activities that provoke thought
of the event)
21. Flashbacks of the event
RECOVERING FROM TRAUMATIC STRESS

Traumatic stress results from a crisis that tends to be both sudden and overwhelming. The
psychological and emotional consequences range from a brief episode, which is acute but
adequately coped with, to sustaining interference in ability to adequately cope with normal
daily stressors accompanied by significant intrusion of thought, emotional reactivity, and
Identifying Traumatic Stress 135

physiological reactivity. Understanding the individualized experience of trauma is the first
step to recovery.
HOW DOES A TRAUMATIC EVENT AFFECT SOMEONE?

It is common for an individual to experience shock and denial not long after a traumatic
event has occurred. This is an almost automatic selfprotective response. During this reac
tive stage, an individual may feel dazed, confused, or stunned. Another way to describe this
emotional experience is that the individual feels numb and disconnected from life in general.
Thought, emotion, and behavior are affected by the experience of trauma. There may also
be stress associated physiological responses.
1. Changes in thought/mental Images
A. Intrusive thoughts
B. Racing thoughts
C. Difficulty with concentration/attention
D. Low frustration tolerance
E. Feelings of being on edge
F. Flashbacks
G. Rumination
H. Cognitive distortions
I. Dissociation
2. Changes in emotion
A. Moodiness
B. Depression
C. Acute anxiety
D. Fear
E. Easily overwhelmed
3. Changes in behavior
A. Unable to remain on task
B. Avoidance
C. Restless/unable to sit still
D. Difficulty maintaining a normal daily routine
E. Detached/withdrawn
F. Easily agitated/argumentative (low frustration tolerance)
4. Physical responses (commonly experienced with acute stress)
A. Rapid heart rate
B. Chest pain
C. Abdominal distress
D. Nausea
E. Headaches
5. Additional Issues
A. Selfmedication
1. Alcohol/drug abuse
2. Prescription medication abuse
B. Anniversary of events (may trigger)
1. Intrusive thoughts
2. Distressing memories

3. Nightmares
4. Feelings of helplessness
5. Feelings of being overwhelmed
6. Difficult emotions
C. Contact with stimuli similar in some way to the event acts as a trigger and
could be experienced by any of the five senses
1. Visual
2. Auditory
3. Tactile
4. Olfactory
5. Taste
THE EFFECTS OF TIME
There is no way to predict the amount of time it will take to recover or if events of trauma
will continue to linger in some evident manner throughout the course of an individual's
lifetime. It is expected that all significant life experiences carry with them some impact of
change. Numerous factors affect the recovery process. Therefore, outcome of such experi
ences is based on the following factors:
1. Prior experiences and how they were resolved

2. How others (society/victim blaming) respond to the individual
in association with the crisis
3. Repetition or number of trauma events
4. General coping ability
5. How the individual views herself or himself
6. How the individual views his/her environment
7. Selfcare
8. Resources
A. Social support
B. Professional intervention
9. Learning
10. Whether the response to the trauma was immediate or
delayed
11. Integration
12. Resolution
TRAUMATIC STRESS AND VEHICULAR ACCIDENTS
This information also applies to other experiences of trauma where there has been signifi
cant physical harm to an individual's physical integrity.
1. Physical review: What happened to the person physically.
A. Physical trauma and near death/disfigurement
B. Multiple injuries
Traumatic Stress and Vehicular Accidents 137

C. Chronic/acute pain
D. Physical limitations
E. Continued medical treatment with associated physical recovery
1. Invasive procedure(s)
2. Experimental procedure(s)
3. Rehabilitation
F. Time that it takes to achieve stability where further procedures are
not anticipated and the person is in a state of true adjustment in the
recovery process
G. Time that it takes to heal (often someone who is released from
medical treatment is in the initial stages of healing; healing can take
a long time)
H. Effects/risks of medications
1. Dependence
2. Used as the only intervention for pain and acute anxiety
management
2. Physical status affecting emotional and psychological
functioning
A. Depression/anxiety/stress may be associated with the following:
1. Losses
2. Changes
3. Adjustment
4. Chronic pain
5. Continuing medical treatment
6. Medical instability
7. Rehabilitation
8. Decompensation (feared or predicted)
B. The body may be depressed just because of what it is going through and
continuing to endure resulting in
1. Fatigue
2. Low tolerance
3. Stress/difficulty/pain associated with normal movement
4. Decreased stamina
C. Ongoing medical treatment may present the following issues:
1. How functional will the person be?
2. Will the physical integrity of the person's body be maintained?
3. Identity issues: "How have I been changed"
a. Selfawareness
b. Other's reflecting a change in personality/mood
3. Role of depression and PTSD
A. Depression
1. Decreased energy/fatigue
3. Mood vulnerability
4. Increased potential for illness (people who are depressed are ill more
often)
* Recovery is a lot of work. Depression slows the process, but it is also a normal part of

adjustment.

4. PTSD (near death trauma/disfigurement with sustaining influence)
A. Ongoing medical treatment/continuing stress or trauma
B. Chronic pain
C. Physical limitations
D. Emotional vulnerability
E. Unpredictable good and bad days (may be emotion or pain related)
F. Health implications
1. Musculoskeletal disorders
2. Neurochemical changes resulting in an increased susceptibility to infection and
immunological disorders
3. Association of physical trauma and fibromyalgia
5. Physiology of stress
A. Stress negatively affects physiology
B. Stress suppresses the immune system
C. Stress impairs resistance to
1. Infection
2. Illness
3. Complications of surgery
D. Stress accelerates metabolic activity
1. Insomnia
2. Nervousness (muscle tension)
3. Fatigue/exhaustion
* Stress is four times as likely to precede infection.
* Stress compromises the immune system enough for infection to take hold.
ASSESSMENT OF PHOBIC BEHAVIOR
This is a special assessment associated with the fear(s) experienced by the individual and
the identification of the practices, thoughts, or situations that reinforce and sustain phobic
anxiety. Situational triggers alone influence physiology, thoughts, behavior, and feelings that
perpetuate the cycle. When an individual is able to clarify the chain of experience, thought,
physiology, behavior, or emotion that is specific to their phobic response, he/she will be able
to problem solve reaction management and behavior modification/change.
Once the presenting problem phobia has been clearly identified, use the following infor
mation to develop an accurate clinical picture and treatment plan.
1. List symptoms in the following areas:

A. Physiology (nervous system/adrenal activity)
1. Palpitations
2. Sweating/chills
3. Insomnia
4. Abdominal distress
5. Dizziness/lightheadedness
6. Decreased libido
7. Others
Assessment of Phobic Behavior 139

B. Behavior
1. Stress reaction
a. Avoidance (identify full range for developing hierarchy)
b. Cries for help (decreased functionality)
c. Isolation
d. Selfdefeating behaviors
C. Thoughts
1. Subjective experience
2. Irrational thinking
3. Distortions of reality
4. Negative selftalk
5. Fear of losing control
D. Feelings
1. Helpless
2. Overwhelmed
3. Fearful
4. Vulnerable
2. Maintaining factors (interfere with progress)
A. Avoidance
B. Cognitive factors, thoughts of dangerousness of phobic stimulus
1. Doubting the value of treatment
2. Doubting one's ability to follow through on treatment
decisions
C. Presence of generalized (heightened) anxiety
1. Associated depression (dysthymia)
D. Possible underlying fear associated with overcoming the phobia
1. Secondary gain
2. Security associated with what is known eliminated, thereby
increasing distress
3. Would other problems develop?
3. Existing coping skills
A. Methods of coping previously employed (may be helpful in
treatment)
B. Use of substances (alcohol/tranquilizers)
C. What has been tried in an effort to overcome phobia?
4. Resources
A. Hobbies
B. Sources of pleasure
C. Sources of success
D. Helpful and caring family and friends
E. Community resources
F. Personal characteristics (persistent, sense of humor, intelligence, etc.)
5. Suitability for treatment
A. Most cases improve with treatment
B. Potential for noncompliant factors
1. Severe depression
> Requires prior treatment intervention
2. Substance dependence
3. Personality disturbance

4. Other difficulties
a. Fluctuating motivation
b. Excessive emotional dependence
c. Excessive hostility
6. Measures
A. Baseline
B. Information on progress
C. Treatment plan and associated time frame
D. Standardized rating scales
E. Selfreports/selfmonitoring
POSTPARTUM DEPRESSION AND ANXIETY
Baby Blues
Postpartum Depression Syndrome
Postpartum Stress Syndrome
Postpartum Anxiety Syndrome
Postpartum Panic Disorder
Postpartum Obsessive Compulsive Disorder
This syndrome refers to an illness that has a typical pattern of symptoms clustered together

but does not have an identified specific single cause. This is the underlying reason why post
partum depression, postpartum stress, and postpartum anxiety syndromes often go undiag
nosed and untreated. Also, it is imperative that prior to treatment of postpartum emotional
syndromes there be a thorough medical examination to rule out other illnesses that may
present similar symptoms but require very different treatment (such as thyroid dysfunction).
It is estimated that in the United States approximately 400,000 women experience post
partum depression each year. The experience of postpartum depression most commonly takes
place six to eight weeks following childbirth. One in four firsttime mothers will experience
postpartum depression syndrome or postpartum stress syndrome. When postpartum anxiety
syndromes are added, the number of women affected by postpartum emotional difficulties is
one in three. The most severe postpartum disorder is postpartum psychosis, and approxi
mately two women per 1,000 will experience it. Generally, there are no early warning signs
or identified predispositions for postpartum disorders. Many women do not even present
with a history of depression or anxiety. Also, postpartum syndromes can happen following
any pregnancy (first, second, third, etc.). Therefore, it is not an exclusive experience for a first
pregnancy; nor is there an assurance that a woman who experiences a postpartum disorder
with one pregnancy will not experience this disorder after another pregnancy as well.
While postpartum syndromes are common, only a small number of women who experi
ence some form of postpartum emotional distress will get help. Often it is not identified by
the woman or her physician. However, this has began to change in recent years. Women have
increased awareness and are seeking help.
DEFINITIONS
1. Baby blues
The "baby blues" is not postpartum depression. However, someone with
postpartum depression may have the baby blues. The baby blues is the most

common experience of depression following childbirth. The baby blues is not
an illness and resolves on its own. Approximately 60 to 80% of women
experience brief and temporary moodiness (crying or feeling sad, irritable,
frustrated) following childbirth. It generally takes place three to four days
following childbirth and lasts for only a few hours or several days. If severe,
the baby blues may last for about two weeks. It is brought on by the
following:
A. Hormone changes
B. Breast engorgement
C. Transition from hospital to home
2. Postpartum Depression Syndrome
Following childbirth, a woman experiences emotional and physical symptoms
of the syndrome of clinical depression. During the course of postpartum
depression, a woman may also experience the baby blues. The following list
presents physical and emotional symptoms associated with postpartum
depression.
Postpartum Depression Symptom Checklist
1. I can't shake feeling depressed no matter what I do.
2. I cry at least once a day.
3. I feel sad most or all of the time.
4. I can't concentrate.
5. I don't enjoy the things that I used to enjoy.
6. I have no interest in making love at all, even though my doctor says I'm
now physically able to resume sexual relations.
7. I can't sleep, even when my baby sleeps.
8. I feel like a failure all of the time.
9. I have no energy; I am tired all the time.
10. I have no appetite and no enjoyment of food (or I am having sugar and
carbohydrate cravings and compulsively eating all the time).
11. I can't remember the last time I laughed.
12. Every little thing gets on my nerves lately. Sometimes, I am even furious at
may baby. Often, I am angry with my husband.
13. I feel that the future is hopeless.
14. It seems like I will feel this way forever.
15. There are times when I feel that it would be better to be dead than to feel
this way for one more minute.
3. Postpartum Stress Syndrome
This condition is also known as Adjustment Disorder. The level
of emotional distress falls between minor baby blues and severe postpartum
depression. Approximately one in five women experience postpartum
stress syndrome. Since symptoms are generally not as striking as
postpartum depression, no one may notice how awful the new
mother feels.
4. Postpartum Anxiety Syndromes
A. Review the Postpartum Panic Disorder Symptom List to see if you identify
with the symptoms. Panic disorder symptoms occur without warning and generally
last for about 10 to 30 minutes. Talk to your physician if you have these
symptoms.

Postpartum Panic Disorder Symptom Checklist
1. I can't catch my breath.
2. My heart pounds, races, or skips a beat.
3. My hands shake or tremble.
4. I have stomach pains, nausea, or diarrhea.
5. I get hot flashes or chills.
6. I feel that something terrible is about to happen.
7. I get dizzy or lightheaded.
8. Things appear "funny" or "unreal."
9. I feel like I'm choking.
10. I feel like I'm dying or about to have a heart attack.
11. I am afraid to leave my house or be alone because I might have an anxiety
attack and not be able to get help.
12. I feel numb or tingly in my hands or around my mouth.
B. Obsessive Compulsive Disorder
While there may be many different symptoms, they all involve recurrent intrusive
ideas or compulsive behaviors that cause significant distress or consume a great deal
of time. There is the experience of certain repeated thoughts, urges, or images that
are irrational and cannot be ignored, which result in discomfort and distress.
Common examples include the following:
1. Horrifying violent images (including thoughts of harming a child)
2. Extreme doubts
3. Severe fear of becoming contaminated by germs
4. Compulsive housekeeping
5. Checking and rechecking things
6. Unnecessary repeated handwashing, counting, or touching certain items
POSTPARTUM CRISIS PSYCHOSIS
The rare and severe postpartum experience of postpartum psychosis is when a woman expe
riences hallucinations or delusions with other symptoms. This is an overwhelming and
terrifying experience. The outcome of a postpartum crisis is potentially tragic. If a woman is
concerned that she may be experiencing symptoms of postpartum psychosis, she should con
tact her physician immediately so that she can receive appropriate treatment and support as
quickly as possible.
Suicide is a consequence of postpartum psychosis more often than harm to a child. There
may not be adequate concern for a woman harming herself because the media sensational
izes the circumstances when a child is harmed by a mother. As a result, equal weight may
not be applied to potential risks of harm to a mother and child (children) associated
with postpartum psychosis. Below is a symptom checklist. If any of the symptoms are being
experienced or the woman is concerned about her safety or the safety of the child, she should
get medical and psychological intervention immediately.
Postpartum Crisis Symptom Checklist
1. I am afraid that I might harm myself in order to escape this pain.
2. I am afraid that I might actually do something to hurt my baby.
3. I hear sounds or voices when no one is around.
4. I do not feel that my thoughts are my own or that they are totally in my
control.
5. I am hearing voices telling me to hurt my baby.
6. I have not slept at all in 48 hours or more.
7. I do not feel loving toward my baby and can't even go through the motions
of taking care of him/her.

8. I am rapidly losing weight without trying to.
9. I am being controlled by forces beyond myself.
10. I am thinking about hurting myself.
When a woman experiences difficulty coping effectively, hospitalization should be considered:
1. When medication requires very close monitoring

2. When necessary support of family and friends is not available
3. When outpatient treatment is not effective and a higher level of care
is necessary
4. When symptoms are severe and unmanageable
Hospitalization is necessary when the individual is not able to adequately function and there

is a lack of support in the home environment to ensure appropriate care and supervision
(not functioning adequately):
1. A woman is suicidal

2. A child is at risk of harm
3. There are psychotic symptoms (heating voices, feeling paranoid, delusional
beliefs)
4. A woman is not able to care for basic daily needs herself or her child
5. A woman cannot tolerate being left alone/or is on able to cope adequately
with normal stressors
HOW TO BREAK THE POSTPARTUM CYCLE

1. Seek professional help
A. Physician for medication and appropriate referrals
B. Group therapy
C. Individual therapy
2. Seek support from caring family and friends
3. Accept that you are experiencing a postpartum syndrome so that you can
deal with it
A. "It is not my fault" (affirmation)
B. "I will not always feel this way."
C. "I will choose to participate in my treatment and help myself improve."
(follow treatment recommendations)
4. Identify patterns of negative response, deal with "what is" not
"what if"
5. Increase awareness for situations, mood changes, tasks, and so forth
that trigger negative responses or escalate symptoms
6. Stop it with increased awareness of negative response patterns, problemsolve
helpful and appropriate ways to respond
A. Thought stopping
B. Thought substitution
C. Behavior change

7. Distract yourself
A. Find something to replace negative response patterns like going for a walk, calling
a friend, meditating
8. Create options
A. Give yourself permission to do what would be helpful and have a backup plan
where a husband or someone else can take care of tasks while you
1. Take a bath
2. Exercise
3. Engage in specific relaxation techniques
4. Meditate
5. Listen to music
6. Pray
9. Be reasonable
A. Remind yourself that it won't last forever
B. Only do what needs to be done
C. Get help
10. Set limits on telephone time
11. Limit visits from family and friends
12. Assert yourself to conserve energy, say no
13. Talk about your experience with someone you trust
14. Deal with difficult feelings
A. Feelings of loss for the perfect pregnancy
B. Feelings of loss for the perfect motherbaby experience
C. Correct romanticizing childbirth and new motherhood
D. Feelings of guilt
E. Feelings of failure
F. Low selfesteem
G. Fear
Adapted from Kleiman & Raskin (1984). This Isn't What I Expected. Bantam Books.
PROFESSIONAL GUIDELINES FOR CRISIS INTERVENTION
If this is a crisis group instead of an individual session, address group rules, identify group

goals, and establish an outline for the series of group sessions.
1. Explain the professional process. Therapist's role, client's role, issues of

confidentiality, expectations, and goals.
2. Elicit the client's description of what occurred. Encourage a thorough description
of visual, auditory, and olfactory experience. Does the client play a role in what
happened. If not, what do they know about it, and how did they learn about it.
3. Review their previous level of functioning and rule out a cumulative effect from
prior crisis experiences which have not been resolved.
Professional Guidelines for Crisis Intervention 145

4. What was the person feeling and thinking before, during, or immediately after
the event? What have been their feelings and thoughts about the situation
since then?
5. Clarify the person's reaction. Identify what had the most impact on them—the
worst aspect of it for them—what part of the experience has made it the most
difficult for them to deal with the situation.
6. What has been their emotional, mental, physical, and behavioral response to
the crisis. Use the aforementioned symptoms to help them identify their
response by breaking it down. Seeing that there are parts to what they are
experiencing makes it more manageable and creates choices for them. They
may feel more capable of dealing with one issue than another, and being in a
position to make a choice gives a feeling of control which also contributes to
progress toward working through and resolving of the crisis.
7. Interventions
A. Educate the person regarding the range of experience accompanying a crisis.
B. Identify strengths. Provide support for strengths and facilitate understanding how
these can be utilized in the current situation.
C. Identify vulnerabilities. Facilitate problem solving to avoid, strengthen, or reframe
these issues.
D. How have they coped with difficult situations and crises in the past?
E. How do they view their own ability to cope, and why?
F. Educate them on how prior crisis experiences that are unresolved may act in
concert with the current crisis to create a cumulative effect. In other words, not all
of what they are currently experiencing may be due to the recent crisis.
G. Educate regarding the working through stages for resolution of a crisis. Also,
educate regarding the importance of developing a selfcare program to improve
coping while dealing with and resolving crisis issues.
8. Resolution
As a client reaches the end stages of crisis resolution summarize what they have experienced,

what they have learned and resolved. Review their selfcare plan, including resources and
"red flags" that might be a signal to regression. Give feedback regarding their recovery
within the context of a normal response and focus on the positives and internal resources as
they prepare to terminate.
SELFCARE BEHAVIORS
Develop a personalized selfcare plan for optimal results. This does require a commitment

to health and follow through. It is recommended that there be a medical exam for medical
clearance, as well as providing the opportunity for a medication evaluation which may be
useful in dealing with unmanageable symptoms following a crisis.
1. Utilize relaxation techniques to decrease body tension and stress level.
2. Process the experience by:
A. Utilizing your support system. Talking about the experience and how you have been
affected. Don't isolate and withdraw. Instead spend time with people who offer a
feeling of comfort and care.

B. Initiate a journal. Instead of keeping thoughts and feelings inside where they build
up, get them down on paper. Some individuals have difficulty expressing themselves
to others, or are afraid of being judged. In order to benefit a similar degree of relief
as talking, journal writing can be useful.
C. Enter therapy for a safe, nonjudgmental environment where you can speak freely
about your thoughts and feelings without feeling how others will respond, or feeling
the need to protect those close to you. Therapy can be extremely beneficial for
resolving a crisis.
3. Regular, moderate exercise. Aerobic exercise such as walking, appears to be
most helpful in alleviating and maintaining decreased body tension.
4. Approach each day with a purpose. Be productive by outlining daily structure
which includes adequate sleep, good nutrition, exercise, relaxation, utilization
of resources, task accomplishment commensurate with level of functioning
(no task is too small to feel good about).
5. Avoid anxietyprovoking talks or making significant life decisions during this
time. You are still vulnerable and do not want to experience a relapse.
6. Avoid being selfcritical. Be as kind and understanding to yourself as you
would be to another. Use positive selftalk to reassure yourself that the
symptoms that you are currently experiencing will subside with time.
What are some additional things that you could add to a selfcare plan to meet your specific

needs?
COUNSELING THE INDIVIDUAL IN A MEDICAL CRISIS
The goal for working with individuals presenting with medical crisis is not to affect a cure,

but to optimize quality of life by facilitating individuals and their families to cope with the
emotional and psychological trauma which often accompany the medical crisis. As they
learn to cope with the crisis and associated life changes they will begin to integrate the ill
ness as part of their life experience, to adjust to what has happened and/or will happen to
them, and to live their life as fully as possible. For a therapist to intervene effectively requires
that they be prepared to be:
1. Holistic in their approach of uniting mind and body

2. Aware and recognize the context of the ecosystem in which the individual is a
part of
3. Able to provide a perspective which is able to assume that this is an individual
with a healthy ego and defenses whose emotional equilibrium has been
disrupted or affected by the intrusive force of a medical crisis versus an
underlying psychopathology
Medical crises can be acute or chronic. In either case, appropriate interventions can help an
individual avoid psychiatric complications and in some cases reduce the intensity or the
onset of physical symptoms. While many of the issues being addressed would benefit an indi
vidual experiencing an acute medical crisis, the focus is on intervening with the individual
experiencing a chronic medical crisis. The three heightened points of distress associated with
Counseling the Individual in a Medical Crisis 147

a medical crisis where intervention is most effective are when a diagnosis has been made, an
individual is released from the hospital, and an exacerbation in symptomatology. The initial
focus of intervention is to reduce stress, address fears, and activate coping mechanisms.
Adaptive coping mechanisms are facilitated by:
1. Developing a clear picture of the situation. In order to process their medical

condition they must have accurate information about its progression and the
prognosis. Other factors which need clarification include an understanding of
financial issues, medical treatment and resources, and family resources
2. Increasing emotional awareness. Asking questions of the self. How they feel
and how they show their emotions
3. Effectively managing emotions. Using clear communication to express
themselves and to get their needs met. Making an effort to remain as flexible as
possible regarding the possible changes of all conditions
4. Ventilation of feelings and thoughts, verbally, with writing, drawing, or other
expressive media
5. Utilizing resources and support—both personal and professional. Creating a list
of all personal and professional resources, their availability, specifically what
context of resources or support is offered, and if possible put the list in order
according to the associated difficulty for which the individual seeks an
intervention. This will help alleviate frustration and other negative feelings
unnecessarily initiated by dead ends and other limitations.
The fears associated with longterm illness include fear of pain, body mutilation, imposed

changes in lifestyle, alteration of social patterns, low selfesteem, fear of the future, and fear
of death. The individual may experience many losses. Loss of body parts, physical function
ing, sexual functioning, job, home, relationships, selfimage, feelings of control, and death
itself. The fear of living with losses and limitations can be as overwhelming as the fear of
death.
Intervening with an individual in a medical crisis requires that these biopsychosocial issues
be applied to the practical problems of daily living which confront an individual with a
chronic illness such as: medical management, treatment compliance, symptom control/
management, dealing with social isolation and developing new resources and supports,
adjusting to physical changes and loss of functioning, establishing some level of comfort in
a new lifestyle, dealing with financial consequences, and how those close to the individual
respond. An entirely different issue not covered here, but of significant importance is the
needs and issues of family members, specifically those who may be the central caregivers.
Similar to the individual they care for, these people are also confronted with isolation, fear,
uncertainty, and changes in their role.
TREATMENT FRAMEWORK AND CONCEPTUALIZATION

1. The focus of treatment are the medical crisis and condition (disease progression
and prognosis)
2. Medical crises are often temporary, but if they appear to be of more a chronic
nature (cycles of flareups or exacerbation), they still provide an opportunity for
growth and learning
3. The issues of adjustment facing people with chronic illness are often predictable
(physical, emotional, financial, lifestyle, relationships, identity, etc.)
4. The focus is on an individual's capacity and ability to facilitate maximal coping

The interventions for medical crisis are short term. However, there may be some individuals
who will require more than one treatment of intervention due to underlying personality
issues which interfere with their adjustment, the issue of secondary gains, or in response to
a new crisis.
As previously stated, there are predictable issues which an individual experiencing a
medical crisis associated with a chronic illness will experience. Support in confronting these
issues will alleviate the fear and make the issue less overwhelming. It is important to
validate the reality basis for the identity of issues and the fear or other emotion associated
with it.
These issues are not experienced as a sequence of stages, but rather are assumed to be
present all of the time. However, one issue may be dominant over another because of certain
circumstances in a given time frame. Clinically, the therapist simply meets the person where
they are emotionally at any given time. Take the cue from the individual as to what seems
to be a prominent issue at the time, do as much resolution around the issue, do not diffuse
it by focusing on other issues at the same time.
THE CENTRAL CRISIS ISSUES
1. Control
A. How did they feel when a diagnosis was given? What did it mean to them? People
do not know what the future will bring and often catastrophize, assuming the worst
possible progression of the illness.
B. Daily experiences of pain.
C. What is the expected course of treatment, and treatment regimens?
D. Facilitate venting of fears, and uncertainty of outcome.
E. Facilitate expressed feelings of loss.
2. Selfimage
A. Acknowledge the impact on an individual living in our society where there is a high
social regard for good health and physical appearance.
B. Validate feelings of loss and having to cope and adjust to the reality that they will
never be the same again. "Who am I?"
C. What are their personal strengths and resources which can help them cope?
D. What was their life like before the diagnosis? Medical treatments? Doing an
inventory of what the individual perceives as valued qualities and abilities can
facilitate the grieving process. This can in turn facilitate a modified version of the
individual's original selfimage so that other problem solving can transpire.
E. Explore the individual's general feelings/belief system about impairments and
disabilities prior to the illness. This clarification will help them correct how they
assume the attitudes of others.
3. Dependency
A. Threats to independence: emotional, physical, financial. This can contribute or lead
to depression and suicidal ideation.
B. Negative feelings associated with the need for support or additional resources in
making the necessary adjustments and accommodations of change.
C. Facilitate the cultivation of selfreliance within the limits of their capabilities.
Validate their fear of loss of personal independence and to effectively deal with the
fear of being a burden on their family. Encourage optimal independence.
D. In evaluating issues related to fears of dependency take into consideration the
following factors: gender, age, psychosocial development, etc.
E. Spousal and/or Family Related Issues
1. What was the type/degree of independence of each individual in the family
system/couple prior to the illness?
2. How troubling is the dependency to each (all) involved?
Counseling tbe Individual in a Medical Crisis 149

3. How easy/difficult is it for the ill person to ask for help?
4. How freely is support given by others?
5. How difficult has it been to accept help/support from others?
6. What are the practical demands of the situation (routines, needs, wants,
financial stressors, time demands, time for self, etc.)?
7. What are the helpful/useful community based resources such as home
health, etc.?
8. Role play scenarios with individual and family members/partner.
9. Facilitate reality checks for objective evaluations.
10. Talk to physician regarding limitations/prognosis.
4. Stigma
A. Issues of selfacceptance.
B. Facilitate development of social skills and belief system to deal with the attitudes of
others.
C. Be aware of the different social impact on the evaluation of men versus women.
Males are more likely to be viewed as being more damaged and heroic, whereas,
there is a tendency to view females as weak, ineffective, and being selfabsorbed or
feeling sorry for themselves.
5. Abandonment/Rejection
A. This issue may be more emotionally distressing than the fear associated with dying.
There is a double bind for the individual: (a) There is a fear of abandonment, but
they also feel bad about being a burden, (b) They want the care, but are aware of
the difficulty that it poses on others. This is also a bind for caregivers who want to
give the necessary care and offer comfort and feelings of security, but also wish that
they did not have to deal with the problem.
B. It is extremely important to facilitate clear communication and joint decision
making as soon as possible.
C. An awareness for the issue of caregiver burnout may prevent it from happening.
With interventions such as acknowledging the caregiver's sacrifices and building in
respite breaks into the regular routine caregiver burnout can be circumvented. For
this to be successful, the individual must be sensitized to the caregiver's need for
time away/breaks.
D. Reframe breaks as part of a functional pattern of longterm management to
alleviate the interpretation of abandonment/rejection.
E. Facilitate utmost selfreliance.
6. Anger
A. Identify, validate, and constructively redirect the anger.
B. Be aware of the possible lack of awareness or denial for feelings of anger.
C. Reframe anger as a normal response to frustration when an individual is unable to
control their life or illness.
D. Facilitate appropriate expression of anger. Possible modes of expressing anger
include, appropriate ventilation, humor, talking, activity, meditation, etc.
E. Facilitate identification of the positive aspects of life: strengths, opportunities, and
life pleasures.
7. Isolation/Withdrawal
A. Physically unable to continue in previous life activities such as work, social life, and
other normal activities. Promote development of abilities.
B. Be aware that the consequences of social, physical, and emotional isolation can
include increased depression, hopelessness, and despair.
C. Being cutoff from friends and family significantly increases the risk of sickness and
death.

D. Feelings of low selfesteem and unworthiness can lead to withdrawal and refusal of
invitations to be with other people and being involved socially.
This issue is just as important for the caregiver as the chronically ill individual. Their world

has been radically decreased. Therefore facilitate development and utilization of a support
system. Also, facilitate identification of options and the setting of realistic goals. Lastly, rec
ognize that isolation and withdrawal may be a consequence of depression, fear, or rejection
(real or perceived).
8. Death
A. Facilitate acceptance.
B. Recognize that the individual may vacillate between grief stages.
C. Emphasize being in the here and now to maximize quality of life.
D. Facilitate the individual to concentrate on living the life they have. Initiate
conversations/discussions about life to promote living life to its fullest.
E. Support the individual in accomplishing important and necessary tasks and to talk
to family members/partner and other significant people in their life.
F. Facilitate problem solving and resolution of practical issues which can
contribute to their investment in living and decreasing a preoccupation with
death.
G. Facilitate clarification of priorities and values:
1. Identifying the most meaningful aspects of life
2. How does the individual want to be remembered.
3. What is important for them to take care of.
4. What are they able to let go of.
5. Facilitate exploration of beliefs about death and life.
6. Clarify philosophical and spiritual beliefs and resources.
7. Facilitate clarification of what gives them both strength and comfort.
8. Facilitate and support grieving.
This has been adapted and summarized from I. Pollin & S.B. Kannan (1995). Medical
Crisis Counseling, New York: Norton.
DEALING WITH THE CHALLENGES OF
LONGTERM ILLNESS
1. Confronting your medical crisis: Recognize that you are not alone

A. Learn skills to help you effectively cope. Instead of the goal to be cured, how do
you learn to live with it and improve your quality of life.
B. By confronting the illness and associated fears, you acknowledge what is
happening and how it affects you. This is the path necessary for problemsolving
how you will live with the illness. Every experience you have becomes a part
of you.
1. Acknowledge it
2. Accept it
3. Learn how to cope with how it changes your life.
4. Learn to cope with how it has changed and is still changing you
Dealing with the C h a l l e n g e s o] LongTerm I l l n e s s 151

C. To accomplish this, review the 8 central crisis issues associated with chronic illness
and consider the following general points for improved coping and management:
1. Identify and accept adjustment as a normal part of life
2. Identify your general style of coping with difficult circumstances
3. Clarify
a. Your view of your illness
b. The stress it creates
c. Your emotional reaction
4. Identify your strengths and weaknesses
5. Maximize resources
a. Personal (psychological and emotional endurance; physical strength)
b. Social (support network such as family, friends, community participation,
support groups, professional help)
6. Decrease negative emotion
a. Stress
b. Anxiety
c. Depression
7. Find ways to improve relaxation and being in the moment
a. Prayer
b. Visualization
c. Meditation
d. Stretching/yoga
e. Formal relaxation techniques
8. Improve positive daily structure and daily functioning
9. Be a positive and cooperative member of your treatment team
a. Ask questions
b. Make decisions
c. Be compliant with treatment
10. Decrease isolation/social withdrawal
11. Foster a sense of control (do what you can do)
12. Continue to strive for quality of life and satisfaction in life
2. Impact of chronic illness on relationships
Once the diagnosis is made or onset of chronic illness is evident, relationships
may change. Not only may it be a time of stress and adjustment, but it may
also be a time when you require an increased level of attention and care from
those closest to you. As a result, everyone experiences a greater degree of stress.
This may be a time of extreme anxiety for you and your family. Because of the
range of intense emotions for all involved, people sometimes try to avoid
friction and pull away with "silencing" being a possible consequence.
A. Keep communication open
B. It is appropriate to experience anxiety, depression, anger, fear, frustration,
resentment, shame, guilt, and fatigue. Talking about it is the only way to find
creative methods of dealing with such changes in yourself and significant
relationships.
C. While you work at identifying how you are emotionally/psychologically responding,
it is also important to understand how your loved ones feel. Don't wall yourself off.
This medical crisis is shared by all those close to you.
D. Take charge
1. Put problems in perspective
2. Identify what is exacerbated or changed by the diagnosis/illness
3. Do not personalize the illness

E. Facilitate a family discussion to address
1. Feelings
2. Responses
3. Fears
4. Impact on the life of each person
5. Problemsolving for managing changes as a family
6. Validating all feelings and thoughts
7. Separating difficult behaviors from the person
8. Expressing care and love
F. Develop realistic expectations and limitations for all family members (including
yourself)
G. Clarify what you need from significant others
1. Tell them how you feel
2. Tell them what you miss (deal with it too)
3. Reassure their feelings about the medical crisis
4. Give them guidance in how to help you
5. Do not manipulate with your illness
6. Share appreciation for help and support
H. Help significant others to
1. Adjust to changes in responsibilities (some will feel a higher level of
demand and others may feel displaced, so be aware and ready to talk
about it)
2. Maintain as much responsibility and involvement in medical decisions as is
possible
3. Keep awareness for overprotectiveness from family
I. Don't use family guilt as an avenue to gain desired attention
J. Make sure scheduling is structured so everyone gets respite care if necessary
K. Develop an effective partnership with your physicians by getting as much
information about your illness as possible. Create a personal list of questions for
you physicians aimed at increasing knowledge and understanding:
1. Are you sure of the diagnosis?
2. How did I get the disease?
3. What factors make it worse or better?
4. How long must I stay in the hospital?
5. What should I expect as far as disabilities?
6. Will the disease get worse?
7. Can the symptoms be controlled?
8. What treatments are available?
9. Is the treatment you are recommending the latest?
10. What is its success rate?
11. What are the risks of this treatment?
12. Do the benefits outweigh the risks?
13. Are there any experimental treatments I should know about?
14. If I take this medication for many years, what are the potential side effects?
15. If I have surgery, will it stop the disease or will the process continue?
16. What should I be doing to take care of myself?
17. What would make me feel better?
18. What would make me feel worse?
L. Clarify what you expect from your physician and what your physician expects
from you
Dealing with the C h a l l e n g e s of LongTerm I l l n e s s 153

M. Feel confident if you choice to do the following:
1. Seek a second opinion if you're dissatisfied with the specialist or feel uncertain
about the diagnosis
2. Get as much information about your disease as possible, but only as much as
you are comfortable with. It should help with your treatment.
3. If you are anxious in your doctor's office, bring in prepared questions and take
notes. Have someone accompany you.
4. Share your feelings and concerns with your doctor and his/her staff, especially if
you feel you are being mistreated
5. If you're going into surgery, put your surgeon's name on the release form. This
will ensure that this particular surgeon will be performing the operation—not
another member of the medical staff.
6. Get copies of your medical records if it helps you to keep track of your
treatment
7. Speak up clearly if you are dissatisfied with a nurse's treatment of you. Start by
speaking with your nurse directly. If that doesn't work, speak to the head nurse
and then with your doctor.
WORKING THROUGH THE CHALLENGES AND FEARS

ASSOCIATED WITH LONGTERM ILLNESS
1. Loss of control
A. Acknowledge you may not be able to control what is medically happening to
you, but that you have a choice in how you deal with it. Your emotional state can
affect your physical state and your physical state can affect your emotional and
psychological functioning. So when you are confronted with some limitations and
forced life changes, you still have power of choice over your psychological and
emotional life.
B. Find a way to come to terms with the loss of control and life
changes
C. Evaluate what you do and do not have control over
D. Find ways to regain maximum control
1. Clarify and separate longterm from shortterm issues
2. Make your own decisions whenever possible
3. Review your life before and after the diagnosis
a. What was a priority?
b. How have you changed?
c. What part of your life remains intact?
d. What changes do you need to make?
4. Identify areas of stress
5. Develop realistic expectations and limitations
6. Continue using coping mechanisms that are or can be effective
7. Explore new ways of decreasing stress
8. Identify/develop your support system (determine who you can depend
on and under what circumstances)
9. Consider joining a support group that focuses on your specific
health issue
10. Be creative
11. Be flexible
12. Plan ahead to maximize choices and control in situations
13. Never underestimate the power of how you think
14. Live an attitude that strives for quality of life

2. Changes in selfimage
A. Identify what was familiar that is now changed or lost in appearance or in physical,
emotional, or psychological functioning
B. Determine if these changes are permanent, temporary, or progressive
C. Grieve your losses, let go, and validate normal responses
D. Identify what losses are ahead of you as a result of the illness
E. Develop a selfimage that currently fits your strengths
F. Remind yourself that change is a normal part of life
G. Encourage family and friends as partners in your efforts of change
H. Do things that make you feel good about yourself
I. Seek professional support
3. Dependency concerns
A. Identify what you can do for yourself versus relying on others
1. Physically
2. Financially
3. Medically
4. Daily life (shopping, house chores, child care, etc.)
B. Find a balance between autonomy and reliance on others
C. Identify how you are emotionally affected by dependency issues
D. Develop realistic expectations and limitations
E. Develop new goals
F. Give to others and participate in their lives
G. Resolve financial issues
H. Participate in your own medical decisions
I. Maintain as much independence as possible
4. Stigma—real and perceived
A. Have a realistic view of the world
B. Examine how you have dealt with the disabilities of others (insight into
you own perceptions, which may result in your own distress with changes
in you)
C. Confront and resolve your own distortions of disabilities
D. Participate in a support group
E. Do not personalize the words or behaviors of others
F. Talk with your family and friends
G. Find ways to laugh at difficult situations and yourself
H. Respond to others in an educative way—"I do things this way because..."
I. Take control of how you present yourself
5. Abandonment
A. Be aware of your sensitivity
B. Avoid misinterpretations in family communication
C. Confront your fear(s)
D. Discuss your fears and concerns with family members and friends
E. Identify negative thinking that is not reality based or shades of reality
F. Be realistic and don't let your fear control you
G. Be sensitive to the needs of your family
1. Be empathic
2. Be appreciative
H. Stay emotionally involved with those you care about
Dealing with the Challenges of LongTerm I l l n e s s 155

I. Continue to participate as much as possible in the lives of family and friends
(there are lots of ways to do the same thing or to be supportive)
J. Do not withdraw and then distort it as a validation of abandonment
by others
6. Anger
A. Begin with selfevaluation
B. Assess your feelings of anger and how you have learned to deal with anger
throughout the course of your life
C. Do not personalize normal responses of anger from those close to you
D. Determine where feelings of rage are being focused
E. Do not burden yourself with being "angry at you"
F. Take responsibility for the future without blaming yourself for the past
G. Talk rationally and appropriately about your anger
H. Find appropriate and helpful ways to vent your anger
1. Be creative
2. Be forgiving
3. Take action
4. Find positive ways to use your energy
I. Acknowledge and accept realty
7. Isolation
A. Identify the different forms of isolation
1. Physical limitations (difficulty walking, wheelchair, bedridden)
2. Social isolation (fewer contacts)
3. Emotional isolation
B. Be empathic; family members may also experience isolation
C. Prepare yourself to deal with issues of isolation (let people know you want
to be included)
D. Participate in a support group for encouragements validation, and problem
solving
E. Identify how much support you need and want
F. Have realistic expectations about family and friends
G. Problemsolve how to reintegrate yourself socially and develop new interests
8. Death
A. Decrease your fear of death
1. Talk about it with family and friends
2. Be helpful to others to decrease selffocus
3. Write about your thoughts and feelings
4. Read
5. Talk with clergy
6. Plan for it—take control
B. Ask the hard questions
C. Plan for the future
D. Face death as you have faced life
E. Comfort your fear of death in your own way
F. Identify what is important to you and accomplish it on your own or with help
G. Continue to make your own decisions
H. Stay close to loved ones and invest yourself in important relationships
I. Remain hopeful and believe in miracles—they do happen

J. Live life to its fullest
K. Be in the moment and enjoy the moment
Adapted from I. Pollin and S. Golant (1994). "Taking charge": Overcoming the challenge
of long term Illness. New York: Times Books
CHRONIC PAIN: ASSESSMENT AND INTERVENTION
Everyone suffers from acute pain when injured, but acute pain abates quickly. Chronic pain

is defined as pain that has not gone away or reoccurs often even after 6 months have passed.
The management of chronic pain is so difficult because traditional methods of pain man
agement frequently fail to bring relief.
The most common types of chronic pain are back pain, headaches, and pain associated
with arthritis. However, there are many other origins of chronic pain. Unfortunately, in
many of these cases, the underlying cause of the pain is not identified.
The most common pain syndrome is myofascial pain, which refers to pain in the muscles
or connective tissue. This pain tends to be diffuse and described as "achy," and is often asso
ciated with the muscles of the head, neck, shoulders, and lower back. The onset can be rapid
or gradual and generally will diminish on its own. There can be a cycle with myofascial pain
which: (1) originates with muscle tension which produces pain; (2) focuses attention on the
pain; (3) increased muscle tension; and (4) resulting in more pain. When an individual is
not focusing on the pain, but instead doing other things and thinking about other things the
distraction acts to minimize the experience and a normal alleviation or subsiding of the pain
occurs.
Another pain syndrome, neuralgia, is similar to myofascial pain in that there appears to
be a lack of tissue damage. The primary sign of neuralgia experienced by people is a severe
sharp pain along a nerve pathway. This pain can occur suddenly with or without stimulation.
It is transient and brief, but can reoccur and at times be intense enough to be incapacitating.
FACTORS AFFECTING THE EXPERIENCE OF PAIN

1. Cultural. Varying cultures offer different explanations of origin or meaning and
expectation. However, there are few differences in sensation thresholds cross
culturally.
2. Cognitive Response. The thoughts and beliefs that an individual has are one of
the strongest influences on the perception of pain. Cognitive distortions such as
excessive worrying, catastrophizing, negative selffulfilling prophecy,
overgeneralization, and personalization are common to individuals who suffer
chronic pain. This type of thinking can play a role in the exacerbation of
depression, requiring a thorough assessment of mood disturbance issues. The
interpretation of pain will determine the overall experience of it, as well as
feelings of control and selfefficacy in pain management.
3. Affect and Stress. As stress increases there is also an increase in the perception
of pain. Psychogenic pain is chronic pain which lacks any physical etiology, and
is believed to be a response to psychological need or disturbance. Often, people
with depression or other emotional distress will manifest their distress in pain.
4. Prior Experiences of Pain. Even though the reaction to pain is autonomic,
earlier experiences influence pain perception. There is no cure for pain; it is a
survival mechanism to prevent harm and death.

CLINICAL INTERVIEW
Individuals with pain often present with additional coping difficulties. Chronic pain is
exhausting, physically limiting, and challenges an individual's identity and sense of control.
Be sensitive to not minimize or invalidate their experience of pain.
1. Identifying information

2. Relationship history
3. Work/academic history
4. Relevant background information and developmental history
5. History of pain (intensity, frequency, quality)
6. Medical history (injuries, hospitalization/surgery, medication, etc.)
7. Psychiatric history (therapy, biofeedback, hospitalization, medication)
8. Mental status
9. Coping mechanisms and problemsolving ability
10. Strength and weakness
11. Diagnosis
12. Tentative treatment plan listing planned collateral contacts for further
information and case management
Use of the MMPI. MMPI scales can be very helpful when used as predictors of paincoping

strategies likely to be preferred by individuals with chronic pain.
ASSESSMENT AND MEASURING PAIN
1. Behavioral Observation. Observed outward manifestations of pain may be
offered by any significant person in the individual's life and by the therapist.
These observations may include distorted posture, distorted ambulation,
negative affect (irritable, fatigue, etc.), avoidance of activity, verbal complaints,
and distressful facial expressions.
2. Subjective Reports. The accuracy of subjective reports of pain are highly
variable. It can be helpful to offer a conceptual range of pain from no
experience of pain to pain that is intolerable (can't be any worse). This
information can be clarified by using:
A. A basic anatomical chart for identifying location/points of pain and type of pain.
B. Facilitate the initiation of a journal for a brief period of time if clarification is
necessary. ** Concern is creating increased focus on the pain. However, information
which can be gathered includes location, frequency, intensity, time of day which is
worse, pain management techniques (what is helpful), etc.
Using the pain chart on the next page show where you experience pain. There are different

symbols for making the location of pain on the diagram which are descriptors of the type of
pain that can be experienced.
Every area that you mark as a location where pain is experienced should also be num
bered between 0 and 10 to indicate the intensity of the pain experienced. For example if a
location had the symbols and numbers such as:
1111 4
1111

It would mean that at the location marked there is an experience of stabbing pain with a
lowmoderate intensity.
About how often do you get the pain?

more than once every day
once a day
at least once per week
at least once per month
less than once per month
only during specific activities (if yes, please explain)
How do other people try to help you when you have pain?.
How does the pain interfere in your life? What activities does it prevent you from doing?

PAIN IDENTIFICATION CHART
Name Date
Mark the areas on your body where you feel the described sensations. Use the appropriate
symbol. Mark areas of radiation. Include all affected areas.
LOCATION AND TYPE OF PAIN
Numbness = = = = Pain and Needles + + + +
= = === + + + +
Burning 0 0 0 0 Stabbing / / / /
0 0 0 0 ////
Please rate the average pain intensity for each location on a 10 point scale.
0 = no pain; 10 = very intense pain
FRONT BACK
COMMENTS

PAIN MANAGEMENT SCALE
Medical understanding of pain management continues to improve. In conjunction with the

body chart, which shows where pain is experienced along with the type of pain, the use
of a pain scale would be beneficial in communicating the degree of pain distress an individ
ual is experiencing. Below is an example of the type of pain scales being utilized by hospi
tals and pain management specialists. As a therapist working with individuals recovering
from various physical injuries and surgical procedures, this information may be valuable in
your consultation with the individual's primary care physician, who is generally the case
manager.
Directions
On a scale of 0 to 10 (with "0" meaning no pain and "10" meaning the worst pain)
circle where your experience of pain is on the number line.
Comments:
If the individual is unable to use the 0 to 10 pain intensity scale, assess the following behav
ioral changes he/she experienced:
1. No behavioral/physiological changes indicating pain

2. Facial expressions (frowning, grimacing, fearful look)
3. Vocalizations (crying, moaning, grunting). Under what circumstances?
5. Withdrawal or decreased social interaction
6. Guarding, rigidity, tension
7. Irritability, fidgeting
8. Physiological measures
A. Increased heart rate/pulse
B. Increased blood pressure

INTERVENTIONS FOR CHRONIC PAIN
There are two perspective of intervention which must be addressed:
1. Understanding the physiological processes of the body

2. Taking into consideration the individuals' belief system and perspective and
response to pain
Case Management requires a multidisciplinary, multimodal, and multilevel approach which

offers individual flexibility and stepwise progression where possible (emotional and physical
rehabilitation).
SIX STAGES OF TREATMENT
1. Assessment
2. Reconceptualization which offers an understanding of the multidimensional nature
of the pain (psychological, emotional, cultural, social, and physical associations).
3. Skills development (cognitive and behavioral)
4. Rehearsal and application of skills developed
5. Generalization of new skills and effective management skills
6. Planned followup treatment sessions to maintain progress
INTERVENTIONS
1. Collateral contact(s) with treating physician(s) for clarification of etiology, lab
results, and pharmacologic treatment.
A. Assess individual's knowledge regarding their pain, its etiology, and its impact on
their life and relationship. Have the individual verbalize in their own words their
understanding of what is happening to them to cause the pain that they are
experiencing and why it is happening.
2. During the initial phase of treatment prepare an individual for their role in
treatment planning and being the most significant person on the treatment team.
Their compliance on recommendations and defined treatment interventions is
imperative to the effective management of the case. Predict for them that, long
term, there is a tendency for regression due to their decrease in compliance and
activity. Therefore, it is beneficial to schedule intermittent followup sessions for
maintenance.
3. Refer for psychopharmacological evaluation if there is evidence of underlying
emotional factors such as depression and anxiety.
4. Cognitive Behavioral Interventions
A. Cognitive restructuring
1. Educate regarding the impact of negative thinking and negative selftalk.
Develop calming selftalk and cognitive reappraisal.
2. Facilitate development of compartmentalizing, or being able to "put things
away." In other words, not having to deal with something all of the time. It
creates some experience of control.
3. Facilitate a focus on "what is" versus "what if"
4. Facilitate a focus on capabilities versus disabilities
5. Prayer helps some individuals alter their thinking patterns
6. Selective attention.

7. Identify thoughts and feelings of helplessness and in a supportive manner
confront with realistic information.
B. Relaxation training
2. Visualization
3. Hypnosis
4. Meditation
5. Systematic desensitization
C. Correcting maladaptive pain behavior patterns
1. Time contingent versus pain contingent programs (e.g., taking pain medication
every 6 hr. as prescribed instead of "as needed").
2. Functional rehabilitation through the use of physical therapy and occupational
therapy to reclaim loss of functioning through a progressive hierarchy of task
mastering.
3. Decrease avoidant behavior and being selfabsorbed/self focused through
increased interests and utilizing resources.
4. Assess for abuse of pain management medication or other substances.
D. Biofeedback (review the literature for efficacy of treatment for specific etiology
of pain). One example is use of the EMG.
E. Stress management
1. Relaxation training
2. Stress inoculation training utilizing breathing techniques, imagery/visualization,
progressive muscle relaxation, selfhypnosis or other focusing strategies, and
cognitive restructuring
3. Development and use of a selfcare program
4. Participation in pleasurable activities
5. "Regular, appropriate exercise
6. Adequate nutrition
7. Time management/prioritizing
F. Identify any precipitating stressors
G. Encourage venting of feelings and explore the meaning that pain holds for the
individual. This will help the individual connect symptoms of pain to emotional states.
H. To redirect the individual to other areas of their life offer them attention when they
are not focusing on the pain. This serves as a reinforcer to encourage their adaptive
behaviors. It may also act to facilitate as a transition to invest individual in
behaviors that distract them from the pain.
I. Explore with individual various methods of intervention to utilize when symptoms
intensify. Emphasize consistency in treatment compliance issues.
J. Facilitate effective coping
1. Validate individual's experience of pain. Acknowledgment and acceptance of
their pain creates a foundation improved coping.
2. Identify any evident or presumed secondary gains related to pain experience such
as attention, increased dependency, decreased responsibility, etc.
3. Following initial fulfillment of dependency needs, begin to gradually withdraw
attention from pain. Eventually any complaints of pain will be referred to the
physician, therefore, reinforcing compartmentalization by the individual.
4. Encourage venting of anxiety and fears. Confront and problem solve with
realitybased information.
5. Facilitate individual's insight into the relationship between psychosocial stressors
and experience of pain.
6. Explore and problem solve the impact that chronic pain has had on
relationships. Educate in a caring manner how the fears and frustration of others
regarding this individual's experience of pain creates emotional distancing.
7. Positive feedback and reinforcement for efforts and
accomplishments.
K. Issues of control
1. Facilitate identification of choices.
2. Facilitate identification of how person (can) manages issues which appear out of
their control or are out of their control.
L. Body image issues
1. Encourage grieving for any issues of loss related to changes in functioning. This
also affects personal identity and requires adjustment.
2. Facilitate identification of distortion individual has regarding body image.
3. Encourage selfacceptance.
4. Encourage development and utilization of selfcare program.
5. Positive feedback and reinforcement for individual's acknowledgment of realistic
body/physical perceptions.
6. The development and utilization of a selfcare program can serve to reorient the
person's perspective of the self and begin to heal damaged selfimage.
SOMATIC PROBLEMS: A BRIEF REVIEW
Somatic presentation is characterized by the following:
1. Observable and identifiable disturbances of bodily functions,

2. Disturbances of bodily functions, which are perceived rather than observed, or
3. Mixed (some combined presentation of items 1 and 2).
Somatic problems commonly seen in the mental health setting include these:
1. Headache
2. Insomnia
3. Abdominal distress
4. Irritable bowel syndrome (IBS)
5. "Often ill" (as seen with some depressive individuals)
6. Hypochondriasis
Both the causation and maintenance of somatic conditions require exploration and treatment.

Sometimes treatment is complicated by the presence of an actual physical condition. Such
situations need a sophisticated direct psychological approach that does not focus on ruling
out a physical condition, but instead frames in a positive psychological manner the problems
experienced by the individual. A consultation with the treating physician is necessary to
appropriately consider the following:
1. A realistic description of the individual's physical state

2. The course of the physical condition
3. Any physical limitations that affect psychological treatment

Individuals presenting with somatic problems believe that their problems have a physical
cause, which may be accurate or inaccurate. When this perception is distorted and exagger
ated, it becomes a source of difficulty and anxiety. They look for evidence to support their
perceptions and as a result misinterpret symptoms. Sometimes this may be an issue of mis
communication between the individual and a medical professional whereby the individual's
physical functioning may be slightly different from the norm but is considered as relative to the
individual and not an impairment as the individual may believe. Regardless, when the therapist
initially assesses the individual, he/she is likely to feel
1. Fearful of the possibility of further decompensation

2. Fearful emotional distress of dependency
3. Dealing with issues of loss
4. Overwhelmed by the process of making associated adjustments
5. Angry
6. Depressed/anxious
Therefore, one's reaction to physical impairment, real or perceived, can be changes in
thoughts, behavior, mood, and physiological functioning.
THE PATIENT WITH PSYCHOSOMATIC ILLNESS WHO

HAS AN UNDERLYING PERSONALITY DISORDER
Such a case requires a sophisticated level of clinical expertise. Consider the following issues:
1. Psychosomatic symptoms associated with an underlying personality disorder
presents a significant challenge to the therapist. In this case, psychosomatic
patients may demonstrate impulse dominated modes of functioning utilizing
the following defenses:
A. Denial/splitting
B. Magical thinking
C. Feelings of omnipotence
D. Demands of perfection versus worthlessness (extremes)
E. Displacement/projection/projective identification
F. Masochistic perfectionism
G. Fantasized parental relationships (i.e., conflictfree motherchild relationship)
2. Psychosomatic families demonstrate a parental psychosocial profile that can be
reviewed for problem solving diagnostically and in the treatment planning
approach. The acronym for this system review is PRISES:
Perfectionism—emphasis on
a. Good behavior
b. Social conformity
c. Exemplary childhood/adolescent developmental performance
* Results in indirect communication and separation attempts.
The Patient with Psychosomatic Illness Who has an Underlying Personality Disorder 165
Repression of emotionscaused by
A. Parental hypermorality (evidenced by)
1. Strict emotional control in front of children
2. Aggressive behavior of children not allowed (in general aggression denied)
3. Downplay/maximizing of successes
4. Mother deferred to as moral authority
* Rigid internalization of good/bad (w/o rational review and growth in belief system.
Infantilizing decisionmaking control
A. Everything had to be a noble purpose
1. Major home activity was intellectual discussion
2. Scholarly reading
3. Independent activity/assertiveness led to consequences of humiliation
* Resulting in inability to make decisions with attempts to get others (therapist) to make
decisions for them.
OrganSystem choice
A. Development of psychosomatic symptoms
1. Ulcerative colitis
2. Anorexia
3. Asthma
Exhibitionism by parent(s)
A. Doors to bathrooms or bedroom left unlocked or open
1. Facilitating child curiosity
2. Overexposure paired with parental hypermorality
3. Resulting inhibition in normal psychosexual development
Selection of one child (unconscious selection)
A. Treated differently than siblings
1. Used as a confidant
2. Infantialized (babied)
3. Total devotion to selected child to exclusion of spouse/siblings
*Lack of individuality, poor boundaries, passiveaggressive.
Adapted from C. P. Wilson, I. L., Mintz (1989). Psychosomatic Symptoms: Psychodynamic

Treatment of the Underlying Pennality Disorder

EATING DISORDERS SCREENING QUESTIONNAIRE
1. Have you ever been diagnosed and treated for an eating disorder?

Yes No
If so, please explain
2. Height:
3. Weight:
4. Highest weight in the past six months:
5. Lowest weight at your current height: How recently?
6. Have you missed two or moree menstrual periods in the past six months?
Yes No
For the following questions answer never (N), sometime (S), often (O), or always (A).

Do you worry about gaining weight?
Do you avoid certain foods because of calories, carbohydrate, sugar, or fat content?
How often do you think about wanting to be thinner?
Are you distressed about having fat on your body?
Do you feel guilty after eating?
Do you feel that food controls your life?
During the past six months, have you exercised to control your weight, even when you
were not feeling well or against the recommendation of your physician?
During the past six months, has exercising to control your weight interfered with other
activities?
Do your concerns or eating behaviors interfere with your relationships?
Do your concerns or eating behaviors interfere with academic/work performance?
Do your concerns, eating behaviors, or weight gain cause you a lot of distress?
During the past six months, have you had periods where you ate unusually large
amounts of food within two hours (binging), and have you felt unable to control how
much you were eating at these times? Never
Less than one time per month
About one time per month
About one time per week
_Two or more times per week
If you have experienced binge eating episodes (as described in the previous question),

would you describe the experience as any of the following:
Yes No Eating faster than usual?
Yes No Eating until you felt uncomfortable?
Yes No Eating a lot of food when you didn't feel hungry?
Yes No Eating alone because you were embarrassed about the amount of food
you were eating?
Yes No Feeling depressed, guilty, or disgusted with yourself for overeating?
For the following statements, answer never (N), less than once a month (LM), about once

a month (AM), about once a week (AW), or two or more times a week (MW).
I have selfinduced vomiting in an attempt to avoid gaining weight or to lose weight.
I have taken laxatives in an attempt to avoid gaining weight or to lose weight.
I have restricted my eating in an attempt to avoid gaining weight or to lose weight.
(eating less than 500 calories a day or skipping two or more meals a day).
Eating Disorders Screening Questionnaire 167

I have taken diuretics (water pills) in an attempt to avoid gaining weight or to lose weight.
I have exercised in an attempt to avoid gaining weight or to lose weight.
How did these behaviors start?
How do you feel when you engage in these behaviors?

THE MOOD EATING SCALE
If you agree with a statement, check it off.

When I feel overwhelmed, eating can help me to feel relieved.
—Eating helps to calm me down when I feel nervous.
If someone treats me badly, I find myself eating after it happens.
If I am feeling frustrated, eating may not make me feel better.
_When I am feeling really happy, eating makes me feel even better.
When I eat certain foods I feel guilty, but I find myself eating more of those foods than
others (those foods are )
__When I am feeling stressed, I eat more food than usual
(for example, when I have relationship problems, exams, or significant changes such as
job, moving, school).
If I had conflict with someone that I care about, eating would help to make me feel
better.
I generally do not eat when I am bored.
If I feel inadequate, I find myself wanting to eat.
If things feel out of control, I seem to eat more than usual.
If I am angry with someone, eating doesn't make me feel better.
If I am disgusted with myself, I feel like eating.
I snack a lot while studying for tests.
At times when everything seems to go wrong, I don't eat any more than usual.
If someone makes fun of how I look, I find myself wanting to eat.
_When I feel like I am about to explode from stuffing my feelings, I feel better if I eat.
If I fail at something I don't eat any more than usual.
If someone has taken advantage of me, it will make me feel better if I eat.
_When I feel stressed and under pressure, I find myself eating more often.
_When I am lonely, I eat more.
Use this information for increasing your awareness for the connection between thoughts,
feelings, and behaviors. Such information can be explored in journal writing and in therapy.
Adapted from L. L. Jackson and R. C. Hawkins II (1980).
EATING HISTORY
Please use the following form to record your eating history. Write about your loss of control
associated with food use, rituals and practices regarding the food you choose. When you
have completed your eating history, share it with another person to break the cycle of secrecy
and loneliness.
Consider the following:
1. Kinds, amounts, and frequency of food use

Put this information in a time line (at what age, what were/are the
triggers)
2. Foggy memories or difficulty concentrating after eating too much
Not able to think clearly
Eating History 169

3. Feeling high after vomiting or starving
4. Feeling powerful and in control after vomiting or starving
5. Behavior changes
A. Mood swings with eating/not eating
B. Withdrawal from others to eat or starve
C. Compulsive patterns, such as purchasing food to binge or changing to another
compulsion when eating behavior becomes more healthy
6. Rituals surrounding food use
A. Overeating or binge eating on certain foods
B. Frequent eating out
C. Sneak eating
D. Weighing self daily or more often
E. Selecting specific foods and why
F. Exercise
7. Preoccupation
A. Thinking about eating/not eating
B. Eating for relief from problems, boredom, frustration, etc. (using food as a coping
mechanism)
C. Protecting your food supply; hiding food/hoarding
D. Preoccupation with body size
E. Carefully choosing clothes that mask starvation
F. Preoccupation with secrecy and control
8. Beliefs
A. What life changes are expected with weight loss/control of eating?
B. How would the relationship with yourself change with weight loss/control of
eating?
9. Attempts to control eating and/or weight
A. Doctor's diets
B. Fad diets
C. Diet pills and/or shots
D. Starving, vomiting, laxative use, or manual extraction of stool
E. Diet clubs or fat farms
F. Hypnosis, acupuncture, stomach stapling, or gastric bypass surgery
G. Spending money to control eating or weight
H. Cosmetic surgery
EATING DISORDER EVALUATION: ANOREXIA
1. Psychological evaluation
A. Eating behaviors
B. Weight
C. Emotional symptoms
D. Stressful life events
E. Stressful life circumstances

F. Parental verbal abuse
G. History of mental/emotional illness
H. Mental status
I. Strengths/weaknesses
J. Motivation for treatment
K. Prior treatment experiences and outcome
L. Collateral contact with family members/other treating professionals
2. Review diagnostic criteria
A. Significant weight loss (less than 85% of ideal weight)
B. Significant failure to gain weight normally
C. Denial of the seriousness of the weight loss or low body weight
D. Excessive influence of body and weight on selfperception and selfevaluation
E. Intense fear of gaining weight
F. Loss of menstruation or delayed onset of menses
G. Exploring other compulsive behaviors such as substance abuse
H. Coexisting disorders (depression, anxiety disorders, Post Traumatic Stress Disorder
(PTSD), Obsessive Compulsive Disorder (OCD) substance abuse)
3. Physical symptoms and signs
A. Dry skin
B. Sallow skin/complexion
C. Appearance/increase in fine hair on the body
4. Medical complications (physician review). Note: This is not an exhaustive list.
A. Cardiac abnormalities (arrythmias, slow heart rate)
B. Low blood pressure
C. Low body temperature
D. Low white blood cell count
E. Chronic constipation
F. Osteoporosis
G. Infertility
H. Hair loss
I. Nail destruction
5. Referrals
A. Physicianmedical evaluation
B. Registered dietician
C. Family therapy
D. Group therapy
E. Specific eating disorder program
F. Inpatient treatment
6. Treatment recommendations
A. Psychotherapy (CognitiveBehavioral, interpersonal, psychodynamic)
1. Individual, family, conjoint, group
B. Antidepressant medication
C. Medical evaluation and possible monitoring
D. Nutritional counseling
E. Selfhelp groups
Eating Disorder Evaluation: Anorexia 1/1

EATING DISORDER EVALUATION: BULIMIA
1. Psychological evaluation
A. Eating behaviors
B. Weight
C. Emotional symptoms
D. Stressful life events
E. Stressful life circumstances
F. Parental verbal abuse
G. History of mental/emotional illness
H. Mental status
I. Strengths/weaknesses
J. Motivation for treatment
K. Prior treatment experiences and outcome
L. Collateral contacts with family members/other treating professionals
2. Review diagnostic criteria
A. Episodic binge eating (eating an extremely large amount of food within a specified
period of time while feeling out of control)
B. Episodic purging behavior, which includes vomiting, laxative use, diuretic use,
enema use, fasting, or excessive exercise to prevent weight gain
C. Overconcern with body weight and shape
D. History of other compulsive behaviors such as shoplifting or substance abuse
E. Coexisting disorders (depression, anxiety disorders, PTSD, OCD, substance
abuse)
* Binge eating disorder lacks purging behaviors
3. Physical symptoms and signs

A. Dental enamel erosion and cavities
B. Swelling of cheeks, hands, and feet
C. Abdominal fullness, constipation, diarrhea
D. Abrasions on nuckles
E. Headaches
F. Fatigue
G. Hair loss
4. Medical complications (physician review). Note: This is not an exhaustive list.
A. Electrolyte and fluid abnormalities (low serum potassium values)
B. Dehydration
C. Enlarged parotid glands (glands in the cheeks associated with salivation)
D. Dental enamel erosian and cavities
E. Bowel abnormalities
5. Referral
A. Physicianmedical evaluation
B. Registered dietician
C. Family therapy
1Z2 2. Assessing Special Circumstances

D. Group therapy
E. Specific eating disorder program
F. Dentist
6. Treatment recommendations
A. Psychotherapy (Cognitive Behavioral, interperson, psychodynamic)
B. Individual, family, conjoint, group
C. Antidepressant medication
D. Medical evaluation and possibly monitoring
E. Nutritional counselling
F. Selfhelp groups
Eating Disorder E v a l u a t i o n : Bulimia 173

ADULT ADD SCREENING
A symptom checklist is a quick way to screen this specific diagnostic area and identify a con

stellation of symptoms that may warrant referral to an ADD specialist. The following areas of
review will only take a few minutes. Check off areas identified as a problem and with each one
checked "yes," explore the frequency of experience (never, rarely sometimes, almost always).
History
Experienced ADD symptoms in childhood, such as difficulty maintaining attention,
tendency to be easily distracted, impulsive, restless (it is a disorder that initiates in
childhood not adulthood)
Has not performed up to level of potential in school or work
History of behavioral problems
Experienced bed wetting beyond age 5
Family history: ADD
Learning disabilities
Mood disorders
Substance abuse problems
Impulse control problems
Attention Span/Distractibility
Short attention span, unless very interested and engaged
Easily distracted
Fails to pay adequate attention to detail
Difficulty listening carefully to directions
Often misplaces things
Difficulty learning new games or tasks
Easily distracted during intimacy
Poor listening skills
_Tendency to space out
Tendency to get bored
Problems Initiating and Following through on Tasks
General procrastination
Does not complete tasks once started
Motivated beginning, poor ending
__Tasks take longer due to inefficiency
Inconsistent school/work performance
Poor Organizational Skills
Poor organization and planning skills
Difficulty maintaining organization in work/living environment
Common to have piles of stuff
Easily overwhelmed by daily tasks
Poor financial management
Able to be effective only with the organizational support of others
Restlessness
Constant motion, fidgeting
Needs to be moving to think about things
Difficulty sitting still for too long (work, home, leisure)
Feels anxious, nervous, on edge
Impulsivity
Impulsive (spending, speaks before thinking)
Difficulty following protocol/proper procedure
Impatient

Difficulty living beyond the moment
Embarrasses others
Lies or steals
Frequent traffic violations
Does not consider consequences associated with actions
Tendency toward addictions (food, alcohol, substances, work)
Internal Feelings/SelfEsteem
Negative selfesteem
Chronic bad feelings about self, which are associated with underachievement
Unhappy with self for not having accomplished more at this stage of life
Feelings that "the other shoe is about to drop"
Negative thinking
__Mood swings
Often feels demoralized
Often feels that things will not work out well
__Tendency to worry needlessly and endlessly
Relationship Issues
Difficulty maintaining relationships (friendships, significant relationships)
Promiscuity
Difficulty with intimacy
Immature behavior
Immature interests
Difficulty empathizing with or understanding the needs of others
Difficulty communicating within a relationship
Selffocused
Difficulty with authority
_Avoids group activities
_Verbally abusive
Anger Management
Short fuse to real or imagined negative personal remarks
Rageful outburst
Damages property
Need for Stimulation
__May be argumentative
_May create conflicts
Gravitates toward a high degree of stimulation (gambling, highstress job)
Dyslexic Responses
Switches numbers, letters, words
Switches words in conversation
Coordination
Poor writing skills (difficulty translating thoughts to written form)
Often prints versus cursive handwriting
General coordination difficulties
Pressure and Performance
Performance deteriorates under pressure
Tendency to go blank during tests (test anxiety)
__Tendency to shut down during social pressure/social situations
Difficulty remaining focused during reading (may feel tired and fall asleep)
No matter how hard one tries, it just gets worse
Easily overwhelmed with pressure
Sensitivity
Easily startled by unsuspecting noises
Sensitive to noise
Adult Add Screening 175

Sensitive to touch
Sensitive to the feeling of clothing
Sensitive to light
Sleep/Wake Cycle
Difficulty resting mind and falling asleep (continues to think about things)
Does not awaken feeling alert
Needs morning ritual of coffee or activity to get going
Energy Level
Episodes of fatigue
Energy low in morning and afternoon
Often feels tired
A history of ADD symptoms in childhood, short attention span, and a high level of dis
tractibility are necessary to consider a diagnosis of ADD.

ADHD BEHAVIORAL REVIEW
Below are a list of behaviors one can review in establishing difficulties experienced by a child
with a potential diagnosis of ADHD. When a therapist is consulting with teachers or par
ents, this information can be used to indicate the importance of an ADHD evaluation and
referral for medical treatment.
Child's name:
Gender: M F
Age: Grade:
1. Does not give close attention to details.

2. Makes careless mistakes in schoolwork.
3. Squirms in seat and fidgets hands/feet.
4. Demonstrates difficulty maintaining attention on tasks/play activities.
5. Does not stay in seat or room as directed.
6. Does not appear to listen when being directly spoken to.
7. Exhibits behavior that is inappropriate to situations (climbing on
things/getting into things when it is appropriate to be relatively quiet).
8. Does not follow instructions.
9. Fails to complete work.
10. Demonstrates difficulty playing quietly.
11. Demonstrates difficulty organizing tasks/activities.
12. Seems to be constantly on the go.
13. Avoids tasks that require consistent/sustained mental effort.
14. Talks constantly.
15. Constantly losing things that are needed for tasks/activities.
16. Is not able to wait his/her turn to talk or blurts out answers.
17. Is not able to wait for questions to be fully stated before answering.
18. Demonstrates difficulty waiting his/her turn.
19. Is easily distracted.
20. Demonstrates forgetfulness in daily tasks/activities.
21. Interrupts others.
22. Is intrusive in behavior/talking.
Adapted from G. J. Di Paul et al. (1998). ADHD Rating, ScaleIV, School Version.
ADHD Behavioral Review 177

Diagnosing ADHD:
Decision tree for clarifying ADHD diagnosis.
| Report of behavioral difficulties]
Yes
Difficulties associated with ADHD reported
from two or more environments
Yes
Six or more attentive symptoms Six or more hyperactive/impulsive

Does not listen symptoms
Does not follow through Often fidgets
Difficulty organizing tasks Leaves seat
Easily distracted Restless (climbing, touching, etc.)
n forgetful Difficulty playing quietly
n loses things s on the go
s tasks requiring sustained s excessively
mental efforts s without thinking
If yes to either
Evidence of deviation from normal
developmental response and performance
Yes
Symptoms evident for at least six months
Yes
Onset before age seven
[Yes
Symptoms accounted for by other
condition or psychosocial situational factors
No
Adapted from A. D. Anastopolous and T. L. Shelton. (2001). Assessing Attention Deficit/

Hyperactivity Disorder.

CHEMICAL DEPENDENCY ASSESSMENT
Date:
Name:
1. Description of Patient (identifying information):
2. Reason for Referral:
3. Patient's Perception of Chemical Use:
4. Patient's Treatment Expectations and Goals:
5. Effects of Lifestyle/Symptomatology:

A. Family (History of family problems in origin and/or present family including
chemical dependency);

B. Social (Description of peer association, isolation/hypersocialization):
C. Occupational/Scholastic (Absenteeism because of chemical use, decreased

performance, dismissal):
D. Physical (Emesis, blackouts/passouts, hallucinations, tremors, convulsions, serious
injury/illness, surgery, handicaps):
E. Psychological/Emotional (Cognitive functioning, emotionality, paranoia, history of

treatment, behavioral problems):
F. Spiritual (Change or conflict within belief system):
G. Financial:
H. Legal Implications (Underage consumption, driving while under the influence,

dealing; include disposition if any):
6. Diagnostic Impression (Multiaxial):
I.
II.
III.
IV.
V
7. Impressions and Recommendations:
Client's response to therapist: cooperative fearful suspicious

hostile negative other

Mental Status:
Mood normal depressed elevated euphoric angry irritable
anxious
Affect normal broad restricted blunted flat inappropriate
liable
Memory intact shortterm problems longterm problems
Processes normal blocking loose associations confabulations
flight of ideas ideas of reference grandiosity paranoia
obsession preseverations depersonalization
suicidal ideation homicidal ideation
Hallucinations none auditory visual olfactory gustatory somatic tactile
Judgment good fair poor
Insight good fair poor
Impulse Control good fair poor
Client's Attitude Toward Treatment: accepting neutral resistant
Communications: talkative satisfactory open guarded

answers questions only other
Therapist Date

CHEMICAL DEPENDENCY
PSYCHOLOGICAL ASSESSMENT
Date: Age:
Name:
S.O. Name Phone:
Religious/ethnic/cultural background:
Marital Status: Children:
Living with Whom:
Present Support System (family/friends):
Chemical History:
Age Last Dose/ Length
Chemical Use Route started Amt. Freq. Last Used of Use
Description of Presenting CD Problems (pt's view):
Previous Counseling:
When Where Therapist/Title Response To
Family/S.O. relationships/History of Chemical Use:

S.O. Relationships and History of Chemical Use:
Effects of CD on Family/Support System:
Daily Activities that: A. Support Abstinence:
B. Encourage Usage:
History of Sexual/Physical Abuse (victim/abuser):
Sexual Orientation:
Education:
Vocational History:
Leisure/Social Interests:
Current Occupation:
Current Employer:
Impact of CD use on Job Performance:
EAP? Yes No Name: Phone:
Socioeconomic/Financial Problems:
Legal: DWI: Yes No Court Ordered: Yes No
Patient's Perceptions of Strengths and Weaknesses:
Chemical Dependency Psychological Assessment 183

Preliminary Treatment Plan: List presenting problems based on initial assessment of the
client's physical, emotional, cognitive, and behavioral status
Detox: Yes No Explain:
Rehab: Yes No Explain:
Problem #1:
Problem #2:
Problem #3:
Immediate treatment recommendations to address identifying problems:
Therapist Date

WITHDRAWAL SYMPTOMS CHECKLIST
Ratings: 0 = none 1 = mild 2 = moderate 3 = severe
PSYCHOLOGICAL
Drowsiness
Excitability (jumpiness, restlessness)
Unreality
Poor memory/concentration
Confusion
Perceptual distortion
Hallucinations
Obsessions
Agoraphobia/phobias
Panic attacks
Agitation
Depression
Fear
Paranoid thoughts
Rage/aggression/irritability
Craving
SOMATIC
Headache Abdominal pain
Pain (limbs, back, neck) Diarrhea/constipation
Pain (teeth, jaw) Appetite/weight change
Tingling/numbness altered sensation Dry mouth
(limbs, face, trunk) Metallic taste
Stiffness (limbs, back, jaw) Difficulty swallowing
Weakness ("jelly legs") Skin rash/itching
Tremor Stuffy nose/sinusitis
Muscle twitches Influenzalike symptoms
Ataxia (lack of muscle coordination) Sore eyes
Dizziness/lightheadedness Flushing/sweating
Blurred/double vision Palpitations
Ringing in the ears Overbreathing
Speech difficulty _ Thirst
Hypersensitlvity (light, sound, taste, Frequency/polyuria, pain on micturition
smell) Incontinence
Insomnia/nightmares Abnormal heavy periods
Tantrums Mammary pain/swelling
Nausea/vomiting Other symptoms (specify)
Withdrawal Symptoms Checklist 185

186
Chemical Use History
Past history Current use (last 6 months)
Range of frequency Comments

Check if Chemical Description First use Age of Frequency (include date of Range of Route of (cost, chemical
used classification of substance (onset) regular use and amount last use) amount administration of choice)
Alcohol
Amphetamines
Cannabis
Cocaine
Hallucinogens
Inhalants
Opiates
Phencyclidine
(PCP)
Sedatives/Hypnotics/
Anxiolytics
SPOUSAL/PARTNER ABUSE
The victim of spousal abuse is often reluctant to acknowledge and admit that abuse has
occurred. They have been beaten down emotionally, suffer from low selfesteem, feelings of
worthlessness or unworthiness, and convinced that they are incapable of managing their
own lives. Therefore, the clinician needs to be astute in recognizing the signs of abuse.
The cycle of abuse can be recognized by three stages. Stage 1 is indicative of stress and
mounting tension. There may be what are described as minor incidents of battering such as
pushing. The individual facing abuse tries to cope by staying out of the way of the abuser
and by making sure that they are not doing anything to upset the abuser. This stage can
endure for a long time. The major coping mechanism for this stage is denial. Stage 2 is where
the explosion occurs. There is a lack of control and predictability by the abuser. Acute bat
tering occurs, and can lead to the police being called or the abused individual seeking out a
shelter/safe environment. Attempts to cope with these circumstances often include shock and
denial. Stage 3 is the honeymoon. This is where the abuser is apologetic, loving, and prom
ises to change. This leads to a denial of the violence and the cycle repeats itself.
ASSESSING SPOUSAIVPARTNER ABUSE
1. Indicators of Spousal Abuse
A. Obvious injuries at various stages of healing
B. Obvious erroneous explanation for their injuries
C. Repeated bruises and other injuries
D. Chronic depression, insomnia, nightmares, and anxiety
E. Fear and hypervigilance
F. Reluctance to offer more than general, superficial information
G. Vague somatic complaints
H. Overdependence on spouse
I. Complaints of marital problems
J. History of alcohol/substance abuse of the offender
K. Spouse makes decisions of what they wear, who they see, and what they do
2. Immediate Interventions
The primary goal is to protest the individual and their children.
A. Obtain medical treatment for the victim.
B. Provide the victim with the information for a shelter, and encourage them to call
from your office.
C. Educate the victim regarding their right to safety and legal intervention.
1. File a police report and press charges so that an intervention can be made with
the abusive partner.
2. Obtain a restraining order so that law enforcement can offer protection and
enforce the law with the offender.
D. Offer support and understanding for what effects the experience has had on them
and reinforce that they deserve better.
E. Educate the victim about the cycle of violence in their own life, and how continuing
to live in that environment perpetuates the roles of victim and abuser for the children.
F. If the victim has a safe place to go to other than a shelter strongly encourage them
to participate in groups offered by the shelter for battered women.
G. Positive reinforcement for efforts and accomplishments of selfcare:
1. Decrease feelings of responsibility for the abusive behavior
2. Develop safety plans for the protection of self and children

3. Develop and utilize support system
5. Decrease fear and feelings of helplessness
6. Decrease dependency on relationship
7. Increase constructive expression of anger and other feelings
3. Issues for the Abused Individual
A. Financial and emotional dependency
B. Control of life is lacking
C. Fear
D. Isolation
E. Distressing emotions, ambivalence
F. Low selfesteem, shame, embarrassment
G. Frustration
H. Competency
I. Minimizing
J. Self blame or low selfworth
K. Harassment
L. Learned acceptance, passivity, and submission
Because of the emotional distance, fear, and defenses of the abused individual, the therapist

needs to be direct, honest, and genuinely caring. Use joining techniques and unconditional
positive regard to reduce the resistance that will be innately present of this type of client.
Identify if the client has someone or something of value that he/she wants to protect (chil
dren, friends, job), and refer to this during treatment to empower the client. Clients may not feel
motivated toward protecting themselves until sometime after this initial work is accomplished.
Identify faulty belief systems that keep clients in the victim role and instruct in cognitive
reframing, thereby offering a healthy alternative to adopt and to utilize constructively as an
agent of change.
Refer to other community resources that will assist clients in their independent function
ing and separate from them the abusers, such as job training, child care services, legal aid,
AFDC, selfhelp groups, and so on.
There are two central features for assessing the perpetrator of violence:
1. Assessing Lethality
A. Homicide risk (weapons, threats, degree of violence)
B. Suicide risk (history and current status of risk factors)
C. Frequency of violence (complete inventory of when violent behavior started, last
episode of violence, typical degree of violence, most violent behavior, range of
violent behavior, i.e., physical, sexual, property, emotional/psychological, cycle of
violence, and current stage of violence)
D. History of violence (own experiences of being abused, witnessing a parent being
abused, violence in previous relationships)
E. Substance use/abuse
F. Assaults on other family members or other individuals
G. Criminal history, criminal behaviors
H. Isolation
I. Proximity of abuser and victim
J. Attitudes and beliefs related to violence
K. Ownership of partner, feelings of being entitled to partner's service, obediance, and
loyality

L. Centrality of partner
M. Depression
N. Prior involvement of law enforcement
O. Evaluation of life stressors
P. Psychiatric history and mental status
Q. Hostage taking
2. Assessment of the Offender's Motivation for Change
A. Listen and carefully observe degree of interest in change.
B. Is the motivation for change internally or externally driven?
C. Do the person acknowledge having a problem with anger?
D. Do the person acknowledge having a problem with violence?
E. Is the person willing to discuss his/her violent behavior?
F. Does the person minimize and deny violence?
G. Are there any signs of remorse?
H. Does the person feel his/her violent behavior is justified?
I. Does the person acknowledge in any way a belief of being able to benefit from
treatment, with any expression of wanting a violencefree relationship?
J. Does the person have any insight into why he/she uses violence?
K. Does the person see violence as a functional or integral part of the relationship?
L. Is the person cooperative with treatment?
M. What is the degree of externalization?
N. Does the person keep appointments and arrive on time?
Issues related to motivation must be observed over time. The reasons for entering treatment

are varied. Clients may not be presenting for treatment out of their own personal desire for
change, but rather as a response to an external demand.
It is recommended that the individual participate in individual therapy, group therapy,
and anger management class as modalities of intervention prior to the possibility of conjoint
therapy, if that is an option. It is also important to assess for substance abuse. The modality
or modalities used will be based on the needs of the client.

Denial is the central key to maintaining the cycle.
To break the cycle, denial must be broken.
Adapted from the Domestic Abuse Intervention Program, Deluth Minnesota.
190 2. A s s e s s i n g Special Circumstances

A General Systems Model of Domestic Violence
THE STAGE MODEL OF DOMESTIC VIOLENCE
The conceptual framework of systems theory is utilized to demonstrate the stepwise pro
gression of the physically abusive relationship. Both the pattern of violence and the response
to violence are learned early and can affect how a person deals with stress within a rela
tionship. This is a process of adaptive change. The proposed stages of domestic violence
(DV) include the following:
1. The establishment of the family system

A. How did earlier life history affect the new family system?
B. How did family boundaries evolve?
C. What are the rules of dominance and power?
2. The first violent event
A. How did the interaction between the couple during the first episode of violence
affect the potential for future violence?
3. Stabilization of violence
A. What functions within the system allow violence to escalate?
B. What role does internal goals between the couple play in the evolution of DV?
4. Pivotal crisis point
A. At what point do patterns of violence become intolerable?
B. What are the criteria for intolerance aside from the amount of violence?
5. Reorientation
A. How do the boundaries that previously defined the system shift?
B. How does leaving the system cause a shift in thinking and personal dynamics?
C. How does the offender respond to the victim's attempts to change the boundaries of
the system?
6. Reorientation and conversion or status quo
A. Does the victim leave the relationship?
B. Is the victim successful in developing new interactional patterns in a new
system?
The Stage Model of Domestic Violence 191

C. If the victim remains in the relationship, will reorientation of system functioning
and boundaries be successful, or will they remain the same?
Adapted from J. GilesSims (1983). Wife battering: A systems theory approach.
ASSESSING FOR DOMESTIC VIOLENCE
According to O'Leary et al. (1992), less than 5% of couples seeking conjoint therapy report

any incident of domestic violence (DV) during intake. However, as many as 66% of those
screened report some form of relationship violence experienced when given written self
report measures. Therefore, if specific questions are not asked during the interview, DV will
not likely be identified and treated.
1. Reasons for not reporting DV

A. Fear
B. Shame
C. Guilt/responsibility
D. Belief that DV is not the problem
2. Complications of samesex relationships
1. Less likely to report DV than heterosexual couples
2. May be more difficult to identify victim versus offender
* Advocates for Abused and Battered Lesbians has developed an assessment model to distin
guish victim from offender (Veinot, T.,)
3. Complications for ethnic minority groups

A. Language difficulties and associated limitations
B. Isolated from their communities
C. Obtaining services may result in increased community isolation
4. Children who are exposed to DV may present with the following concerns:
A. Academic problems
B. Social problems
C. Low selfesteem
D. Externalization demonstrated by behavioral problems
E. Internalization of emotional effects
F. Anger
G. Aggressiveness
H. Depression
I. PTSD
5. Considerations to rule out in screening children (family history important):
A. Other forms of trauma
B. Depression
C. ADD
D. Conduct disorder

6. Victim symptom presentation
A. Depression
B. Anxiety
C. Sleep disorder
D. Eating disorder
E. Substance abuse disorder
F. Somatization disorder
G. Panic attacks
H. Hypervigilance
I. Intrusive thoughts
J. Suicidality
Housekamp and Foy (1991) stated that most symptoms are PTSD related. As a result, one or
more of the preceding symptoms/disorders would be a common presentation. Additionally,
be aware of a misdiagnosis of borderline or histrionic personality disorder. According to
Root (1992), the development of personality disorder symptoms are a normal reaction to
abnormal situations, and the condition may have developed as a coping mechanism.
Once DV has been identified, then assessment regarding the level of risk can be made.
Assessment instruments include (but are not limited to) the following:
1. Dangerousness Assessment (Campbell, 1995)

2. Dominance Scale (Hamby, 1995)
3. Propensity for Abusiveness Scale (Dutton, 1995)
4. Psychological Maltreatment of Women Inventory (Tolman, 1989)
5. Relationship Conflict Inventory (Bodin, 1996)
6. Risk checklist/Psychological Violence Inventory (Sonkin, 2000)
7. Spousal Assault Risk Assessment (SARA) (Kropp & Hart, 1997)
8. Women's Experience with Battering (Smith, Earp, & DeVillis, 1995)
* Assessment for children: See Trauma Symptom Checklist for Children (TSCC) (Briere,
1996).
INTERVENTION CATEGORIES
1. Crisis intervention
A. Resolution of immediate threats
B. Resolution of other issues that may impair safety
C. Identification of resources (medical, legal, community, social)
D. Facilitation of access to resources
E. Minimizing or eliminating dangerousness
F. Development and implementation of a safety plan
2. Intervention for victims
A. Immediate or shortterm objectives
1. Identify impact of violence and abuse
2. Promote personal sense of empowerment
B. Emphasis on longterm adjustment
1. Resolution of emotional/psychological difficulties
Assessing for Domestic Violence 193

C. Modalities
1. Support group
2. Psychoeducational programs
3. Psychotherapy
4. Shelter
3. Intervention for children exposed to DV
A. Resolution of psychological and emotional consequences
1. Distorted views of couple/family relationships
2. Secondary trauma
3. Assumption of ageinappropriate roles
B. Modalities
1. Support group
2. Psychoeducational programs
3. Psychotherapy
4. Shelter (or some other safe placement)
4. Intervention for offenders
A. Social control
B. Psychoeducational programs
C. Psychotherapy (accepting responsibility/commitment to refrain from acts of DV)
5. Intervention for couples or families of DV
A. Requirements for conjoint therapy to proceed
1. Maintenance of no violence
2. Successful completion of individual goals in prior treatment interventions
3. Both parties equally invested in safety for all parties involved as a priority over
conjoint therapy and resolution of couple's issues
The literature is controversial regarding conjoint therapy. Some believe that conjoint therapy
is prone to perpetuating further abuse, others believe that it is an essential intervention.
Geffner and Mantooth (2000) have identified the following factors as being contraindicative
for conjoint therapy:
1. Offender does not refrain from violence

2. Failure to accept responsibility for his/her actions
3. Failure to accept the discontinuance of abuse as the primary treatment objective
4. Inability to promote and preserve safety of all parties
5. High degree of fear and intimidation
6. Stalking or other obsessive behaviors
7. Use of alcohol or other substances
8. High degree of dangerousness and lethality
9. Disinterest or discomfort by either party to participate in conjoint therapy
COUNSELING VICTIMS OF DOMESTIC VIOLENCE
Primary goal: To protect self and children.

OBJECTIVES
1. Enhance experience of selfempowerment
2. Decrease/eliminate responsibility for the behavior of others
3. Develop social support
4. Increase utilization of resources (medical, legal, welfare, social
support)
6. Increase protections skills (for self and children)
7. Improve selfcare skills
A. Stress management
B. Selfpresentation
C. Nutrition
D. Selfaffirmation
E. Health care
8. Increase utilization of selfcare skills
9. Decrease fear, immobilization, and helplessness
10. Decrease dependency on relationship with offender
11. Educate regarding family and social facilitators of domestic violence
12. Improve assertive communication
13. Begin vocational training/education
14. Increase awareness of behavioral patterns and vulnerability
CHILD ABUSE AND NEGLECT
Child abuse encompasses physical abuse, emotional/psychological abuse, neglect, and sexual
abuse. The report of suspected child abuse is a written narrative describing the suspected
abuse, a summary of statements made by the victim or person(s) accompanying the child,
and an explanation of known history of similar incident(s) for the minor victim on a form
which can be obtained from child protective services or other agency whose jurisdiction
oversees and investigates suspected child abuse. The foundation of the report is based on the
verbalized statements of alleged abuse as well as the physical and emotional indicators of
child abuse.
A therapist may participate at various levels of prevention, intervention, and treatment.
As mandated reporters of child abuse, all therapists should be familiar with identifying
families at risk for abuse as well as the interdisciplinary and community resources available
to victims of child abuse and their families.
PREVENTION
Primary is community education aimed at improving the general wellbeing of families and their chil
p . dren. The focus is to facilitate the development of skills which improve family functioning
and to prevent or alleviate stress or problems which could lead to child abuse.
Secondary is the available or specifically designed services which identify highrisk families and help
prevention them prevent abuse.
Prevention

Tertiary is defined as the intervention or treatment services which assist a family in which child abuse
or neglect has already occurred and acts to prevent further abuse or neglect.
Prevention
INDICATORS OF ABUSE
Indicators of 1. Bruises
Physical Abuse 2. Burns
3. Bite marks
4. Abrasions, lacerations
5. Head injuries
6. Whiplash (shaken baby syndrome)
7. Internal injuries
8. Fractures
Indicators of 1. The child is depressed and apathetic

Emotional/ 2. The child is withdrawn
Psychological 3. The child is overly conforming to authority figures
4. Demonstrates behavioral problems or "acting out"
Abuse
5. Demonstrates repetitive, rhythmic movements
6. Overly concerned with detail
7. Unreasonable demands or expectations are placed on the child
8. The child is triangulated into marital conflicts
9. The child is viewed as property of the parent (referred to as "it" instead of
by name)
10. The child is used to gratify parental needs
11. The child demonstrates exaggerated fears or antisocial behaviors
12. The child is unable to perform normal, ageappropriate behaviors/skills
13. Constantly seeking the attention and affection of adults
Indicators of 1. Lack of adequate medical/dental care

Child Neglect 2. The child demonstrates poor personal hygiene
3. The child is always dirty
4. The child is inadequately dressed
5. Poor supervision/left home alone
6. Unsanitary environmental conditions
7. Lack of heating and plumbing
8. Fire hazards and other unsafe home conditions
9. Inadequate sleeping arrangements (cold, dirty, etc.)
10. Inadequate nutrition/children fend for their own nutritional needs
These conditions existing as chronic and extreme constitute the definition of an unfit home

and neglect.

General Symptoms 1. Enuresis or fecal soiling
of Possible Child 2. Eating disturbances
Sexual Abuse 3. Fears/phobias/compulsive behaviors
4. Ageinappropriate behaviors (pseudomaturity or regressive behaviors)
5. Problems with school performance and attitudes
6. Difficulty concentrating
8. Depression, low selfworth, and withdrawal
9. Overly compliant
10. Poor social skills
11. Acting out/runaway/antisocial behaviors
12. Substance abuse
13. Ageinappropriate excessive selfconsciousness of body
14. Sudden possession of money, new clothes, or other gifts
15. Selfdestructive behavior, selfdefeating behavior
16. Suicidal thoughts, plans, attempts
17. Crying without apparent reason
18. Fire setting
19. Sexually transmitted diseases, genital infection
20. Physical trauma or irritation to the anal or genital area
21. Difficulty walking or sitting due to genital/anal pain
22. Pain on voiding/elimination
23. Psychosomatic symptoms
24. Ageinappropriate knowledge of sexual behavior
25. Inappropriate sexual behavior with siblings, peers, or objects
26. Compulsive masturbation
27. Excessive curiosity about sexual issues and/or genitalia
28. Promiscuity or prostitution
TREATMENT
When dealing with issues of neglect or psychological abuse, appropriate education and sup
port are often sufficient to alter the identified circumstances of neglect. There are, of course,
instances in which the psychological/emotional functioning of the parent(s) is not adequate
to consistently provide the child's necessities for health and wellness without an increased
level of intervention and treatment, possibly removing the child from a home.
With issues of physical abuse, child safety is the central focus. The court relies on expert
witness testimony, collateral observations and information, interview of the victim and the
parent(s) or other offender if not a parent to make the determination of setting appropriate
goals. Treatment goals could range from removal of the child to insure safety with a tenta
tive plan for early reunification to longterm placement of a child who cannot be safety
returned to their home.
While a child experiencing any level of abuse may benefit from therapy, a child who has
been sexually abused should be referred for therapy as soon as possible. Even if the family
is participating in a treatment program, the child should be referred for individual therapy
so that the impact of abuse can be evaluated without the family dynamics overshadowing
the child's intrapersonalinterpersonal experience resulting from the abuse.

Likewise parent(s) or caretaker(s) need assistance in understanding what the assessed abu
sive behaviors are, why they are abusive, how to effectively manage their own lives, and how
to effectively parent. These families need to have resources identified for them that can be
helpful for ongoing support, education, and crisis intervention.
CHILD CUSTODY EVALUATION
When mediation has not been successful, a qualified psychologist is often called on to con

duct a child custody evaluation. Requirements of standard of care following ethical and pro
fessional guidelines act to protect and preserve the rights of all with the best interest of the
children being the central focus of outcome.
GUIDELINES FOR PSYCHOLOGICAL EVALUATION
A. Examination of Child
1. Mental status with behavioral observations noted.
2. Developmental milestones.
3. Coping methods, especially with regard to issues of change in lifestyle, family
constellation in their daily environment, use of transitional objects in lieu of
absence of a parent, and dealing with loss.
4. Degree of attachment to parents.
5. Stage of development and what type of parenting indicative of each parent.
6. Presence of psychosocial impairment, severity, interventions recommended.
7. Use of psychological testing instruments as deemed necessary.
B. Individual Examination of Parents
1. Mental status with behavioral observations noted.
2. Personality functioning and parenting skills. Are there issues/concerns related
to parental functioning which could compromise and/or damage the child's
wellbeing?
a. Psychopathological states which are indicative or have demonstrated the
fostering of delinquent/antisocial behavior.
b. Pathology which impairs the ability to parent consistently and safely such as
psychosis, substance abuse issues, character disturbances.
c. An unhealthy focus or unconscious concerns related to dependency, power,
sexuality, anger, and using the child(ren) to meet their own needs.
3. Personal history with reference to their own childhood experiences, i.e., how did their
family deal with anger, discipline, emotional needs met, parental relationship, etc.
4. Demonstration of flexibility in accepting feedback related to their parenting
responsibilities, skills, and recommendations for change.
5. Likely method of restoring missing partner—cooperative or noncooperative.
6. Ability and willingness to form treatment alliance serving the best interest of their
child(ren).
7. Use of psychological testing instruments as deemed necessary.
C. Conjoint Examination of Parents
1. How do they complement each other in appropriate parenting ability?
2. How do personality dynamics affect minimal cooperative efforts in managing the
needs of child(ren)?
3. How will they likely respond to their expartner's choices such as remarriage?

The purpose of the Bonding Study is to develop an understanding of the degree to which the
child demonstrates an attachment with their perspective family.
ABILITY OF THE CHILD TO BOND
1. Is the child bonded to the parent(s)?
2. What is the quality of attachment?
3. Does the child have the capacity to bond to anyone?
4. If the child were removed from this home would it result in psychological damage?
5. Are the visitations between child and parent(s) meeting
developmental/psychological needs of the child?
6. Compare/contrast the relationship of the child to both parents and both
parents to the child.
7. Observe leavetaking behavior and affect.
8. Be aware of any impediments to child bonding such as child or parent deafness.
Some children identified as "at risk" and requiring special care may need specific parental

qualities of nurturance and positive regard. The potential parents must be thoroughly eval
uated for their ability and desire to care for a specialneeds child. In observing the child and
interactions with the potential parents it is necessary to have a clear picture of the level of
child development and maturity.
Additional issues include:
1. History and current status of the child's health.

2. Any changes in the child's behavior observed by the custodial/foster parent on
the way to a visit, on the way home from a visit, or for the reset of the day
following the visit.
3. Be prepared by being familiar with the history of the child and the relationship
being observed.
ABILITY OF THE PARENT TO BOND AND OTHER

PERTINENT INFORMATION
1. Thorough review of background and courtrelated history.
2. Observation of parent's mental status.
3. Clinical interview.
4. Psychological testing if necessary for clarification on issues of functioning.
5. Observe nature of family relationships.
6. Collateral contacts for information related to history of child (number of
caretakers, quality of care, history of abuse, previous psychological treatment,
etc.) history of perspective parent(s) {similar issues).
7. Stage of development versus behavioral manifestations in various settings.
8. Additional considerations if present related to cultural or familial factors,
substance abuse, support system, reunification, etc.
The unique information required in a Bonding Evaluation can be applied to the report out
line of a Child Custody Evaluation.

CHILD CUSTODY EVALUATION REPORT OUTLINE
A. Identification of Case
1. Parties and minor children
2. Legal issues and standards
3. Referral source(s)
4. Referral question(s)
5. List collateral contacts and cite the form of contact such as phone, record review, etc.
B. Schedule of Appointments
1. Individual(s) seen
2. Date(s) of service
3. Amount of time devoted to evaluation of each individual and the methods of
evaluation utilized.
C. Assessment
1. Document the stated objectives of each party related to custody and visitation.
2. What does each party view as the primary issues such as conflicts, and allegations.
3. Parent statements, from their perspective, of their own strengths, weaknesses, and
limitations as a parent and their view of the child(ren) in terms of needs and
impairments—and their view on the same issue as it pertains to the other parent.
4. Information gathered from prior findings (records, summary analyses, etc.) which
establish a foundation of relevant background and context for the current evaluation.
D. Results of Evaluation
1. Statement of evaluation findings which includes:
a. mental status exam
b. interview information as it pertains to child custody
c. observations
d. relevant psychological testing information
E. Interpretation of Findings
1. Parental abilities, strengths/concerns/impairments that either enhance or detract
from competent parenting.
2. Mental health of child(ren) clarifying developmental needs, special considerations,
vulnerabilities, etc.
3. Quality of parentchild interaction, parentparent interaction with issues of
consistency and congruence.
4. Issues of credibility related to these findings.
F. Discussion of Findings
This section utilizes specific references to detail each parent's competencies as it pertains to

the best interest of the child(ren). Address issues of health, safety, and welfare of the
child(ren). Include relevant issues such as child abuse, neglect, etc. Use this section to inte
grate all relevant findings presented in the evaluation.
G. Opinions
If requested regarding specific referral questions and legal issues in reference to legal and
physical custody, visitation, activities, contact with other significant people in the support
system of the child(ren), etc.

H. ParentChild Interaction
1. How does the child(ren) spontaneously respond to the parent—valued, devalued,
close, distant—and the reason behind it.
2. Is the parent appropriately engaged with the child(ren), listens and communicates
with them, facilitates appropriate selfmanagement by the child(ren), provides them
choices, etc.?
3. Is the parent nurturing and resourceful to the child(ren)?
During the assessment of the parentchild(ren) interaction, the interaction is broken down

or defined by the following factors:
PARENTAL BEHAVIOR
1. Eye contact
2. Ageappropriate structure/limit setting/discipline
3. Type of objects brought by parents for the child(ren): food, toys, clothing, etc.
4. Amount and emotional quality of physical contact
5. Initiative toward interaction
6. Ageappropriate expectations
7. Appropriateness of verbal interaction, questions, etc.
8. Attitude and behavior, before, during, and after interview
INTERACTION BETWEEN PARENTCHILD (REN)

1. Child(ren) behavior toward parent, and parent's response to it
2. Eye contact or avoidance on the behalf of parent or child (ren)
3. Affectionate, positive, nurturing body language
4. Quality and type of physical contact between parent and child(ren), i.e., sit
together in chair, together on floor, playful, engaged in any way
5. Verbal exchanges
6. Parent limit setting/structure and child(ren) response
BONDING STUDY VERSUS CUSTODY EVALUATION

The reference of bonding is related to the issue of adoption. A bonding study minimally
requires:
1. An observation of the minor

2. Interviews with the bonding parent(s)
3. Observations in combinations of parent, parentschild, parentchild, whole family
4. Some of the observations are to be made in the home environment
5. Psychological testing will be utilized if the perspective parents have not been
previously evaluated
6. Interviews with anyone significant to the child's life: prospective siblings,
teachers, etc.
7. Thorough review of available documents
8. Recommendations

Specify treatment recommendations, individual (parent or child), conjoint remediation
between parent or between parentchild(ren), need of special programs, etc. Be sure that all
issues and questions raised by the court have been addressed.
PARENTAL ALIENATION SYNDROME
Parental alienation syndrome (PAS) occurs when parental influence or programming is com
bined with a child's own disparaging views of a parent. Overall, there are four contributing
factors to PAS:
PARENTAL PROGRAMMING
1. Most often overt and obvious
2. Often there is an infrequency of visits or lack of contact with the alienated
parent (which decreases opportunity to correct the alienating parent's
distortions. Without actual experience, the child may completely accept the
alienating parents criticisms)
3. Common complaints of the preferred parent
A. He/she has to pay for everything
B. He/she cannot depend on the alienated parent
He/she "abandoned us"
He/she destroyed the family
He/she is mean, abusive, or sick
C. The preferred parent exaggerates the psychological problems of the alienated
parent
1. Uses sarcasm to highlight how undesirable the alienated parent is
2. Interferes with phone calls from alienated parent
3. Mentors child in being deceitful to alienated parent, making the child an
accomplice in warfare (message is that alienated parent is not worthy of honesty
and respect)
4. Labels attempts of hated parents to contact child or be involved in their lives as
harassment
SUBTLE AND UNCONSCIOUS INFLUENCING
1. Preferred parent may state that he/she never criticizes the other parent to the
child, however, says things like "I could tell you some things (about the other
parent), but I'm not the kind of parent who speaks badly about the other
parent"
2. Respects the child's wishes to spend time with the alienated parent, but
the child generally knows that the preferred parent doesn't want him
or her to or uses subtle sabotage: "If you don't visit, he/she will take us to
court"
3. Provokes feelings of guilt for abandoning the preferred parent when the child
spends time with the alienated parent
4. Finds neutral ways to convey the inadequacies of the alienated parent
5. Undoing (i.e., criticizes the other parent and then says, "I didn't mean it" or
"I was just kidding")

CHILD'S OWN SCENARIOS
These are experiences or perceptions of the child, which play a role in the alienation process
by feelings of validation, juvenile punishment of the alienated parent, protectiveness of the
preferred parent, experience of viewing emotional/physical abuse perpetrated by alienated
parent toward the preferred parent, and so forth
1. Lack of nurturance from alienated parent

2. Lack of bonding
3. Anger or disappointments
4. Seeing preferred prerent as a victim or fragile
5. Experiencing parent as nongratifying
6. Seeing alienated parent as mean and rigid (difficult to get the child's needs met)
*It is important to not lose sight of the child's contribution in parental alienation.
FAMILY DYNAMICS AND ENVIRONMENT/
SITUATIONAL ISSUES
1. System structure parents create (nurturer, disciplinarian, understanding, rigid
rules, encouragement, controlling, etc.)
2. Closed versus open family system
3. History of colluding behavior
4. Poor health in a parent
5. Prioritizing (work, couple's time, individual time, family time, etc.)
6. Values/morality
For the alienated parent, PAS only applies when this parent has not engaged in any degree

of abusive behavior that would warrant such a response from the child. Generally, these par
ents have provided relatively normal nurturing parenting. Sometimes there is evidence of
minor weakness/deficiencies, which are exaggerated and become the benchmark of focus in
the development of PAS. Children are preoccupied in an unjust and exaggerated manner on
these deficiencies in the parent.
As instruments to be used, these children become an ally with the preferred parent in an
effort to preserve what they identify to be the most desirable living arrangement. This hap
pens without awareness that in some situations primary custody by the alienated parent
might actually be in the child's best interest. Here the child becomes a weapon, thereby
enabling the preferred/loved parent to gratify his/her hostility toward the alienated/hated
parent through the child. The loved parent is also preoccupied with the hated parent's
defects, thus creating and reinforcing a distorted image.
CRITERIA FOR ESTABLISHING PRIMARY CUSTODY
1. Preference is given to the parent with the stronger and healthier bond
2. The primary caretaker during the early formative years of a child's life is likely
to exhibit the stronger/healthier bond
3. The more extensive time between these formative years and the time of the
custody decision, the greater the likelihood that other factors may influence
custody in either direction.

BEHAVIORS OF THE PARENTS
1. The preferred parent
A. Denies positives in relationship between the child and the alienated parent
B. Describes behaviors in absolutes of "always" or "never"
C. Emotional boundary disintegration
1. Merges his/her own feelings/views with the child ("We won't let them take
us to court and hurt us anymore")
D. Makes direct/indirect attempts to interfere with the relationship between the
child and the alienated parent
E. When the child is with the alienated parent, creates intrusive interference by
numerous phone calls
E Involves the child in spying and information gathering
G. Uses child as confidant, sharing adult issues about divorce, blaming,
and so on
H. Uses child as a messenger between parents
I. Creates family splitting and feuding
*The evaluator will need to take into consideration if the behaviors of the preferred parent

are associated with real or perceived deficiencies of the alienated parent. Depending on what
is found, there needs to be recommendations that address these issues. If the issues are
addressed in the recommendations in the form of intervention, to whom they are directed
depends on whether they are genuine or not (i.e., does the alienated parent need to modify
or cease certain behaviors, or does the alienating parent need to alter perceptions and
acknowledge the ways in which a child is negatively affected by the situation?).
2. The alienated parent
A. Healthy relationship with child prior to separation
1. Being shut out of the child's life
2. Insightful, willing to accept responsibility and examine a range of possibilities
associated with a child's behavior
3. History of actively participating in his/her child's life
4. Nurturing qualities with possible tendency toward passivity
5. May experience some difficulty dealing with overwhelming emotion
* These factors provide an environment for alienation to take hold. In such family systems,

the preferred or alienating parent is typically emotionally overreactive and extreme, whereas
the alienated parent is empathic, sensitive, nurturing, and passive or avoidant of conflict
(peacemaker). Therefore, when the alienation is put in motion the alienated parent may ini
tially respond in a more passive manner, feel overwhelmed and not knowing what to do.
Unfortunately, there may be a tendency to detach to avoid conflicts, and this reinforces the
behavior of the alienating parent. Additionally, if the court system reinforces or rewards the
alienating parent's behavior, it creates a momentum to the alienation that seems impossible
to stop. In this situation, when the alienated parent has finally had enough and responds
with repeated efforts to participate more in the child's life, he/she is easily labeled with
harassment, and when he/she sets firm limits with the alienating parent, he/she is labeled
vengeful and often reprimanded and told he/she is fueling the situation.
B. The parent claims alienation is the source of estrangement, however, he/she is

defensive, avoidant, externalizes blame, and has difficulty with selfresponsibility,
which are really the original souces of estrangement

1. Had little to do with the child prior to separation (workaholics/selfcentered)
2. Quickly involved in a new relationship with an insensitivity to child's feelings
and issues of adjustment and relationship building
3. Controlling, powerful, dominating (blame/externalizing is common)
4. Expectation of child exceeds their investment in the relationship (demanding
without nurturing, but expects the child to be a certain way following
separation)
5. Less child centered and less empathic
6. Parentchild relationship has a superficial quality due to years of neglect
7. Has a keen sense for showing up at the right moments for credit as being
supportive—"Kodak moments"
8. May report being active in the child's life via encouragement in activities or
coaching sports, but the child actually feels pushed into these activities
9. May alleged alienation as a means to continue to control and blame
* Identification of these parents is initially challenging, but clarity can be achieved by explor

ing the history of their investment in family and the parentchild relationship coupled with
defensiveness, control, selffocus, blaming/externalization, and overall superficial quality to
the parentchild relationship.
CHILDREN
The relationship between parents and children can be fragile and tenuous, even if it were a
positive one prior to separation. Children don't have the ability, let alone the power, to main
tain the necessary boundaries for normal and healthy relationships with their parents. They
are dependent on parents setting and maintaining the guidelines for healthy relationships. As
a result, when parents lack respect and responsibility in guiding their own behaviors and
making decisions that are truly in the best interest of their children, the children are eclipsed
and caught in the middle. It is these dynamics in which parental alienation is initiated and
encouraged. The child become a pawn in vengeance and in meeting the needs of the parent.
The needs of the child are secondary.
As the war ensues, causation and reason for the conflicts are often not clearly discernible.
What is clear is that anyone or anything that is not supportive of the preferred parent's per
ception is viewed as negative and rejected. The child may already have his/her own slightly
tainted image of the alienated parent, but this is accelerated under the influence of the pre
ferred parent. If a child is somewhat passive, dependent, and feels a need to care/protect/
nurture the alienating parent, he/she is even more susceptible to alienating programming.
This boundariless fusion of feelings enmeshes the child and the alienating parent. Some of
the psychological/emotional problems that these children are at risk for developing include
the following:
1. Depression
2. Dependency
3. Psychological vulnerability
4. Abandonment issues
5. Splitting
6. Inability to tolerate anger/hostility
7. Anger and rage
8. Difficulty developing intimate relationships
9. Conflicts with authority figures
10. Psychosomatic symptoms

11. Eating disorders
12. Entitlement
Often when these children are evaluated, there is little evidence of them being placed in the

middle. Many have experienced one parent being controlling or dictatorial, severe hostility,
and spousal abuse. There is a quality of sadness in them and either ambivalence associated
with a desire for a healthy relationship with the alienated parent or just the lack of a rela
tionship with this parent. This would indicate being aligned to the preferred parent, but not
total alienation for the other parent.
As the clarity of systems dynamics develops, several other issues may become apparent
regarding the quality of the relationship the child shares with each parent. There may be
an alignment with one parent, but it is not due to alienation. Time is spent with a specific
parent because of shared interest (sports, arts/music, outdoors). The child also spends a
modified amount of time with the other parent. Second, alignment with one parent may be
an adaptive maneuver that removes the child from the middle as conflict escalates in an
effort to decrease anxiety and vulnerability. In this case, the child is demonstrating a desire
to not be a part of parental conflicts, not as an instrument in parental alienation, and it may
not even matter which parent it is. Therefore, it is the conflict (anxiety and vulnerability) that
drives the parental alignment and splitting.
THREE CATEGORIES OF PARENTAL ALIENATION

1. Mild (as evidenced by)
A. Subtle attempts to alienate a child against the other parent may take place
B. The child is influenced to take on the preferred parent's point of view with
unconscious or conscious efforts and a lack of insight of how it makes a child feel
C. The alienating parent maintains the importance of a relationship with both parents
D. Generally, both parents recognize that alienation from either parent is not in the
best interest of the child
E. Communication between parents exists and there is a more conciliatory approach
to requests by the alienated parent to be involved in the child's life
F. Even though the preferred parent wants sole custody and believes that it would be
best for the child, he/she recognizes that protracted legal proceedings may cause
more suffering for the child
G. Children develop their own views, with slight prodding from the preferred parent
H. Children though ambivalent regarding visitation, are free to express their feelings
*For most children the consequences are minimal and include minor loyalty conflicts and
anxiety, there is no fundamental change in the child's own view of the alienated parent
2. Moderate (as evidenced by)

A. Preferred parent often feels hurt, angry, and vengeful
B. Preferred parent expects the child to take sides and be loyal to him/her
C. Preferred parent actively interferes with visitation arrangements and relationship
with the alienated parent
D. Preferred parent supports the notion of a relationship with the other parent, yet
consciously/unconsciously perpetrates sabotage
E. Preferred parent may ignore court orders (if he/she can get away with it)
F. Paranoid projections are not as extreme as in severe PAS
G. There is some ability to differentiate between allegations that are
dishonest/outlandish versus genuine complaints

H. Significant desire to withhold child from the alienated parent as vengeful maneuvering
I. Though unreceptive, the preferred parent complies with court orders under
pressure, threat of sanctions, transfer of custody, and so on
J. Psychological bond may be healthy but is compromised by anger/rage
K. The preferred parent likely demonstrated good parenting prior to divorce
* Common consequences for children
1. Insecurity
2. Distortions (viewing the alienating parent as the good parent and the alienated
parent as the bad parent with some integration of positives about the alienated
parent)
3. Anxiety
4. Splitting/manipulating
5. Limited relationship with the alienated parent
3. Severe (as evidenced by)
A. Preferred parent is angry, bitter, and possibly feels abandoned and betrayed by the
alienated parent
B. Conscious, consistence disparaging programming of the alienated parent by the
preferred parent and the child (initiated by parent and adapted by child)
C. In most cases, the child and alienated parent had a relatively positive and healthy
relationship previously
D. The preferred parent will utilize every mechanism and opportunity to prevent
visitation
E. These parents are not logical, reality based, or appeal to reason
F. Paranoid projections
G. Impaired child rearing capacity prior to separation/divorce
H. The alienated parent is outraged by the influence and changes in the child and
blames the other parent
EVALUATION AND DISPOSITION CONSIDERATIONS
FOR FAMILIES WHERE PARENTAL ALIENATION OCCURS
The degree of parental alienation syndrome may be viewed as reflective or directly related

to the degree of motivation demonstrated by parents who present or are courtordered for
psychological evaluations and treatment from family court. As a result, these are inherently
difficult cases, which pose an issue for risk management on behalf of the therapist involved
in such a case. Document your case well. The following information presents the mother as
the loved or preferred parent and the father as the hated or alienated parent. However, this
scenario works in the reverse direction as well. Consider the following points and questions
in your evaluation and recommendations.
1. Proper placement of the child is imperative. Without proper placement,
treatment will be futile.
2. Though the parental alienation syndrome is actually a continuum with discrete
markers defining the severity, it is necessary that the therapist evaluating a case
Evaluation and Disposition Considerations for Families Where Parental Alienation Occurs 20/

specifically differentiate between moderate and severe cases because of the
implication on placement.
3. A guardian ad litem for the children at the center of a custody litigation may be
useful. However, if the guardian ad litem is not familiar with the dynamics of
PAS, his/her involvement could prove to be a detriment to the outcome of the
disposition in the case.
4. If the situation does not render reasonable certainty as to what would be the
best decision, offer a "tentative" recommendation subject to review and
reevaluation. However, when possible, every attempt to make a permanent
recommendation is preferred.
5. Create a balance sheet overview of assets and liabilities, including stepparents if
they are in the current clinical picture being evaluated.
6. The parent who is going to discourage the child from visitation is most likely to
deprive the child from important information from the other parent. The
healthier parent, even with his/her own personal issues associated with the
divorce, recognizes the importance of continuing as positive a relationship as
possible with both parents. This is a very important issue in determining
primary custody. The decision of custody is extremely difficult, and there is no
completely satisfactory solution to this issue.
QUESTIONS TO ASK CHILDREN
1. Ask the children to describe one parent and then the other. If PAS is present,
the children will describe one parent with a number of criticisms and the other
with a clear delineation of positive responses.
2. Ask the child to describe each parent's family. If PAS is present, the responses
will reflect a distinct similarity to the answers in the prior question—thus,
preferring the family of the preferred parent and alienation toward the family
of the alienated parent.
3. If PAS has been established by the information gathered and, for example, the
mother is the preferred parent and the father has been alienated, ask the child if
his/her mother interferes with visitation of the father. It is very likely that the
child will describe his/her mother as being neutral and not interfering, stating
that the decision of visitation is entirely the child's own.
4. Again, assuming that the father is the hated/alienated parent, ask the child why
he/she does not want to visit the father. The response initially may be vague. When
pressed for specifics, horrible abuses may be conjured, which are exaggerations
not warranting concern. Sometimes there will be a proclamation that the child's
desire is to have absolutely no contact with the hated/alienated parent.
5. If the mother is the loved/preferred parent, ask the child if the mother harasses
his/her. Normally, it would be expected that a child would offer several
situations where he/she is not gratified. When PAS is present, the mother is
likely to be described more in terms of being a perfect parent. The alienated
parent's attempts to have contact and be involved with the child is what would
be viewed as harassment.
6. Ask the child if the hated/alienated parent harasses him/her. The response
would generally validate the harassment with any attempt (phone calls, letters,
legal intervention, etc.) identified as harassment.

QUESTIONS TO ASK THE PARENTS
1. What is their opinion of parentchild relationships?
A. What is the history of each relationship?
1. What has changed?
2. How has the child been affected?
B. How does each parent demonstrate support of the child's relationship to the other
parent?
C. What do the parents think the child should know about what has happened in the
marriage?
2. What are their ideas of how to improve the circumstances?
3. How do they believe that their behavior has affected their child?
4. What are they willing to do differently?
5. If they make the change recommended, what would be the evidence of that
change in three months, six months, or one year.
PARENTAL ALIENATION SYNDROME TREATMENT
1. Mild PAS
A. Most cases do not require intervention
B. Generally, a final court order will confirm the custody arrangement, often with the
preferred parent due to history of being the primary caretaker and demonstrating a
stronger bond with the child
2. Moderate PAS
A. It is recommended that there be one therapist for the family system
1. Reduce fractionization of communication
2. Decrease antagonistic subsystems
3. Beneficial if therapist is court ordered (with the court being willing to impose
sanctions)
B. Some parents in this category may involve themselves meaningfully in the treatment
process. They may even pursue individual therapy in an effort to take responsibility
for and work through unresolved issues.
C. Because they are good child rearers, the child is often to remain in custody of the
preferred parent
D. Combined effort of therapist and court realigns children to resume normal
visitation
3. Severe PAS
A. One therapist for the family system
B. The alienating parent is not receptive to therapy
1. Will consider a therapist who believes his/her position or is at least passively
supportive by not implementing necessary change or confrontive of the PAS
he/she is instigating
C. The literature's view of how to proceed on the disposition of custody varies
1. Gardner (1989) has stated that the child should be removed from the custody
of the alienating parent with custody being transferred to the alienated parent.
He has recommended a period of decompression/debriefing where there is
no contact from the alienating parent to allow for the reestablishment of a
Parental Alienation Syndrome Treatment 209

relationship with the alienated parent. If there is visitation, it is minimal and in
the presence of a designated third party contracted with the court to formally
monitor the interaction. Once there has been stabilization with parentchild
realignment, the contact with the alienating parent is proceeded with slowly to
prevent a reoccurrence of the previous level of dysfunction. The belief is that if
no intervention has been made, the risk of lifelong alienation between the child
and the alienated parent will result.
Both parents are to be educated about the PAS and what is expected of them regarding
their interaction the child and with issues associated with the other parent. Addressing the
importance of a strong bond with both parents
a. Child's exaggerated hatred is generally a facade (not allowed to be honest,

fear of displeasing, protective, etc.)
b. The need to develop a thick skin to deal with negative outbursts from the
child
c. The importance of neither parent withdrawing from participation in the
child's life
2. Stahl (1999) stated that any abrupt custody change may have significant negative
consequences on the child. Therefore, any proposed changes should be
thoroughly problemsolved so as to not cause more problems for the child. He
has advocated a more balanced custody arrangement of equal time sharing in
larger chunks (two weeks or more at a time). The belief is that in some families
there may never be a viable relationship between the child and the alienated
parent, even with structural changes in custody, therapy, and monitoring. In
such cases, with guidance from the therapist, there may be the recommendation
that the alienated parent temporarily withdraw from the child's life in order to
prevent the child from experiencing any pain due to being in the middle. The
decision to withdraw is only to help their child. It is also made clear that the
parent loves the child, highly desires a relationship with the child, and will make
contact every several months. The parents further states that the child will
always know where the parent is and how to contact him/her.
Research has not been conclusive or consistent on what the right intervention is in severe
PAS cases. Instead, it appears that there should be a thorough review about how to proceed
on a casebycase basis. One intervention that may be helpful in every case for monitoring
of change and information that the court could concretely reinforce for outcomeoriented
specified results would be to explain to each parent the effects of PAS on the child:
1. Have the information reiterated in written form

2. Have both parents sign a form acknowledging their understanding
3. Develop a written treatment plan that breaks down the expected changes and
outlines the associated consequences if there is not compliance have parents
sign the form.
4. Referral for individual therapy for resolution of personal issues is made and a
consultation is made with the individual therapist so that he/she understands
the situation and what is expected
5. Meet intermittently to review progress or lack of progress
The information on PAS was adapted from R. A. Gardner (1989) and P. Stahl (1999).

VISITATION RIGHTS REPORT
When there has been a marital separation, divorce, or outofthehome placement it is some
times necessary to evaluate the parents and child for the purpose of visitation rights. The
goal is to serve the best interest of the child by assuring adequate contact with each parent
in a safe environment under which the visitation occurs. If there is concern related to safety
or a history of difficulties associated with the contact of either parent with the child then
appropriate steps must be taken to provide for the safety of the child.
VISITATION RIGHTS REPORT
1. Dates of gathering information for the report
2. Names of father, mother, and child
3. Referral source
4. Identifying information for each party
5. Relevant background information
6. Site of visitation (and reason for that selected site)
7. History of visitation
8. Child's relationship with mother/evaluation of mother
9. Child's relationship with father/evaluation of father
10. Conclusions
A. Temporary arrangement pending further information, supervision, completion of
recommended classes (anger management/parenting/first aid/etc.), or other
identified issues to be resolved
B. Trial visitation arrangements
C. Permanent arrangement
D. Other parameters/considerations
11. Recommendations
DISPOSITIONAL REVIEW: FOSTER PLACEMENT;
TEMPORARY PLACEMENT
A primary responsibility of mental health professionals (MHP) working with mistreated
children and their families is to remedy difficult situations and prevent placement if possible.
Placement of a child outside of the family home is indicated only as the last option or when
a child is in danger of harm. The task of the MHP may be as a consultant to a child pro
tective service agency in directing the appropriate disposition of the child and family, what
necessary placement would be appropriate, and the monitoring of all parties participating in
a place (Disposition Review).
In evoking the placement process it is important to minimize traumatic disruption and
replacement of caretakers and environments. Placements should be thoroughly screened to
ensure that potential caretakers are prepared to cope effectively with the behaviors of trou
bled children. The last thing an abused or neglected child needs is the validation of rejection.
Therefore, there should be continuity of care where the caretakers are consistent, depend
able, and the basic needs of physical comfort, nurturance, affection, encouragement, gratifi
cation, intellectual development, and social development are offered and facilitated.
D i s p o s i t i o n s ! Review: Foster Placement, Temporary Placement 211

Because the court monitors such placements and because there can be planned or war
ranted charges in placement there may be a request by the court for a Dispositional Review.
The Dispositional Review is a thorough evaluation of all parties and the environment of the
placement. Historically, it addresses the background leading to placement and the placement
goals. The conclusion must address issues of adjustment, and status of goals and objectives.
The last segment of the report is the area of recommendations. This report serves as a baseline
for review and must lend itself to updated addendums to supply to the court with necessary
information during the course of the placement.
DISPOSITIONAL REVIEW REPORT OUTLINE
1. Identifying information of minor/family courtappointed caretakers
2. Reason for referral
3. Relevant background information
4. Sources of data
5. Evaluation of
A. Minor
B. Mother
C. Father
D. Courtassigned caretakers
E. Interaction/relationship functioning between minor and parents and minor and
courtassigned caretakers
F. Environment of placement
6. Conclusions
7. Recommendations

PSYCHIATRIC WORKRELATED
DISABILITY EVALUATION
This is a formal report format for the evaluation of an individual who is believed to be
unable to work due to psychiatric disability.
Name
Date of Report
Date of Birth
Date of Last Day Worked
Case Number
IDENTIFYING INFORMATION
A. Date, place, and duration of examination
B. Reason for referral and referral question(s)
C. Names of all individuals participating in the examination. Include the use of
interpreter or any other party present and why they are present.
D. Sources of Information
1. Collateral contacts
2. Prior reports/progress notes/medical records
3. Clinical interview
4. Mental status exam
5. Psychological tests
DESCRIPTION OF CLIENT AT TIME OF INTERVIEW

A. Appearance (include any physical variance)
B. General behavior, demeanor, presentation
C. The observed effective state
D. Stream of speech
DESCRIPTIONS OF CLIENT'S CURRENT COMPLAINTS

A. Subjective complaints, described in their own words
B. The client's view of the impairment created/resulting from the described
complaint
HISTORY OF PRESENT ILLNESS

A. Client's description of workrelated/industrial stressors, onset
of the complaints, and the alleged injuries/illness associated with
the onset
B. Psychological/emotional response to the alleged injury situation
Psychiatric WorkRelated Disability Evaluation 213

C. History of mental health problems since the alleged injury
D. History of treatment since the alleged injury
E. Current treatment
1. Medication (including medication taken on the day of the interview)
2. Psychotherapy
3. Group therapy
4. Alternative approaches used for management of complaints
OCCUPATIONAL HISTORY
This section includes work events prior to injury, concurrent with injury, and after
injury.
A. Educational level and profession, technical, and/or vocational training

B. Sequence of work experience/occupations pursued including military and
internship trainings
1. Training and skills required
2. Management/supervisory responsibilities
3. Career mobility (vertical or lateral moves)
C. Accomplishments and/or difficulties in each position and occupational
setting
D. Previous occupational injuries, time lost, leaves of absence, and outcome to all
situations addressed
PAST PSYCHIATRIC HISTORY AND RELEVANT
MEDICAL HISTORY
A. Prior experiences in therapy
B. Hospitalizations
C. Psychotropic medication history/prescribed by whom
D. Medical history resulting from occupational setting or exacerbated by it
FAMILY HISTORY
A. Family of Origin
1. Parent's age, education, and occupational history
2. Sibling's age, education, and occupational history
3. Composition of family during client's childhood and adolescence
4. Mental health history and relevant medical history of family members
5. Family response to illness
6. Relevant social history of family members
7. Quality of family relations
B. Family of Procreation
1. Present marital status/history of previous marital relationships
2. Spouse's age, education, occupational history
3. Number of offspring (if offspring are of adult age obtain same data as
for spouse)

4. Mental health history and relevant medical history of family members
5. Relevant social history of family members
6. Quality of family relations
DEVELOPMENTAL HISTORY
A. Developmental milestones (met at appropriate ages/delays/difficulties)
SOCIAL HISTORY (DISTINGUISH PRIOR TO DISABILITY,

DISABILITY CONCURRENT, AFTER INJURY)
A. Interpersonal relationships
B. Previous life changes/crises/losses and how responded to
C. Educational history
D. Relevant legal history (prior workers' compensation and personal injury claims
with circumstances and outcome)
E. Relevant criminal history
F. Substance use and abuse
G. Client's description of a typical day
MENTAL STATUS EXAM
A. Hygiene, grooming, anything remarkable about appearance
B. Mood (normal, depressed, elevated, euphoric, angry, irritable, anxious)
C. Affect (normal, broad, restricted, blunted, flat, inappropriate, labile)
D. Memory (intact, shortterm/remote memory)
E. Orientation (time, place, person, situation)
F. Speech (descriptors, expressive language, receptive language)
G. Processes (normal, blocking, loose associations, confabulations, flight of ideas,
ideas of reference, grandiosity, paranoia, obsession, perseverations,
depersonalization, suicidal ideation, homicidal ideation)
H. Hallucinations
I. Evidence of deficit (learning, problem solving, and judgment)
J. Impulse control
K. Behavioral observations/evidence of physiologic disturbance (somatoform or
conversion symptoms, autonomic, skeletal muscle system)
L. Client's response to the examiner/appropriateness during course of
interview
REVIEW OF MEDICAL RECORD
FINDINGS FROM PSYCHOLOGICAL ASSESSMENT

(attach complete psychological report which has been completed as per workers' compensa
tion guidelines)
Psychiatric WorkRelated Disability E v a l u a t i o n 215

INTERVIEWS WITH COLLATERAL SOURCES AND REVIEW
OF EMPLOYMENT OR PERSONNEL RECORDS (COMPARE
DESCRIPTION OF INDUSTRIAL INJURY WITH CLIENTS
DESCRIPTION)
DSMIV DIAGNOSIS (MULTIAXIAL, USING DSM CRITERIA

AND TERMINOLOGY)
SUMMARY AND CONCLUSIONS
A. Brief summary of relevant history and finding
B. Present and justify an opinion concerning the current cause(s) of disability if
present
1. The relationship of the work environment to the disability
2. Nonindustrial causes of disability and preexisting causal factors
3. Aggravating or accelerating factor (industrial and nonindustrial)
4. Natural progression of preexisting disorder
5. Active or passive contribution of the workplace to the disability
6. Client's subjective reaction to stress at work
C. Indicate any diagnostic entities which were work disabling prior to the alleged
industrial injury and provide evidence.
D. State whether the disability is temporary or has reached permanent stationary
status and cite evidence. If the condition is permanent and stationary, state on
what date it became so and cite evidence. Consider the history of the disorder,
and the response to treatment. If the condition is not yet considered to be
permanent and stationary, state when you expect it will be so. If the opinion is
that reasonable medical treatment will improve the condition, then describe the
treatment and the expected benefits.
E. If the disability is permanent and stationary, offer an opinion regarding the
nature and severity of the disability. Describe the disabling symptoms
(subjective and objective), citing symptoms, mental status findings,
psychological test data, and history to support opinion.
F. Make an advisory apportionment of disability. Do this by describing the
disability that would exist at this time in the absence of the workplace injury.
Cite the evidence on which the estimated preinjury level is based on.
G. Recommend treatment and/or rehabilitation if indicated and define using the
following:
1. The effects of the injury, combined or not with any previous injury
2. Whether the individual is permanently precluded or likely to be precluded from
engaging in their usual and customary occupation, or the occupation in which they
were engaged in at the time of the injury (if different).
H. Be sure that all referral questions have been addressed and address any
questions and/or issues raised in the referral reports.
Indicate whether or not actual events of employment were responsible for a substantial
degree of the total causation from all sources contributing to the psychiatric injury (clarify
if the state that you practice in stipulates a percentage of total causation related to employ
ment for valid workrelated disability claim).

PSYCHOLOGICAL PREEMPLOYMENT EVALUATION
The purpose of a preemployment evaluation is to determine whether the individual being

considered for a certain position has the psychological suitability (emotional nature and psy
chological character) necessary to effectively perform the job requirements and the ability to
cope with the emotional factors to which they are likely to be exposed to.
REPORT OUTLINE
Name of Candidate
Date of Birth
Date Tested
Date Interviewed
Referral Source
1. Identifying Information

A. Age, ethnicity, marital status, the position being sought by the candidate, and any
other pertinent information designated to identification.
2. Procedures
A. Clinical interview
B. Adult History Questionnaire (thorough exploration of life experience)
C. Minnesota Multiphasic Personality Inventory
D. California Psychological Inventory
E. Rotter Incomplete Sentence Blank
F. BenderGestalt Sentence Blank
3. Relevant History
4. Behavioral Observations and Mental Status
5. Assessment Results
6. Interpretation of Results
7. Summary and Conclusions
A. Designating reasoning for conclusion of supporting or not supporting candidate for
selection for employment position.
The areas of psychological suitability being assessed include attitude, impression formation,

moral and ethical behavior, dominance, emotional control, anxiety, social adjustment,
mood, somatic concerns, intelligence, maturity, sensitivity/guardedness, independence, and
conformity.
Psychological PreEmployment Evaluation 21/

COMPULSORY PSYCHOLOGICAL EVALUATION
A compulsory evaluation is used for a variety of circumstances. A common reason for refer

ral is to establish the following:
1. Workrelated problems

A. Job performance
B. Inappropriate behavior in the workplace
2. Determining remediation of difficulties and/or criteria for returning
to work
3. A thorough assessment of psychiatric difficulties in order to clarify
psychopathology and to offer treatment planning
COMPULSORY PSYCHOLOGICAL EVALUATION

1. Client Name
2. Date of Birth
3. Dates Tested
4. Dates Interviewed
5. Tests Administered
6. Referral Source
7. Reason For Referral
8. Identifying Information
9. Relevant Background Information (historical and of current
problem)
10. Behavioral Observations and Mental Status
11. Significant Test Results
12. Summary
13. Recommendations

FORENSIC EVALUATION
The legal issue of competency in a criminal proceeding are related to stages of the legal
process, and may demonstrate some overlap in their definitions. Every state has its own def
inition of competency which includes with deficiencies described in the context of mental
disorders, disease, or defect. However, this does not mean that all defendants in a criminal
proceeding who present with a documented or currently evaluated mental disorder are
incompetent. It is also important to note that a defined incompetency in a civil situation does
not automatically translate to incompetency in any level of a criminal proceeding.
A competency evaluation is not a quest for clarification of treatment issues, but rather a
format in which to present relevant information to the court when making legal decisions
related to the defendant. Therefore, competency evaluations deal with issues of legal con
cern. According to Grisso (1988), the five objectives of competency evaluations are:
1. A functional description of specific abilities which defines the defendant's

strengths and deficits by the legal standard or criteria for competency. This
aspect of the evaluation is the assessment of understanding and reasoning
about trials and the defense process.
2. Information indicative of the cause of deficits in competency abilities. This
aspect of the evaluation offers information derived from clinical observation
and other data to determine:
A. Symptoms or criteria of a mental disorder
B. The identification of any other plausible explanations
C. The logical relation between a mental disorder or other plausible explanation(s)
and functional deficit(s)
3. The interactive importance of deficits in any competency ability. This aspect of
the evaluation demonstrates the degree or level of practical significance to the
identified deficits in relationship to the demand of the legal process confronting
the defendant.
4. Conclusory opinions about legal competency and incompetency. This is the
examiner's opinion about the defendant's ability to stand trial given their
strengths, deficits, and the demands of the process. This aspect of the
evaluation is not necessary unless requested to make comment. Generally, this
is not a component of the evaluation.
5. Advised remedy for the deficits identified in competency abilities. This
aspect of the evaluation offers the court methods or recommendations to
remedy deficits or other options for dealing with the current disposition. As
previously noted, it is not the court's quest to determine necessary treatment
but rather what treatment or time frame would be required to restore the
defendant to a level of functioning appropriate for resocialization in the
community.
Forensic Evaluation 219

REPORT OUTLINE
COMPETENCY
1. Interview Date
2. Patient/Admonishment (optional if civil versus criminal proceeding)
3. Sources of Data
4. Reason for Referral and by Whom
5. Relevant Background Information (including family if information is
available)
6. Determination of Competency
A. Behavioral observations
B. Assessment of intellectual functioning
C. Assessment of adaptive functioning
7. Conclusions
8. Recommendations
COMPETENCY TO PLEAD AND/OR CONFESS
1. Interview Date
2. Patient/Defendant Identifier/Admonishment
3. Sources of Data
4. Reason for Referral and by Whom
5. Relevant Background Information
6. Personal History
7. Mental Status
8. Observations Concerning Competency to Confess
9. Observations Concerning Competency to Plead Guilty
COMPETENCY TO STAND TRIAL

1. Interview Date
3. Sources of Data
4. Referral Source
6. Mental Status
7. Defendant's Understanding of the Legal Situation
8. Conclusions Concerning Competency to Stand Trial
9. Recommendations for Treatment (optional)
MENTAL STATUS AT TIME OF OFFENSE

1. Interview Date
3. Sources of Data

4. Referral Source
6. Circumstances of the Offense
7. Present Mental Status/Predefense Mental Status
8. Mental Status At Time of Offense
Report Outline 221

Chapter 3
SkillBuilding Resources for
Increasing Social Competency
In an effort to be efficient and timely, therapists need to develop their own resources for facil

itating cognitive and behavioral changes with the individuals that they work with. This sec
tion offers resources in a form that can be used as homework, education, and increasing
awareness as agents of change.
WHAT IS STRESS?
Stress is the body's physical, emotional, and psychological response to any demand. It is gen
erally perceived mentally as pressure or urgency to respond, which is experienced as mental
strain. Stress is associated with the more primitive survival "fight" or "flight" response.
When confronted with danger, the body responds physiologically with the release of adren
alin and hydrocortisone (cortisol). Short term, these chemicals shut down some biological
mechanisms in order to conserve energy, which may be needed for fight or flight. After
the challenge has been met and resolved, the body returns to normal. Normal body func
tioning is demonstrated by muscles relaxing, hands becoming dry, stomach unwinding, and
gastrointestinal relaxation heart rate and blood pressure returning to normal. Long term
adrenalin and hydrocortisone can result in numerous negative influences physiologically,
psychologically, and emotionally. One of these negative consequences is suppression of the
immune system. If managed effectively, stress is not necessarily bad for you. It can provide
223
momentum to get things going and increase productivity. Review some differences between
positive stress and negative stress:
1. Positive stress

A. Is short term
B. Motivates
C. May feel exciting
D. Improves productivity
E. Improves performance
F. Is pleasant
G. Is beneficial
H. Is important to physical and mental fitness
I. Focuses energy
J. Sharpens the mind
2. Negative stress (referred to as distress)
A. Can be harmful, especially if experienced for a long period of time
B. Drains energy reserves
C. Causes emotional depression
D. Suppresses immune system
E. Builds over time instead of diminishing
F. Can lead to mental and physical problems
G. Can change the way a person thinks
Stress has no boundaries, everyone experiences it. It is a part of daily life. Most individ

uals live a lifestyle and life circumstances at a medium level of stress. This level is enough to
keep one's attention sharp and motivation high in order to remain task oriented with the
goal of alleviating stress. It is when stress escalates beyond this moderate level that it can
become harmful. No one is immune from the negative effects of stress, and it may be cumu
lative in how individuals are able to respond over time (burnout).
Since everyone evaluates their experiences differently, no particular factors are identified
as the causes of stress. Stress can come from pressures at home or work, from relationships
from school, or as the result of other personal situations. Oftentimes, stress is associated
with the "too much" phenomenon:
1. Too many changes
2. Too high of expectations
3. Too much responsibility
4. Too much information (overload)
The more stressors you have in a short period of time, the more severe their effects. In all
likelihood, if one were able to experience these stressors over time allowing one to process
and resolve each situation, then the stressors would be manageable. When there is not enough
time between stressful events, however, the experience is overloading and debilitating.
There are generally two ways to define the source of stress: internal factors or external
factors. Additionally, how each individual responds to stressful events can either increase or
decrease the overall experience of stress. Failure to effectively cope with a stressful situation
contributes to a feeling of things being more difficult, adding to the level of stress already
felt from external sources. Selfcare, use of resources, and selftalk form the foundation of
effective stress management.
224 3. S k i l l B u i l d i n g Resources for Increasing Social Competency

The difference between being stressed and not being stressed is associated with three
factors:
1. Individual perception of stress

A. People often view the same situation very differently, depending on their life
experiences, personality, and health. A visit to a personal physician for the same
purpose may be stressful to one individual and not stressful to another.
*An individual's perception of stress will determine its effects on him/her.
2. Personal and family resources

A. Time, skill, financial resources, and family resources all affect one's ability to handle
stress. For example, money is doubleedged: it can either be a stressor or a resource
for resolving it. Personal management styles such as patience and perseverance also
affect the way an individual or family system deals with stress.
3. Social support
A. Your relationships with family, friends, and your community as well as access to
professional resources can all be avenues for relieving stress
Aside from stress being derived from internal or external factors, there is another way to

define the kinds of stress experienced:
1. Ordinary daily life stressors

A. Regular daily schedule (getting up, going to work/school, etc). These stressors
can be dealt with by setting priorities, following a schedule, having resonable
expectations, and delegating when possible.
2. Developmental Stresses
A. Stage of life issues
B. Learning new things/changing old habits
These stressors can be dealt with by looking forward to known developmental changes,
looking forward to the challenge. Being proactive in thinking through choices and how one
wants to deal with things versus being forced to deal with the event when it happens can also
minimize stress.
STRESS REVIEW
1. Keep a journal. Write what you think and feel to improve selfunderstanding
2. Identify the issues or situations that cause stress
3. Brainstorm a list of all possible ideas for dealing with these issues and situations
4. Clarify ideas
5. Evaluate all possible outcomes
6. Choose the best solution
7. Plan who does what (individual, family, outside resource); delegate, but be
realistic
8. Create a trial period (day, week, month, etc.) for putting a plan into action
What is Stress? 225

9. Evaluate the plan: What worked? what didn't work?
10. Integrate the new information you have in order to improve effectiveness of
stress management
STRESS MANAGEMENT
Often, when a person enters therapy they are feeling overwhelmed by the stressors in their

life. This crisis presents an opportunity for cognitivebehavioral changes which are benefi
cial to the person's overall ability to cope effectively. During a period of crisis a person's
normal defenses are down and emotional distress is high. The person feels an urgency to
decrease the level of emotional distress. Because they are motivated toward alleviating emo
tional distress they are open to new ways of thinking and behaving.
Some people have little awareness of the role that negative stress or too much stress plays
in the complaints and physical ailments that they are reporting which are reactions to the
pressures and circumstances in their lives. The body generally offers several opportunities for
the person to intervene via some method to decrease distress. If ignored these signals often
lead to emotional problems and physical ailments.
Change is stressful, even when it is beneficial. Change requires effort and conscious
awareness. In preparing to engage someone in the process of change, it is important to
understand how they normally interact with their environment. A life stress assessment
includes a review of life events occurring in the last year, personality characteristics, and a
review of significant historical life stressors which have not been resolved and/or have con
tributed to how the person currently copes.
The responses to stress are numerous, and so are the approaches for dealing with it. What
works for one person may not work for another. Therefore, it is necessary to be prepared
with a number of strategies for handling stress.
The mind plays a powerful role in illness and in health. Because cognitions or mental
processes have a strong influence, negative or positive, on the physical and emotional reac
tions to stress cognitive restructuring is an important intervention.
The five aspects of mental processing that play a significant role in stress include:
1. Expectations/SelfFulfilling Prophecy. What a person believes will happen or

expects to happen sometimes influences their behavior in a way that makes that
outcome more likely to happen. Negative expectations increase anxiety and
stress. Identifying goals for change and facing such challenges with optimism
and a positive attitude will facilitate optimal coping and management.
2. Mental Imagery/Visual Imagery. Along with expectations for a given situation
a person will develop an accompanying mental picture and internal dialogue.
This mental imagery can itself elicit emotional and physiologic responses.
Negative mental imagery increases anxiety and stress reactions; whereas
positive mental imagery minimizes the effects of life stressors and increases
effective coping.
3. SelfTalk. This is the internal dialogue that the person carries on with themself
all day long. Most people do not have a conscious awareness for selftalk or the
influence it has on anxiety, stress, and selfesteem. Selftalk has a similar
influence to that of mental imagery. Negative mental images and negative self
talk can result in anxiety and psychosomatic symptoms, whereas positive
mental images and positive selftalk encourages selfconfidence, effective coping,
and a general feeling of well being. Initially, an awareness for negative selftalk

must be facilitated, followed by the development of rational substitute
statements to replace the negative thoughts for cognitive restructuring.
4. Controlling and Perfectionistic Behavior. Perfectionism and unrealistic
expectations often go together. Responses of controlling and perfectionistic
behaviors are frequently an effort to avoid abuse, conflict, the unknown, or a
feeling of uneasiness and inadequacy associated with perfectionism. Placing
unrealistic expectations on others is a form of controlling behavior. It takes
enough energy to manage yourself. Efforts to control the behavior of others
leads to stress, anxiety, frustration, and anger. The goal is for the person to
develop realistic expectations for themself and accept that they have no control
over the behavior of another.
5. Anger. Anger is a normal, healthy emotion when expressed appropriately.
It can be damaging to the self and others when not expressed appropriately
because of the internal stress and tension it causes as well as predisposing the
person to "blowups" with others. This behavior results in low selfesteem and
poor interpersonal relating. Chronic anger and hostility are related to the
development or exacerbation of a number of physical symptoms, illnesses, and
diseases. A person has a choice in how they evaluate a situation. Appropriate
management of anger will decrease stress.
For a person to effectively manage stress they must understand what they need and want

emotionally, take responsibility for their own thoughts and behaviors, release themself from
the selfimposed responsibility of and efforts to control others, develop realistic expectations
and limitations, have appropriate boundaries in relationships, express themself honestly, and
take care of themself (by getting adequate sleep, eating nutritionally, exercising regularly,
and utilizing relaxation techniques).
The central strategies for effective stress management focus on living healthy. This
includes exercise, eating habits, how stress is dealt with, belief system, and attitude. Effective
living requires goals, appropriate prioritization, and time management.
Given the pace of daily living and the demands placed on people it is not difficult to
understand the level of stress experienced by the average person. Because it is physiologically
impossible to be stressed and relaxed at the same time developing techniques for alleviating
distress (negative stress) is an important step in coping effectively with life stressors.
Excellent results have been found in the treatment of numerous physiological symptoms and
emotional or psychological problems through the regular use of relaxation techniques. Regular
use of relaxation techniques prevents the development of cumulative stress. Cumulative stress
is generally associated with high levels of anxiety which have become unmanageable. The
effective discharge of stress and tension associated with relaxation techniques creates the
opportunity for the body to recover from the consequences of stress and places an individual
in an optimal position for managing normal stressors, especially if they are engaging in regu
lar exercise, getting adequate sleep, and eating nutritionally.
Difficulties leading to stress are often related to a person's style of managing or interact
ing with their environment. An approach which results in unnecessary stress includes:
1. Attempting to do too much at one time.

2. Setting unrealistic time estimates, or poor time management.
3. Procrastinating on the unpleasant.
4. Disorganization.
5. Poor listening skills.
6. Doing it all yourself.
Stress Management 227

7. Unable to say "no."
8. Trouble letting other people do their job.
9. Impulsive, snap decisions.
10. Not taking responsibility for the quality of your own life. Blaming others.
EARLY WARNING SIGNS OF STRESS

Emotional Signs 1. Apathy, feelings of sadness, no longer find activities pleasurable
2. Anxiety, easily agitated, restless, sense of unworthiness
3. Irritability, defensive, angry, argumentative
4. Mentally tired, preoccupied, lack of flexibility, difficulty concentrating
5. Overcompensating, avoiding dealing with problems, denial that you have
problems
Behavioral Signs 1. Avoidance behavior, difficulty accepting/neglecting responsibility

2. Compulsive behaviors in areas such as spending, gambling, sex, substances
3. Poor selfcare behavior (hygiene, appearance, etc.), late to work, poor follow
through on tasks
4. Legal problems, difficulty controlling aggressive impulses, indebtedness
A Life Events Survey can be administered to determine the specific stressors as well as a
rough estimate of stress experienced by an individual. This can clarify acute crises and
chronic problems which therapeutic interventions can seek to alleviate and resolve.
STRESS SIGNALS
The following messages from your body may indicate that you have a health problem or are
on the road to developing a health problem. Also explore family history for any predisposi
tion to a particular disease.
1. Insomnia. If you go to bed thinking about things or worrying, the physiological

response is adrenaline, which is activating and interferes with getting to sleep
or achieving restful sleep. Create a routine for winding down and putting your
mind to rest. Before bed, swim, walk, meditate, drink warm milk or herbal tea
(no caffeine), take a hot bath, or choose to think of peaceful, pleasant thoughts.
2. Headaches and sore muscles. When you body is in high gear, you are
continuously on alert to respond and body tension accumulates. If tension is
chronic, the result can be muscle soreness and rigidity. A tight neck, upper
back, and shoulders can lead to a headache. Stretching and light exercise every
couple of hours throughout the day may help to relieve these symptoms.
3. Stomach problems. When you are stressed, acid is secreted in the stomach,
which can cause heartburn, stomach cramps, or other digestive problems.
Overthecounter antacids may alleviate the symptoms, but don't ignore the
real culprits of irritation: stress, caffeine, smoking, alcohol, poor nutrition,
inadequate sleep and relaxation, or spicy foods. Use physical activity, deep
breathing, and selfsoothing activities for calming your digestive track. Be sure
to consult you physician. Don't ignore these symptoms.
.2.2(5 3. S k i l l B u i l d i n g R e s o u r c e s for I n c r e a s i n g Social Competency

4. Addictive behavior. Efforts to escape chronic stress by drinking too much,
increased smoking, overeating, overspending, gambling, or other negative
patterns lead to increased stress. Find helpful and healthful ways to deal with
stress. Talk with your physician and seek professional help.
5. Low sex drive. While this can be a signal of stress and fatigue, a variety of
other issues need to be explored with your physician:
A. High blood pressure
B. Sedentary lifestyle
C. Decreased testosterone
D. Excessive salt consumption
E. Excessive alcohol use
F. Certain drugs and diseases that may cause high blood pressure in some people
STRESS BUSTING
1. Deal with stress when it strikes. Breath slowly and deeply. Exercise to diminish
adrenalin.
2. Think positively. What causes stress is not the situation but how you think
about it.
3. Practice improved management of stress by visualizing stressful situations and
how you will manage them effectively. That way, when the stressful event occurs
it feels like you have already successfully dealt with it numerous times before.
4. Set limits. Create a work frame of time and when the time is up, shift gears and
stop thinking about work. Consider how unfair it is to the people you care for
if you are always thinking about work when you are with them, rather than
being emotionally available and listening.
5. Be honest about what you have control over and what you don't control.
If you have control, take action and plan for a resolution. If it belongs to
someone else, let go of it.
EFFECTIVE MANAGEMENT OF STRESS
There are two approaches for coping with excessive stress:
1. Selfcontrol, which requires taking responsibility for reactions to a situation.

2. Situation control, which includes problem solving, assertiveness, conflict
resolution, and time management.
CRITICAL PROBLEM SOLVING
1. Acknowledge and clarify the problem or issue.
2. Analyze the problem, and identify the needs of those who will be affected.
3. Employ brainstorming to generate all possible solutions.
4. Evaluate each option, considering the needs of those affected.
5. Select the best option and implement the plan.
6. Evaluate the outcome or problemsolving efforts.
Effective Management of Stress 229

ASSERTIVENESS
To assert oneself positive includes:
1. Acting in your own best interest.

2. Standing up for yourself, expressing yourself honestly and appropriately.
3. Exercising your own rights without diminishing the rights of others.
CONFLICT RESOLUTION
Conflict resolution can be achieved cooperatively through a combination of problemsolving
skills, assertiveness, good listening skills, and mutual respect until differing viewpoints are
understood. This is followed by a course of action that satisfies the parties involved.
TIME MANAGEMENT
1. Clarify a plan(s) of action, or tasks to be completed
2. Clarify priorities
3. Divide the plan of action into manageable goals and tasks
4. Allot a reasonable amount of time to complete all tasks
For optimal time management eliminate procrastination, combine tasks when possible,

do things one time, and delegate when possible.
SELFCARE
1. Adequate sleep and good nutrition
2. Good hygiene and grooming
3. Regular exercise
4. Relaxation techniques or other strategies for decreasing tension
5. Development and utilization of a support system
6. Use of community resources
7. Personal, spiritual, and professional growth
8. Selfmonitoring for staying on task selfcare behaviors to develop a
routine
TIPS FOR STRESS MANAGEMENT
1. Learn to meditate and use other relaxation techniques (yoga, progressive

muscle relaxation, visualization, etc.)
2. Practice good nutrition and be physically active
3. Review how you choose to think about things. How you think influences
your stress level:
A. Is your cup half empty or half full?
B. Are you a chronic worrier?
C. Do you catastrophize?
D. Are you always thinking about "what if" instead of dealing with "what is?"

E. Are you a perfectionist?
F. Are you overly critical?
4. Take short breaks
A. Reenergize with a short, refreshing time out
5. Manage your time
A. Set priorities
B. Be realistic about the amount of time it takes to do tasks
6. Talk about it
A. Talk out your problems with a friend or family member to relieve stress and put
problem into perspective
7. Live a balanced life
A. Balance work with play
B. Develop interests or hobbies
C. Participate socially
*Make sure you have laughter in your life.
8. Develop goals

A. Set realistic goals
B. Make sure you have what is required to successfully meet your goals
C. When necessary, break tasks into small, manageable steps
D. Reevaluate goals from time to time
9. Anticipate stress
A. Use your awareness of situations coming up and plan ways to respond
B. Review what you have control over and what you don't control
C. Identify anything that can be done ahead of time to reduce the
stress that will be a part of expectations associated with a given
situation
10. Get help
A. When you feel overwhelmed by stress, get professional help
B. Identify supportive resources in the community
TIPS TO SIMPLIFY LIFE
Are you exhausted? Do you feel overwhelmed and overworked? If you answered yes to these
questions, take the time to step back, look at the choices you are making, and make simple
changes. Small changes can often lead to an improved quality of life. Consider the follow
ing recommendations in reviewing life changes:
1. Reduce the "to do" list. Separate the following items:

A. What needs to be done
B. What does not need to be done
C. What you want to do
Tips to Simplify life 231

2. Stop procrastinating
A. Be honest with yourself about what you are willing to do
B. Acknowledge what needs to be done and just do it
C. Accept that motivation is not something you have, it is something you do
3. Take some time to yourself every day
A. Keep your lunchtime personal
B. Do what you want to do during your brief "personal" time
C. Try to increase personal time gradually
4. Set a stop time
A. Set a time to stop working a task, and stick to it
B. Move on to a restful enjoyable task to balance things
C. Make others aware of your "stop time" so that it will be respected
5. Financial responsibility
A. Consider how many hours you have to work pay for a purchase and then ask
yourself, "Is it worth it?"
B. Disengage from "retail therapy" (buying to feel good for a while)
C. Get a handle on debt and create a special fund for desired purchases
6. Streamline
A. Do not reinvent the wheel
B. Do not do more than is necessary to complete a task (get over perfectionism)
C. Consider the purpose of a task its importance
7. Organize
A. Create manageable order to belongings
B. Utilize time management
C. Create a central information center for family demands
8. Identify qualityoflife issues
A. Identify what matters most
B. Enjoy the moment
C. Spend time with people you enjoy or doing activities you enjoy
D. Calm your soul—find peace
TEN SIGNS THAT YOU NEED TO SIMPLIFY YOUR LIFE

1. You feel that people are always expecting you to do things and are always
making demands on you
2. Your storage spaces (cabinets/closets) are a disaster
3. You don't keep up on small daily tasks (making bed, spiffing the
kitchen)
4. You are easily upset or overwhelmed when something goes wrong
5. You find it difficult, if not impossible, to complete all the tasks on your
todo list
6. You take on another task before finishing the one you are working on
7. Tasks seem too complicated or take too long to complete
8. You have little or no patience and snap at people around you
9. You often misplace things
10. You find it difficult to concentrate and to keep things straight

HOW TO IMPROVE PLANNING
1. Keep a list of tasks and errands posted on the refrigerator (all family members
can be helpful)
2. Keep a phone book in you car in case you need to find a new resource
3. Carefully think out the rout of running errands in order to save time
4. Choose one day a week for appointments and errands
5. Make a master list of home chores done monthly, quarterly, and yearly, and
note these chores on the calendar so you don't have to try to remember them
6. Coordinate with your partner to save time and energy—two work faster than one
7. Ask you partner for input on planning
8. Identify individual strengths when you explore your resources
9. Always weave in desired activities
10. Reevaluate effectiveness and identify necessary changes
PAIN MANAGEMENT
Over time, deep relaxation may be as helpful for relieving pain as medication. Even if med

ication is used, relaxation and physicianrecommended exercise should be used daily as part
of a painmanagement program, Deep relaxation relates specifically to relieving muscle
tension and focusing on breathing. One relaxation technique is meditation. The foundation
of meditation is to focus on a specific word, sound, thought, or rhythm of breathing.
Meditation, as with other forms of relaxation, is most beneficial when practiced routinely
on a daily basis. Many individuals with chronic pain become more debilitated over time,
being less physical than they could have been and participating less in life. When this hap
pens, a person's entire life may focus on the pain and its effects.
Deep relaxation can shortcircuit pain, improve mood, increase energy, diminish feelings
of helplessness, and result in an overall sense of wellbeing. Developing a sense of control in
pain management can decrease feelings of stress and the degree of discomfort associated
with chronic pain.
Be patient. When you first begin to practice relaxation, it may be difficult to remain
focused. It is not uncommon for those preoccupied by acute distress of any kind to report
that they experience difficulty not thinking about other things while trying to engage in deep
relaxation. However, with continued practice they find that part of deep relaxation is recon
ditioning the mind and body and teaching it to relax. Therefore, it may be easiest to start
out learning the technique of deep breathing.
Follow these steps to enhance deep breathing:
1. Be comfortably seated with feet on the floor or elevated

2. Dim the lighting or turn off the lights
3. Breath in deeply so that you are ware of your stomach expanding before
your chest
4. Once you have taken air deeply into your lungs, hold for a count of five
5. As you exhale, imagine the tension leaving your body and mind
To master meditation, one must practice deep breathing and other relaxation techniques

repetitively. Some people find it helpful to start with an audiotape that guides them. After a
Pain Management 233

period of regular use, they find that they do not need the tape any longer. This is such an
easy way to improve the quality of life. Get started immediately!
Talk with your therapist about the different types of relaxation training. He/she may have
specific recommendations for what would be most helpful for you. The therapist may also
be able to give you a printed dialogue of a relaxation technique that you could use to make
a tape in your own voice. There are many choices, so begin to get to work on improving
your painmanagement program with the addition of relaxation.
SOME EXAMPLES OF INDIVIDUALIZED TIME

MANAGEMENT OPTIONS
Effective time management contributes to a balanced lifestyle. Review the following list and

choose some time management tips that you can incorporate into your life to accomplish
more and to feel less stress.
1. Be realistic with yourself regarding how much you can actually accomplish in

a given span of time.
2. Say "NO" to additional responsibilities that infringe on personal/leisure or
work time.
3. Prioritize your tasks because they are not equally important. Set
priorities on a daily, weekly, and monthly basis for maximizing
accomplishments.
4. Develop an awareness for your peak energy periods and plan to do the
activities with the highest energy demand at that time.
5. On a regular basis, review what the best use of your time is currently.
6. Striving for perfection is generally not necessary and can burn up time better
spent in another way. Complete tasks well enough to get the results that you
really need.
7. Delegate tasks and responsibilities to others whenever appropriate. Just be
sure to communicate your expectations clearly.
8. Don't waste time thinking and rethinking the decisions for basic issues. Make
those decisions quickly and move on.
9. If you have a difficult task to do that you are not looking forward to, do
yourself a favor and approach it with a positive attitude. You will be surprised
about how much stress that can relieve from you.
10. Break big overwhelming tasks into small manageable ones, that way it is
easier to keep track of your progress and achievements.
11. Be prepared to make good use of "waiting" time by having small tasks
or activities to do. Another way to deal with it is to always be prepared to
take advantage of potential relaxation time when there are no demands
on you.
12. When you need time to focus on your goals without interruption then request
it. Take responsibility for creating a conductive work environment at home
and at work.

13. Set goals and reward yourself when have accomplished them. If it is a big goal
you may want to build in rewards at certain milestone of effort and
accomplishment as a reinforcer.
14. From time to time remind yourself how good it feels to accomplish tasks,
what the benefits of accomplishment are, and the relief of having that weight
off your shoulders.
15. Good use of time means more than completing "necessary" tasks. It means
building in time for selfcare like leisure activities and exercise. You being the
best that you can be is a priority.
SELFCARE PLAN
Develop a personalized selfcare plan for optimal emotional health and a positive sense
of wellbeing. This does require a commitment to health and follow through. It is recom
mended that there be a medical exam for clearance to participate in desired physical activity.
Components of a selfcare plan include:
1. Utilization of relaxation techniques to decrease body tension and to manage

stress.
2. Review the social supports available to you. If necessary, work at developing
and adequate and appropriate support system. Utilizing your social supports
can offer relief, distraction, and pleasure. Make a list of your supports.
3. Initiate a journal. Instead of keeping thoughts and feelings inside, where
they can build up and cause confusion and emotional/physical distress, get
them down on paper. A journal is useful for venting thoughts and feelings,
clarifying issues, and problem solving. It can also be helpful in determining
patterns, relationships, health, and emotional functioning. Keeping a journal
will help you monitor progress in life goals.
4. Get adequate sleep and rest.
5. Smile and have laughter in your life. Be spontaneous at times and playful.
6. Feed your body, mind, and spirit. Eat meals regularly and nutritionally.
Practice good hygiene and grooming. Participate in life for personal,
spiritual, and professional growth.
7. Approach each day with a purpose. Be productive by outlining daily structure.
No task is too small to feel good about. Each step can be important to reach
goals that you develop.
8. Avoid being selfcritical. Be as kind and understanding of yourself as
you would be to another person. Use positive selftalk to reassure yourself,
to cope effectively, and to allow yourself to see that there are always
choices.
9. Be sure to build in to your schedule time for relationships and pleasurable
activities.
10. Take responsibility for your own life. Life is about choices. Understand
yourself, your behaviors, your thoughts/beliefs, and your motivations.
SeljCare Plan 235

HOW TO GET THE MOST OUT OF YOUR DAY
Whether you are simply considering a project or wanting to change something about your

current lifestyle, the following tips will be useful.
1. Start your day right. Eat a light breakfast followed by some quiet time

meditating or reading inspirational material.
2. Choose to greet the day with a positive attitude. You have the choice of
setting the right tone for a positive outlook or a negative outlook every day.
You get back what you give out. What do you choose to create?
3. Organize your daily tasks on a list. You will feel great every time you put
a line through an accomplished task. Be realistic about what is reasonable
for you to accomplish and how much time a task really requires to
complete.
4. Inspire yourself by seeing yourself in a positive light. Overall, success is the
adding up of all the little successes along the way. Each day, make a positive
contribution.
5. Remind yourself of past successes. Tell yourself, "I am a capable person." Do
not overwhelm yourself by thinking about all you had to do. Just do it. Life is
genuinely difficult. However, it does not seem so bad when you just do what
you need to do.
6. Work on your gratitude. Do you take the time to appreciate your blessings?
Genuine gratitude offers a great attitude adjustment.
7. Be prepared. Break a task down into manageable steps if necessary and
establish a routine for accomplishing it.
8. Practice selfimprovement. From time to time, do a personal inventory. Work
toward positive changes and personal growth while you actively make
changes that you know will benefit you in all areas of your life.
9. Increase motivation. Enhance your actions by remembering this statement:
"Motivation is not something you wait to get, motivation is something that
you do."
10. Incorporate creativity into your life. Being creative leads to personal growth
and is a great way to relax.
11. Bring out the child in you and play. Playing is a great way to rejuvenate and
reenergize.
12. Be active. Use your bodywalk or do some other activity. Walking is great for
decreasing stress, increasing energy, improving sleep, and improving libido.
13. Have faith in yourself and your ability. The power of positive thinking works.
14. Practice selfdiscipline. Set goals. Decide what it is you need to do to
accomplish the goals, and remind yourself on a daily basis of the importance
of the goals that you set.
15. Convince yourself about the importance of your goals. Write a list about why
it is important to you and why you believe you will accomplish it.
16. Make your vision a reality. Imagine yourself successful. Take that mental
picture with you wherever you go.

17. Stay with it. Persevere. Never quit. Eventually you will accomplish what is
important to you.
18. Be committed to being your best. If you stick with it, it will come true.
19. Reward yourself for your efforts. Sometimes the accomplishment is the
reward itself. Other times, create a reward that is waiting for you at the
finish line.
20. Always have things to look forward to. Anticipate things that are going to be.
How exciting!
Each day carries with it its own significance in our lives. It is not what happens to us that
necessarily creates problems; it is the manner in which we choose to deal with the event.
EMOTIONAL IQ
Emotional IQ plays an important role in our personal and professional success. Some of the
central qualities that make up emotional intelligence are the following:
1. Selfawareness
A. The ability to recognize a feeling as it happens
B. Increased awareness and understanding of "gut feeling"
C. Being able to answer the following two questions objectively. They address taking
responsibility for your own choices and an understanding of the motivation behind
the choice of response.
1. "What am I doing?"
2. "Why am I doing it?"
2. Mood management
A. We generally have little control over experiences that provoke or result in negative
emotional experiences (anger, frustration, hurt feelings). However, we do have the
choice/selfcontrol over how we feel, how long, and how we demonstrate the
feelings we have. For example, the more you think about how angry you are, the
angrier you get.
B. Reframe. When situations are emotionally difficult, choose to reinterpret the
situation in a realistic or more positive light.
C. Take time to yourself to calm yourself down and think clearly
D. Don't waste time on negatives. If you have control over something, deal with it in a
productive manner and then move on. If you do not have control over it, let the
other person own it.
E. Distract yourself from negatives with positives
F Engage in selfcare
1. Meditation
2. Prayer
3. Formal relaxation techniques
4. Regular exercise
5. Adequate rest and good nutrition
6. Positive use of resources
G. Be aware of your mood and thoughts about your mood
Emotional IQ 237

3. Selfmotivation
Motivation is not something that you have, it is something that you do.
A. Requires clear goals, with an optimistic "I can do this" attitude
B. Catch negative, selfdefeating thoughts as they occur and reframe them in less
negative terms. For example, when optimistic people experience failure, they
blame the situation, not themself. They think in terms of what they learned,
what they can do, how to improve something, or break it down so that it is
manageable. Regardless, they have rational and realistic belief in themselves.
They say, "I can do it."
4. Impulse control or delay of gratification
A. This is emotional selfregulation—the ability to delay a desired impulse in order
to reach a goal. This is a very important trait associated with success. It is also
associated with social competence, selfawareness, and the ability to cope with
frustration. The ability to resist impulses can be developed through increased
awareness and practice. Remind yourself the longterm goal. It will be worth it.
B. Delaying gratification helps to regulate your mood. You don't allow yourself to get
focused on the disappointment of not getting what you want now; instead you look
at the big picture of ultimately achieving your goals and doing what is necessary—
even waiting. This perspective facilitates positive problem solving, which motivates
a person to continue to try in the face of setbacks by finding more ways to perform
effectively.
5. Social skills
A. Empathy is the capacity to understand how another person feels, whether you are
at work, with friends or family, or in romance. Go back to selfawareness. Do you
leave people feeling dismissed, unimportant or patronized versus genuinely
appreciated and cared for? Remember, It is not all about you.
B. The better we are at paying attention to signals that other people put off, the better
we are at choosing effective signals that we send to people because we have improved
understanding of how others experience us.
The interrelationship among all of the factors associated with emotional IQ results in know
ing yourself and knowing how others experience you.
RELAXATION EXERCISES
DEEP BREATHING (5 MIN)

1. Select a comfortable sitting position.
2. Close your eyes, and direct your attention to your own breathing process.
3. Think about nothing but your breathing, let it flow in and out of your body.
4. Say to yourself: "I am relaxing, breathing smoothly and rhythmically.
Fresh oxygen is flowing in and out of my body. I feel calm, renewed, and
refreshed."
5. Continue to focus on your breathing as it flows in and out, in and out,
thinking about nothing but the smooth rhythmical process of your own
breathing.
6. After 5 minutes, stand up, stretch, smile, and continue with your daily
activities.

MENTAL RELAXATION (5 TO 10 MIN)
1. Select a comfortable sitting or reclining position.
2. Close your eyes, and think about a place that you have been before that you
found to be a perfect place for mental and physical relaxation. This should be a
quiet environment, such as the ocean, the mountains, a forest, a panoramic
view, etc. If you can't think of a real place, then create one.
3. Now imagine that you are actually in your ideal relaxation place. Imagine that
you are seeing all of the colors, hearing all of the sounds, smelling all of the
different scents. Just lie back and enjoy your soothing, rejuvenating environment.
4. Feel the peacefulness, the calmness, and imagine your whole body and mind
being renewed and refreshed.
5. After 5 to 10 minutes, slowly open your eyes and stretch. You have the
realization that you may instantly return to your relaxation place whenever you
desire, and experience a peacefulness and calmness in body and mind.
TENSING THE MUSCLES (5 TO 10 MIN)

1. Select a comfortable sitting or reclining position.
2. Loosen any tight clothing.
3. Now tense your toes and feet. Hold the tension, study the tension, then relax.
4. Now tense your lower legs, knees, and thighs. Hold the tension. Study the
tension, then relax.
5. Now tense your buttocks. Hold and study the tension. Relax.
6. Tense your fingers and hands. Hold and study the tension, then relax.
7. Tense your lower arms, elbows, and upper arms. Hold it, study it, relax.
8. Tense your stomach, hold the tension, feel the tension, and relax.
9. Now tense your chest. Hold and study the tension. Relax. Take a deep breath
and exhale slowly.
10. Tense the lower back. Hold and study the tension and relax.
11. Tense the upper back. Hold the tension, feel the tension, then relax.
12. Now tense the neck, back, and front of your neck. Hold the tension, study the
tension, then relax.
13. Now tense the shoulders. Hold and study the tension. Then relax.
14. Now tense your entire head. Make a grimace on your face so that you feel the
tension in your facial muscles. Study the tension and then relax.
15. Now try to tense every muscle in your body. Hold it, study it, then relax.
16. Continue sitting or reclining for a few minutes, feeling the relaxation flowing
through your body. Know the difference between muscles which are tense and
muscles which are relaxed.
17. Now stretch, feeling renewed and refreshed, and continue with your daily
activities.
MENTAL IMAGERY (10 TO 15 MIN)

Mental imagery can deepen relaxation when used with other techniques, or may be used by
itself. The purpose is to calm your body, thoughts, and emotions. It gives you the opportunity
to take a break from tension and stress. Mental imagery uses all of your senses to create and

recreate a relaxing place, perhaps a meadow, a walk through the woods, along the beach, or
perhaps a special place from your memory.
Prepare your environment so that you can complete this relaxation exercise without inter
ruption. Spend some time getting comfortable. Close your eyes, as you scan your body for
any tension. If you find tension, release it. Let it go and relax.
Relax your head and your face.

Relax your shoulders.
Relax your arms and hands.
Relax your chest and lungs.
Relax your back.
Relax your stomach.
Relax your hips, legs, and feet.
Experience a peaceful, pleasant, and comfortable feelings of being relaxed as you prepare

to make an imaginary trip to a beautiful place.
Take a deep breath, and breathe out slowly and easily. Take a second deep breath, and
slowly breathe out. Allow your breathing to become smooth and rhythmic.
Picture yourself on a mountaintop. It has just rained and a warm wind is carrying the
clouds away. The sky is clear and blue, and the sun is shining down.
Below you are beautiful green trees. You enjoy the fragrance of the forest after the rain.
In the distance you can see a beautiful white, sandy beach. Beyond that, as a far as you can
see, is a crystal clear, brilliant blue water. A fluffy cloud drifts in the gentle breeze until it is
right over you. Slowly, this little cloud begins to sink down on you. You experience a very
pleasant, delightful feeling. As the fluffy cloud moves down across your face, you feel the
cool, moist touch of it on your face. As it moves down your body, all of the tension slips
away, and you find yourself completely relaxed and happy.
As the soft cloud moves across your body, it gently brings a feeling of total comfort and
peace. As it sinks down around you it brings a feeling of deep relaxation. The little cloud
sinks underneath you, and you are now floating on it. The cloud holds you up perfectly and
safely. You feel secure. The little cloud begins to move slowly downward and from your
secure position on it, you can see the beautiful forest leading down to the beach. There is a
gentle rocking motion as you drift along. You feel no cares or concerns in the world, but are
focused completely on the relaxed feeling you experience. The cloud can take you any place
you want to go, and you choose to go to the beach. As you move to the beach, the cloud
gently comes to the ground and stops. You get off the soft cloud onto the beach, and you
are at peace. You take some time to look around at the white sandy beach, and the beauti
ful blue water. You can hear sea gulls and the roar of the waves. As you feel the sun shining
on you, you can smell the ocean air. It smells good. As you walk slowly on the beach, you
enjoy the feeling of the warm clean sand on your feet. Just ahead on the beach is a soft blan
ket and pillow. You lie down and enjoy the feeling of the soft material on the back of your
legs and arms. As you listen to the waves and the sea gulls and feel the warmth of the sun
through the cool breeze, you realize that you are comfortable, relaxed, and at peace. You
feel especially happy because you realize that you can return to this special and beautiful
place any time you want to. Feeling very relaxed, you choose to go back to the place where
you started, knowing that you will take these peaceful and relaxed feelings with you. There
is a stairway close by that leads you back to the room where you started. As you climb the
five steps, you will become more aware of your surroundings, but you will feel relaxed and
refreshed. You are at the bottom of the stairs now, and begin climbing.
Step 1 to Step 2: moving upward

Step 2 to Step 3: feeling relaxed and more aware
Step 3 to Step 4: you are aware of what is around you, and your body is relaxed
Step 4 to Step 5: your mind is alert and refreshed, open your eyes and stretch gently

BRIEF RELAXATION (5 TO 10 MIN)
Get comfortable.
You are going to count backwards from ten to zero.
Silently say each number as you exhale.
As you count, you will relax more deeply and go deeper and deeper into a state of
relaxation. When you reach zero, you will be completely relaxed.
You feel more and more relaxed, you can feel the tension leave your body.

You are becoming as limp as a rag doll, the tension is going away.
You are very relaxed.
Now drift deeper with each breath, deeper and deeper.

Feel the deep relaxation all over and continue relaxing.
Now, relaxing deeper you should feel an emotional calm.
Tranquil and serene feelings, feeling of safety and security, and a calm peace.
Try to get a quiet inner confidence.
A good feeling about yourself and relaxation.
Study once more the feelings that come with relaxation.
Let your muscles switch off, feel good about everything.
Calm and serene surroundings make you feel more and more tranquil and peaceful.
You will continue to relax for several minutes.
When I tell you to start, count from one to three, silently say each number as you take a
deep breath.
Open your eyes when you get to three. You will be relaxed and alert.
When you open your eyes you will find yourself back in the place where you started your
relaxation.
The environment will seem slower and more calm.
You will be more relaxed and peaceful.
Now count from one to three.
BRIEF PROGRESSIVE RELAXATION
Clench both fists, feel the tension. Relax slowly... feel the tension leave. Feel the difference
now that the muscles are relaxed.
Tighten the muscles in both arms. Contract the biceps... now relax the arms slowly.
Curl the toes downward until the muscles are tight up through the thigh... now slowly relax.
Feel the tension ease.
Curl the toes upward until the muscles in the back of the legs are tight... now relax slowly.
Curl the toes upward until the muscles in the back of the legs are tight... now relax slowly.
Push the stomach muscles out and make it tight. Now slowly... relax. Your arms are relaxed,
your legs are relaxed, and your even breathing gives you a feeling of calmness and releases stress.
Pull your stomach in up until your diaphragm feels the pressure. Now... slowly relax...
slowly. Feel the tension ease.
Pull your shoulders up to your ears. Feel the tension in your back and chest. Now... slowly
relax. Let your arms relax. You are feeling good. Your beating is easy and restful.
Tilt your head backward as far as you can. Stretch the muscles. Feel the tenseness.
Now... slowly... relax. Feel the tension go.
Wrinkle your forehead. Hold it. Feel the tension. Now, relax. Feel the tension go.
Squint your eyes as tight as you can. Hold it. Now... relax.
Make a face using all of your face muscles. Hold it. Now relax... slowly... let it go. Your
arms are relaxed... your breathing is easy and you feel good all over.
R e l a x a t i o n Exercises 241
In a perfect state of relaxation you are unwilling to move a single muscle in your body. All
you feel is peaceful, quiet and relaxed. Continue to relax. When you want to get up count
backward from four to one. You will feel relaxed and refreshed, wide awake and calm.
PROGRESSIVE MUSCLE RELAXATION (20 TO 25 MIN)
Prepare your environment so that you can complete this relaxation exercise without inter
ruption. Spend a little time getting as comfortable as you can. Prepare yourself for a pleas
ant and comfortable experience. Lie down or recline in a comfortable chair. Uncross your
legs, loosen any tight clothing, and remove your shoes and glasses. Your arms should be
placed comfortably at your sides. Slowly open your mouth and move your jaw gently from
side to side. Now let your mouth close, keeping your teeth slightly apart. As you do this,
take a breath, and slowly let the air slip out.
As you tighten one part of your body, try to leave every other part limp and relaxed. Keep
the tensed part of your body tight for a few seconds and then let the tension go and relax.
Then take a deep breath, hold it for a moment, and as you breath out, think the words, "Let
go and relax." You don't have to tense a muscle so hard that you experience discomfort or
cramping. The goal of this technique is to recognize the difference between tension and
relaxation. It's time to begin progressive muscle relaxation.
First, tense all the muscles in your body. Tense your jaw, eyes, shoulders, arms, hands,
chest, back, legs, stomach, hips, and feet. Feel the tension all over your body. Hold the ten
sion briefly, then think the words, "Let go and relax." Let your whole body relax. Feel a
wave of relief come over you as you stop tensing. Experience feeling calm.
Take another deep breath, and study the tension as you hold your breath. Slowly breath
out and think the words, "Let go and relax." Feel the deepening relaxation. Allow yourself
to drift more and more with this relaxation. We will continue with different parts of your
body. Become aware of the differences between tension and relaxation in your body.
Keeping the rest of your body relaxed, wrinkle up your forehead. Feel the tension. Your
forehead is very tight. Be aware of the tense feeling. Now let the tension go, and relax. Feel
the tension slipping away. Smooth out your forehead and take a deep breath. Hold it for a
moment, and as you breathe out, think the words, "Let go and relax."
Squint your eyes as if you are in bright sunlight. Keep the rest of your body relaxed. Feel
the tension around your eyes. Now, let the tension go, and relax. Take a deep breath and
think the words, "Let go and relax," as you breathe out.
Open your mouth as wide as you can. Feel the tension in your jaw and chin. Experience
the tension. Now, let your mouth gently close. As you do, think the words, "Let go and
relax." Take a deep breath, and as you breathe out, think the words, "Let go and relax."
Close your mouth. Push your tongue against the roof of your mouth. Feel the tension in
your mouth and chin. Hold the tension for a moment, then let it go and relax. Take a deep
breath. Now think the words, "Let go and relax" as you breathe out. When you breathe out,
let your tongue rest comfortably in your mouth, and let your lips be slightly apart.
Keeping the rest of your body relaxed, clench your jaw. Feel the tension in your jaw
muscles. Hold the tension for a moment. Now let it go and relax. Take a deep breath out,
think the words, "Let go and relax."
Focus now on your forehead, eyes, jaw, and cheeks. Are these muscles relaxed? Have you
let go of all the tension? Continue to let the tension slip away and feel the relaxation replace
the tension. Your face will feel very smooth and soft as all the tension slips away. Your eyes
are relaxed. Your tongue is relaxed. Your jaw is loose and limp. All of your neck muscles are
also very relaxed.
The muscles of your face and head are becoming more and more relaxed. Your head feels
as though it could roll gently from side to side. Your face feels soft and smooth. Allow your
face, head, and neck to continue becoming more and more relaxed as you now move to
other areas of your body.
Become aware of your shoulders. Lift your shoulders up and try to touch your ears with
each of your shoulders. Become aware of the tension in your shoulders and neck. Hold on
to that tension, now let the tension go and relax. As you do, feel your shoulders joining the
relaxed parts of your body. Take a deep breath. Hold it, and think the words, "Let go and
relax" as you slowly breathe out.
Notice the difference between tension and relaxation in your shoulders. Lift your right
shoulder up and try to touch your right ear. Become aware of the tension in your right
shoulder and along with the right side of your neck. Hold on to that tension, and now, let
it go and relax. Take a deep breath and think the words, "Let go and relax" as you slowly
breathe out.
Now lift your left shoulder up and try to touch your left ear. Notice the tension in your
left shoulder and along the left side of your neck. Hold on to that tension. Now, let the ten
sion go, and relax. Take a deep breath, and think the words, "Let go and relax" as you
slowly breathe out. Feel the relaxation spread throughout your shoulders. Feel yourself
become loose, limp, and relaxed.
Stretch out your arms in front of you and make a fist with your hands. Feel the tension
in your hands and forearms. Hold that tension. Now, let the tension go and relax. Take a
deep breath and think the words, "Let go and relax" as you slowly breathe out.
Press your right hand down into the surface it is resting on. Be aware of the tension in
your arm and shoulder. Hold the tension. Now, let the tension go and relax. Take deep
breath and as you slowly breathe out, think the words, "Let go and relax."
Now push your left hand down into whatever it is resting on. Experience the tension in
your arm and shoulder. Hold on to that tension. Now let go and relax. Take a deep breath
and think to yourself, "Let go and relax" as you slowly breathe out.
Bend your arms toward your shoulders and double them up as if you were showing off
your muscles. Feel the tension, and hold on to it. Now let it go. Take a deep breath and think
the words, "Let go and relax" as you slowly breathe out.
Move your attention to your chest. Take a deep breath that completely fills your lungs.
Feel the tension around your ribs. Think the words, "Let go and relax" as you slowly
breathe out. Feel the relaxation deepen as you continue breathing easily, freely, gently.
Take another deep breath. Hold it and again experience the difference between relaxation
and tension. As you do, tighten your chest muscles. Hold on to that tension and as you
slowly breathe out, think the words, "Let go and relax." Feel the relief as you breathe out
and continue to breathe gently, naturally, and rhythmically. With each breath, you are
becoming more and more relaxed.
Keeping your face, neck, arms, and chest relaxed, arch your back up (or forward if you
are sitting). Feel the tension along both sides of your back. Hold that position for a moment.
Now, let the tension go, and relax. Take a deep breath and think the words, "Let go and
relax" as you breathe out. Feel the relaxation spreading up into your shoulders and down
into your back muscles.
Feel the relaxation developing and spreading all over your body. Feel it going deeper and
deeper. Allow your entire body to relax. Your face and head are relaxed. Your neck is
relaxed. Your shoulders are relaxed. Your arms are relaxed. Your chest is relaxed. Your back
is relaxed. All of these areas are continuing to relax more and more, as you are becoming
more deeply relaxed and comfortable.
Move your attention to your stomach area. Tighten your stomach muscles, and briefly
hold that tension. Let the tension go, and relax. Feel the relaxation moving into your stom
ach area. All the tension is being replaced with relaxation, and you feel the general well
being and peacefulness that comes with relaxation. Take deep breath and think the words,
"Let go and relax" as you breathe out.
Now push your stomach out as far as you can. Briefly hold that tension. Now let it go and
relax. Take deep breath. Hold it, and think the words, "Let go and relax" as you breathe out.
Now pull your stomach in. Try to pull your stomach into your backbone. Hold it. Now,
relax and let it go. Take a deep breath and think the words, "Let go and relax" as you
breathe out.
You are becoming more and more relaxed. Each time you breathe out, feel the gentle
relaxation replace the tension in your body. As you continue to do these exercises, your body
will relax more and more. Check the muscles of your face, neck, shoulders, arms, chest, and
stomach. Make sure they are still relaxed. If they are not as relaxed as they can be, just tense
and release them again. You are experiencing control over your body. Whatever part is still
less than fully relaxed is starting to relax more and more. You are learning to recognize when
you have tension in any part of your body. You are learning that you can become relaxed
and let go of the tension you may find in any part of your body.
Now, focus your attention on your hips and legs. Tighten your hips and legs by pressing
your heels down into the floor or couch. While you are tightening these muscles, keep the
rest of your body as relaxed as you can. Hold on to the tension. Now, let the tension go and
relax. Feel your legs float up. Take a deep breath and think the words, "Let go and relax"
while breathing out. Feel the relaxation pouring in. Be aware of the differences between the
tension and relaxation. Let the relaxation become deeper and deeper. Enjoy the comfortable
feeling.
Keeping your feet flexed toward your knees, tighten your lower leg muscles. Feel the ten
sion, hold on to that feeling. Now, let it go and relax. Take a deep breath and think the
words, "Let go and relax" as you breathe out.
Now, very gently, curl your toes downward toward the bottom of your feet. Be careful
that you don't use so much tension that you experience cramping. Feel the tension. Now, let
go of the tension. Feel the relaxation taking the place of the tension. Take a deep breath and
think the words, "Let go and relax" as you breathe out.
Keeping your lower legs relaxed. Bend your toes back the other way, toward your knees.
Feel the tension. Hold on to the tension. Now let it go and relax. Feel the tension slip away.
Take a deep breath, and think the words, "Let go and relax" as you slowly breathe out. Feel
the tension leaving your body and the relaxation coming in.
You have progressed through all of the major muscles in your body. Now, let them
become more and more relaxed. Continue to feel yourself becoming more and more relaxed
each time you breathe out. Each time you breathe out, think about a muscle and think the
words, "Let go and relax." Your hands are relaxed. Your chest is relaxed. Your back is
relaxed. Your legs are relaxed. Your hips are relaxed. Your stomach is relaxed. Your whole
body is becoming more and more relaxed with each breath.
Focus on the peaceful, comfortable, and pleasant experience you are having. Realize
that this feeling becomes more readily available to you as you practice becoming aware of
your body.
In a moment, I will start counting from five to one. At the count of three, I will ask you
to open your eyes. On the count of two, just stretch your body as if you were going to yawn.
And at the count of one, you have completed this relaxation exercise and can feel well rested
and refreshed. 5 ...4 ... 3 ...open your eyes... 2 ...stretch your muscles gently... 1 ...you
have completed the progressive muscle relaxation exercise.
When a relaxation technique has been completed, visual imagery can be utilized while the
person is still in the relaxed state. The visual imagery can range in emotional intensity from
neutral to overwhelming anxiety. Its utility can be in the form of a hierarchy or in the repe
tition of a single troubling scene for the person that they are striving to master and resolve.
In this form of imagined rehearsal, the person gains more practice in coping with anxiety
provoking situations. This acts to build behavioral repertoire and confidence.
The following example (from Navaco as cited in Meichenbaum and Turk, 1976, pp. 69)
is a demonstration of the type of statements that can be used in conjunction with stress man
agement and relaxation training to enhance or facilitate behavioral change. This particular
example counters the negative selfstatements indicative of an anger reaction. Because the
individual is in a relaxed state with their defenses down they are psychologically less resist
ant to changing their schemata. This is a beneficial way to increase coping in a variety of
anxietyprovoking situations.
What can you tell yourself to control your feelings?
PREPARING FOR THE PROVOCATION
What is it that you have to do to?
You can work out a plan to handle it.
You can manage the situation.
You know how to regulate your anger.
There won't be any need for argument.
Take time for a few deep breaths of relaxation. Feel comfortable, relaxed, and at ease.

CONFRONTING THE PROVOCATION
Stay calm. Just continue to relax.
As long as you keep cool, you're in control.
Don't take it personally.
Don't get all bent out of shape, just think of what to do here.
You don't need to prove yourself.
There is no point in yelling.
You're not going to let them get to you.
Don't assume the worst or jump to conclusions.
Look for the positives.
It's really a shame this person is acting the way they are.
For a person to be that irritable, they must be really unhappy.
There is no need to doubt yourself, what they say doesn't matter.
Your muscles are getting so tight, it's time to slow things down and relax.

Getting upset won't help.
It's just not worth getting so angry.
You'll let them make a fool of themselves.
It's reasonable to get annoyed, but let's keep a lid on it.
Time to take a deep breath.
Your anger is a signal of what you need to do.
IT'S TIME TO TALK TO YOURSELF*

You're not going to get pushed around, but you're not going to be
aggressive and out of control either.
Try a cooperative approach, maybe you're both right.
They'd probably like for you to get angry. Well, you're going to
disappoint them.
You can't get people to act the way you want them to.
It worked!
That wasn't as hard as you thought it would be.
You could have gotten more upset than it was worth.
You're doing better at this all of the time.
You actually got through that without getting angry.
Guess you've been getting upset for too long when it wasn't even necessary.
The components of the last paragraph can progressively change in accordance with
behavioral and cognitive modification and change.
A GUIDE TO MEDITATION (THE TIME FOR MEDITATION

IS DECIDED BY THE INDIVIDUAL)
Meditation is a silent, internal process in which an individual attempts to focus their atten
tion on only one thing at a time. It doesn't matter what the focus of attention is, only that
all other stimuli are screened out. There are a variety of ways in which to practice medita
tion. Different meditation techniques are suited for specific purposes. Therefore, it is neces
sary to determine the needs or desired goal prior to determining the meditation technique to
be utilized. The following meditation technique is general in nature and may be altered
accordingly. Meditation does not eliminate the problems in a person's life. However, the
resulting decrease in stress and tension would be an obvious contribution to an improved
ability to cope.

Five steps of instruction on meditation will be presented. It is suggested that an individ
ual experiment with the various techniques to determine which step they elicit the most
comfort, ease, and benefit from. During periods of experimentation make an effort to
increase the awareness for changes in both internal and external experiences.
STEP 1:. Find a quiet place. Practice daily, at the same time each day, for at least 5 minutes. Choose

a comfortable sitting position. Sit with your back straight and remain alert. Be sure that you
Preparation and
are comfortable, that clothing fits loosely, and that the environment lacks distractions.
Determining Your
Posture
STEP 2: Close your eyes and focus on the sensations you are experiencing. With your eyes closed take
several deep, cleansing breaths. Notice the quality of your breathing. Notice where your
Breathing
breath resides in your body, and how it feels. Try to move your breath from one area to
another. Breathe deeply into the stomach (i.e., the lower area of the lung) and continue up
until you reach the chest (i.e., the upper lung region). Likewise, when you exhale, start at the
bottom, gently contracting the abdomen and pushing the air out of the lower lung. During
this process be focusing on how you feel and how the breathing feels. This technique takes
the shortest amount of time.
STEPS3 There are focal points, or centers in the body which enhance certain abilities when focused

on. The middle of the chest is the heart center, the center of the forehead is the wisdom
Centering
center, and the navel is the power center. There are other focal points, but these are most
commonly used. Concentrating on the heart center increases and intensifies a person's com
passion and offers the experience of being one with the universe. Focusing on the wisdom
center expands wisdom and intuition. Focusing on the power center enhances the experience
of personal power. The collective focus on all three centers represents compassion, wisdom,
and power.
STEP 4: Visualization creates mental imagery impressions that can consciously train your body
to relax and ignore stress. The use of visualization is wide ranging. It has been used to
Visualization and
improve athletic performance, and can be a powerful contributor toward the goals of self
Imagery development and selfexploration. To fully experience the varying sensations associated with
different images meditate on the following topics, adding others to expand your experience
if you choose:
1. A mountain lake

2. A forest
3. A happy time in your life or pleasing experience
4. Having as much money and success as you want
5. Radiating physical health
6. White light
7. Nirvana
8. A spiritual icon (Jesus, Buddha, Mohammed)
Choose a visualization that symbolizes what you want or are looking for in your life and
mediate on that symbol daily.

STEP 5: Words are powerful and focusing your meditation on certain words or phrases can be
enlightening. The word or phrase is similar to what was described for visualization and
The Word
imagery except, instead of a mental picture, the power of words are used instead. Most peo
ple are familiar with associating the power of words with positive affirmations.
Meditating words is generally done by repeating the word or phrase that have meaning
to you. Some examples are:
1. Love, God, Peace, or Creator

2. I am prosperous or my life is spiritually filled
3. Relax and feel the peacefulness
CRITICAL PROBLEM SOLVING
An intervention strategy that has special potential for enhancing your ability to cope is prob

lem solving. Mastering these principles prepares you to cope more effectively with the
diverse problems of life. Much of your negative life experience is likely related to ineffective
behavior that fails to solve life's challenging problems and leads to undesired effects such as
psychosomatic illness, depression, anxiety, and various other difficulties.
It is generally found that individuals lacking adequate problemsolving skills:
1. Generate fewer possible solutions.

2. Suggested solutions that often don't include social supports.
3. Have inaccurate expectations about probable consequences of alternate
solutions.
By mastering a systematic approach to making decisions and solving problems, individu

als gain the following benefits:
1. Learn a process that promotes collaboration, cohesiveness, and mutual respect

among family and group members.
2. Prevent interpersonal conflicts produced by dysfunctional modes of reaching
decisions or solving problems (such as authoritarian patterns or competitive
power struggles).
3. Reduce tension, anxiety, and depression by solving stressproducing problems
effectively.
4. Generate a wider range of options for coping with problematic situations,
thereby enhancing chances of selecting maximally effective decisions or
solutions.
5. Enhance the likelihood that family and group members will commit
themselves to implementing options that are selected.
6. Increase confidence, selfefficacy, and selfesteem by acquiring a
mode of problem solving that can be employed in future problematic
situations.
C r i t i c a l Problem Solving 247

PREPARING TO LEARN PROBLEMSOLVING SKILLS
Preparing yourself to learn this skill is critical and requires motivation and commitment
along with practicing the components of problem solving. This challenge is not simple
because marital partners and family members typically view themselves as victims of unrea
sonable and offensive behavior on the part of other significant members of their system.
Failing to see how they contribute to their difficulties, they perceive the solution as consist
ing of favorable changes by the "offending" person. Therefore, they see no need for collab
orative problem solving. Often having assumed an adversarial quality, their interactions tend
to be characterized by arguments, mutual recriminations, putdowns, and power struggles.
Begin by clarifying what the problemsolving process is all about. Basically, it is a sys
tematic approach that will help you collaborate in solving problems or in reaching decisions
effectively. It involves a number of steps that will assist you to define problems accurately
and to generate several possible solutions so that you can select the best possible option. The
best option is the one that best meets your needs, so another step involves helping you to
identify and understand each other's needs. The process also involves guidelines that will
assist you to work together as a team and avoid needless and unproductive hassles.
The process is effective and you can succeed in applying it, but only if you commit to fol
lowing the steps and guidelines.
MANAGING INTERACTION DURING PROBLEM SOLVING

As individuals prepare to begin practicing problemsolving steps they need to observe the
following guidelines:
1. Be specific in relating problems.

2. Focus on the present problem rather than on past difficulties.
3. Focus on only one problem at a time.
4. Listen attentively to the concerns and feelings of others who are sharing
problems.
5. Share problems in a positive and constructive manner.
DEVELOPING GOOD PROBLEMSOLVING SKILLS

EQUIPS INDIVIDUALS TO:
1. Identify the causes of emotional difficulties.
2. Recognize the resources they have to deal with their difficulties.
3. Give them a systematic way to overcome their current problems.
4. Enhance their sense of control.
5. Prepare them to deal more effectively with future problems.
STAGES OF PROBLEM SOLVING (AS THERAPIST

FACILITATES SKILL DEVELOPMENT IN INDIVIDUAL):
1. To acknowledge and define the problem.
2. Identify their resources—assets and supports.
3. Obtain information from other sources if helpful.
4. Decide on practical arrangements—who will be involved.
5. Establish a therapeutic contract which clarifies the individual's and therapist's
responsibilities in problem solving.

Implementing the process does not ensure that resultant decisions and solutions will
always produce desired results. However, using the process does avoid discord and substan
tially enhances the chances of achieving favorable outcomes.
STEPS FOR PROBLEM SOLVING
1. Acknowledge/identify the problem.
2. Analyze the problem, and identify needs of those who will be affected.
3. Employ brainstorming to generate possible solutions.
4. Evaluate each option, considering the needs of those affected.
5. Implement the option selected.
6. Evaluate the outcome of problemsolving efforts.
PROBLEMSOLVING DIAGRAM
Take a few minutes to focus on yourself. Are you (1) a person who generally copes well but

is having current difficulties associated with a specific situation or (2) a person who experi
encing difficulty coping? If you identified yourself as generally experiencing difficulty cop
ing, be prepared to be patient as you learn to improve your problemsolving skills, and use
the necessary resources for reaching this important goal.
Identifying the problem
> No personal control I
Problem belongs to
someone else Falls under personal control
t go I
Clarify information
(may use additional resources)
Clarify thoughts/behaviors that impede change
Identify resources
(assets/supports)
If more than one problem, "prioritize"
I
Identify goals
Work out the steps to achieve goal(s)
1
Identify what is necessary to initiate problem solving
Review progress
Selfmonitoring
Problem Solving Diagram 249

ASSIGNMENT 1
SAMPLE PROBLEMS:
1. "I wish you would ask me in advance about taking the car. When you wait
until the last minute, it really annoys me and puts me in a bind because
sometimes I need the car. I would like to be considered when you think
about taking the car."
2. "I don't like you going to the bar with your buddies several nights in a row.
I feel unimportant to you when you spend so little time with me. I would like
to share more evenings with you."
3. "It humiliates me when you get on my case in front of my friends. I would like

to feel I can bring my friends home without fear of being embarrassed."
Make a list of your own problems and how you plan to resolve them.
ASSIGNMENT 2
1. Discuss a situation that you have experienced that was easy to get into, but

difficult to get out of.
a. Why was the situation so difficult to get out of?
b. What have you learned from your experience, has it changed you, and what would
you do differently next time or in a similar situation?
250 3, S k i l l B u i l d i n g Resources for Increasing Social Competency

ASSIGNMENT 3
Taking Risks
1. What is the meaning of risk?
2. Discuss a "risk" you need to take in your life.
3. What keeps you from taking the risk?
4. Why do you feel this risk should or should not be taken?
5. What is possible positive outcome(s) if the risk is taken?
Assignment 3 251
RISKS
Nothing ventured, nothing gained.
A venture is a risk. It is trying something new, or approaching the same problem in a
different way.
There are many times when we must take certain risks to bring about desired change,
growth, and learning. By avoiding risk you may avoid suffering and sorrow. However, you
will also avoid learning, feeling, change, growth, love—living. To avoid risk is to remain a
prisoner of fear and doubt.
1. What does the statement, "nothing ventured, nothing gained" mean?
2. Do you live your life taking well thought out risks or do you fear risk and
remain stuck? Explain.
3. Does the way you approach problems offer you few choices or more choices

with alternatives in case something doesn't work out the way you planned?
4. Explain how you currently live your life, and what you want to try to do

differently.

COMPONENTS OF EFFECTIVE COMMUNICATION
"I" Statements, Active Listening, Reflection, and Nonverbal Communication
"I" STATEMENTS
Rationale: To improve communication by being able to rephrase statements into more
assertive statements.
Goal: To be able to identify assertive statements.
Objective: To be able to see the difference between hostile blaming and manipulative
statements versus assertive statements. It is also important to take responsibility
for your own emotions. Taking responsibility for how you feel instead of
blaming someone for how you feel allows you to express yourself honestly
and appropriately.
Material Needed: Pencil and paper.
Activity: Rephrase each statement by starting with "I."
Example; You don't care about anyone.
versus
I feel sad when I'm left out.
1. You are wrong.
2. You make me mad.
3. Go away.
4. Give it back.
5. You embarrass me.
6. It's your fault.
7. This is mine.
8. That is bad.
Notes:
ACTIVE LISTENING
Rationale: To demonstrate that attention is being paid to what is being communicated
to you.
Goal: To define and be able to demonstrate active listening.
Objective: To be able to pick up the emotional message and be able to restate it in your
own words, without analyzing, criticizing, or giving advice.
Activity: Use one of the following sentences for an idea to practice. Have one person give
and one person receive.
Example: #1 says: "My purse was just stolen by a man as I walked to my car when I left
the store."
#2 responds; "Are you alright? That must have been frightening."
Components of Effective Communication 253

1. Describe your feelings prior to your first date.
2. Describe your feelings prior to an important exam.
3. Describe your feelings prior to tryout for a team.
4. Describe your feelings prior to a confrontation.
5. Describe your feelings when you were intimidated by someone.
Remember: Active listening demonstrates interest with appropriate concern and questions
for clarification.
Notes:
REFLECTION
Rationale: To demonstrate interest and understanding of what is being communicated to you.
Goal: To be able to give feedback or reflect emotional messages using "I" statements.
Objective: To clarify message offered by another person.
Activity: Using the same format as with Active Listening and the same sentences.
Example: "I feel you..."
"It sounds like..."
Notes:

NONVERBAL COMMUNICATION CHECKLIST
Behavior observed (check all observed) Yes No
A. Eye Contact
1. Spontaneous eye contact and eye movements
2. Breaking eye contact
3. Staring too intensely
4. Looking down
5. Looking directly at helper when speaking
6. Looking directly at helper when listening
7. Looking away
8. Staring blankly
B. Body Posture
1. Slight forward lean
2. Body facing helper
3. Relaxed posture
4. Relaxed hand position
5. Spontaneous hand and arm movements
6. Gestures for emphasis
7. Touching helper
8. Relaxed leg position
9. Slouching
10. Fixed, rigid position
11. Physically distant from helper
12. Physically too close to helper
13. Arms across chest
14. Body turned sideways
C. Head and Facial Movements
1. Affirmative head nods
2. Calm, expressive facial movements
3. Appropriate smiling
4. Expressions matching helper mood
5. Face rigid
6. Continual nodding
7. Extraneous facial movements
8. Continual smiling
9. Little smiling
10. Cold, distant expression
11. Frowning
12. Overly emotional expression
D. Vocal Quality
1. Pleasant intonation
2. Appropriate loudness
3. Moderate rate of speech
4. Simple, precise language
5. Fluid speech
6. Monotone
7. Too much affect
8. Too loud
9. Too soft
10. Use of jargon
11. Use of slang
12. Too fast
13. Too slow
14. Use of "you know"
15. Use of "um," "ah"
16. Voice quiver
E. Distracting Personal Habits
1. Playing with hair
2. Fiddling with pen or pencil
3. Chewing gum
4. Smoking
5. Drinking
6. Tapping fingers or feet
Other
Nonverbal Communication Checklist 255

IMPROVING COMMUNICATION SKILLS
Less than 10% of what you communicate to someone will be interpreted based on what you
say. Over 40% of interpretation is derived from how it is said, and over 40% is interpreted
by how you present yourself physically. An additional problem in communication, which
contributes to its ineffectiveness, has to do with nonverbal behaviors or habits that are dis
tracting to the person you are communicating with (such as smoking, drinking, fidgeting,
tapping fingers/feet, tapping a pin/pencil, chewing gum, playing with one's hair, mustache or
beard, etc.).
HOW YOU PRESENT YOURSELF: BODY LANGUAGE

1. Eye contact
A. Look directly at the person you are speaking to
B. Remain relaxed, spontaneous/normal, serious but not overly intense
2. Body posture
A. Face the person you are speaking to
B. Slightly lean forward toward the person
C. Maintain a relaxed, attentive posture
D. Keep your hands loosely clasped or on your lap
E. The occasional fluid movement of arms and hands is okay
F. Keep legs parallel or comfortably crossed
G. Avoid being, rigid, tense, or threatening
3. Head/facial movements
A. Occasionally nod your head affirmatively
B. Use appropriate facial responses
C. Mirror the person you are talking to
HOW YOU SAY IT: QUALITY OF VOICE
1. Tone of voice
A. Effective tone of voice
1. Pleasant
2. Interested intonation
3. Appropriate loudness
4. Moderate rate of speech
5. Natural and relaxed conversation
6. Simple and precise language
7. Fluid speech
8. No to minimal use of slang
Work at increasing your awareness for how you are experienced by others. Do they clearly
understand what you want them to? Do you leave them with the thoughts and feelings about
you that you intended as a result of your communication efforts? Identify what communica
tion skills you effectively demonstrate and what you need to work on. Observe others you feel
are skilled communicators, and try to learn from their modeling of effective communication.
Use the checklist of items describing the quality of your communication to improve your
effectiveness and to maintain good communication skills.
256 3. SkillBuilding Resources for I n c r e a s i n g Social Competency

EFFECTIVE LISTENING
1. Focus on what is being said
2. Acknowledge what has been said (not your interpretation of it)
3. Ask questions for clarification
4. Pay attention to body language
5. Resist the usage to interrupt or give advice
6. Know your "hot buttons"
ASSERTIVE COMMUNICATION
Assertiveness means to communicate your thoughts and feelings honestly and appropriately.
Assertive communication can be verbal and nonverbal. To express yourself assertively
requires selfawareness and knowing what you want and need. It means showing yourself
the same respect that you demonstrate toward others.
If you do not assert yourself, by letting other people know what your thoughts, feelings,
wants, and needs are then they are forced to make assumptions about you in those areas.
Assumptions have about a 50% chance of being correct. That means that you only have half
a chance of people understanding you and responding to you in a way that you desire.
Once you begin to assert yourself you will find that you will feel better about yourself,
have more selfconfidence, that you get more of what you want out of life, and that others
will respect you more.
Be prepared that not everyone will be supportive of your changes in thinking and behavior.
Some people that you interact with, such as family members or a significant other, may even
demonstrate some negativity toward these changes. This could be because change is difficult
for them to accept, they are comfortable with what is familiar to them, they benefited from
your passive, peoplepleasing behavior, or they fear losing you through change. However,
you can't give up who you are to please other people, or to keep certain people in your life.
Take one day at a time, focus on the positive, and be the best that you can be.
To clarify the variations of responses and styles of communication/behavior review the
following descriptions.
1. Passive: Always giving into what others want. Don't want to make waves.

Don't express your thoughts or feelings. Afraid to say no. Discounting your
own wants and needs.
2. Aggressive: Being demanding, hostile, or rude. Insensitive to the rights of
others. Intimidates others into doing what they want. Is disrespectful.
3. Passiveaggressive: You tell people what they want to hear which avoids
conflict. However, you really feel angry inside and you don't follow through on
the expectations or requests which results in the other person feeling frustrated,
angry, confused, or resentful.
4. Manipulative: Attempt to get what you want by making others feel guilty. Tend
to play the role of the victim or the martyr in order to get other people to take
responsibility for taking care of your needs.
5. Assertive: Directly, honestly, and appropriately stating what your thoughts,
feelings, needs, or wants are. You take responsibility for yourself and are
respectful to others. You are an effective listener and problem solver.
A s s e r t i v e Communication 257
ASSERTIVENESS INVENTORY
The following questions will help determine how passive, assertive, or aggressive you are.

Answer the questions honestly and write out how you would handle each situation.
1. Do you say something when you think someone is unfair?

2. Do you find it difficult to make decisions?
3. Do you openly criticize the ideas, opinions, and behavior of others?
4. If someone takes your place in line do you speak up?
5. Do you avoid people or events for fear of embarrassment?
6. Do you have confidence in your own ability to make decisions?
7. Do you insist that the people you live with share chores?
8. Do you have a tendency to "fly off the handle?"
9. Are you able to say "no" when someone is pressuring you to buy or to do
something?
10. When someone comes in after you at a restaurant and is waited on first do
you say something?
11. Are you reluctant to express your thoughts or feelings during a discussion or
debate?
12. If a person is overdue in returning something that they have borrowed from
you do you bring it up?
13. Do you continue to argue with someone after they have had enough?
14. Do you generally express what you think and feel?
15. Does it bother you to be observed doing your job?
16. If someone's behavior is bothering you in a theater or lecture, do you say
something?
17. Is it difficult for you to maintain eye contact while talking with someone?
18. If you are not pleased with your meal at a restaurant, do you talk to the
waitress about correcting the situation?
19. When you purchase something that is flawed or broken do you return it?
20. When you are angry do you yell, namecall, or use obscene language?
21. Do you step in and make decisions for others?
22. Are you able to ask for small favors?
23. Do you shout or use bullying tactics to get your way?
24. Are you able to openly express love and concern?
25. Do you respond respectfully when there is a difference of opinion?
You can tell by your pattern of responses if you generally fall within the descriptor of
being passive, assertive, or aggressive. Use this exercise to better understand yourself and to
help you set a goal for change if necessary.
Share the results with your therapist.
(Adapted from R. Alberti & M. Emmons, Stand Up, Speak Out, Talk Back, 1975.)
To further clarify what style of communication and behavior that you use, explore how
you would handle the following situations.

1. You are standing in line and someone cuts in front of you, or it is your turn
and the clerk waits on someone else.
2. Your doctor keeps you waiting for half an hour for your appointment.
3. You are not served something that you ordered at a restaurant.
4. Your neighbors are keeping you awake with loud music.
5. Your teenager is playing the stereo too loud.
6. Your friend borrowed some money from you. It is past the date that they
promised to pay you back.
7. You receive a bill and it looks like there is an error on it.
8. You purchased something and decide that you want to return it to the store
for a refund.
9. The people behind you at the theater are talking during the movie.
10. You realize that the person that you are talking to is not listening to you.
11. You are displeased by your partner's behavior.
12. The dry cleaners did a poor job on several articles of clothing.
This exercise will help you better understand yourself, and help you determine appro

priate and effective responses to normal, everyday experiences.
Passive: Failing to stand up for yourself or standing up for yourself ineffectively which can
lead to a violation of your rights.
Assertive: Standing up for yourself in a way that does not violate the rights of other. It is a
direct, appropriate expression of thoughts and feelings.
Aggressive: Standing up for yourself in a way that violates the rights of another person.
They may feel humiliated or put down by your response.
Assertiveness Inventory 259

NONVERBAL COMMUNICATION
Rationale: To explore ways of communicating.
Goal: To show that we always communicate even when we try not to.
Objective: To become more aware of your own nonverbal communication.
To make sure your nonverbal communication accurately projects
what you are thinking and feeling
Materials Needed: 3x5 cards with words describing a feeling/emotion.
Example: happy depressed nervous
sad surprise tired
angry fear embarrassed
bored mischievous curious
Activities:
A.
1. Get your partner.
2. Sit facing your partner.
3. For one minute, try and "not communicate" anything to your partner.
4. Discuss how "we" always communicate.
5. Did you laugh, look away, make faces, etc?
6. How did you feel?
B.
1. Select a card and try to act out the word using only facial expressions
(no hands).
Notes:

DEVELOPING ASSERTIVENESS
1. What do you want (negotiable)?
2. What do you need (nonnegotiable)?
3. What are you thinking and feeling that you are not expressing that prevents
you from getting what you want and need?
Learning assertive communication and behavior and using it effectively requires the devel
opment of all aspects of what it means to be assertive. Effective, assertive communication is
like a circle—to be complete all aspects of it must be continuous.
Components of Assertive Communication
(all of the parts must be practiced to be effective)
Recognizing and
Nonverbal expressing your rights
assertive behavior
Avoiding passivity, Becoming aware
manipulation, passive of your own
aggression, aggression thoughts, feelings,
needs, and wants
Learning to say
"no" Practicing assertive
communication
and behavior
NONVERBAL ASSERTIVE BEHAVIOR
1. With square shoulders and good posture, look directly at a person when
talking to them.
2. Maintain personal space and openness (don't cross arms or legs).
3. To express yourself in an effective assertive manner, don't back up or move
from side to side while speaking. Maintain eye contact and be respectful.
4. Remain calm. Do not become emotional. Express yourself appropriately.
Developing Assertiveness 261

PERSONAL BILL OF RIGHTS
1. I have a right to ask for what I want.

2. I have a right to say no to requests or demands that I cannot meet.
3. I have a right to express all of my feelings—positive and negative.
4. I have a right to change my mind.
5. I have a right to make mistakes and do not have to be perfect.
6. I have a right to follow my own values and beliefs.
7. I have the right to say no to anything if I feel that I am not ready, if it is
unsafe, or if it conflicts with my values.
8. I have the right to determine my own priorities.
9. I have the right not to be responsible for the actions, feelings, or behavior of
others.
10. I have the right to expect honesty from others.
11. I have the right to be angry at someone I love.
12. I have the right to be myself. To be unique.
13. I have the right to express fear.
14. I have the right to say, "I don't know."
15. I have the right not to give excuses or reasons for my behavior.
16. I have the right to make decisions based on my feelings.
17. I have the right to my own personal space and time.
18. I have the right to be playful.
19. I have the right to be healthier than those around me.
20. I have the right to feel safe, and be in a nonabusive environment.
21. I have the right to make friends and be comfortable around people.
22. I have the right to change and grow.
23. I have the right to have my wants and needs respected by others.
24. I have the right to be treated with dignity and respect.
25. I have the right to be happy.
If you are not familiar with your personal rights then take the time to read this daily until
you are aware of your rights and begin to assert them. It may be helpful to post a copy of
this where you have the opportunity to see it intermittently for reinforcement.
ASSERTIVENESS
1. Enables a person to act in their own best interest.

2. Supports a person to stand up for themself without mounting anxiety, to
express their feelings honestly, and assertively.
3. Facilitates a person to exercise their own personal rights without denying the
rights of others.

THE STEPS OF POSITIVE ASSERTIVENESS
1. Prepare for a neutral conversation by first diffusing your emotions and by
waiting until the other person is likely to be least reactive and most receptive.
2. Deliver your message as briefly and directly as possible, without being sarcastic,
condescending, or judgmental. Contribute to the interaction being a positive one.
3. Be respectful. Allow enough time for the other person to respond without pressure.
4. Reflectively listen. If the person becomes defensive reflect to them what you
hear them saying and validate their feelings.
5. Reassert your message. Stay focused on the original issue, do not be derailed.
6. Reuse this process, using a lot of reflective listening to decrease emotionality,
debating, or arguing. It takes two people to escalate things. Don't participate.
7. Focus on the solution, without demanding that the person respond as you do.
Because you brought it up, you have probably been thinking about it and
resolved some aspects of the situation. Therefore, it is important that you
facilitate their participation in problem solving the issue so that they don't feel
like they have been railroaded.
Nonverbal behaviors are as important as verbalizing your assertiveness. The signals that
a person sends, as well as receives, are crucial to the success of assertive communication.
Nonverbal cues include eye contact, body posture, personal space, gestures, facial expres
sions, tone of voice, inflection of voice, vocal volume, and timing. Other variables include
smile, head nodding, and appropriate animation.
Entering an ongoing conversation requires the observation of those already involved. As
you observe the body language of others, make eye contact, and become part of the group.
Join in with appropriate statements and comments.
Ending a conversation can take place by stating a form of closure. "I've really enjoyed this
discussion," or "I see someone I must say hi to that I haven't seen for some time." Other
solutions could include a change in content, less selfdisclosure, and fewer openended state
ments which encourage ongoing conversation. For body language, there is less eye contact,
less head nodding, and increasing physical distance.
PRACTICING ASSERTIVE RESPONSES
1. Describe several problem situations. Arrange them in order of increasing
discomfort or emotional distress that they cause you. In describing a problem
situation include who is involved, when it happens, what bothers you about
this particular situation, how you normally deal with it, and what fears you
have about being assertive in this situation.
Once you have fully describe a problem situation then determine your goal. How would

you like to deal with it, and what is the outcome you want.
2. Developing an Assertive Response
A. Determine what your personal rights are in the situation.
B. Speak directly with the person involved, clearly stating how the situation is
affecting you. Use "I" statements so that your communication is not blaming or
provokes defensiveness (e.g., I feel this way... when... happens).
C. Express your thoughts and feelings honestly and appropriately. Respect
demonstrates that you are taking responsibility for yourself and that you are
motivated to cooperatively resolve issues.
Assertiveness 263
D. Clarify what it is that you want by requesting it directly. Stay focused on the issue
and don't be sidetracked.
E. Seek to make them aware of the consequences of having or not having their
cooperation. Initiate it from a positive perspective of winwin, helping them to see
that you will both benefit, e.g., "If you help me clean up the kitchen after dinner
we can leave early for the game like you want to do."
TEN STEPS FOR GIVING FEEDBACK
1. Describe what you see or observe instead of making an evaluation or giving

your judgment.
2. Be specific instead of general. Specifics are helpful.
3. Feedback should provide information about that which can be controlled and
changed, otherwise it only adds to frustration.
4. Timing is important; always consider it, but do not use it as an excuse.
5. Check out what the person you were giving feedback interpreted you as
saying. Assumptions cause problems and can lead to hard feelings.
6. Check out the validity of your feedback with others.
7. Encourage feedback, but do not pressure others or impose yourself on them if
it is not wanted.
8. Do not overwhelm others with a lot of information. Offer your feedback in
small pieces.
9. Own your own feedback, and feelings by using "I" statements. After all, it is
only your opinion.
10. Share your feedback with others in a way that makes it easy for them to listen
to what it is you want to express.
SAYING "NO"
Many individuals find it difficult to say "no" or to accept someone saying "no" to them,
without experiencing negative emotions. Saying "no" can be thought of as a way of taking
care of oneself, not to make another individual feel rejected, or to experience feelings of guilt
if you are the individual saying "no."
TO OVERCOME GUILT IN SAYING "NO"

Ask yourself the following questions:
1. Is the request reasonable?

2. Ask for more information to clarify what all the facts are.
3. Practice saying "no."
4. Quit apologizing, if it is something that you do not want to do or cannot do.
Therefore, quit saying, "I'm sorry, but..."

REVIEW FOR YOURSELF THE CONSEQUENCES
OF SAYING "YES"
1. End up angry with yourself for doing something you don't want to.
2. Gets in the way or distracts from things you want to do.
3. Resentment begins to develop and build up.
4. Because you are doing something that you don't want to do, but aren't being
honest, it leads to a lack of communication and dishonest communication.
ACCEPTING "NO" FOR AN ANSWER
Each time you hear someone saying "no" to a request that you have made, think to your
self, "I am not being rejected as an individual, it is my request that is being rejected."
Rejection comes up emotionally because your need for approval is strong. You view
accepting your requests as an acceptance and approval of you. It is not.
Remember, assertive communication does not mean getting what you want. Assertiveness
means honest communication which contributes to respectful relationships.
TEN WAYS OF RESPONDING TO AGGRESSION
1. Reflection: Reflect back to demonstrate that the message has been received.

If you like, add information, selfdisclosure, or limit setting.
2. Repeated assertion: Instead of justifying personal feelings, opinions, or desires,
repeat the original point. This requires ignoring issues that are not relevant or
are meant to push buttons.
3. Pointing out assumptions of the aggressor's opinion or position: Do this and
then wait for a response. Then state your own opinion or position.
4. Use "I" statement: "I think," "I feel," etc.
5. Ask questions: Questions are especially effective against nonverbal aggression.
Questions help the individual become more aware of nonwarranted reactions
and behaviors.
6. Paradoxical statements: Making a statement that will make others realize that
their aggressive statement could backfire on them.
7. Time out: Stop, and pause. You can do this by excusing yourself in some way,
such as ending a phone conversation. This is helpful when you need time to
think about how you want to respond, such as refusing a request or demand.
8. Repeat back: When you do not think that another individual is listening to
you, ask the a question such as, "What do you think I am asking for?", or
"What is your understanding of what I just said?"
9. Feedback reversal: Clarify what you think is being said to you by restating
what has been said, in your own words. For example, "Are you saying yes?".
10. Clipping: If you feel like you are under attack, do not want the discussion to
be prolonged, and do not feel like you want to defend your position then
answer directly: "yes" or "no."
Ten Ways of Responding to Aggression 265

THE COMMUNICATION OF DIFFICULT FEELINGS
HOW YOU CAN DEAL WITH UNCOMFORTABLE FEELINGS

1. Talk to someone
A. Report the fact of the situation. Do not use the word "you." When you use the
word "you," the person that you are speaking to generally becomes defensive,
because they are responding like they are being blamed for something.
B. Use "I" statements. I feel... (angry, happy, scared, upset, etc.) when this happens or
when this is said. An "I" statement identifies that you are taking responsibility for
your feelings and are speaking assertively with the person to deal with the outcome
of any given experience.
C. Compromise. Ask: "what can we do about this?" This demonstrates respect for the
other person's point of view as well as facilitates desired changes, which can benefit
both parties.
2. Take action
A. Call a friend and get together.
B. Go for a drive.
C. Write in a journal your feelings and thoughts.
D. Write an uncensored letter that you do not intend to send.
E. Go to a movie.
F. Do something creative (paint, draw, needlework, etc.)
G. Help someone else.
H. Read a book that helps to relax and distract you.
I. DO SOMETHING!
3. Physical activity
Physical exercise is an excellent way to decrease stress and clear your mind so that you can
think more rationally. Often, when people are upset they say and do things which complicate
an already difficult situation. Emotional distress of any kind creates muscle/body tension.
When you feel less distressed you are in a better position to participate in constructive prob
lem solving—alone or with someone else.
Problems occur or get worse when you ignore or neglect to deal with your emotions, or
deal with them in a nonproductive pattern.
Three common errors:
1. Fight. If you know how to argue things through to resolution it can be helpful.

However, most people lack this skill. Therefore, they end up causing more
problems.
2. Flight. Walking out on others and on your own emotions can have negative
effects for your emotional and physical wellbeing.
3. Withdrawal. When you don't deal with things they pile up. Things that
pile up over time show up as headaches, fatigue, depression, anxiety, panic
attacks, etc.
Sometimes people are no longer able to talk constructively to their partner because either a
person lacks the skills of good communication, or they are in an emotionally difficult situa
tion that has been dragging on because they are unable to resolve it. The poor communication

may be isolated to specific subjects or it can be a general problem that now crosses many
boundaries. If this is the case try writing about your feelings.
Writing about your feelings allows you to describe them more accurately and more honestly.
An additional benefit to writing about your feelings is that it allows you to understand yourself
and your feelings more deeply. You can put away your defenses, fears, and anxiety. This may
not feel safe with others, but when it is only you that you explore the depth of your emotions
with the honesty can be a relief and can create opportunities for change never before considered.
Feelings are a spontaneous inner reaction connected to your interpretation of life experi
ences. Over time you may begin to recognize that how you choose to view or interpret things
has a significant impact on how you feel emotionally. It is your responsibility to identify accu
rate and inaccurate interpretations. For example, sometimes you may take personally some
one's behavior or what they said. We cannot take responsibility for others. However, we are
responsible for our own thoughts, feelings, and behavior. Once this issue is clarified you will
find that you conserve your energy in a constructive way, especially if, in the past, you often
interpreted things negatively and tended to personalize them as well.
Feelings are constantly changing. You can have many feelings at once. If you are honest
emotionally and accurate in your interpretation of situations then you are ready to begin to
speak openly about many of the issues you have only felt safe writing about. Do not speak
for others, only yourself. Communicating your own feelings accurately, responsibly, and
with care eliminates an atmosphere of judgment and blame.
When you express your feelings with care it is an act of giving. No one can describe your
feelings as clearly and accurately as you. Communication on a feeling level is an important
aspect of a couple's relationship. It is the giving and receiving of each other. This is true of
all feelings, even unpleasant and difficult feelings.
To make an assumption or judgment about another opens the door to criticism, blame,
defensiveness, accusations, and argument. All of these things lead to the distancing of two
people who care about one another. Sometimes the way in which information is given makes
it difficult to hear. Therefore, ask yourself, "Am I saying this in a way that the other person
can hear what I want them to hear?"
Begin your selfexploration with writing. As soon as you feel comfortable, begin sharing
some of the things that you have learned about yourself, and about yourself in your rela
tionship. A lot can be learned, understood, and resolved when two people write. Consider
the possibility of each person doing what has been stated as a couple's project in personal
and relationship growth.
WRITING
Remember: Keeping a personal journal can be useful for clarification and deeper self under

standing, but in this particular writing project you are writing to your partner and your part
ner is writing to you. Therefore, you will be writing in the same manner that you would like
to verbally express yourself. This means writing in a caring and tender manner with honesty
and sincerity.
This requires that you clarify the difference between thoughts and opinions and your feel
ings. Make an effort to describe your feelings as thoroughly as possible and in terms that
your partner will be able to relate to and understand. To begin, use the next sheet (List of
Potential Conflicts) which defines some potential topics of relationship conflicts. Together
you will choose one area to write about using the directions given.
This writing project is not to be a means to vent and get things off your chest. Nor is it
the means to make your partner feel bad or to put them in their place. Its purpose is to
improve the understanding and communication between the two of you in order to build a
stronger and more satisfying, sharing relationship.
In your writing be sure that you do not blame your partner for how you feel or try to
change them. The purpose of your writing is to reveal the real you with an invitation for
Writing 267
them to symbolically take your hand and grow toward a stronger bond of genuine respect
and positive regard and love for one another.
The outcome of improving your communication will be to come to mutually agreeable
solutions and problem solving.
Once the two of you have completed your writing it is time to exchange your notebooks.
This exchange is done in a gentle, caring manner without any discussion. To share yourself
with one another so openly and honestly is a gift. Each person is to read what their partner
has written two times without saying anything. Try to understand the words that they have
written to you about their feelings.
The next step is to talk about what you have shared with one another through your writing.
Listen to one another carefully so that there can be full understanding between the two
of you. Remind yourself that this is a time of growth. A time to grow closer through under
standing and validation.
AREAS OF POTENTIAL CONFLICT
1. Read through the list. Put a check by any area that you identify as an area of

difficulty, where you believe that others do not understand how you feel, or
where you may lack understanding in how other people feel.
2. If you have marked more than one area, choose the one that elicits the
strongest feelings for you.
3. Write a letter to your partner as described on the handout. As you describe
how you feel in detail be sure that the manner of your expression is respectful
as you attempt to grow in awareness and understanding of one another.
LIST OF POTENTIAL CONFLICTS
Money/finances
Time management
_Work
Leisure time
Couple's time
Sexual relationship
Intimacy/touching/hugs
Children/parenting issues
Inlaws or other family members
Atmosphere of the home
Maintenance of home
Decision making
Friends
Differences in religious or spiritual beliefs
Use of alcohol/drugs
Other

LIST OF FEELING WORDS
PLEASANT FEELINGS
OPEN HAPPY ALIVE GOOD
understanding great playful calm
confident gay courageous peaceful
reliable joyous energetic at ease
easy lucky liberated comfortable
amazed fortunate optimistic pleased
free delighted provocative encouraged
sympathetic overjoyed impulsive clever
interested gleeful free surprised
satisfied thankful frisky content
receptive important animated quiet
accepting festive spirited certain
kind ecstatic thrilled relaxed
satisfied wonderful serene
glad free and easy
cheerful bright
sunny blessed
merry reassured
elated
jubilant
LOVE INTERESTED POSITIVE STRONG

loving concerned eager impulsive
considerate affected keen free
affectionate fascinated earnest sure
sensitive intrigued intent certain
tender absorbed anxious rebellious
devoted inquisitive inspired unique
attracted nosy determined dynamic
passionate snoopy excited tenacious
admiration engrossed enthusiastic hardy
warm curious bold secure
touched brave
sympathy daring
close challenged
loved optimistic
comforted reenforced
drawn toward confident
hopeful
DIFICULT/UNPLEASANT FEELINGS
DEPRESSED CONFUSED HELPLESS
irritated lousy upset incapable
enraged disappointed doubtful alone
hostile discouraged uncertain paralyzed
insulting ashamed indecisive fatigued
sore powerless perplexed useless
annoyed diminished embarrassed inferrior
upset guilty hesitant vulnerable
hateful dissatisfied shy empty
unpleasant miserable stupefied forced
offensive detestable disillusioned hesitant
bitter repugnant unbelieving despair
aggressive despicable skeptical frustrated
resentful disgusting distrustful distressed
inflamed abominable misgiving woeful
provoked terrible lost pathetic
incensed in despair tragic
List of Feeling Words 269

infuriated sulky uneasy in a stew
cross bad pessimistic dominated
worked up a sense of loss tense
boiling
fuming
indignant
INDIFFERENT AFRAID HURT SAD

insensitive fearful crushed tearful
dull terrified tormented sorrowful
nonchalant suspicious deprived pained
neutral anxious pained grief
reserved alarmed tortured anguish
weary panic dejected desolate
bored nervous rejected desperate
preoccupied scared injured pessimistic
cold worried offended unhappy
disinterested frightened afflicted lonely
lifeless timid aching grieved
shaky victimized mournful
restless heartbroken dismayed
doubtful agonized
threatened appalled
cowardly humiliated
quaking wronged
menaced alienated
wary
TIME MANAGEMENT
Time is defined by how we use it. If you feel like you are constantly rushing, don't have
enough time, are constantly missing deadlines, have many nonproductive hours, lack suffi
cient time for rest or personal relationships, feel fatigues, and feel overwhelmed by demands,
it is likely that you suffer from poor time management.
FOUR CENTRAL STEPS TO EFFECTIVE

TIME MANAGEMENT
1. Establish priorities. This will allow you to base your decisions on what is
important and what is not, instead of wasting your time.
2. Create time by realistic scheduling. People tend to misjudge how
much time tasks will really take to accomplish. Therefore, give yourself
adequate time to accomplish a given task and eliminate lowpriority
tasks.
3. Develop the skill of decision making.
4. Delegate tasks to others. If you tend to control everything or believe that only
you can do whatever it is, then realistically evaluate all the tasks that you do
and you will be surprised to find that many people in your life are capable of
doing some of the things that you do.
HOW TO START YOUR TIME MANAGEMENT PROGRAM

1. Making an initial assessment of how you spend your time takes approximately
3 days of observation. Keeping a journal specifically to log how you spend your
2/0 3. S k i l l B u i l d i n g Resources for Increasing Social Competency

time will clarify your time management or lack thereof. This will be easy to
manage if you break up the day into three parts:
A. From waking through lunch.
B. From the end of lunch through dinner.
C. From the end of dinner until you go to sleep.
2. It will take one day to define and prioritize your goals and activities.
3. To adequately develop a habit of effective time management will
take between 3 and 6 months.
Once you begin your time management program continue to do a weekly review to mon
itor your consistency and progress. Maintain an awareness of what you are doing and why.
You will find that effective time management will significantly reduce your stress.
SOME EXAMPLES OF INDIVIDUALIZED TIME
MANAGEMENT OPTIONS
Effective time management contributes to a balanced lifestyle. Review the following list and

choose some time management tips that you can incorporate into your life to accomplish
more and to feel less stress.
1. Be realistic with yourself regarding how much you can actually accomplish

in a given span of time.
2. Say "NO" to additional responsibilities that infringe on personal/leisure or
work time.
3. Prioritize your tasks, because they are not equally important. Set
priorities on a daily, weekly, and monthly basis for maximizing
accomplishments.
4. Develop an awareness for your peak energy periods and plan to do the
activities with the highest energy demand at that time.
5. On a regular basis, review what the best use of your time is currently.
6. Striving for perfection is generally not necessary and can burn up time better
spent in another way. Complete tasks well enough to get the results that you
really need.
7. Delegate tasks and responsibilities to others whenever appropriate. Just be
sure to communicate your expectations clearly.
8. Don't waste time thinking and rethinking the decisions for basic issues. Make
those decisions quickly and move on.
9. If you have a difficult task to do that you are not looking forward to, do
yourself a favor and approach it with a positive attitude. You will be surprised
about how much stress that can relieve.
10. Break big overwhelming tasks into small manageable ones so that way
it is easier to keep track of your progress and achievements—which is
reinforcing.
Some Examples o/ Individualized Time Management Options 271

11. Be prepared to make good use of "waiting" time by having small tasks or
activities to do. Another way to deal with it is to always be prepared to take
advantage of potential relaxation time when there are no demands on you.
12. When you need time to focus on your goals without interruption then request
it. Take responsibility for creating a conducive work environment at home
and at work.
13. Set goals and reward yourself when you have accomplished them. If it is a big
goal you may want to build in rewards at certain milestones of effort and
accomplishment as a reinforcer.
14. From time to time, remind yourself how good it feels to accomplish tasks,
what the benefits of accomplishment are, and the relief of having that weight
off your shoulders.
15. Good use of time means more than completing "necessary" tasks. It means
building in time for selfcare like leisure activities and exercise. You being the
best that you can be is a priority.
DECISION MAKING
Life is about choices. Decision making is a skill that can help you to make choices that are

necessary and right for you. It is an active process that requires you to take responsibility for
yourself, your life, and your own happiness. People who are good at making decisions have
the selfconfidence that comes from knowing how to make good choices in their life.
STEPS FOR DECISION MAKING
1. Isolate the problem. Sometimes things are not what they seem.
Be careful in not just looking at the surface issues and making a decision based
on that. Instead, try to understand any underlying issues that may actually be
the source of the problem. If you allow yourself to examine the problem from a
number of different perspectives or angles, you may find yourself defining the
problem in a number of different ways. The more options you have the better
your chance of making the best choice.
2. Decide to take action. Once you have identified and isolated the problem, the
next step is deciding whether or not you need to take action now. Sometimes
the best decision is to do nothing. However, there is a difference between
making a choice to do nothing versus procrastination, and avoidance of dealing
with an uncomfortable situation.
3. Gather resources. Ideally it is best to gather as much information as possible
about the situation. Sometimes this may even mean consulting with a
professional or expert could be beneficial. Gather as much information as you
can, but use common sense. Gathering information could be a way to delay
taking any action based on the premise that you don't have all the information
that you know its out there.
4. Make a plan. In other words, "make a decision." You have analyzed the
problem, looked at it from all the different angles. Now it is time to decide
how you will carry out your decision.

5. Visualize your plan of action. It is not possible to anticipate the outcome of
any decision you make, because making a decision involves some degree of
risk. However, you can do a test run on your plan by visualizing the potential
outcome of your decision. Use your gut feeling or intuition. If it doesn't feel
right, don't ignore it, try to understand the source of your discomfort with the
decision.
6. Take action. You have successfully completed all the steps required for good
decision making. Now it is time to take action, and put your decision to work.
At this point you should feel confident about the work you have done in
making this decision, and you will be able to maintain that feeling of self
confidence as you take action.
GOAL DEVELOPMENT
Before a person can reach goals they must set goals. Often, people have a lot of different
things on their mind that they would like to see happen. However, they have not taken
the time to sit down and thoroughly think through all that is required to see those things
happen. Strategizing for success is an easy process, doesn't take much time to do, and when
you are completed you will have a much clearer idea of what you want and how you are
going to go about making it happen.
STEPS FOR DEVELOPING GOALS
1. Keep it simple. Define the goal as clearly as possible. If you are not sure of
exactly what you want, the course to get there will be bumpy, and it will take
more time and energy than necessary.
2. Break it into small steps. Once you have clearly defined the goal, break it down
into small steps that you take to reach your goal. Small steps are helpful
because they are manageable, require the least amount of stress, and allow you
to see the progress that you are making toward your goal.
3. Choose a starting point. Once you have broken your goal down into steps, the
next thing to do is to choose a starting point. When will you begin working on
your goal? This is a question which clarifies how much of a priority it is to
you. Life is about choices, and everyone is responsible for the quality of their
own life.
4. Redefine the goal. Sometimes it becomes necessary to redefine a goal that
you have set. Maybe it was an unrealistic goal because you lacked the resources
to reach it, it is not as important to you as it once was, or maybe as time has
gone on you have learned some new information which changes the way that
you are looking at things. In redefining the goal you go through the same steps
as setting the original goal. Redefining goals is often related to personal
growth.
5. Act on your plan. By the time you actually initiate a formal starting point of
your goal you will already have completed several of the steps toward it. You
will have thought it through, and actually planned it out. Accomplishing steps
toward your goal will reinforce positive selfesteem, and following through on
other important changes in your life if that is your choice.
Goal Development 273

SETTING PRIORITIES
Once you have set major goals and decided on your plan of action, you need to determine

how important it is for you to reach your goal. This is what is meant by "setting priorities."
Sometimes people get frustrated with themself because they start things that they never
finish. It is important to explore the reason behind the lack of accomplishment. It could be
that motivation is low, avoidance is at work, or that it is simply not a priority for you.
STEPS FOR SETTING PRIORITIES
1. Develop a strategy. This relates back to the steps of clearly defining your goals.
Once the goal is decided, you then break it down into steps that will ensure
that you are able to reach it. Because you remain focused your goal the steps to
getting there are each a priority set in sequence.
2. Know what is important. To be satisfied with the outcome of your goal it is
important to be aware of all of the issues related to it. In some ways your goal
may open the door for other opportunities, or it may present some limitations.
Understand where you are going and how things may change for you over
time, which may alter priorities.
3. Investigate alternatives. Use your resources, take the time to educate yourself,
and ask as many questions as possible. Because goals can include investments
of time, money, and effort, thoroughly investigate the different paths for getting
to the same goal. Then, when it comes time to put your plan into action, you
will know if there is more information that you need to update yourself or if
you feel assured that you are ready to proceed.
4. Reaching your goal. By having a clearly defined goal and a plan which is
broken down into manageable steps, you will be able to reach your goal. You
will have put your priorities into place and will be on your way to
accomplishing your goal.
RATIONAL THINKING: SELFTALK, THOUGHT
STOPPING, AND REFRAMING
SELFTALK
Much of what a person feels is caused by what they say to themselves. People talk to them
selves all day long with little awareness for it. This is because selftalk is automatic and car
ried out repeatedly. However, people generally have some idea for the type of selftalk they
use once exploring the subject of selftalk begins.
When people are not sure why something is the way it is they often start looking outside
themselves for the source of unhappiness or other form of emotional distress. They have the
impression that what is happening around them is what "makes" them feel the way they do.
While there is likely to be some contribution from their environment, it is really their
thoughts and interpretation about the situation that causes the associated feelings.
Situation or DistortedNegative Emotional Response

Experience SelfTalk

Therefore, what a person thinks about a situation is likely the greatest factor influenc
ing how they feel and respond. The most positive aspect about this is that a person has
choices. Choices with effort leads to change in the way they interpret events and think
about them.
It is likely that if they do engage in negative selftalk that they have been doing it for a
long time. It may have even started when you were very young.
It starts by a person telling themselves negative things about themselves and their life
situation. Not surprisingly, these types of internal messages could start when a person is
young because they are unhappy, a negative thing may be repeatedly said to them which
becomes part of their identity, they didn't feel like they had control over their life, and/or
they have not been taught good coping skills. All of this makes it easier for a person to
externalize or blame the way that they feel and their responses to some entity outside of
themselves and their control instead of taking responsibility for their own feelings and
actions.
As an adult all of this negative selftalk is seen as perfectionism, chronic worrying, always
being a victim, selfcritical, low selfesteem, phobias, panic attacks, generalized anxiety,
depression, and hopelessness. It is also possible that when people feel so bad emotionally
that it affects them physically.
For example: headaches, abdominal distress, intestinal disorders, seems to be sick all the
time.
If you experience physical symptoms, you should consult your physician. Examples:
Distorted 1. What if I don't pass the employment exam (worrier).

Thinking— 2. I am a weak person (critic).
Negative 3. I will never get over this (victim).
SelfTalk 4. I will be devastated if I don't get acceptance/approval
(perfectionist).
List some negative selfstatements that you are aware of:
1.
2.
3.
4.
5.
Rational Thinking: SelfTalk, Thought Stopping, and Rejraming 275

6.
7.
8.
9.
10.
The realization that you are mostly responsible for how you feel is empowering. When
you take responsibility for your reactions you begin to take charge and have mastery over
your life. Once you become aware of the distortions in your thinking you will be able to
change negative thoughts to positive ones.
Accomplishing this is one of the most important steps to living a happier, more effective
and emotionally distressing free life.
THOUGHT STOPPING
Now that you are aware of negative selftalk and how it affects how you think, feel, and
respond you are ready to learn some additional strategies to facilitate new ways of thinking.
Thought stopping is a technique that has been used for years to treat obsessive and pho
bic thoughts. It involves concentrating on the unwanted thoughts, and after a short time,
suddenly stopping and emptying the thoughts from your mind. The command "stop" or a
loud noise is generally used to interrupt the unwanted and unpleasant thoughts.
As previously discussed regarding negative selftalk, it has been well documented that
negative and frightening thoughts invariably precede negative and frightening emotions. If
the thoughts can be controlled, overall levels of stress and other negative emotions can be
significantly decreased.
Thought stopping is recommended when the problem is primarily cognitive, rather than
acted out. It is indicated when specific thoughts or images are repeatedly experienced as
painful or leading to unpleasant emotional states. Assess which recurrent thoughts are the
most painful and intrusive. Make an effort to understand the role that these thoughts have
had on emotional functioning and how you experience your environment in general, based
on the following statements.
Explore Your List 1. No Interference. This thought does not interfere with other activities.

of Stressful 2. Interferes a Little. This thought interferes a little with other activities, or wastes
a little of my time.
Thoughts (from
3. Interferes Moderately. This thought interferes with other activities, or wastes
selftalk section)
some of my time.
4. Interferes a Great Deal. This thought stops me from doing a lot of things, and
wastes a lot of time every day.

ThoughtStopping 1. Close your eyes and imagine a situation where the stressful thought is likely to
Practice occur. Include the neutral as well as distressing thought related to this situation.
2. Interrupt the thought
A. Set a timer or alarm of some sort to go off in 3 min. Close your eyes and imagine
the stressful thought as stated in #1. When the alarm goes off, shout "stop." Let
your mind empty of the stressful thoughts, leaving only neutral and nonstressful
thoughts. Set a goal of about 30 sec after the stop, with your mind remaining
blank. If the stressful thoughts return during that brief period, shout "stop"
again.
B. Using a tape recorder, record yourself shouting "stop" at the varying intervals of
3 min, 2 min, 3 min, 1 min. Repeat the taped "stop" messages several times at
5sec intervals. Proceed the same way with your timer or alarm. The tape recording
is beneficial to strengthen and shape your thought control.
C. The next step is to control the thoughtstopping cue without an alarm or tape
recorder. When you are thinking about the stressful thoughts shout "stop." When
you succeed in eliminating the thought(s) on several occasions by interrupting the
thought with "stop" said in a normal voice, then start interrupting the thought by
whispering the "stop" cue. When you are able to interrupt the thought with the
whispered cue begin to use a subvocal cue of "stop" (moving your tongue as if you
were saying it out loud). When you have success at this level then you will be able
to stop the thoughts alone or in public without making a sound and not calling
attention to yourself.
D. The final step of thought stopping involves thought substitution. In place of
the distressing thought, use a positive, affirming, and assertive statement. For
example, if you were afraid to go out on a lake in a boat you might say to yourself,
"This is beautiful and relaxing out here." Develop several alternative statements to
combat the negative one, since the same response may lose its power through
repetition.
Special 1. Failure with your first attempt at thought stopping means that you have

Considerations selected a thought that is very difficult to eliminate. In this situation choose a
stressful thought that is either less stressful or intrusive than your first choice.
Repeat the technique.
2. If the subvocalized "stop" is not successful, and saying "stop" out loud
embarrasses you, then keep a rubberband around your wrist so that no one can
see it and when the thought occurs snap it. Or pinch yourself, or press your
fingernails into your palms.
3. You should be aware that thought stopping takes time. The thought will return
and you will have to eliminate it again. The main idea is to stop the thought
when it returns again, and to concentrate on something else. The thoughts will
return less and less in most cases and eventually cease.
REFRAMING
You have learned about how negative selftalk affects how you think, feel, and respond.
Now you are going to learn additional strategies for changing how you think and what you
do related to how you will interpret situations and how you feel.
Often the way you interpret things is linked to irrational beliefs or negative selfstatements.
Reframing, or relabeling is a technique you can use to modify or change your view of a prob
lem or a behavior. You will also find it helpful in decreasing defensiveness and to mobilize
your resources.
Therefore, reframing provides alternative ways to view a problem behavior or perception.
Look for overgeneralizations like never and always.
Rational Thinking. SelfTalk, Though Stopping, and Reframing 277

For example:
if labeled stubborn independent or persistent

greediness ambitious
anger loving concern
When a behavior is labeled negatively ask the following questions:
1. Identify a situation which typically produces uncomfortable or distressing

feelings.
2. Try to become aware of what you automatically focus on during the situation.
3. What are you feeling and thinking?
To challenge the longterm negative labeling ask the following questions:
1. Is there a larger or different context in which this behavior has positive value?

2. What else could this behavior mean?
3. How else could this situation be described?
Steps to Successful 1. To understand and accept an individual's belief that perceptions about a

Refraining problem situation can cause emotional distress.
2. To become aware of what is automatically attended to or focused on in problem
situations. You can use imagery or role paying to reenact situations to become
more aware of what thoughts and feelings are present. When you identify your
perceptions and feelings you will be able to be prepared for the next step.
3. Identification of alternative perceptions. Generally this means to attend to other
features of the situation that have a positive or neutral connotation. The
reframe must fit, be acceptable to the individual, and at least as valid as the
perception they are reframing.
4. Modifying the perceptions in a problem situation are designed to break the old
patterns by creating new and more effective reframes. This requires
commitment and practice.
5. Homework using reallife situations and recording it in your journal will
reinforce desired change(s). The experience, perception with associated
thoughts, feelings, and responses, and the chosen reframe (it may be helpful to
list several possible alternative reframes).
THINKING DISTORTIONS
1. AllorNothing Thinking. You see things in black and white categories.

If your performance falls short of perfect, you see yourself as a total
failure.

2. Overgeneralization. You see a single negative event as a neverending pattern
of defeat.
3. Mental Filter. You pick a single negative detail and dwell on it exclusively so
that your vision of all reality becomes darkened, like the drop of ink that
discolors the entire beaker of water.
4. Disqualifying the Positive. You reject positive experiences by insisting that
they don't count for some reason or other. In this way you can maintain a
negative belief that is contradicted by your everyday experiences.
5. Jumping to Conclusions. You make a negative interpretation even though
there are no definite facts that convincingly support your conclusion.
A. Mind Reading. You arbitrarily conclude that someone is reacting negatively to
you, and you don't bother to check it out.
B. The Fortune Telling Error. You anticipate that things will turn out badly, and you
will feel convinced that your prediction is an already established fact.
6. Magnification, Catastrophizing, or Minimization. You exaggerate the
importance of things (such as failure, falling short of the mark, or
someone else's achievement), or you inappropriately shrink things
until they appear tiny (your good and desirable qualities or someone else's
limitations).
7. Emotional Reasoning. You assume that your negative emotions necessarily
reflect the way things really are, "I feel it, so it must be true."
8. Should Statements. You try to motivate yourself with shoulds and shouldn'ts,
as if you had to be whipped and punished before you could accomplish
anything. "Musts" and "oughts" also fall into this faultythinking category.
The emotional consequence is guilt. When you direct should statements
toward others, you feel anger, frustration, and resentment.
9. Labeling and Mislabeling. This is an extreme form of Overgeneralization.
Instead of describing your error, you attach a negative label to yourself, "I'm
a loser." When someone else's behavior rubs you the wrong way you attach a
negative label to him, "He's a jerk." Mislabeling involves describing an event
with language that is highly colored and emotionally loaded.
10. Personalization. You see yourself as the cause of some problem, or take on
someone's opinion as having more value than it does.
REALISTIC SELFTALK
1. This too shall pass and my life will be better.

2. I am a worthy and good person.
3. I am doing the best I can, given my history and level of current awareness.
4. Like everyone else, I am a fallible person and at times will make mistakes and
learn from them.
5. What is, is.
6. Look at how much I have accomplished, and I am still progressing.
7. There are no failures only different degrees of success.
Realistic SelfTalk 279

8. Be honest and true to myself.
9. It is okay to let myself be distressed for awhile.
10. I am not helpless. I can and will take the steps needed to get through
this crisis.
11. I will remain engaged and involved instead of isolating and withdrawing
during this situation.
12. This is an opportunity, instead of a threat. I will use this experience to learn
something new, to change my direction, or to try a new approach.
13. One step at a time.
14. I can stay calm when talking to difficult people.
15. I know I will be okay no matter what happens.
16. He/She is responsible for their reaction to me.
17. This difficult/painful situation will soon be over.
18. I can stand anything for a while.
19. In the long run who will remember, or care?
20. Is this really important enough to become upset about?
21. I don't really need to prove myself in this situation.
22. Other people's opinions are just their opinions.
23. Others are not perfect, and I won't put pressure on myself by expecting
them to be.
24. I cannot control the behaviors of others, I can only control my own
behaviors.
25. I am not responsible to make other people okay.
26. I will respond appropriately, and not be reactive.
27. I feel better when I don't make assumptions about the thoughts or behaviors
of others.
28. I will enjoy myself, even when life is hard.
29. I will enjoy myself while catching up on all I want to accomplish.
30. Don't sweat the small stuff—it's all small stuff.
31. My past does not control my future.
32. I choose to be a happy person.
33. I am respectful to others and deserve to be respected in return.
34. There is less stress in being optimistic and choosing to be in control.
35. I am willing to do whatever is necessary to make tomorrow better.

PRACTICE REFRAMING HOW YOU
INTERPRET SITUATIONS
You have a choice in how you view or interpret situations. If you tend to overgeneralize or

focus on the negatives you make it difficult to cope effectively, you decrease your opportu
nity for happiness, and you remain stuck instead of adjusting and adapting.
1. Identify several situations which typically produce uncomfortable or distressing

feelings.
2. What is your automatic focus, thoughts, and feelings in each situation?
3. What is a more useful way to view each situation which offers you choices and

the potential for growth?
Practice Rejraminij How You Interpret Situations 281

DEFENSE MECHANISMS
Defense mechanisms are a way of coping with anxiety, reducing tension, and restoring a
sense of balance to a person's emotional experience. Defense mechanisms happen on an
unconscious level and tend to distort reality to make it easier for the person to deal with.
Everyone uses defense mechanisms as a way to cope with the everyday garden variety mild
to moderate anxiety. When defense mechanisms are used to an extreme, they interfere with
a person's ability to tell the difference between what is real and what is not.
Defense mechanisms are used independently or in combination with one another. They
are used to various degrees, depending on how well they meet our needs.
Choose three defense mechanisms and describe how you use each. Additionally, describe
how it prevents your personal growth. Identify constructive alternatives for coping that you
could use instead of the defense mechanisms.
1. Defense Mechanism:

DEFENSE MECHANISM DEFINITIONS
1. Denial Protecting oneself from unpleasant aspects of life by

refusing to perceive, acknowledge, or face them.
2. Rationalization Trying to prove one's actions "made sense" or were
justified; making excuses.
3. Intellectualization Hiding one's feelings about something painful behind
thoughts; keeping opposing attitudes apart by using
logictight comparisons.
4. Displacement Misdirecting pentup feelings toward something or
someone that is less threatening than that which
actually triggered the feeling response.
5. Projection Blaming. Assuming that someone has a particular
quality or qualities that one finds distasteful.
6. Reaction Formation Adopting actions and beliefs, to an exaggerated degree
that are directly opposite to those previously accepted.
7. Undoing Trying to superficially repair or make up for an action
without dealing with the complex effects of that deed,
"magical thinking."
8. Withdrawal Becoming emotionally uninvolved by pulling back
and being passive.
9. Introjection Adopting someone else's values and standards
without exploring whether or not they actually fit
oneself; "shoulds" or "ought to's."
10. Fantasy Trying to handle problems or frustrations through
daydreaming or imaginary solutions.
11. Repression Unconsciously blocking out painful thoughts.
12. Identification Trying to feel more important by associating oneself
with someone or something that is highly valued.
13. Acting Out Repeatedly doing actions to keep from being uptight
without weighing the possible results of those actions.
14. Compensation Hiding a weakness by stressing too strongly the
desirable strength. Overindulging in one area to make
up for frustration in another.
15. Regression Under stress, readopting actions done at a less
mature stage of development.
ANGER MANAGEMENT
Anger is a normal, healthy emotion. When it is expressed appropriately you are letting go of

the stress and frustration that you are experiencing, and those around you understand and
accept that you are upset. When anger is expressed inappropriately with blame and aggression
it can be a destructive force—both to the person experiencing it and for those subjected to it.
Anger Management 283

As with other things that are negative, there is a tendency to hold something or someone
else responsible. When you hold someone else responsible for your stress, anxiety, or frus
tration you feel that you have the right to express it in an aggressive manner.
1. You are responsible for your own life, the choices you make, and the quality of

your life experience.
2. Clarify your thoughts, feelings, needs and wants. You are the only one who
knows what goes on inside of you.
3. Compromise with others when wants or needs are in conflict, or an issue of
some contention. It is unreasonable to always or rarely get what you want.
Therefore, with mutual respect, compromise, and negotiation people can seek
an equitable solution.
4. Develop effective skills for managing your life. Examine the difficulties that you
experience, assess how you contribute to the difficulties, and decide what you
are willing to do differently.
SEVEN STEPS OF TAKING RESPONSIBILITY

1. Make a commitment to change in order to improve the quality of your life.
2. Be aware of how the behavior of others affect you. Seek activities which are
pleasurable and beneficial to you. People who feel good about their lives are
less negative and angry. They are happy, accepting of responsibility and take
good care of themselves.
3. Selfcare is the core of taking responsibility for yourself. Balance your life;
Nutrition, adequate rest, regular exercise, people and activities that you enjoy,
personal growth, things to look forward to, etc.
4. Broadening your resources and support system is a lifelong endeavor. Don't limit
yourself with minimal resources. Create as many choices for yourself as possible.
5. Clear boundaries and setting limits reinforces everyone being responsible for
themselves. Don't do things just to please others. Give yourself permission to say
"no." If you ignore this step you are likely to feel used, abused, and resentful.
6. Define your goals. Break each goal down into manageable steps. Regularly check
on the progress you had made toward your goals. You create your own destiny.
7. Let go. If something is unresolved then take care of it and move on. If there is
something that you don't have any control over then make peace with it, accept
it, and let go. Letting go is also important if you choose to remain in situations
or relationships which are frustrating to you. You only have control over
yourself. You are responsible for your own happiness.

UNDERSTANDING ANGER
1. What are the stressors, fears, and frustrations that are at the bottom of your

anger?
2. Triggers: What do you think or say to yourself that increases anger?
3. Is anger effective in getting others to do what you want them to do? Explain.
4. What are more effective techniques you can use to get what you want and need?
5. What are resources or sources of support you utilize when you are feeling angry?
6. What are you going to do differently to manage anger? How can you decrease

or eliminate feelings of anger?
7. Are there things that you need to limit or eliminate from your life

(obligations, relationships, saying yes to everyone, etc.)?
8. How can you get what you want and need through compromise and problem

solving?
Understanding Anger 285

9. What are your goals of anger management and how are you going to go
about the changes needed to reach your goals?
(e.g., Goal: I choose to no longer feel angry all about my husband's behavior.
Object: Recognize and accept that he is responsible for his own behavior)
10. If you feel that you have tried everything and are unable to resolve issues with

a person or situation the only thing left for you to do is to LET GO. How will
you be able to make peace with such a situation?
How do you feel about having wasted so much of your energy, time, and life on anger?
HANDLING ANGER
GENERAL PRINCIPLES REGARDING ANGER
1. Anger is a common emotion.
2. Anger needs to be expressed for healthy adjustment.
UNDERSTANDING YOUR EXPERIENCE OF ANGER
1. Socialized to believe that anger is wrong.
2. Anger is associated with anxiety.
3. Anger is used to control and intimidate others.
4. Fear of anger.
A. Fear of your own anger.
B. Fear of the anger of others.
5. Anger is a normal reaction to a stimulus.
6. A belief that you are unable to control anger.
7. Physiological response with anger (survival emotion).
8. Pretending that you don't get angry can make you sick.
9. Blocked and unexpressed anger does not go away.
10. When not expressed assertively and appropriately, anger tends to pop up in
destructive ways, such as resentment and hostility.

RECOGNIZING THE STAGES OF ANGER
It is not uncommon for people to deny that they have any feelings of anger or to simply be
unaware that they are angry until it escalates to a rageful explosion. Once anger begins to
intensify, this feeling may be carried over into your communication with others. Unfortunately,
when this happens people do not listen to what you are trying to tell them; instead they either
discount your message or become defensive to the display of anger. This could simply mean
that your anger has built to a level that is overwhelming to you, and when it is expressed to
someone else it overwhelms that person as well.
Start paying more attention to what you are thinking, feeling, and the physical changes
you experience when you are angry. It would be expected that the more intense the feeling
of anger, the more intense the emotion and physical response associated with it. It is impor
tant to increase your awareness for anger so that it can be expressed at an earlier stage with
less intensity and to decrease the impact on you physically.
The following list identifies feelings that lead to a progressively intense level of anger.
Read through the list and identify your feelings. Use this awareness to monitor these feelings
and to take responsibility for effectively dealing with them. If you do this, you will find that
you are increasingly expressing your feelings appropriately at an earlier stage of anger, which
is less distressful to you emotionally and physically.
1. Uneasy
2. Uncomfortable
3. Withdrawn
4. Irritated
5. Agitated
6. Annoyed
7. Upset
8. Mad
9. Angry
10. Furious
11. Rageful
The following is a brief list of physical responses to anger:
1. Headache
2. Muscle tension
3. Clenched fists
4. Changes in breathing
5. Upset stomach
6. Tight stomach
7. Sleep disturbance (ruminating)
8. Yelling/screaming
9. Hitting/breaking things
DECREASE THE INTENSITY OF ANGER:
1. Clarify your needs, thoughts, and feelings
A. Express them
B. If other are not supportive or caring, problemsolve appropriate ways to get your
needs met
Handling Anger 287

2. Take time out
3. Exercise or do relaxation techniques to decrease body tension
4. Write about your feelings
5. Decide how you are going to take responsibility for you, and take positive
action.
BARRIERS TO EXPRESSING ANGER
1. Fear of disapproval.
2. Fear of the power of your anger.
3. Denial of the fact of your anger.
A. Stressed out
B. Tired
C. Sick
4. Allow others to deny your right to be angry.
5. Avoidance of all feelings.
A. Out of touch with emotional experience. Not aware of when angry, sad,
happy.
INAPPROPRIATE EXPRESSION OF ANGER:

VIOLENCE AND RAGE
1. Take responsibility for your emotional experience.
2. Acknowledge that inappropriate expression of anger is not acceptable.
3. Learn anger management.
4. Identify how your behavior has affected and harmed others.
PENALTIES FOR NOT EXPRESSING ANGER
1. Depression—experienced as feeling incompetent.
2. Anxiety—often experienced with fear.
3. Guilt—socialized to believe that it is wrong to feel angry.
4. Selfdestructive activities.
A. Drinking/drugs
B. Eating to mask feelings
C. Psychosomatic Illnesses
1. Headache
2. Gastrointestinal problems
3. Hypertension
5. Aggression/violence.
6. Disguised anger.
A. Hostile humor (sarcasm)
B. Nagging
C. Silence and withdrawal
D. Withholding sex
E. Displacement

WAYS TO DEAL WITH ANGER
1. Recognize anger when you are experiencing it.
2. Express it appropriately when it occurs.
A. Express how you feel with an "I" statement and in a courteous, respectful,
assertive manner.
3. What if you are intensely angry?
A. Acknowledge and take responsibility for dealing with it in an appropriate and
constructive manner.
A. Activities
B. Exercise
C. Talk—express your emotions with someone who can empathize
D. Journal writing
THE STEPS FOR LETTING GO OF ANGER
1. Awareness of your feelings and behaviors.

2. Taking responsibility for your emotions and responses.
3. Attitude—will greatly influence your success or failure. If you have a negative
attitude don't expect good things to happen.
4. Selftalk. What you say to yourself will determine how you think and feel.
It is a choice.
5. Don't take responsibility for people and other things that you don't have
control over.
6. Develop resources and a support system that encourages the positive changes
in you and in your life.
7. Selfcare behaviors. People who take care of themselves feel better about
who they are, have more energy, and are more likely to be happy.
8. Develop positive selfesteem.
9. Develop positive alternative responses to counter the older anger
responses.
10. Practice rehearsing the new responses. Keep a journal to track and
reinforce change. A journal will also clarify issues which require further
problem solving, or dysfunctional patterns which are keeping you from
the progress and change that you desire.
PREVENTING VIOLENCE IN THE WORKPLACE
The Northwest National Insurance Co. (1995) presented the results of a study of 600 work

ers, which demonstrated that one in four workers was harassed, threatened, or attacked in
the period 19921993. The results additionally stated that the rate of workrelated homicide

had tripled in 15 years. Therefore, when a therapist interfaces with workplace issues, it is
important to be prepared to discuss the following:
1. The negative work environment

2. The bully in the workplace
3. Workplace violence
4. Prevention
NEGATIVE WORK ENVIRONMENT

A negative work environment contributes to stress and violence. Some specific contributing
factors include the following:
1. Feeling disrespected and unappreciated

2. A lack of appropriate/earned advancement
3. Authoritarian and unpredictable management
4. Invasion of privacy
5. A high degree of secrecy
6. A high level of demand with inadequate support
7. The influence of substances (drug and alcohol use is correlated to acts of
violence)
8. Media influences, which offer a disgruntled employee the attentive forum
he/she is seeking
THE DANGEROUS EMPLOYEE

The following characteristics are not to be used to profile an employee, but instead are to be
used to increase awareness for potential factors often seen in dangerous employees. These
include the following characteristics:
1. Male
2. 35 years old age or older
3. Has a history of violence toward women, children, or animals
4. Owns a firearm
5. Is invested in the job for selfesteem and identity
6. Has few interests or hobbies
7. Is a loner/socially withdrawn
8. Externalizes
9. Has a history of substance abuse
10. Has a history of emotional/mental illness
11. Is extreme in opinions/attitudes
12. Has a history of making unwelcome sexual comments
13. Has difficulty with authority
14. Frequently engages in conflicts
15. Makes threatening statements

BULLY IN THE WORKPLACE
A bully in any environment creates difficulties. A bully can be a coworker or a manager.
Bullying can be described as follows:
1. An intense method of threat used to exert pressure on others.

2. Harassment with a purpose.
WORKPLACE VIOLENCE
Causes of There is no way to determine a specific cause. There are different categories of violence and
a number of contributory factors. The general categories are the following:
Workplace
Violence
1. Workrelated causes
A. Robbery is the number one cause of violence in the workplace, and the offenders
come from outside the workplace
B. Terrorism or hate crimes
2. Personal Causes
A. Fear of losing a job
B. Loss of a job
C. Warning/reprimand from a supervisor
D. Not receiving an expected promotion or raise
E. Acts or words viewed as unfair, threatening, or hostile
F Unresolved hostility or conflicts with coworkers
G. Personal problems
1. An abusive partner may follow an employee to work where a physical attack is
triggered by rage, fear, or jealousy
2. A romantic fantasy or grudge becomes an obsession leading to stalking, threats,
harassment, or attack
3. An individual is unable to cope with stressors and lashes out at others
4. The use of substances contributes to decreased inhibition for normative expected
social behavior or influences violent acting out (use of crack, PCP)
3. Behavioral patterns indicative of potential violent acts
1. Evidence of substance abuse
2. Emotional outbursts or threatening statements/belligerent
3. Attendance problems
4. Decreased productivity/evidenced deterioration in performance
5. Inconsistent work patterns (extremes)
6. Poor workplace relationships
7. Difficulty with concentration and attention
8. Safety issues/accident prone
9. Fascination with weapons (guns/knives)
10. Evidence of unmanageable stress (death of loved one, bill collectors, emotionality)
11. Poor hygiene and grooming
12. Continual excuses, blaming others for problems
13. Chronic depression, suicidality
14. Destruction of property/theft
15. Abusive language and general uncooperativity
16. Disregard for policies and procedures

17. Acts of violence
18. Sees self as victimized by coworkers or management
4. Early warning signs of potential workplace violence
A. Direct or veiled threats of harm
B. Intimidation of others. This can be physical or verbal intimidation. Harassing
phone calls and stalking are examples
C. Carrying a concealed weapon or flashing a weapon to test reactions
D. Paranoid behavior. Perceiving that the whole world is against one.
E. Moral righteousness and believing the organization is not following its rules and
procedures
F. Inability to take criticism of job performance. Holding a grudge, especially against a
supervisor. Oftentimes verbalizing hope for something to happen to the person
against whom the employee has the grudge
G. Expression of extreme desperation over recent family, financial, or personal
problems
H. History of violent behavior
I. Extreme interest in semiautomatic or automatic weapons and their destructive
power to people
J. Fascination with incidents of workplace violence and approval of the use of
violence under similar circumstances
K. Disregard for the safety of coemployees
L. Obsessive involvement with the job, often with uneven job performance and no
apparent outside interests
M. Being a loner and having a romantic obsession with a coworker who does not share
this interest
5. Level of violence
A. Level 1
1. Refuses to cooperate with immediate supervisor
2. Spreads rumors and gossip to harm others
3. Consistently argues with coworkers
4. Is belligerent toward customers/clients
5. Constantly swears at others
6. Makes unwanted sexual comments
B. Level 2
1. Argues increasingly with customers, vendors, coworkers, and management
2. Refuses to obey company policies and procedures
3. Sabotages equipment and steals property for revenge
4. Verbalizes wishes to hurt coworkers or management
5. Sends sexual or violent notes to coworkers or management
6. Sees self as victimized by management (me against them)
C. Level 3—Frequent displays of anger resulting in the following:
1. Recurrent suicidal threats
2. Recurrent physical fights
3. Destruction of property
4. Utilization of weapons to harm others
5. Commission of murder, rape, or arson
Prevention Not all angry people become violent. However, most violent people are angry. The moment
in which a situation is unfolding and what takes place are the most important factors in

determining if acts of violence will occur. Therefore, the most basic information may be how to
be in control of one's own anger: don't take anger personally, do not counterattack, do not
respond with verbal abuse (escalate), and do not invalidate the other person's experience of
anger.
1. Dealing with the bully
A. Train employees to avoid being the victims of bullies
1. Report to a supervisor, union representative, or human relations personnel
immediately
2. Educate employees regarding the harassment policy and procedure in the
workplace
2. Employee safety
A. Increase security
B. Restrict entry to the workplace via specialized identification, signin sheets,
and so on
C. Improve lighting where needed in workplace interiors like stairwells and parking
areas
D. Screen potential employees for a history of violent or threatening behavior
E. Instill a notolerance policy for threats
F. Instill a notolerance policy for weapons in the workplace
G. Do not allow former employees on the premises without management
permission
H. Establish an employee hot line to report harassment, threats, bullying, or bizarre
behavior
I. Promote rapid firm responses to workplace threats, harassment, aggressive
behavior
J. Educate and train employees on conflict resolution
K. Offer counseling to employees in distress
3. Learning to reduce tension
A. Remain calm and courteous
B. Be respectful to others, even when you do not agree
C. Focus on the problem/behavior, not the person
D. If a situation feels like it is possibly escalating, talk with appropriate management
immediately
E. Do not argue, raise one's voice, or respond to threats
4. Appropriate responses to criminals who enter the workplace
A. Do not try to be a hero, give robbers what they demand
B. Report all suspicious or criminal behavior to the authorities
C. If an assault takes place (especially sexual assault), do not change clothing or bath
before a physical examination can take place
D. Acknowledge emotional responses
1. Pain, fear, stress
2. Do not blame yourself; the offender is responsible for acts of violence
3. Counseling should be offered for validation, improved coping, and resolution
5. Investigation of threats
It is important to consider the various roles available for dealing with threats of violence

in the workplace. The investigation is often best handled by a professional, independent

third party trained to deal with such situations. The common investigative and interven
tion roles and where their alliance exists include the following:
A. Management consultantallied with management exclusively

B. Mediatorneutral party to problemsolve and resolve conflicts
C. Counselorallied with suspected perpetrator
D. Counselorallied with alleged victim
E. Professional evaluator of suspected perpetrator, though neutral investigator, they
are referred to by management and will likely be viewed as biased by suspected
perpetrator
F. Risk assessment evaluator—allied with management
G. Risk prediction specialist—allied with management
6. Guidelines for reporting threats
A. Obtain identifying information
B. Collect information from direct sources
C. Separate fact from embellishment
D. Remain neutral
7. Assessing level of risk
A. Has anyone been physically/emotionally harmed?
B. Is anyone in imminent danger (as evidenced by what?)?
C. Have there been threats (details)?
D. Are weapons involved? Are there any weapons on workplace premises (or part of
the threat)?
E. Do involved parties appear out of control (as evidenced by what?)?
F. Where are the involved parties at this time?
G. Have authorities been notified (management, human resources, security, police)?
H. Who has been interviewed about the situation and given details (indirect sources)?
8. Professional crisis response
A. Identify and proceed with crisis response options
B. Develop an threat management team (TMT) whose purpose is to provide ongoing
monitoring and assessment
C. Notify identified management of the incident
D. If warranted, notify security, law enforcement, and emergency response
services
E. Be prepared with the development of a central processing center for dealing with
such issues (know how to process intake information and disseminate information,
what actions are to be taken and under what circumstances)
*If someone is dealing with an angry person, the following recommendations may be helpful

in preventing an escalation of aggression:
1. Stay calm, composed, and confident that you can manage the situation. This is

easier to say than do, but portraying a lack of confidence and fear may be an
unexpected escalator in a difficult situation.
2. If possible, arrange for the two of you to sit down
3. Use the person's name. Being personally addressed can get someone's attention
and have a calming effect.

4. Lowering one's tone of voice or toning down speech and body movements may
have a calming effect
5. Be careful to not hurry the person off. If an angry person feels that he/she being
invalidated and brushed off, it may escalate anger.
6. Be receptive to what is being said
7. Adopt open posture
8. Maintain positive eye contact (pay attention)
9. Demonstrate good listening skills
A. Listen attentively
B. Be open minded
C. Reflect on what has been heard
D. Reman focuses
E. Show care for the problem being presented
F. Answer questions
G. Talk; don't argue as arguing escalates anger
H. Avoid attempts at humor, which demonstrates discounting and
invalidation
I. Facilitate resolution by clarifying questions
J. Demonstrate a sharing of mutual interests/goals
K. When appropriate offer, "I don't know" or " I apologize"
L. Explore potential solutions
M. Remain respectful
HOW TO HANDLE ANGRY PEOPLE
Backlund and Scott (Assertiveness: Get What You Want Without Being Pushy) offer the
acronym "BULLETS" to consider when dealing with people who are angry:
Be seated. Place yourself in a relaxed position sitting down and ask the other

person to also sit down. This could slow behavioral reactiveness as well as
maintain a measure of distance for personal space.
Use the person's name. Speak directly to someone who is angry in a calm and low
tone of voice addressing them by name.
Lower your voice. With awareness for the tension that is present, systematically
lower your voice and do not verbally react.
Listen. Listen and be validating about what the person has to say. Remember,
validation does not mean agreement; it is only acknowledgment for the other
person's thoughts or feelings. Listen thoroughly to what the person has to say and
do not try to rush him/her out the door and minimize the anger that the person is
experiencing.
Eliminate humor. Do not try to make light of the situation when someone
is upset. Such a response feels disrespectful and minimizing. It immediately
conveys that the person is not being taken seriously, which would escalate
anger.
How to Handle Angry People 295

Talk, don't argue. Arguing increases tension and escalates feels of anger. When
things have calmed down, then share your ideas if you have points to share that
you feel are important. Discussing things rationally requires people to be relatively
calm and prepared to validate and problemsolve.
Slow down. Slowing the rate of speech is a way to initiate calm and
rolemodel to the other person the manner in which to speak without addressing
it directly.
For problem solving and negotiation to take place, both parties must remain calm, rational,

and mutually respectful.
WHAT MANAGEMENT CAN DO TO MINIMIZE
EMPLOYEE STRESS
1. Be familiar with community resources and company resources available

to employees
2. Be sensitive to work demand and adequate support to get tasks done
3. Make sure that employees are given advance notice of upcoming
deadlines
4. Keep employees informed of changes taking place in the organization or
changes in philosophy so that they feel included in change
5. Be respectful of general ongoing work demand when considering adding
demands unless it is absolutely necessary, and be realistic, validating, and
supportive
A. Acknowledge the extra stress and inconvenience
B. Demonstrate appreciation
C. When possible, reward for extra efforts
6. Make sure that adequate training is offered
7. Whenever possible, offer continuing education
8. Maintain regular evluations so that people are aware of how they are
doing the job
9. When employees request support or are in obvious need of support,
offer it
10. Reinforce positive efforts, contributions, and accomplishments
11. Whenever possible, challenge employees with interesting work
12. Promote employees who have earned advancement
13. Clearly define employee roles, expectations, areas of responsibility, and
limits of authority
14. Encourage employees to take breaks and mealtime breaks
15. Encourage good health behaviors in employees. Offer smoking cessation
information, nutrition and exercise education, stress management, and so
forth whenever possible. If your company is not large enough, then have
available a list of community resources

16. Recognize that work stress and personal stress mutually affect all areas
of a person's life
17. Educate management about the signs and symptoms of stress in
employees
18. Consult with a professional who specializes in workplace environments
and employee issues to maintain an optimally positive work
environment
19. As management, be aware of your own level of stress, and be a role
model in practicing stress management techniques yourself
20. Recognize your own limits of responsibility and power in the
workplace
What Management Can Do to M i n i m i z e Employee Stress 297

ADJUSTING/ADAPTING
A. LIFE CHANGES
Factors involved in personality and social development include heredity, family factors, peer
factors, and age. It can be helpful to understand what experiences have contributed to how
you respond to your environment because if there are difficulties such information offer indi
cations of necessary change and growth. Looking at your past for information and under
standing can be emotionally painful, but it can also help you take responsibility for making
the change that will help you reach your goals.
Because a significant review of your life experience will be related to parental interaction
it is important to maintain awareness for what you are trying to accomplish. Don't get stuck
blaming your parents or other people for what is wrong. As an adult, only you can take
responsibility for your choices and behavior.
There are common stages of development that everyone experiences. There are also expe
riences that individuals have that for various reasons have a significant impact on their life,
how they define themselves, and how they deal with things.
Some Common 1. Selecting a mate.

Life Changes 2. Learning to live with a partner.
Which Require 3. Starting a family.
Adjusting and 4. Rearing children.
5. Getting started in an occupation, and then changing and growing
Adapting
professionally.
6. Developing a support system/peer group affiliation.
7. Developing adult leisure time activities.
8. Relating oneself to one's partner as a person.
9. Accepting and adjusting to physiological changes.
10. Altering one's role in family as appropriate and necessary.
What are all the life changes that you have experienced?
Understanding 1. Write about a difficult or challenging experience you had in which you were

Your Skill of able to adjust.
2. What did you do, and how were you able to accomplish it?
Adjusting and
Adapting
3. What is something that you have experienced that you have had difficulty

adjusting to or have not been able to adjust to?

4. What has prevented the necessary adjustment?
B. DEVELOPMENTAL PERSPECTIVE
The basic view of development begins with a look at your family experience. There are five
specific aspects of family functioning to consider.
1. Leadership. The parents serve as models. The parental modeling is determined

by each parent's personality, the relationship between the parents, the presence
or absence of mutual support and esteem, the effectiveness of their
communication, absence of mutual support and esteem, the effectiveness of
their communication, their way of relating to relatives and others in the
community, power, and discipline.
2. Boundaries. Family boundaries include the individual's self boundaries, the
boundaries between generations, and the boundaries between the family and
the community. Boundaries need to be semipermeable. Boundaries serve as a
guideline to appropriate interaction between individuals and between
generations. The familycommunity boundary needs to become increasingly
permeable. As children grow they need to cross it more freely to participate in
community. Boundaries that are inadequate, overly rigid, or overly loose
present a risk because they interfere with optimal family functioning as an open
system (versus closed system).
3. Emotional climate. Emotional forces are the glue that holds the family together.
No family can function well unless its family members care for and support each
other. The family needs to be a place where intimacy and anger can be tolerated
(to a greater extent than in the community and where people can relax more
freely than they can outside the home). Discipline and how parents exercise their
power are related to and often determine the emotional climate of the family.
There are also wide cultural variations in emotionality and its expression.
4. Communication. Language, the basis for social interaction, is learned in the
family. Language develops best when children are talked to, read to, sung to,
and encouraged to respond to others and to express feelings and experiences
verbally. Communication consonant with the thinking and values of the
community and culture underlies an important aspect of sociocultural
development. Any communication handicap is a potential risk factor, and
communication difficulties and deviance are significant risk indicators in
children's development.
5. Family goals and tasks. The understanding of family goals and tasks
throughout the life cycle is the most important component of family
functioning to decrease risk. Society expects families to nurture and socialize
the young to become productive members of society with appropriate value
systems. The family life cycle begins with marriage and family formation and
passes through many stages.
Adjusting/Adapting 299
LEARNING HISTORY
1. What did you learn from your family that you have carried on in how you

interact with other people, the community (POSITIVE AND NEGATIVE)?
2. How do you deal with your emotions?
3. How do you deal with anger?
4. How would you rate your selfesteem?
5. How do you take care of yourself?
6. What are the consequences of your behaviors?
7. What are your choices?
8. What changes do you need to continue working on in order to reach your goals?

LOSSES/OPPORTUNITIES
Sometimes changes in life, even positive changes, result in losses. When you experience a loss
it is important to work through the associated thought and feelings. This working through
is called grieving. Grief is a normal and natural response to loss. People grieve over the death
of someone they love and sometimes over life changes including changes in family patterns
or behavior. Grieving is related to adjusting and adapting.
Examples of situations which may facilitate grieving include:
1. Children starting school

2. Children going away to school
3. Marriage
4. Divorce
5. Addictions
6. Retirement
The negatives or losses in each of these situations seems pretty easy to pick out. Can you
pick out the potential positive. Quite often with losses also comes opportunity, and you need
to be prepared to look for it. There are stages to the grieving process:
1. Denial
2. Anger
3. Bargaining
4. Despair
5. Acceptance
These stages do not occur in the same order for everyone.
WHAT IS MEANT BY RESOLVING GRIEF/LOSS?
1. Claiming your circumstances instead of them claiming you (discuss what this
means).
2. Being able to enjoy fond memories without having the precipitation of painful
feelings of loss, guilt, regret or remorse.
3. Finding new meaning in living, and living without the fear of future
abandonment.
4. Acknowledging that it is okay to feel bad from time to time, and to talk about
those feelings.
5. Being able to forgive others when they say or do things that you know are
based on a lack of knowledge and understanding.
WHY ARE PEOPLE NOT PREPARED TO DEAL WITH LOSS?

1. They have been taught to acquire things not to lose them.
2. They have been taught that acquiring things will help them feel complete or whole.
Losses/Opportunities 301
3. They have been taught that if they lose something replacing the loss will make
it easier (i.e., bury their feelings).
WHAT ARE THE MYTHS OF DEALING WITH LOSS?

1. Put off until later to do things that are frightening or painful.
2. Regret the past (get stuck wanting it different, better, or more).
3. Just give it time.
4. Grieve alone (don't need to talk about thoughts or feelings).
Two major issues bury your feelings and forget the loss.
HOW DO YOU KNOW YOU ARE READY?

1. You have acknowledged that a problem exists.
2. You have acknowledged that the problem is associated with the loss.
3. You acknowledge that you are now willing to deal with your loss.
FINDING THE SOLUTION: THE FIVE STAGES OF

RECOVERING FROM LOSS
1. Growing Awareness—that issues are unresolved
2. Accepting Responsibility—for resolving the loss
3. Identifying—what you need to do to resolve the loss
4. Taking Action—to resolve the loss
5. Moving Beyond Loss—through sharing with others and taking action which
facilitates resolution and growth
HOW DO YOU DEAL WITH LOSS
People deal with loss in various ways. Do you identify with any of the following examples?
1. Intellectualize—don't deal with feelings, don't talk or write about how

they feel
2. Be fine and put on a happy face for those around you "Academy Award
Winning Recovery."
3. Want the approval of others; want others to be accepting of your feelings.
4. Acting out ("don't expect anything of me because I hurt so bad").
OTHER WAYS?
Write about how you have dealt with the loss(es) you have experienced, and be prepared to
discuss it.
302 3. SkillBuilding Resources for Increasing Social Competency

GRIEF CYCLE (WHERE ARE YOU STUCK?)
DEFINITION: THE NATURAL EMOTIONAL RESPONSE TO
THE LOSS OF A CHERISHED IDEA, PERSON, OR THING
1. DENIAL (Isolation)

A. Powerlessness
B. Psychological Buffer (defense)—protects knowledge or awareness of thoughts
or feelings that you are not ready to deal with mentally, emotionally, or
spirituality
C. Denial of Reality
1. The more you have depended on the last object, the stronger your
denial
2. ANGER (SelfDisappointment, SelfHatred)
A. Anger over loss and not being able to find it
1. Regrets
B. Can become destructive if not expressed in healthy ways
1. Out of control anger = rage, violence
2. Held in, stuffed anger = out of control physical illness
a. anger turned inward toward self = Depression
b. Despair, suicide
3. BARGAINING (Postponing the inevitable. Attempt to control the
uncontrollable)
A. "What IPs" and "If Only"
B. Desperate attempt to regain control
C. Keeps you from facing reality
D. Destructive if one gets stuck here
4. DEPRESSION (Sorrow, Despair)
A. Anger channeled back into self, turned inward against self
B. Response typically associated with grief but actually only one part of the whole
process
1. Tears, funerals, wakes allow you to be sad
2. Trapped (stuck) sorrow = selfpity leads to destructive behavior
3. Can be immobilizing = total helplessness
4. Crying is a good way to express sorrow. It washes away sadness. Heals.
Is a sign of strength when used as part of the grieving process, but if stuck
crying can become a chronic behavior which does not effectively promote
grieving
5. ACCEPTANCE
A. Final goal with achieving resolution of grief
B. Belief that it is possible to heal and recover
C. Surrender to reality
D. Recognition of responsibility = ACTION
D e f i n i t i o n : T be Natural Emotional Response to the Loss of a Cherished Idea, Person, or Thing 303
GRIEF
Grief is intense emotional suffering caused by a loss. When unresolved, it can lead to acute

anxiety and depression. Usually when we think of loss and the grief process, we think of
someone very close to us dying or leaving. When this happens, we experience intense
emotional pain (hurt, sadness). So we can say that grief is the natural, normal, inevitable
process that all human beings experience when they lose something that is important to
them. The stages of grief are denial, anger, bargaining, depression, and acceptance.
The varying things that a person can experience during the course of their life that can
result in feelings grief and loss include:
1. Death of a loved one.
2. The ending of an important relationship (boyfriendgirlfriend).
3. Loss of relationship with a parent through divorce.
4. Feelings of loss for a friend that moved away (or you moved away).
5. Feelings of loss associated with school, neighbors, house, etc. because you
moved away.
6. Loss of job due to restructuring, lack of transportation, drinking, etc.
7. Loss of your special place in the family because another child was born.
8. Damaged reputation due to someone who doesn't like you, your own poor
judgment, mistakes, etc.
9. Physical impairment—accident illness.
10. Loss of a pet.
11. Not being able to return to school, friends, family, or spouse for some
reason.
12. Recognizing that life dreams will not be realized.
13. Others
What are the things that you may have wanted to happen that never occurred and you

feel hopeless about.
NEVER HAPPENED
1. Happy childhood.
2. Normal or happy home perhaps like a friend has or you saw on TV or a
movie.
3. To belong to a certain group.
4. Get a particular person to care about you.
5. Parents you didn't have.
6. A beautiful or great body (according to the narrow and damaging social
perspective that slim is okay and any variation from that is not as good as....).
7. A smooth and clear complexion (this can be a painful experience).
8. Color of hair or eyes (not accepting of self).
9. Parents that were home or spent time with you or didn't get drunk and abusive.
10. Grandparents.

From this place of pain, hurt, and disappointment comes a wall of protection called
denial:
1. I don't care.
2. It's not really that.
3. Who wants it anyway.
4. Everyone does it.
5. There's no problem.
6. Drugs aren't my problem.
When we quit denying our loss, we move into the next stage: ANGER. Your anger may

be reasonable or unreasonable and it may be felt in varying degrees.
Hate Rage Anger Frustrated

Hurt Upset Irritated
This is a stage where blaming occurs. Perhaps distrust, revenge, or get even. Externalization
takes place—"It's all his fault."
Make a list of all the people, places, and things that you are angry about to some degree.
BARGAINING
When anger begins to calm down there is an attempt to bargain with:
1. Life
2. Ourselves
3. Another person
4. God
A. I'll try harder to please...
B. Maybe if I had...
C. Bargaining in an attempt to postpone the inevitable; in an attempt to prevent it.
DEPRESSION
It begins when there is realization that bargaining has not worked, the struggle to ward off
reality, and the belief that the experience has been unfair an overwhelming depression can
take over. This is when the full force of the loss is experienced and is accompanied by cry
ing, and intense emotional pain. Feelings associated with this stage include:
1. Helpless
2. Powerless
3. Selfpity—Why me?
4. Sadness
5. Guilt
6. Suicidal thoughts
7. Selfdestructive or selfdefeating behaviors
Grit} 305
ACCEPTANCE
This is the last stage of the grieving process. Acceptance is not necessarily a happy stage.
It is almost void of feeling. It is as if the pain is gone and the struggle is over. There is peace,
but it does not mean that healing is complete or the feelings of emptiness are gone.
1. At peace
2. Learn coping skills
3. Accept our past
4. Accept life as it is
5. Accept our present circumstances
6. Accept our loss
7. Free to go on with your life
8. Begin to feel comfortable with your life again
9. Adjusting
10. Set new goals
11. May strive for some understanding of the loss
12. Stop avoiding issues associated with the loss or rumination about the loss
Are you or someone in your life going through this grief process for a major loss? What
stage do you think you are in?
Review your life and consider the major losses and changes you have gone through. Recall
your experiences with the grief process. Write about your feelings as you remember them.

HISTORY OF LOSS GRAPH
On your graph write:
1. What happened

2. When did it happen
Below your graph write about:
1. How did it affect your life

2. What issues do you now have to resolve
EXAMPLE:
year 1977 1980 1981 1987
loss lost Father son spouse

job died went had
off to an
college affair
year
loss
RELATIONSHIP GRAPH
Above the time line write down the happy experiences, and below the line write the unhappy

experiences. Start with your first conscious memory or recollection of a loved one. Include
on your graph relationships with people, things, or changes.
1. How many positive experiences were never acknowledged or talked about?

2. How many negative events were never acknowledged or talked about?
3. Did you become aware of other unspoken communications, either things
you wish you had heard or things you wish you had said?
EXAMPLE:
1st family
Happy memory vacation
time
Unhappy 1969 1972 1975

bad separation death
argument from of
w/dad spouse mother
Happy
time
Unhappy
Relationship Graph 307

IS LIFE WHAT YOU MAKE IT?
1. Write about what the following statements mean.

2. Do you apply this type of attitude/perspective to your life?
If yes—how do you apply it to your life.
If no—how do you go about changing it.
SOMETHING LOST—SOMETHING GAINED
IS YOUR CUP HALF EMPTY OR HALF FULL
JOURNAL WRITING
Sometime changes can occur just by recognizing the source of the problem. However, most

changes come from an accumulation of changes in beliefs, priorities, and behaviors over a
period of time. Consistency and an investment in yourself is necessary. Journal writing can
be useful for keeping track of a wide variety of things that can help you achieve your goals.
Use your journal to record your thoughts and feelings. "Just doing it" can make a difference.
Acknowledging underlying thoughts and feelings and writing about them can help increase
self understanding, and selfawareness which can make it easier to change old patterns of
behavior and to start new ones. Consistently keeping a journal is a strong message to your
self that you want to change and that you are committed to make it happen.
People often experience greater successes when they have established goals. Unpredictable
situations do occur which can cause setbacks, but they can also allow for a reevaluation of
your problems and can offer an opportunity. However, when goals are defined and the unex
pected happens, you are more likely to reach them even if you are initially thrown off course.
Most people don't clearly establish their goals, let alone write them down and think about
what it will take to accomplish them.
STEP 1
Write down the goals you want to accomplish in the next 12 months. Make them as specific
as possible. They should be realistic, but also challenging.
STEP 2
Write down ten goals you want to accomplish this month. These should help you move
toward some of your goals for the year. The monthly goals should be smaller and more
detailed then the yearly goals.
STEP 3
Write down three goals you want to accomplish today. Goals need to be accompanied by
plans to make them happen. If your goals are too large, you are likely to stop before you
start. Better to start small and build upward. Small successes build big successes.
STEP 4
Selfmonitoring: Keep track of where you are now. Create realistic plans that can get you to
your goals.

STEPS
Begin observing which selftalk has been maintaining the old patterns you want to change.
List at least five to ten negative selfstatements that feed into your old patterns.
STEP 6
List five to ten positive statements that are likely to help create the new patterns you want
to create.
STEP 7
Create challenges that will replace the negative selftalk you listed in Step 5.
STEP8
Programming new healthy selftalk. Each day, say at least ten positive selfstatements to
yourself.
STEP 9
Imagination and visualization: Five times each day, take one minute to visualize a positive
image.
STEP 10
Building selfesteem: Use your journal to list good things about yourself. Be supportive to
yourself.
STEP 11
Each day record three of the days successes—big or small. Praise yourself. Plan small
rewards for some accomplishment each week.
STEP 12
In your journal, frequently ask what parts of yourself you are involved with. The various
issues you face (e.g., the needy child, the rebellious adolescent, etc.).
STEP 13
Each day, forgive yourself for something you have done. Like selfesteem, forgiveness is one
of the keys to successful change. Forgiving yourself for past actions allows you to take
responsibility for what happens in the future.
STEP 14
List the fears of success that the different parts of you may have. Work on making success safe.
STEP 15
Be willing to do things differently. If you don't, nothing is going to change.
Journal Writing 309

DEVELOPING AND UTILIZING SOCIAL SUPPORTS
When someone lacks emotional health they tend to withdraw from pleasurable activities and
socially isolate. One important way to regain emotional health is to develop and utilize
social supports.
We all need several good friends to talk to, spend time with, and to be supported by with
their care and understanding. For someone to be a part of your support system requires that
you care for them and trust them. A partner or family member is a likely candidate for your
support system. You may develop relationships with people through activities or interests
that you share. These relationships could become strong enough to become part of your sup
port system. Other resources could be clubs or other social group affiliations that you feel a
part of and feel important to. Whoever the person or group is, it is necessary that there be
mutual care, positive regard, and trust.
CHARACTERISTICS OF A SUPPORTIVE RELATIONSHIP
1. Objectivity and openmindedness. They let you describe who you are and how
you feel. They validate you.
2. They support and affirm your individuality and recognize your strengths. They
validate and encourage your goals.
3. They empathize with you. They understand your life circumstances and how
you are affected by your life experiences.
4. They accept you as you are without being judgmental. You can ask one another
for help and support.
5. You can laugh with them and be playful. You will both enjoy it.
6. They are at your side, supporting you to do whatever is important to you.
List the People that Make Up Your Support System:
1.
2.
3.
4.
5.
If you didn't have anyone to list as your support system or only one to two people don't

feel bad about yourself and give up. What you have done is to accomplish the first step in
understanding what you need to do: change your situation. The good news is that there is a
lot you can do to change your situation.
What Stands in Your Way of Developing Your Support System (check the items that apply
to you):
you have a hard time reaching out

you have a hard time making and keeping friends

low selfesteem
you tend to very needy and draining to others
you become overly dependent and wear people out
you lack the social skills necessary to develop relationships
you have inappropriate behaviors which embarrass others
you are unreliable
What Is It That You Need and Want From Your Support System (check the items that
apply to you):
.someone to talk to
.understanding
.someone to stand up for you
companionship
caring
.sharing
.someone to watch or monitor you
.someone who will listen to you
someone to do things with
.someone who writes to you or phones you
mutual support and positive regard
Are there other things that you would want or expect from a friend?
People that help you get started in making the changes necessary to develop a strong sup
port system include your therapist, minister, and various support groups. There are also
many helpful books that have been written that you can find in the psychology or selfhelp
sections of a bookstore. The main thing to is make a commitment to yourself to develop a
support system and to not give up.
Developing and Utilizing Social Supports 311

HOW TO BUILD AND KEEP A SUPPORT SYSTEM
1. To be emotionally well and keep my moods stable.

What do you do to maintain stable moods?
2. To take care of myself.
List your selfcare behaviors:
3. To recognize and accept that others can help, but that I am responsible for

making myself okay.
Define what you must do for yourself versus what is reasonable for others to
do for you:
4. Develop appropriate social skills.

This can be done by working with your therapist, reading and practicing the
techniques you read about, participating in activities in the community or
special groups, taking a class at adult education programs if available,
watching what other people do and what responses they get. Be involved.
What resources are available to you?
5. Do volunteer work and be supportive of others.

Whether it is doing volunteer work or being supportive to people you know, it
is good practice.
Where could you volunteer?
Who supports you and how can you be supportive back to them?
6. Make it a point to keep in touch with friends and acquaintances.

When was the last time you invited someone to do something or made an effort
to get together? If it didn't work out was it the timing, the activity, or someone
who really isn't capable of being a social support for you? What are you going
to do to become more successful with this point?
7. How will you know if you are making progress in developing a support system?

RECOGNIZING THE STAGES OF DEPRESSION
There is a wide range in the experience of depression. Sometimes we feel sad about something
happening, we experience depression with grief when we have experienced a serious loss, or we
have a building depression, which does not go away when something serious has happened and
it is not resolved or lots of difficult things happen over time without our having the opportunity
to resolve them. Also consider the following issues as related to the experience of depression:
1. You do not express your needs, thoughts, or feelings in order to keep the peace

2. You have lost your sense of identity
3. Have you lost hope with what you need and feel
4. Do you feel empty and confused
5. Have you stopped expressing your hopes and goals
6. Have you given up on your hopes and goals
Is it possible that your experience of depression is the result of you not being true to your
self? If so, think about the following statement: If you are not true to yourself and are deny
ing yourself, you lose yourself, and when you lose yourself you become depressed.
The following is a list of feelings that progressively lead to depression. Read through
the list and identify your feelings. With this awareness you will then begin to monitor these
feelings and take responsibility for the appropriate selfcare to decrease or eliminate these
feelings and therefore decrease or eliminate your experience of depression.
1. Withdrawn and quiet

2. Sad
3. Decreased enthusiasm
4. Lonely
4. Melancholy
5. Sense of helplessness and hopelessness
6. Feeling overwhelmed
7. Despair
DECREASING THE INTENSITY OF DEPRESSION

1. Clarify your needs, thoughts, and feelings
A. Express them
B. If others are not supportive or caring, problemsolve appropriate ways to get your
needs met
2. Be assertive; say "no" to certain activities and people
3. Identify and change negative self talk. It takes you down and keeps you there.
4. Get regular exercise; walk, it relieves stress, increases energy, and changes brain
chemistry to decrease depression
5. Prioritize tasks and do not overload yourself
6. Engage in creative projects that are fun and distracting from other stressors
7. Practice good nutrition
8. Get adequate rest (not too much or too little)
Recognizing the Stages o/ Depression 313

9. Ask for help and delegate when possible
10. Develop a supportive social network
11. Develop goals and get focused
12. Pamper yourself with a pedicure or manicure, get a massage, buy yourself a
small gift, and so on.
MANAGING DEPRESSION
Depression is a common human experience. Most people will at some time in their life expe
rience depression. The most dramatic sign is a lack of pleasure in normally pleasing life activ
ities and feeling fatigued. Most experiences of depression do not interfere in daily activity.
People go on doing the things they have to do, but they must push themselves.
When the level of depression becomes severe and does interfere in a person's ability to
follow through on their daily activities it is called major depression. The difference between
normal depression and major depression is that symptoms are more severe, last longer, and
impair a person's ability to function. What used to be satisfying is frustrating or tedious. You
may withdraw from people and isolate, you may avoid people and situations, experience neg
ative thinking, experience hopelessness, feel overwhelmed, experience disturbance of appetite
and sleep. You may feel that you are a prisoner of this state of emotion and fear/believe that
it will never end. Some people with major depression experience suicidal ideation or death
wish (where they wish something would happen to them so they didn't have to live with the
struggle any longer, but do not actively think about taking their own life).
THE CAUSES OF DEPRESSION

1. Environmental or Situational Factors. This depression is triggered by the stress
of changes or losses such as losing a job, divorce, or death of a family member
or friend.
2. Biological Factors. There are chemicals in the brain called neurotransmitters
which communicate messages between the nerve cells of the brain. If there is an
imbalance in these brain chemicals the result can be changes in thought,
behavior, and emotion.
Other biological relationships to depression could be hypothyroidism, medications,

chronic pain or other medical illness, and the longterm experience of stress with a com
ponent of hopelessness.
3. Genetic Factors. There appears to be a relationship between family history of

mood disturbances. This suggests that if there are family members who have
chronic depression there may be a predisposition to having depression.
Approximately 25% of people who experience depression have a relative with
some form of depressive illness.
If you experience depression there a number of interventions that you can use which can
improve the quality of your life experience.
Therapy is a key factor in understanding the source of your depression and making the
appropriate interventions. Also, discuss the possibility of antidepressant medications with
your physician.

DEPRESSION SYMPTOM CHECKLIST
The symptoms of depression vary widely from person to person. Which of the following feel
ings and symptoms do you experience?
feeling low tense fatigue

feeling sad agitated heaviness
difficulty with sleep quiet fear
compulsive eating withdrawn disorganized
no appetite guilty cries easily
low selfesteem hateful empty, void
hopelessness angry like a failure
obsessed with the past hoping to die unbearable
hating my life plan to kill self dead inside
helplessness selfcritical body aches
anxious no motivation miserable
apathetic worthless alone
difficulty concentrating excessive worrying feelings of loss
If there are other symptoms that you experience please list them.
It is important to identify the symptoms that you are experiencing so that a course of
intervention can be determined. Often, when someone is depressed they have numerous
physical symptoms. These symptoms or sensations can be purely related to stress and depres
sion or may have a physical basis. Therefore, if you have not been recently examined by your
physician it is a good idea to make an appointment to rule out any physical complications
that are contributing to your experience of depression.
Possible medical causes could be:
endocrine system problems (such as a malfunctioning thyroid)

medication interactions
acute or chronic stress reactions
allergies
_PMS
chronic health problems
drug/alcohol abuse or dependence
recently stopped smoking
recent surgery
seasonal affective disorder
Managing depression requires that you gain some sense of control over the depression.
Because everyone's experience is unique to them it is necessary that you take the time to
increase your awareness, take the risk of trying some interventions, and make the commitment
to follow through. Managing depression requires that you take responsibility for improving
the quality of your life. If your depression has been chronic and severe discuss antidepres
sant medication with your physician. There may be a biological or genetic factor influencing
your mood which requires a medical intervention. Once this is determined then you must
Depression Symptom Checklist 315

decide what you are going to do. This is accomplished by developing a SelfCare Plan. The
significant components of a SelfCare Plan include:
1. Structure. How you will structure your day to include the factors or

interventions of taking care of yourself. This can be easily established by using
a daily activity chart until you are able to consistently engage in selfcare
without constant reminders.
2. Support. Developing and utilizing resources to eliminate social isolation and
withdrawal.
3. Positive Attitude. Choosing positive thoughts instead of negative ones,
reminding yourself that depression is a temporary emotional state, and focusing
on taking one day at a time.
4. Awareness. To maintain and continue the progress that you make in
managing your depression requires that there be an increased awareness for
what works and is beneficial and what does not help you. Keeping a journal
can be useful for selfmonitoring. You will want to identify the "red flags"
of potential regression and any patterns of behavior which affect you
negatively.
5. Exercise. Before you initiate any exercise program check with your physician.
Walking aerobically (quick paced 3540 min.) at least every other day is
helpful in reducing body tension, improving sleep, creating a sense of well
being, increasing energy, and decreasing stress.
6. Nutrition. Eating daily wellbalanced meals. If you are unsure of what it means
to eat healthy consult your physician, dietitian, or go to a bookstore where you
will find many resources. People who are depressed often experience some
disturbance in a normal healthy eating pattern, and as a result, there can be
weight loss or weight gain.
7. Value System. Clarify what your values are and do an inventory. If you are not
living in accordance with your value system this could be contributing to your
experience of depression.
As you can see managing depression means total selfcare. If you neglect to take care of

yourself once you begin to feel better you will likely begin to reexperience some symptoms
of depression. Emotional health, as well as physical health, is about lifestyle.

SURVIVING THE HOLIDAY BLUES
For some, the holidays are an emotionally difficult time because of negative and hurtful
childhood and adolescent experiences. For others, holidays emphasize the fact that the struc
ture of our lives change over time. These changes can be associated with children growing
up, leaving home, and creating new rituals with a life partner, the modification of traditions
as inlaws are incorporated into available holiday time, changes in health, death, or other
crises. It is highly uncomfortable to face the holidays when they are anticipated with dread
or distress. If, for any reason you feel out of sync with the holidays, consider the following:
1. Develop new holiday traditions. If you do this, start out with realistic

expectations. Whatever you do, it is not going to feel the same way to you as
the way it was. It may take repeating the new tradition several times before it
begins to feel like something that you are really looking forward to. However,
because many people do not have the resources of a large family or the money
to travel far to see family, developing new traditions is something you have
control over, so make the effort to create a special time.
2. Choose to participate. Do not withdraw from everything during the holidays.
Do not isolate yourself. While it may be difficult to feel much enthusiasm for
social gatherings, choose to do it. Chances are once you are in the midst of
participating you will be distracted and find yourself feeling better. Participate
at a level that feels comfortable to you—but participate. Also, even
participating a little may lift your spirits.
3. Take care of you. The commercialization of the holidays can be overwhelming.
Do not let that influence how you choose to participate in the holiday season.
This is also a time to reflect and give yourself a little tender loving care. Don't
park yourself in front of the television and be in a trance. Instead, choose a
movie you have wanted to see, read a good book, listen to pleasing music, send
cards, or write letters. You may be surprised to find that taking a little time for
yourself can help you feel better.
4. Volunteer. Sometimes we get so focused on our on losses or distress that we
forget all we have to be grateful for. A lot of social service programs really try
to reach out to those who have no resources and are destitute, as well as other
holidayoriented extras like special programs at museums. These organizations
would be pleased to have the gift of some of your time. Sometimes helping
others who are in a more difficult place than ourselves can fire up appreciation
for the good things in our own lives. There are numerous ways to give some of
your time: call the volunteer bureau, look in the paper, and ask others.
5. Talk about it. The holidays blues are more common than you may realize.
Do not suffer in silence. There is the risk that the blues could get worse and
become depression. Take some time to think about why the holidays are
distressful for you. Again, get informed about what is happening in your
community. Churches and community centers often offer special programs for
people who are alone or experiencing difficulty during the holidays. Also,
if it seems to be getting worse, talk to your physician and seek advice from
other professional resources. Talking about it is an important step to increased
selfunderstanding, validation, and problem solving.
Surviving the Holiday Blues 317

UTILIZING YOUR SUPPORT SYSTEM
EXAMPLES:
1. Talking about your feelings or thoughts with an understanding person
2. Talking to a therapist or counselor
3. Talking to staff at a clinic, hospital, or hot line
4. Arranging not to be alone
5. Going to a support group
6. Spending time with people you like
7. Spending time with a pet
8. Planned activities with a caring and supportive person
Make a list of the things that you plan to do or have done in the past that have been help
ful in decreasing your depression.
Make sure that some of the information you have listed is put into the structure of daily

scheduled activities that you developed. This will reinforce a lifestyle of selfcare.
THE POWER OF POSITIVE ATTITUDE
Your attitude will have a significant influence on how you feel and how you evaluate your
life experiences. If you are an optimistic person it is likely that you tend to expect a positive
outcome even from difficult situations. If you are pessimistic you are likely to expect the
worst and probably even look for it. This tendency to expect or look for the negative is
sometimes referred to as a selffulfilling prophecy.
If you have a habit of negative thinking there are things that you can do to improve your
attitude.
1. Change your negative thinking to positive thinking. This is not as hard as it

sounds. Taking the following steps will help you change your negative thinking
patterns.
A. Awareness. Work to increase your awareness for negative thoughts. Keep a
journal and write down your negative thoughts. You cannot change the way you

think unless you clearly understand how you think and talk to yourself about
situations.
B. Correcting negative thoughts and statements. Once you have identified your
negative thoughts and negative patterns of thinking then you can develop positive
statements to substitute for the negative ones. It generally is not too difficult to find
a different and positive way of viewing things, but it does take a consistent effort to
change.
C. Monitoring your efforts and progress. Again, this is where the journal can be
helpful. However, an even better way of assessing your success is by how you feel.
If you are changing to a positive pattern of thinking you will find that you worry
and catastrophize less, which also contributes to a sense of wellbeing.
2. Be Active. Exercise and other pleasurable activities. Exercise promotes a sense
of wellbeing, decreasing body tension, and decreasing stress. All of which
contribute to decreasing depression and feeling good. Spending time with
people you like and participating in activities you enjoy are also positive ways
of managing depression.
3. Live one day at a time. People often waste a lot of energy worrying about
"what if." That means that they are worrying and suffering about something
that might not even happen. Then, because they are expecting the worst they
do not take care of themselves or other things that need to be taken care of
today. Deal with "what is" not "what if."
4. Remind yourself that depression ends. States of emotional distress are generally
temporary. If you have felt chronically depressed for a long time talk to your
physician about medication that may help. However, it is also important that
you take responsibility for yourself and your emotions. Review what you are
doing in the way of selfcare behaviors to promote emotional and physical
wellbeing.
5. Refuse to feel guilty. If there is something that you need to take responsibility
for then do it. Apologize or make amends. Then make peace with whatever it is
and let go. Feelings of guilt consume emotional energy and prevent a person
from moving forward.
6. Life is about choices. Some choices have positive consequences and some
have negative consequences. Do the best you can and learn from your errors.
Accept that throughout your life you will continue to learn, sometimes from
mistakes.
SELFMONITORING CHECKLIST
MANAGEMENT BEHAVIORS
getting up in the morning
getting dressed and ready for the day
practicing good hygiene
start the day off with a positive affirmation
thinking positive through the day
maintaining good awareness for my thoughts and behaviors
problemsolving issues instead of avoiding
attending work or school daily

. participating in pleasurable activities
. spending time with people I enjoy
. getting my needs met appropriately
. getting adequate sleep and rest
. exercise
. eating nutritionally
. meditation or relaxation techniques
. getting in touch with your spirituality
. not engaging in selfdefeating behaviors
. not engaging in selfdestructive behaviors
. spending time outside
. keeping busy
. consistently taking medication as prescribed
. maintaining a balance of rest and pleasurable activities
. using my resources
. attending support groups or meetings
. attending therapy
. Find Something Positive In Every Day
What strategies have you found for decreasing or eliminating your depression?
Using a schedule of Daily Activities can alleviate the pressure of trying to get through a

day in a positive and useful manner because it outlines expected activity.
A person who is feeling depressed may spend an entire day or many days doing nothing
but existing. This inactivity and lack of accomplishment can maintain or contribute to your
depression. Because selfesteem is an active process, when a person is lacking activity and
accomplishments in their life they develop low selfesteem. When they have low selfesteem
they tend to devalue their efforts, viewing whatever they do as unimportant. To feel worth
while will take a commitment to develop a selfcare program which includes a positive atti
tude, adequate nutrition, exercise, relaxation, participation in pleasurable activities, and a
daily structure for facilitating the development of a healthy and fulfilling lifestyle.
In everyone's life there are responsibilities which must be taken care of ranging from pro
fessional duties to housekeeping chores. Some of these tasks may be enjoyable while others
are not. When you develop your Daily Activity Schedule be sure to create a balance of pleas
ure and accomplishment. This will contribute to a sense of wellness. Some things may be
both a pleasure and an accomplishment. Some examples are given so that you will have an
idea of the types of things to include in your Daily Activity Schedule.
get out of bed
get dressed
good hygiene
go to work
read the paper
have coffee/tea

balance the checkbook
go for a walk
paint/draw
talk with a friend
lunch with a friend/someone special
go to a support group
make dinner
wash the dishes
do the laundry
gardening
watch a movie
write a letter
journal writing
relaxation/meditation/affirmations
helping others
listening to music

DAILY ACTIVITY SCHEDULE
DATE:
MOOD(S):
Planned Activity
Time and Expectations Actual Activity How It Felt
78 a.m.
89 a.m.
910 a.m.
1011 a.m.
1112 noon
121 p.m.
12 p.m.
23 p.m.
34 p.m.
45 p.m.
56 p.m.
67 p.m.
78 p.m.
89 p.m.
910 p.m.
Keep a Daily Activity Schedule until your depression is manageable and you feel that you do not need the

support of this strategy to remain stable.

CONFRONTING AND UNDERSTANDING SUICIDE
Everyone is unique in the life crisis that they experience which can contribute or result in

suicidal thoughts and behavior. However, there are 12 factors which often trigger suicidal
thoughts:
hopelessness/despair
depression
feeling overwhelmed or desperate
life is out of control
guilt
loneliness
chemical imbalance
low selfesteem
bad memories/fears
recent loss
seasonal anniversary such as a loss
fatigue/sleep deprivation
HOPELESSNESS AND DESPAIR
no hope that things will ever change and be better
no hope for the future
no hope that there will ever be stability and wellness
no hope that life goals will ever be met
no hope that there will ever be a feeling of happiness or enthusiasm
no hope that there will ever be a successful career
no hope that there will ever be a successful relationship
a feeling and belief that life is a miserable existence
no point in being alive
When a person is severely depressed they are unable to see things clearly and objectively.
As a result, everything is perceived and experienced from a position of hopelessness and
despair. However, there is hope.
If you have ever experienced hopelessness and despair describe how you felt and what
your beliefs were or are:
What are the positive things in your life that you may take for granted, such as a good

partner, a pet, home, friends, job, etc.?:
Confronting and Understanding Suicide 323

DEPRESSION
When a person experiences the hopelessness and despair of profound depression they may

feel that the only way to end their painful existence is suicide. The black, slippery hole of
depression seems impossible to escape from and suicide is seen as a relief. The person may
become obsessed with thoughts of death to stop the endless and overwhelming pain of hope
lessness and despair.
As previously stated, a person experiencing severe depression is likely to not be thinking
clearly or objectively. Therefore, it is difficult for them to acknowledge or reason that there
is an end to the depression.
If you have had prior episodes of depression do you remember that hopeless feeling that
it would never end? Write a little bit about your experience and how that episode of depres
sion ended:
Use this information, which demonstrates to you that your depression did go away or
became manageable, to confront the irrational thinking that the depression is a miserable, per
manent state of existence. By changing circumstances, beliefs, using selfcare behaviors, and
taking medication if prescribed by a physician, depression can be alleviated or even disappear.
If you feel unable to cope, and find that it is hard for you to distract yourself from thoughts
or suicide or destructive impulses then you must reach out to others for support. Develop a
list of resources that you can contact so that if you are in crisis you can just look at your list
and call someone to help you get through and take care of yourself.
PHONE NUMBERS
Family Member
Friend(s)
Therapist
Crisis Hotline
Hospital
Other

FEELING OVERWHELMED AND DESPERATE
When a person is depressed they often lack the energy to resolve problems as they arise. As a
result, all of the new problems pile up on top of the difficulties which originally contributed
to the state of depression. When this happens a person becomes overwhelmed. Being over
whelmed feels like there is just too much to deal with. They feel desperate because it seems
like no matter what they do they will be unable to accomplish all that they have to. It may feel
like there are no choices which can really help them. When this happens it may appear that
suicide is the only way to escape from the awful, trapped feeling that they are experiencing.
Unfortunately, they are considering a permanent solution to temporary problems. There
is always another way no matter how difficult the problems may be. If a person is at the
point where they feel desperate and unable to cope the thing to do is to ask for help. If they
are feeling that bad then they know that they are not emotionally well and it may require
that others who care (family members, friends, therapists, ministers, physicians) are needed
to break this downward spiral. Reach out to the people in your support system. If you don't
have a support system tell your physician or call a hospital emergency room for help. Get
whatever help is necessary to problem solve the solutions that will create the support and
structure to stabilize and manage the potentially destructive behavior. Sometimes someone
else can offer a solution that a person in a state of being overwhelmed would not even be
able to see because they are focusing only on how to escape these awful feelings.
If you have ever felt overwhelmed and desperate describe how you felt.
How did you resolve the situation?
What did you learn that could help you now?
Feeling Overwhelmed and Desperate 325

FEELING LIKE YOUR LIFE IS OUT OF CONTROL
When a person feels like their life is out of control their negative thinking increases, they feel

overwhelmed and desperate, their selfesteem plummets, and there does not seem to be any
thing that they can do to get back in control. It is like having a lot of conversations in your
head with yourself and you cannot turn it off. It is such a frightening feeling that suicide may
appear like the only way to get away from it all. Most people experience this feeling a little
bit when they have a lot of different things going on at one time and the demand is greater
than what they can give to take care of everything.
It may not be what would be expected, but when a person is feeling like this they tend to
engage in behaviors which contribute to feeling and being more and more out of control. It
can be like a vicious cycle. The thing to do is to get help from someone who is trusted and
can be objective. There are choices, but to effectively make good choices a person will have
to slow things down, evaluate and define what the problems are, and then prioritize the iden
tified issues so that they can be systematically resolved one by one. You can only do one
thing at a time. When this process is followed it becomes possible to take one step at a time
toward any goal that has been set. It helps to deal with "What Is" instead of "What If."
If you are feeling like your life is out of control describe it.
What are all of the things that you are feeling pressure from?
What resources can you use to help you slow things down to get a handle on your situation?
* Remember: Take one day at a time.
You can only do one thing at a time.
Give yourself credit for your efforts and accomplishments because every step
You take contributes to regaining control over your life.

GUILT
A person who is experiencing feelings of guilt is focusing on something that they have done

that is embarrassing, harmful to another person, or some other behavior which has contribute
to negative consequences for themselves or someone else. Sometimes this feeling of guilt
becomes so big that they feel an intense need to escape, and the only way out appears to be
suicide.
Feelings of guilt and shame are very hard to deal with, mainly because it requires that you
forgive yourself for whatever has happened. Forgiving yourself requires honesty and self
acceptance. When you own your behavior and confront it with appropriate problem solving
it will feel like a huge weight has been taken off of your shoulders.
If you regret your actions, do you attempt to learn from them so that your future behav
ior does not repeat the same mistakes. Or do you choose to suffer over the past and remain
passively stuck in the patterns of behavior you know are not helpful or appropriate?
Selfforgiveness requires an understanding for the possibility of special circumstances,
assuming the responsibility for the damage or consequences of your behavior, to make amends
for your actions, and to make a firm commitment to do things differently in the future. If you
do not make this commitment to change and follow through on it you will not be free from
guilt. In fact, you will very likely repeat the same dysfunctional behavior patterns.
Change can be difficult because there is some comfort in what is familiar to you. Who
knows what life may confront you with if you did not have your depression, hopelessness,
and selfloathing. Misery can provide its own kind of insulation from the rest of the world,
whereas happiness, in its own way, is more demanding. Happiness requires energy, con
sciousness, commitment, and discipline. So it takes time, energy, and work to liberate your
self from guilt.
What have I done or said which makes me feel guilty?
How can I take responsibility for what I have done?
How can I make peace with what has happened, accept and forgive myself, and move on?
How does what has happened help me understand what my values are?
When I feel defensive about positives
Guilt 327
If I hide myself through fear, envy, or resentment
When I act against what I understand and know to be right.
I will imagine how I would feel if I did things differently in the future

LONELINESS
When a person feels that one cares or they really do not have anyone that they feel close
enough to talk to and to get help this can contribute to thoughts of suicide. The factor of
loneliness can work in two directions with severe depression. When a person feels depressed
they may isolate and withdraw from their resources which leads to feelings of loneliness. Or,
when someone lacks resources they may experience an increasing sense of isolation and lone
liness. Both increase depression and the likelihood of suicide.
When trying to understand and deal with the issue of loneliness consider, on the most
basic level, that behavior has only two purposes: To bring people closer together or to push
them apart. People who experience depression may find it difficult to maintain close rela
tionships for several reasons.
1. They may not follow through on friendship behaviors because of their negative

thinking and expectations of rejection and abandonment.
2. Because of their depressed mood people may feel helpless themselves and not
know what to do.
3. People may get frustrated with the depressed person who talks about how bad
they feel or who obviously looks like they are having a difficult time, but do
not appear to follow through on behaviors to help themselves.
Even though you may think that no one cares about you, you probably do have friends

and family who care and are genuinely concerned about you. Do you take advantage of com
munity resources which can help you to establish or reestablish a feeling of belonging and
connectedness?—A feeling that you are a part of life and the world.
Make a list of the people who care about you and the resources in your community that
you could participate in to decrease your feelings of loneliness and isolation.
1.
2.
3.
4.
5.
6.
CHEMICAL IMBALANCE
There are a variety of things that can contribute to a chemical imbalance. To identify and

appropriately treat a chemical imbalance requires that you make an appointment with your
physician and explore some simple possibilities and test for others.
Some examples of health or other treatment factors which could cause a chemical imbal
ance are:
thyroid dysfunction
diabetes with poor nutrition
Chemical Imbalance 329

some medications can contribute to depression
medication interactions
alcohol and drug abuse
Do not avoid taking care of yourself. You are responsible for your mental health and
physical wellbeing. Utilize your resources and comply with treatment interventions that can
help you to feel better and to more effectively manage your emotional state and life.
If you experience chronic health issues explore how your life has been affected, and if
there are different resources available to help you manage and cope with your specific
situation. Health issues have a significant impact on how people feel emotionally.
LOW SELFESTEEM
Selfesteem is composed of such factors as selfworth, selfcompetence, and selfacceptance.
When a person is severely or chronically depressed their selfesteem is diminished. The cloak of
depression perceives everything from the dark or negative side and offers little hope of change.
This, most importantly, affects how the person views themself. If their selfesteem has been
lost they view themself as worthless and cannot imagine what others could see in them. This
feeling of unworthiness and failure as a person can play a large role in a person considering
suicide to be the answer to their worthless existence.
If this is how you are feeling it is time to take an honest, objective look at your accom
plishments. Your accomplishments will include the things you have done in efforts to obtain
goals as well as things you have done to help other people. Selfesteem is an active process
so it is related to behaviors and thoughts that are promoting growth and change. Another
way of stating this is that a person with good selfesteem is a person who does not just talk
about it—they do it. This activity affirms a sense of worthiness through accomplishment. It
does not matter how small the step is as long as it is a step forward.
People who take responsibility for their own existence tend to generate healthy self
esteem. They live an active orientation to life instead of a passive one without hope of
change. They make change happen. They understand that accepting full responsibility for
their life means growth and change. They recognize that they must make the decisions and
use the resources presented to them. They also recognize that it is smart to ask for help when
they need it, and for that help to benefit them they must use it. As a result, they have healthy
selfesteem.
Avoiding selfresponsibility victimizes people. It leaves them helpless and hopeless. They
give their personal power to everyone except themselves. Sometimes when this occurs peo
ple feel frustrated and blame others for the losses in their life. When a person takes respon
sibility for their feelings they quit being passive and start taking the necessary action to
reclaim their life. They recognize that nothing is going to get better until they change the way
they look at things, the way they choose to feel about things, and the way they respond to
things.
As you objectively evaluate the different areas of your life you may find that you are more
responsible in some areas and less responsible in other areas. It is likely that the areas where
you practice greater responsibility are the same areas that you like most about yourself. To
accept responsibility for your existence is to recognize the need to live productively. It is not
the degree of productivity that is an issue here, but rather the choice to exercise whatever
ability that you do have. Living responsibly is closely associated with living actively which
translates into healthy selfesteem.
If you wish to raise your selfesteem you need to think in terms of behaviors. If you want
to live more responsibly you need to think in terms of turning your thoughts into behaviors.
For example, if you say that you will have a better attitude describe how that will be seen in
behaviors.

Describe the behaviors associated with having a positive attitude.
List the resources you can use for the support of developing healthy selfesteem.
Making the changes to improve selfesteem requires increased awareness and under
standing of myself. Complete the following sentences to initiate this process:
1. As I learn to accept myself
2. If no one can give me good selfesteem except myself
3. What follows is an honest and objective evaluation about the positive and

negative things in my life.
A. Negatives
B. Positives
4. The things that I can do to raise my selfesteem include
Low SelfEsteem 331

THE SELFESTEEM REVIEW
Directions: Review the following statements. Rate how much you believe each statement,
from 1 to 5. The highest rating, 5, means that you think the statement is completely true,
0 means that you completely do not believe the statement.
Rating
1. I am a good and worthwhile person.
2. I am as valuable a person as anyone else.
3. I have good values that guide me in my life.
4. When I look at my eyes in the mirror, I feel good about myself.
5. I feel like I have done well in my life.
6. I can laugh at myself.
7. I like being me.
8. I like myself, even when others reject me.
9. Overall, I am pleased with how I am developing as a person.
10. I love and support myself, regardless of what happens.
11. I would rather be me than someone else.
12. I respect myself.
13. I continue to grow personally.
14. I feel confident about my abilities.
15. I have pride in who I am and what I do.
16. I am comfortable in expressing my thoughts and feelings.
17. I like my body.
18. I handle difficult situations well.
19. Overall, I make good decisions.
20. I am a good friend and people like to be with me.
0 100
I I
Total lack of selfesteem High selfesteem
Your score

TEN SELFESTEEM BOOSTERS
1. Be realistic
A. Do not compare yourself to others
B. Be Satisfied with doing your best
2. Focus on your accomplishments
A. Each day review what you have done
B. Give yourself credit for what you do
3. Use positive mental imagery
A. Imagine success
B. Mentally rehearse confidence
4. Look inside not outside
A. Avoid being materialistic or identifying yourself by what you have
B. Identify your sense of purpose
5. Actively live your life
A. Set goals
B. Think strategically
6. Be positive
A. Substitute negative thoughts with realistic positive thoughts
B. Acknowledge that how you think affects how you feel
7. Have genuine gratitude
A. Be grateful for all that you have
B. Appreciate your life as a gift
8. Meditate
A. Think of peaceful, pleasant things
B. Learn to relax and let go of stress
C. Use positive affirmations
9. Develop positive selfcare as a lifestyle
A. Believe you are worthy of taking care of yourself
B. Take care of your health
10. Appropriately get your needs met
A. Identify what you need
B. Identify your choices for getting those needs met
Positive selfesteem is an active process. Daily efforts will make a difference in your life
experience.
Ten Sel/£st«ew Boosters 333

AFFIRMATIONS FOR BUILDING SELFESTEEM
1. I am a valuable and important person, and I'm worthy of the respect of

others.
2. I'm optimistic about life; I look forward to and enjoy new challenges.
3. I am my own expert and I am not affected by negative opinions or attitudes
of others.
4. I express my ideas easily, and I know others respect my point of view.
5. I am aware of my value system and confident of the decisions I make based
on my current awareness.
6. I have a positive expectancy of reaching my goals, and I bounce back quickly
from temporary setbacks.
7. I have pride in my past performance and a positive expectancy of the
future.
8. I accept compliments easily and give them freely to others.
9. I feel warm and loving toward myself, for I am a unique and precious being,
ever doing the best I can, and growing in wisdom and love.
10. I am actively in charge of my life and direct it in constructive channels. My
primary responsibility is for my own growth and wellbeing (the better I feel
about myself, the more willing and able I am to help others).
11. I am my own authority, and I am not affected by the negative opinions or
attitudes of others.
12. It is not what happens to me but how I handle it that determines my
emotional wellbeing.
13. I am a success to the degree that I feel warm and loving toward myself.
14. No one in the entire world is more or less worthy, more or less important,
than me.
15. I count my blessings and rejoice in my growing awareness.
16. I am an action person; I do first things first and one thing at a time.
17. I am kind, compassionate, and gentle with myself and everyone.
18. I am a genuine person who lives consciously.
SELFNURTURING: A COMPONENT OF SELFESTEEM
You will know that you are developing selfcare and selflove when you feel worthy,
confident, and secure about who you are. The following are demonstrations of progress in
selfnurturing:
1. You spend a day alone and are able to enjoy your own company and

peacefulness.
2. You are able to make choices and do things to make yourself feel better.

3. You are able to be objective and loyal to yourself. You are able to hear the
opinions of others while maintaining your own point of view.
4. While you strive to avoid becoming materialistic, you also feel worthy of
giving yourself things that are important to you.
5. You take care of your health and wellbeing.
6. You do not engage in selfdestructive behaviors or choices.
7. When you laugh, you laugh deeply and you laugh often.
8. You feel good about all of your successes large and small. You feel good
about all that you achieve. You always strive to be the best you can be.
9. If someone is rejecting or hurtful, you do not take it personally. You are
objective and honest with yourself. You realize that the problem may belong
to the other person. Likewise, you are honest with yourself about you, take
responsibility, and make changes as needed.
10. You are assertive in asking for what you need and want in your relationships
with others. You set appropriate boundaries in relationships.
Adapted from a handout by J. Hays, author of Smart Love.
SelfNurturing. A Component of SelfEsteem 335

CHARACTERISTICS OF LOW SELFESTEEM
1. Fearful of exploring his/her real self

2. Believes that others are responsible for how he/she feels
3. Fearful of taking responsibility for his/her own emotions and actions
4. Fearful of assertively communicating wants and needs to others
5. Feels and acts like a victim
6. Judgmental of self and others
7. Does not live according to your his/her values (chameleon)
8. Covert, phony, "social personality"
9. Exaggerates, pretends, lies
10. Puts self down, shameful, blaming, selfcritical, condemning
11. Nice person, approval seeking, people pleaser, puts the needs of others first
12. Negative attitude
13. Triangulates by talking badly about one person to another
14. Rationalizes
15. Jealous/envious of others, has trouble being genuinely happy for the
successes of others
16. Perfectionistic
17. Dependencies/addiction, compulsive, selfdefeating thinking and behavior
18. Complacent, stagnates, procrastinates
19. Does not like the work one does
20. Focuses on what doesn't get done instead of what does
21. Leaves tasks and relationships unfinished and walks away without
resolving issues
22. Judges selfworth by comparing to others, feels inferior
23. Does not accept or give compliments
24. Excessive worry or catatrophizing
25. Is not comfortable with self, hard to be alone with self
26. Avoids new endeavors, fears mistakes or failure
27. Irrational responses, ruled by emotions
28. Lack of purpose in life
29. Lack of defined goals
30. Feels inadequate to handle new situation, easily stressed
31. Feels resentful when doesn't win
32. Vulnerable to the opinions, comments, and attitudes of others
33. Feel like one's life is in the shadow of another
34. Gossips to elevate self
35. Continues to blame past experiences (or family) instead of dealing with the
current self (the past is an explanation, not an excuse)

Identify your characteristic of low selfesteem. What have you learned from this selfreview?
Characteristics of Low SelfEsteem 337

CHARACTERISTICS OF HIGH SELFESTEEM
1. Lives authentically

2. Demonstrates selfresponsibility—does not blame others
3. Takes responsibility for life and consequences of actions
4. Sets goals and is committed
5. Has purpose in life
6. Is emotionally and intellectually honest with self and others
7. Confronts and deals with fears
8. Is aware of both strengths and weaknesses (selfobjective)
9. Is selfrespectful and sets appropriate limits and boundaries
10. Does not lie about the choices he/she makes
11. Selfaccepting and selfsoothing (does not seek external sources
to "make it okay")
12. Selfsufficient (thinks and makes decisions independently)
13. Does not hold grudges
14. Is persistent in all efforts
15. Is genuinely grateful
16. Positive attitude (cup is half full not half empty)
17. Accepts others
18. Genuinely pleased for the success of others
19. Does not compare oneself to others
20. Directs efforts toward being the best he/she can be (recognizes that life is
about continual personal growth with an aim for excellence not perfection)
21. Lives according to one's own internal values, principles, and standards
22. Chooses to see opportunity and challenges instead of problems
23. Is spontaneous and enthusiastic about life
24. Is able to praise oneself and others for efforts and accomplishments
25. Is able to see the big picture versus being trapped by stumbling blocks
(mistakes have value)
26. Appropriately asks for help and utilizes resources
27. Is an active participant in life
28. Is comfortable with self and can enjoy alone time
29. Is true to oneself
30. Has quiet selfconfidence
Identify your characteristics of high selfesteem. What have you learned from this self review?

WHAT MOTIVATES ME?
1. First, identify the life goals for which you are striving. If you do not identify your goals
on the list below, write them down.
wealth security love selfacceptance power
status achievement success peace fulfillment
truth contribution social change personal growth
excellence lasting relationships comfort challenge
2. What values guide you in the pursuit of your goals?

commitment marriage experience excitement
selfdiscipline integrity honor selfrespect
pain avoidance leisure cooperation decency
kindness meaning sexual gratification serving others
happiness education friendship affection
instant gratification actualization honesty health
control anger independence noncommitment anger
revenge adventure travel children family
position superiority selfimportance laziness freedom
selfsacrifice substance use isolation job satisfaction intimacy
assertiveness accountability pain seeking advantage
dishonesty selfishness irresponsibility pleasure justice
selfserving resentment insecurity vulnerability
play shyness equality hatred compulsiveness conflict
curiosity selfconfidence illness affluence resisting change
STANDING UP TO SHYNESS
Shyness is very common. Most people who are shy can share experiences of being embar

rassed which resulted in making them feel more selfconscious and shy. It is also common
for people who are shy to have unrealistically high expectations of themselves. They overes
timate the amount of attention they receive from others, especially when they are feeling
intensely selfconscious.
Those who are shy often believe that others are observing them and judging them. What
they do not realize that most people are focusing more on themselves than on the presenta
tion or performance of others.
If you want to overcome your shyness, it will require a commitment to change. This means
practicing change several times a week to desensitize your level of anxiety. This weekly
Standing Up to Shyness 339

practice could take place specifically in a group for overcoming shyness, or use the follow
ing tips in social settings:
SOCIALIZING
Meet people and talk with them. Everyone's social skills get rusty when they are not used.
Practice, practice, practice.
1. Break experiences down into small, manageable steps. Be consistent.

A. Set a goal to make eye contact
B. Say hello
C. Inquire into how someone is doing
D. Ask another's opinion on a community event
2. Learn to ask questions
A. Ask openended questions
B. Listen to responses, which may bring up more questions
3. Choose to be in control

A. Structure social situations
1. Have dinner with a friend
2. Have lunch with one or two coworkers
3. Attend a structured class like photography, dancing, painting where
4. Conversation is minimal and optional
4. Learn to accept yourself and your imperfections. Be honest and objective with
yourself about your struggles in conversation and use this information to come
up with several ways of dealing with your discomfort. This will contribute to
feeling in control.
5. Let it go. Do not put yourself down if you think you have made a mistake or
done something you think is embarrassing. How you think about yourself and
how others perceive you are often very different. Take the "oh, well" attitude,
and try again.
6. Help someone else. Since you know how uncomfortable you can feel at a large
social gathering, help yourself and someone else. It won't be hard for you to
identify someone else who is withdrawn and looks uncomfortable. Take that
person under your wing and provide support.
340 3. S k i l l B u i l d i n g R e s o u r c e s for Increasing Social Competency

BAD MEMORIES AND FEAR
Feeling depressed in combination with feeling overwhelmed by disturbing memories can lead
to thoughts of suicide or to selfdestructive behavior.
People overwhelmed by bad memories from painful experiences often find it difficult to
adequately cope. It could be that they were in some way abused as a child. Such abuse can
be physically, emotionally, and psychologically traumatizing and damaging. One of the most
upsetting things about a situation such as this is that while they were being hurt by some
one else in the past, now they may be engaging in behaviors that continue to harm them.
In addition to haunting memories the fears which make it very difficult to trust others. If
this is the case, then it is likely that it has been hard to utilize resources even if you are aware
of them. However, because you have decided that you no longer want to feel this way any
longer there are some things that you can do to initiate a program of hope and recovery.
1. Therapy. Individual and/or group therapy will be very helpful in facilitating

the release of the memories which have held you hostage. Make sure that
the therapist is familiar with these issues. Whether or not you participate
in short or longterm therapy will depend on your needs and goals.
2. Venting Your Feelings and Thoughts. Talking with a friend, family member,
or therapist that you trust will help you to get out your feelings instead
of carrying them around inside, and will help you begin to identify what
you need to do to take care of yourself and to heal.
3. Journal Writing. This is a very helpful strategy. Instead of using emotional
energy to hold everything inside, write your feelings and thoughts in a
journal. Writing is a constructive way to vent thoughts and feelings, to
clarify issues, and to problem solve what you need to do to take care of
yourself. A journal is always there when you need it.
4. Creative Expression. You do not have to be a trained artist to express yourself
in a variety of creative or artistic ways. This can be helpful for distracting
yourself so that you can have a break from painful memories or it can give
form and texture to your feelings, emotions, and mood.
5. SelfHelp Resources. There are so many things available to help such as self
help groups, books, tapes, and community presentations. Check out a local
bookstore, see if the local newspaper offers a listing of available support groups
and also inquire with your physician or local mental health associations for
information on resources.
Painful or fearful memories that I need to let go of are
Things that I have done that have been helpful to me in the past are
Bad Memories and Fear 341

Resources that I am aware of that would be helpful are
Helpful resources that I am willing to use are.
Formulate a plan for letting go of painful and fearful memories so that they no longer
interfere with the quality of your life
SEASONAL ANNIVERSARY OF LOSSES
The anniversary of a death or other major loss can trigger thoughts of suicide or selfdestructive
behaviors. Additionally, another time of year that is difficult for a number of people is
the holiday season. There are expectations of a loving and caring family coupled with the
excitement and enthusiasm of being with others and sharing the holiday spirit. For people
who grew up experiencing tension and emotional distress or other issues associated with the
holidays this can be a very difficult time. Yet, other people suffer from Seasonal Affective
Disorder (SAD). When the days are shorter, the number of hours of daylight are reduced
which makes some people experience depression.
Identify which of these issues presents a difficulty for you.
What has made it so difficult to deal with this issue(s)?
What are things that you have done in the past that was helpful in managing this
distressing situation?

What is your plan for managing this issue in the future or resolving it?
Seasonal Anniversary of Losses 343

FATIGUE OR SLEEP DEPRIVATION
There is a noted relationship between fatigue and sleep deprivation to severe difficulty coping.
Sometimes the inability to cope results in suicidal thoughts. If you experience either or both
of these issues get help immediately. Tell your physician, therapist, family members, and/or
friends so that you can receive the appropriate support in intervening in this difficult situa
tion. If you are suicidal, let someone in your support system know and allow them to be
there with you so that thoughts do not escalate into actions.
If you are not in treatment then talk to your physician about the options for treating
depression. There are a range of interventions encompassed by medication, therapy, and the
development of your own selfcare program. At the very least components of selfcare
include good nutrition, adequate sleep and rest, exercise, relaxation, being involved in pleas
urable activities, and spending time with people that you enjoy.
If I am not getting adequate rest and sleep I will
If I am feeling fatigued I will
If you experienced these difficulties before what did you do that was helpful
My plan for managing the problem with sleep, fatigue, and depression is
WHAT IS PANIC ANXIETY?
There is not a single answer to the question "What causes panic attacks?" However,
biological, environmental, and genetic factors play a role.
1. It is possible that separation anxiety during childhood may be a predisposing

factor for the development of panic anxiety later in life

2. Imbalance in brain chemistry may be responsible
3. Genetic predisposition may be evident when looking at family history of
anxiety disorders
4. Learned behaviors play a role—for example, continuously taking care of the
needs of others while neglecting your own needs, build up of stress over time,
or the chronic feeling of being overwhelmed and not having enough time to
get to everything that demands your attention
5. The experience of losing someone close to you such as a family member can
result in panic anxiety. A death can result in feelings of being helpless and
out of control.
6. Physical trauma past or present may trigger panic anxiety.
7. Sexual trauma past or present may trigger panic anxiety.
8. Positive life events (marriage, job promotion, etc.) may also contribute to
panic anxiety. This may be because there are feelings or concerns of some loss
associated with the change. It could be that a person does not feel worthy or
believes he/she does not deserve to be happy, which may result in negative
ruminating and anxiety associated with the change.
SYMPTOMS
Panic attacks are diagnosed when an individual experiences at least 4 of the following
13 symptoms. Additionally, the symptoms develop and peak in a short period of time, which
results in feelings of significant distress.
1. Palpitations/pounding heat/accelerated heart rate

2. Chest pain/tightness
3. Sweating
4. Chills/hot flashes
5. Trembling/shaking
6. Feeling short of breath/smothering
7. Feeling of choking
8. Nausea/abdominal distress
9. Feeling dizzy/lightheaded/faint
10. Numbness/tingling in hands or feet
11. Derealization (feelings of unreality)
12. Depersonalization (being detached from oneself)
13. Fear of losing control/going crazy
14. Fear of dying
TREATMENT
1. Cognitivebehavioral therapy
2. Medication
3. Health behaviors (exercise, decrease or eliminate caffeine and alcohol, develop
a selfcare plan)
What is Panic Anxiety? 345

POSTTRAUMATIC STRESS DISORDER (PTSD)
When a person is given specific information that is traumatic and overwhelming, witnesses,
or has an experience of a traumatic event, the person may experience anxiety, fear, distress,
or relive of the traumatic event for months and sometimes years after. Often the experience
may have been life threatening or physically harming.
Posttraumatic stress disorder affects twice as many women as men. Half of all adults will
experience a significant trauma, and 20% of them will develop posttraumatic stress disor
der. Immediately following a traumatic experience, a person may develop acute stress, which
if treated may prevent the onset of the more enduring posttraumatic stress disorder.
Additionally, some individuals do not have an apparent acute stress reaction, but at a later
date the trauma is triggered by some event or significant level of emotional distress and the
person then experiences a delayed onset of posttraumatic stress disorder.
Individuals most at risk for PTSD are
1. Victims of sexual assault
2. Victims of child sexual abuse
3. Victims of child neglect, emotional abuse, and physical abuse
4. Victims of spousal abuse
5. Victims of random acts of violence
6. Survivors or witnesses of
A. Car accidents
B. Plane crashes
C. Fires
D. Natural disasters
7. Veterans and victims of war
8. Family or friends of someone who has died suddenly
9. Individuals who experience a lifechanging medical condition
Three major categories of symptoms are present when a person is diagnosed with a post
traumatic stress disorder:
1. Intrusive memories
A. Bad dreams
B. Sudden thoughts
C. Images/flashbacks
* These symptoms can result in physical reactions such as feelings of panic, shortness of
breath, sweating, tightness in the chest or palpitations.
2. Avoidance behavior or loss of joy

A. As thoughts of the trauma are pushed out of conscious awareness or to some
corner in one's mind the person may avoid anything that could trigger thoughts of
the trauma. As a result, these individuals quit participating as they normally would
and no longer find joy in previously enjoyed activities.

3. Hypervigilance (being on guard)
A. Feeling onedge
B. Easily startled
C. On high alert
* These symptoms can result in difficulty sleeping, difficulty concentrating, irritability, emo

tional reactivity, or anger.
Treatment includes therapy and the consideration of medication. Other sources of informa

tion include the PTSD Alliance at 877507PTSD and the Moving Past Trauma hotline at
8004558300.
MANAGING ANXIETY
Anxiety is a part of everyday life. It is a normal emotional experience. Something that
is different from the anxiety which is a normal response to environmental stressors are
anxiety disorders. In an anxiety disorder the anxiety is much more intense, it lasts longer,
and it may be specific to people, places, or situations.
The goals in managing anxiety are to understand what your personal reaction to anxiety
provoking situations are, identify what your related concerns are, and to learn to "let go"
of anxiety. You may need the help of a therapist to learn the skills useful for managing and
eliminating anxiety disorder symptoms. You may also benefit from the use of antianxiety
medications in conjunction with therapy to accomplish these goals. The hope is that, by
reading that there are a number of strategies, you can learn to deal with anxiety you feel.
As with almost everything, if you want things to be different then you need to be willing
to do things differently. It takes a commitment to change and consistency in following
through in the use of the strategies that you will develop to manage the distress of anxiety
disorders. Some people experience anxiety in specific situations whereas others experience a
certain level of anxiety all the time. To develop a treatment plan that will help you manage
anxiety effectively requires that you clearly identify your symptoms, the circumstances
related to the onset of the symptoms if there are any, and what efforts you have used to cope
with the distress of anxiety.
In identifying the possible issues related to anxiety you may have to pay better attention
to the thoughts in your mind. People talk to themselves continually throughout the day.
When you talk to yourself about the emotion or fear that you attach to it, you can have a
significant impact on the development and maintenance of anxiety disorders. Increasing your
awareness for what these selftalk statements are will allow you to begin to change and cor
rect thinking that has contributed to your unmanageable anxiety.
It is recommended that you keep a journal. A journal is useful for venting your feelings,
clarifying what the problem is, and then problem solving the situation by taking the appro
priate action. To problem solve the situations that you write about ask yourself if this is
something that you have control over. If the answer is yes then consider the options for deal
ing with it, and make a decision after considering the various consequences or outcomes. Be
prepared to try an alternative if the first attempt does not work effectively. If it is something
that you do not have any control over then "let go." Learning to accept what you cannot
change will relieve anxiety. It takes time to learn how to let go, but the increased energy, free
dom, and relief that you will experience are well worth it.
During the course of your journal writing, as you become more aware of the internal
selftalk, you may begin to become aware of the relationship between your thoughts and feel
ings. Thoughts affect feelings, feelings affect actions. When you choose to think more posi
tively about a situation you will feel better. Likewise, when you worry excessively, expect the
worst to happen, and when you are selfcritical you can expect to feel bad.

Now that you know that beliefs affect emotion and behavior you will want to pay more
attention to your own beliefs.
1. Do you feel an intense need for approval from others? People pleasing behavior

means that you put the needs of others before your own needs. This leads to
frustration and, over time, resentment. Frustration and resentment are intense
feelings that can contribute to chronic anxiety and tension.
2. Do you have an intense need for control? Do you worry about how you
appear, do you feel uncomfortable in letting other people be in charge of a
situation? Do you believe that if you are not in control, that you are weak
and a failure?
3. Do you tend to be perfectionistic and selfcritical? Do you often feel that what
you do is never enough or not good enough? Do you often criticize your own
efforts and feel a constant pressure to achieve?
These patterns of beliefs and behavior are irrational. If this is your approach to life expect
to experience chronic stress, anxiety, and low selfesteem. Who could feel calm and relaxed
with this approach to life. Chances are that if you engage in any of these behaviors
and beliefs that you also have a tendency to discount what you are experiencing physically.
The mind and body function as one. When there is emotional distress you know it.
Generally, there are physical symptoms as well, especially with chronic stress. Often when
people ignore all of the ways that their body tries to tell them to slow down and take care
of themselves the result is an escalation in symptoms. When this happens it is called a panic
attack. Symptoms of panic attacks include:
1. anxiety
2. palpitations, accelerated heart rate, or pounding heart
3. chest pain or discomfort
4. shaking or trembling
5. muscle tension
6. shortness of breath
7. nausea or abdominal distress
8. feeling dizzy or lightheaded
9. numbness or tingling
10. feelings of unreality
11. feelings of being detached from oneself
12. fear of losing control or going crazy
13. chills or hot flashes
14. feeling of impending doom/fear of dying
If you have not had a panic attack, you can recognize by looking at the symptoms that

it is a terrifying experience. Yet, the person who has experienced a panic attack has likely
been building up to it for a long time, ignoring their own high level of chronic emotional,
psychological, and physical distress.

WHAT DO YOU DO
Ineffective and dysfunctional approaches to relationships with others and with yourself need
to be changed. To be the best that you can be in a relationship requires that you be the best
you can be as an individual.
1. Develop good boundaries. This means having a realistic view of other people's

approval, and that you don't depend on it to feel worthy or accepted. It also
means learning to deal with criticism in an objective manner. Everyone is entitled
to their opinion. If they offer information that is beneficial to you then use it.
If not, then let go. If you have a tendency to put the importance of their needs
above your own then recognize your codependency and take responsibility for
changing it. This can be a big contributor to states of chronic anxiety and stress.
2. Develop realistic expectations and limitations. Change your belief that your
worth is based upon what you accomplish and achieve. Focus on what is right.
You can drive yourself to the point of exhaustion with selfcriticism. Once you
develop realistic goals you will have the time you need for other personal
necessities such as spending time doing things that you find pleasurable and
being with people that you enjoy.
3. Recognize that not everything can be neat and predictable. Learning acceptance
and patience will help you be more comfortable with the things that are
not predictable. The next step is learning to trust that most problems eventually
work out. One of two things will happen; either you will find a solution to the
problem or you will see that it cannot be changed. If it cannot be changed then
you find a way to accept it or make some decision based on its influence in your
life and do something else. Overall, things become clearer and coping is easier.
As previously discussed, people with chronic anxiety and stress tend to ignore their body's
response to stress. This means that you may be ignoring physical symptoms. If this is the
case, you will keep pushing yourself without slowing down to take care of yourself. One
consequence of pushing yourself with controlling, codependent, perfectionist standards is a
chronic high level of stress that turns into panic attacks. A panic attack is also a warning
sign. This warning sign is not as easy to ignore as others. If you have a panic attack, chances
are that you have ignored taking good care of yourself for some time and that irrational
thinking is playing a large role.
In order to learn to manage stress requires that you be able to identify your own symp
toms of stress. Once you have this awareness then you can do things to relieve your stress
and anxiety. You are responsible for your own physical and emotional health.
It is important to note that it is not uncommon for someone with an anxiety disorder to
also be experiencing some level of depression.

SURVEY OF STRESS SYMPTOMS
Check each symptom that you have experienced in the last month, and then count the num

ber of items that you have checked. The symptoms must be experienced to the level that you
identify it as a problem
PSYCHOLOGICAL SYMPTOMS
anxiety loneliness
depression intrusive thoughts
difficulty concentrating relationship problems
forgetful family problems
agitation, hyper work problems
feeling overwhelmed irritability
irrational thoughts/fears excessive worry/obsessing
compulsive behavior feelings of guilt
confusion tearful
feelings of unreality nightmares
feeling of being detached from oneself social isolation/withdrawal
restless/on edge apathy/indifference
mood swings sexual dysfunction
PHYSICAL SYMPTOMS
headaches fatigue
muscle tension high blood pressure
low back pain sleep disturbance
upper back, neck, or shoulder pain appetite disturbance
clenching teeth diarrhea
abdominal distress digestive problems
nausea constipation
shaking or trembling rash/hives/shingles
numbness or tingling use of alcohol/cigarettes or other
drugs to deal with stress
feeling of choking bowel problems
chills or hot flashes thyroid dysfunction
sweating other stressrelated health problems
sleep disturbance
ESTIMATE YOUR STRESS LEVEL
Number of items checked estimated level of stress
07 low (within the normal range)
814 moderate (experiencing some distress)
1521 high (experiencing difficulty coping)
22+ very high (unable to cope)
As you review your symptom list think of ways that you can take care of yourself, make

changes, delegate tasks to others, etc. that can alleviate the physical and emotional distress
that you experience.

HOW YOUR BODY REACTS TO STRESS AND ANXIETY
Stress is a part of everyday life. Even "good" stress can affect you by leaving negative con

sequences such as fatigue and body tension. The body's response to stress is its conditioned
habit for coping with difficult situations.
The physiological changes associated with stress and anxiety are initiated with the brain's
interpretation of the experience. The brain then sends a message to a gland in the brain
(hypothalamus), which then sends the message to another gland in the brain (pituitary—
known as the master gland). From there, hormones are released that relay messages to other
glands in the body, which also release hormones (like adrenalin). If the stress reaction is brief
no significant damage is done. However, if the stress reaction lasts a long time, other stress
hormones are released, which begin to negatively affect the immune system and the body
becomes more susceptible to infection and disease. The weakest part of the body will be the
first to show signs of dysfunction as the ravages of chronic stress takes their toll.
Remember, the body's initial response to stress is the same whether the stress is positive
or negative. It is the experience of prolonged stress that is damaging.
MANAGING STRESS
It is physically and psychologically impossible to be stressed and relaxed at the same time.
Therefore, the goal is to create a state of relaxation. When the body has been exposed to
acute stress for too long or stress has been chronic (one difficult situation after the other),
the body forgets what it feels like to be relaxed.
To retrain or recondition to your body to the experience of being relaxed, seek the
following:
1. Adequate sleep
2. Good nutrition
3. Laughter and recreation
4. Aerobic physical activity (walking is great)
5. Deep breathing techniques
6. Relaxation techniques (aside from deep breathing, which is a first step in
the process)
The mind needs to rest and be distracted so that there can be relief from body tension.
Meditation, deep relaxation, and the other reconditioning factors listed earlier help to
alleviate tension in the muscles/body and the mind. The result is as follows:
1. An increase in energy
2. A sense of well being
3. Balance in lifestyle
For emotional, psychological, and physical health, learn to relax physically, emotionally,

and psychologically. Don't worry about things you can't control, let go of issues that belong
to someone else, be effective in your life by accomplishing tasks and then moving on, and
practice good selfcare behaviors.
How Your Body Reacts To Stress and Anxiety 351

25 WAYS TO RELIEVE ANXIETY
1. Positive thinking. Look for the opportunity instead of the negative.

2. Task oriented. Feel good about your efforts and accomplishments.
3. Accept yourself. Don't be selfcritical. If there is something you want to
change then change it.
4. Be flexible. Not everything is black and white. Be open to the gray area
of things.
5. Develop realistic goals. Evaluate what it will take to reach a goal.
6. Develop a positive view of life.
7. Nurture your spirituality.
8. Distract yourself from stressors. Sometimes you have to put everything aside
to relax and have fun.
9. Deep breathing, relaxation, meditation, or visualization.
10. Finding humor in things.
11. Spending time with people you enjoy.
12. Keeping a journal for venting, and at the end of every entry closing with
something positive.
13. Take time regularly to do activities that you enjoy.
14. Utilize your support system. This could be friends, family, individual therapy,
group therapy, or community support groups.
15. Practice being assertive. You will feel better for taking care of yourself.
16. Good communication.
17. Take short breaks throughout the day. Take 5 to 10 minute breaks
throughout the day to relax and remove yourself from stressors or
demands.
18. Regular exercise. Walking is excellent for decreasing body tension and
alleviating stress.
19. Get adequate rest and sleep. If you don't get enough sleep you can't cope well.
20. Practice good nutrition.
21. Massage. A good way to relieve muscle tension and relax.
22. Choose to be in environments that feel good to you.
23. Work on your financial security.
24. Practice good time management.
25. Do things that demonstrate respect, care, and nurturing of the self.
That means take good care of you.
Develop a selfcare plan. Incorporate these strategies and others to develop a plan of
selfcare behaviors, beliefs, and attitudes that can become a new and healthy lifestyle. That is
preventive medicine.

PLAN OF ACTION FOR DEALING WITH ANXIETY
1. Recognize and identify anxiety symptoms, and situations related to it.

2. Develop relaxation skills. Most people will be able to feel relaxed by using
progressive muscle relaxation. If you have made a good effort to use it and do
not find that it is relaxing for you then it is your responsibility to try other
techniques until you find one that is effective for you. Other techniques
include deep breathing, visualization, meditation, body scanning, and brief
forms of progressive muscle relaxation. This is a very important part of
managing anxiety. Because of the way the nervous system works it is
physically impossible to be stressed and relaxed at the same time. Learn a
relaxation technique.
3. Confront anxiety. Make a commitment to understand and deal with the issues
underlying your experience of anxiety.
4. Problem solve. Once you have identified the underlying issues contributing to
the anxiety you experience deal with the issues that you can do something
about and let go of the issues that you cannot do anything about.
5. Develop positive selfesteem. If you do not accept and like who you are, how
can you effectively manage the things that are causing your anxiety. The
managing of anxiety is about lifestyle changes. This requires a commitment to
yourself. To make this commitment and follow through will depend on how
important your wellbeing is to you.
6. Exercise. Aerobic exercise, especially walking is a good stress reliever. It
decreases muscle tension, increases energy, and can improve sleep. You will
experience the benefits of walking after several weeks of commitment to this
anxiety relieving strategy. It feels good to take care of yourself.
7. Using positive selftalk. How you talk to yourself will make a big difference in
how you interpret things around you, how you choose to feel, and how you
choose to respond. In other words, how you talk to yourself affects your
entire life experience. Practice positive, rational selftalk and incorporate daily
use of positive affirmations.
8. Keeping a journal. A journal is a great tool for venting your feelings and
thoughts. It takes emotional energy to keep all of this "stuff" inside. Get it
out. Writing your thoughts and feelings can also clarify issues. Problem solve
these issues to alleviate distress and to unclutter your mind. A journal is also
a great way to monitor your consistency and actual commitment to the
changes necessary for managing your anxiety.
9. Confront and change selfdefeating behavioral patterns and personality traits.
This means changing perfectionistic, controlling, codependent behaviors.
These behaviors do not help you get your needs met and they do not make
you feel better. Contrary, they generally leave you feeling stressed, frustrated,
anxious, angry and over time resentful.
10. Desensitize phobias. If there are specific situations that elicit extreme anxiety
for you then work with your therapist using a technique called systematic
desensitization.
Plan of Action For Dealing With Anxiety 353

11. Utilize your support system. If you do not have a support system then develop
one. Start by putting in place the supports that you need for confronting and
dealing with your anxiety. A support system can include your therapist
(individual or group), your physician, family members, friends, people at your
church, etc. Generally the reason why a person lacks a support system is
because they have made the choice to not allow others to help them. Instead,
they have this distorted belief that it is only themselves that can be there to
support other people.
12. Energize yourself with pleasure and humor. This means spending time with
people you enjoy and doing activities that you like. Laughter is a great stress
reliever. Have laughter in your life everyday.
13. Practice good nutrition and get adequate sleep. You must take care of yourself
to live life fully which includes work, relaxation, and pleasure.
14. Develop assertive communication. Being able to say "no" and to otherwise
effectively express yourself is a skill. If you do not have it learn it. To get your
needs appropriately met requires that you speak honestly and appropriately
about what you want and need.
15. Develop selfnurturing behaviors. You are so good at taking care of the needs
of others. Practice doing things that feel good to you.
If you have developed a program for managing anxiety and are consistently practicing it

you are probably feeling much better. Because change is difficult, people need to feel moti
vated to do things differently. Originally, it was the extreme distress and physical symptoms
that facilitated your change. Sometimes when people start feeling better they quit following
through on the changes in their thinking and their behaviors. This can lead to a relapse of
symptoms. If a relapse happens to you view it as an opportunity to understand the impor
tance of the components of your management program and the validation that if you do not
make a commitment to take care of yourself your body will keep sending you the message
that it needs to be taken better care of.
Some people experience relapse as a normal part of their recovery from extreme stress and
anxiety. It could be that they are consistently practicing all of the parts of their program but
reexperience some symptoms. This has likely happened because there was so much body
tension that you may go through one or more stages of a readjustment. So if you are con
sistently doing what is prescribed in the way of changes continue even if some symptoms
reoccur. They will subside. Remember, it took a long time to get to this state, and it may take
a while to alleviate all of the emotional and physical distress. Therefore, think of relapse as
a normal, predictable part of recovery.
Be prepared to deal with the possibility of a relapse. If it does occur, it is likely that the
symptoms will not be as intense or last as long as they did before. This is because you have
developed skills to manage your anxiety.
RELAPSE—SYMPTOM REOCCURRENCE
When you have a relapse you fall back into old behaviors and old ways of thinking. When

you started feeling better you probably thought that you had conquered the anxiety and
would not be bothered by those symptoms again. What happens in relapse is just a recycling
of the old patterns. Relapse is a predictable and expected part of recovering.

In preparing yourself for the management of a relapse remind yourself of the self
perpetuating cycle of extreme anxiety.
When you experience any relapse, take the time to assess your reactions so that you can

evaluate your feelings and behaviors. This will help you to appropriately intervene in the
relapse cycle earlier and earlier. The result will be decreased setbacks and stronger progress
and stabilization.
INTERVENING IN THE RELAPSE CYCLE

1. Managing Stress
A. use strategies such as relaxation, meditation, exercise, utilization of support system,
delegating tasks to others, etc.
2. Challenging Negative/Irrational Thinking
A. use positive selftalk, remind yourself that the anxiety will not last forever, use
positive affirmations, use your journal so that you can identify patterns of negative
selftalk being initiated by specific situations and deal with it.
3. Resolving Internal/External Conflicts
A. the conflicts were initiated by the stressors at the beginning of the cycle and then
again through negative selftalk. Take the opportunity to understand the conflict
and problem solve it. This is an opportunity to resolve and let go of past issues and
dysfunctional thinking patterns.
You will break the relapse cycle with your increased awareness, use of management skills

(assertiveness, relaxation, spending time with people you enjoy, participating in activities
that are pleasurable, improving your selfesteem, positive selftalk, etc.), and selfcare behav
iors (adequate rest/sleep, good nutrition, exercise, etc.)
Your consistency and repeated efforts to cope effectively with stressors using the strate
gies that you develop will pay off. Remember to use your journal or other source to moni
tor your efforts and consistency in changing your lifestyle to one in which you take care of
yourself and avoid exhaustion.
You know that the progress that you have made is becoming more stable when you have
learned to experience normal anxiety without panicking. Therefore, continue to be consis
tent in your efforts to overcome anxiety. You are responsible for your health.
Relapse—Symptom Reoccurrence 355

WARNING SIGNS OF RELAPSE
1. negative thinking
2. controlling behavior
3. excessive worrying/catastrophizing
4. perfectionistic behavior
5. codependent behavior
6. change in appetite
7. difficulty with sleep
8. difficulty getting up in the morning
9. fatigue/lethargy
10. feeling bad about yourself
11. feeling less hopeful about the future
12. decreased exercise
13. unwilling to ask for what you want or need
14. procrastination
15. social isolation
16. withdrawal from activities
17. use of alcohol or other drugs
18. irritable/agitated
19. impatient
20. negative attitude
21. lacking confidence
22. feeling insecure
23. poor judgment
24. misperceptions
25. selfdefeating behaviors
26. destructive risktaking behaviors
27. distrustful of others
28. obsessive thoughts
29. difficulty concentrating
30. not experiencing pleasure in anything you do
31. suicidal thoughts
32. others
In the early stages of your recovery from anxiety you can use this item survey to regularly
review for the presence of symptoms that indicate that currently there is a relapse, or that a
relapse is inevitable if immediate intervention with management strategies is not made. As
your progress begins to stabilize, intermittently review this list to maintain awareness and to
reinforce efforts and accomplishments.

SYSTEMATIC DESENSITIZATION
Systematic desensitization is a technique which couples progressive relaxation training and

visual imagery for the extinction of maladaptive anxiety reactions.
To ensure that anxiety is inhibited by the counter response to anxiety of muscle relax
ation, the anxious individual is instructed to imagine anxietyprovoking scenes arranged in
a hierarchy. Hierarchies of anxietyprovoking situations are formulated as a range from
mildly stressful or nonthreatening to very threatening. This imaging of these events occurs
while the individual is deeply relaxed. Should any imaginary event in the hierarchy elicit
much anxiety the individual is instructed to cease visualization and regain their feelings of
relaxation. Depending on the situation, the hierarchy is adjusted accordingly (broken down
into smaller steps or reorganized) or the imaginal representation of the event is repeated until
the individual does not experience anxiety in response to the event image.
THE TEN STEPS OF SYSTEMATIC DESENSITIZATION

1. Identify the event which provokes the extreme anxiety.
2. Develop a hierarchy of ten steps leading to the anxietyprovoking event. Begin
with the least stressful aspect in the chain of events leading to the anxiety
provoking event which is avoided because of the associated distress.
3. Make sure that there will not be any disruptions or distractions as the process
is initiated. Begin with 15 to 20 minutes of progressive muscle relaxation.
4. Once deep relaxation is achieved, present the first scene from the hierarchy.
Talk the person through this scene with realistic detail, utilizing all senses if
appropriate. Instruct the individual to picture fully this scene in their mind.
Draw their attention to their emotional experience while visualizing this
scene. Pause for 15 to 20 sec while they visualize this scene.
5. Instruct the individual that if they experience any anxiety they are to signal
by raising their right index finger. If there is an experience of intense anxiety
or early symptoms of a panic attack instruct the individual to raise two fingers.
If this occurs, instruct the individual to let go of distressful scene and to
imagine a safe serene place (discussed and developed prior to the initiation of
the systematic desensitization process). Instruct the individual to stay in that
safe serene place until they feel relaxed again. When relaxation is achieved,
proceed again. If this happens in a later stage and the individual experiences
difficulty regaining the relaxed state, back up to the previous imagined event
and consolidate the mastery at that step or break down the event further if
necessary before proceeding.
6. If there is a signal from the individual that they are experiencing anxiety, have
them stay in the scene briefly. While they are still visualizing the scene instruct
them to, "take a deep breath and exhale the anxiety, to imagine the tension and
anxiety leaving their body. Let go of the anxiety and relax." Allow the person
to remain in the relaxed state with the visualized image for one minute.
7. Once relaxation has been achieved with that step of the hierarchy, instruct the
individual to turn off that image and again enter a state of relaxation without a
visualized event from the hierarchy. This relaxation period can be done with
further relaxation statements or a guided imagery to a safe and relaxing place.
Allow them to remain in the relaxed state for a one minute.
Systematic Desensitization 357

8. Have the individual signal with raising the right index finger when total
relaxation has been achieved. Check in at intervals of one minute monitoring
the state of relaxation versus anxiety. When there is no anxiety present
proceed to the next step.
9. Repeat the initial scene, going through the entire desensitization process.
Continue to repeat this scene with desensitization until there is visualization
of the scene without provoking anxiety. This can take two to four repetitions
per scene.
10. Once anxiety has been eliminated at one step/event proceed onto the next
imagined event, repeating the process as previously stated.
WHAT IS DEMENTIA?
Dementia is a medical term that describes when a person's intellectual capacity is impaired.

Dementia is not a normal part of growing old. Older and younger people can develop demen
tia. A variety of diseases and disorders cause dementia. There are numerous kinds of dementia:
1. Presenile
2. Senile
3. Chronic
4. Organic brain syndrome
5. Arteriosclerosis
6. Cerebral atrophy
SYMPTOMS
1. Shortterm memory loss
2. Inability to think problems through
3. Inability to complete simple tasks without supervision and stepwise instruction
4. Difficulty concentrating
5. Paranoia/distrust
6. Inappropriate/bizarre behavior
The National Institute on Aging states that there are more than 100 conditions that
mimic serious disorders that are often treatable and reversible. These are referred to as
psuedodementias.
CONDITIONS CAUSING REVERSIBLE SYMPTOMS

1. Reaction to medication
2. Emotional distress
3. Metabolic disturbances
4. Vision and hearing deficits
5. Nutritional deficiencies

6. Endocrine abnormalities
7. Infections
8. Subdural hematomas
9. Normal pressure hydrocephalus
10. Brain tumors
11. Atherosclerosis
CONDITIONS CAUSING DEMENTIA THAT
ARE NOT REVERSIBLE
1. Head trauma
A. Fall or accident (can cause personality, thinking, and behavior changes)
B. If brain injury is mild, the previous level of functioning may be restored
2. Cerebral degenerative disease
A. Progressive cognitive deterioration
1. Alzheimer's Disease
2. Parkinson's Disease
3. Huntington's Chorea
4. Pick's Disease
5. Cereborvascular accident (stroke)
6. Anoxia (loss of oxygen to the brain)
7. CreutzfeldJakob's Disease
8. Binswanger Disease
9. AIDS
10. Multiple Sclerosis
DIAGNOSIS
1. Complete physical and neuropsychological evaluation is recommended
*Much of the diagnostic testing is done to rule out any possible treatable causes of
dementia.
UNDERSTANDING SCHIZOPHRENIA
Schizophrenia appears equally in men and women. However, if often appears earlier in men.
The age of onset for women is in their twenties or thirties, whereas the age of onset for men
is in their late teens or twenties. It is also possible for children to develop the disease, but it
is uncommon for children to experience hallucinations or delusions prior to adolescence.
The experience of schizophrenia can be terrifying
1. Hearing internal voices

2. Belief that others are reading one's mind
3. Belief that others are controlling one's thoughts
4. Belief that others are plotting to cause one harm

SYMPTOMS OF PERCEPTUAL DISTURBANCE
1. Hallucinations and delusions
A. Hallucinations can be auditory (sound), visual (sight), tactile (touch), olfactory
(smell), and gustatory (taste)
*The most common type of hallucination is hearing voices that others do not hear. Auditory
hallucinations can be of different associations:
1. Describing the person's activities

2. Carrying on a conversation
3. Warning of impending danger
4. Issuing orders to other individuals
B. Delusions
1. False beliefs with evidence to the contrary and numerous possible themes
2. Onethird of schizophrenics are of the "paranoid type" with delusions of
persecution, which are false and irrational beliefs
3. Other delusions include being cheated, harassed, poisoned, conspired against,
being a victim of mind control by magnetic waves or television transmitting
special messages, or granduer
C. Disordered thinking
1. Thoughts come and go rapidly
2. Unable to concentrate on one thought for very long
3. Easily distracted and unable to focus
4. Unable to sort out what is and is not relevant
5. Unable to connect thoughts in a logical sequence or continuity of thought
D. Emotional expression
1. Blunted or flat affect (severe decrease in emotional expression)
2. May not show signs of normal expression
3. May speak in monotone voice
4. Diminished facial expression
5. Appears extremely apathetic
POTENTIAL FOR VIOLENCE
Most individuals with schizophrenia are not prone to violent behavior. Instead, they are
generally withdrawn. The use and abuse of substances increase the risk of violent behavior
for those with schizophrenia just as it does in the general population. Individuals who
discontinue medication that was prescribed to treat paranoia and psychotic symptoms are at
increased risk for violent behavior. If violent behavior does transpire, it is generally focused
on family members or friends and usually takes place in the home.
SUICIDE
Those with schizophrenia are at increased risk for suicide. It is a difficult illness to live with,
and numerous losses are experienced.
WHAT CAUSES SCHIZOPHRENIA
1. Genetic relationship
A. The illness does run in families
B. Identical twins have the highest risk (40 to 50% if one's twin has the illness)

C. Children of a parent with schizophrenia have approximately a 10% risk
D. It appears that multiple genes are involved in creating a predisposition
E. There is evidence that prenatal trauma may be involved (intrauterine starvation,
viral infections, perinatal complications, etc.)
F. It cannot yet be predicted who may develop the illness
G. To learn more about current research, visit the website at www
grb.nimh.nih.gov/gi.html
2. What is happening in the brain
A. There is continuing research regarding neurotransmitters (brain chemicals)
B. Studies show subtle abnormalities in the structure of the brain of some individuals
C. It may be a developmental disorder originating during fetal development
Source: Adapted from NIH Publication No. 003517.

TEN WARNING SIGNS OF ALZHEIMER'S DISEASE
According to the Alzheimer's Disease and Related Disorders Association, we should famil

iarize ourselves with the following ten warning signs of Alzheimer's disease:
1. Memory loss. This is specifically most identifiable when it affects job skills.

Everyone forgets a name or an assignment once in a while, but frequent
forgetfulness with confusion in the home or workplace is definitely a sign that
something is wrong.
2. Difficulty performing normal and familiar tasks. For example, preparing a
meal and then forgetting to serve it. This is not an issue of getting distracted
or forgetting one course of a meal. You could apply this type of situation to
many different tasks and see the disconnection.
3. Difficulty with language. Everyone from time to time has the experience of
not being able to find a certain word when speaking or thinking about
something. However, people with Alzheimer's forget simple words and
substitute inappropriate words making it difficult to understand what they
are saying.
4. Disoriented to time and place. This issue creates great concern for the family
members of someone who has Alzheimer's disease. These individuals become
lost in environments that have been familiar to them for years. They don't
know where they are, how they got there, or how to get back home (like their
own street and neighborhood).
5. Poor judgment or a decrease in effective judgment. They seem to lack the
common sense of even selfcare such as getting a sweater or coat on a cold
day or wearing layers on a hot day. They do not dressing appropriately
to go out on errands (such as wearing a bathrobe over clothes to the store).
6. Difficulty with abstract thinking. Recognizing numbers or performing
elementary math operations may be impossible.
7. Misplacing things. Unlike the situation where someone misplaces their
keys, the Alzheimer's patient may file away all kinds of items in totally
inappropriate places and then not remember how they got there.
8. Changes in mood or behavior. A broad range of emotional expression is
normal. Those with Alzheimer's disease may display quick inappropriate
changes in emotion for no known reason. There may be an expression of
being blank, vacant, or flat.
9. Changes in personality. While its not uncommon for our personalities
to change as we age, the Alzheimer's patient's personality can change
dramatically over a dramatic short period of time or over a longer period
of time.
10. Loss of initiative. Everyone loses interest and wants to shirk responsibilities
every now and then. However, when the individual with Alzheimer's disease
has this experience, he/she may not reexperience or regain that interest and
may remain uninvolved.

CAREGIVING OF ELDERLY PARENTS
It may be helpful to first clarify exactly what is taking place between you and your parents.

Caregiving is a supportive role in which you are helping someone who is actively taking care
of himself/herself. Caretaking involves doing for others what they are capable of doing for
themselves and what they should do for themselves.
If you currently find yourself in a caretaking codependent relationship with your parents,
you are likely rescuing and helping them to be less capable. These behaviors may result from
efforts to please or elicit some other response from your parents. Old family patterns that
may have had a negative influence on early emotional development can resurface and inten
sify as you become more codependently involved in your parent's lives. There are many
issues that require attention and management:
1. The degree of help necessary

2. Transportation
3. Living arrangements
4. Health care
5. Financial issues
6. Emotional support
7. Issues of loss
The potential for blurred boundaries is significant. To avoid unnecessarily becoming a
caretaker requires awareness and appropriate boundaries. Consider using the following
information to create a healthy caregiving relationship while you continue to effectively live
your own life:
1. Set appropriate boundaries

A. Set limits
B. Decide what you will, won't, and can't do
1. Problemsolve alternatives
2. Effectively utilize community resources
2. Live in the here and now
A. Don't worry about what cannot be changed
B. Don't worry about "what if"—deal with "what is"
C. Live the feelings of today, stop anticipating what you may feel later
D. Do what is right for you to do (for your heart and your conscience)
E. Accept that parents may not follow medical recommendations (you can't control others)
3. Avoid excessive unnecessary worry
A. This coincides with living in the here and now
B. Don't secondguess decisions, acknowledge you are doing the best you can
C. Stay focused on selfcare and selfresponsibility
*If you are feeling anger and resentment, you may not be taking care of your own needs.
This is your first responsibility. If you are not the best you can be it will eventually take a
toll on your supportive care of others.
Caregiving of Elderly Parents 363

4. Cope with what needs to be done
A. No "What ifs"—the circumstances are what they are
B. When you do what needs to be done without over thinking it doesn't feel so bad.
C. Deal with it—even if that means the decision is to delegate, use other resources
and assert your own limits
5. Avoid emotional blackmail
A. Do not give into intimidation, tantrums, anger, silence, or being guilted into
sympathy
B. If you give in to negative efforts to get you to respond, you are likely to feel
resentful and that is not fair. Take responsibility for the choices you make.
C. Give adequate, appropriate care
6. Avoid the useless feeling of guilt
A. Be clear about what you are doing and why you are doing it
B. Recognize your own limitations
C. Feel at peace by doing the best you can
D. Don't selfcriticize with "shoulds"
7. Exercise conservation of energy
A. Avoid the stance of "I can do it all"
B. Identify and utilize appropriate resources
C. If you find yourself complaining a lot, use this awareness as an opportunity to
make necessary changes
D. If you find yourself experiencing physical fatigue or depression, you need to review
your own needs and commitment to selfcare and selfresponsibility
8. Take care of yourself first
A. If you are going to take care of some of the needs of another, it is imperative
that you take care of yourself so that you have the physical and emotional energy
to do what you feel is necessary
B. Utilize resources
1. Family
2. Friends
3. Professionals
4. Community resources
C. Get adequate rest, eat well, do things that you enjoy, spend time with people that
are fun and who can distract you from your daily obligations. You need to laugh
and to have fun.
9. Acceptance of current circumstances
A. Don't waste your energy trying to think your way out—it won't change
the situation
B. Look realistically at the situation and make sensible choices
C. Participate in a support group if one is available in your community
D. If there are not any support groups for caregivers in your community, read on
the subject to reinforce your positive efforts
10. Selfreview
A. From time to time, take an inventory of your
1. Emotions
2. Use of time
3. Selfcare
4. Personal goals

B. Make amends when necessary
C. Evoke selfresponsibility
D. Be honest with your parents about realistic limits
11. Obtain help for yourself
A. It is painful to see those you love in pain and decompensating physically
or psychologically
B. Find resources in your community that are helpful and healing to you
C. Review personal losses
1. Health
2. Relationships
3. Enjoyed activities
4. Finances
D. Problemsolve what must be done
12. Grieve
A. Grieving is a necessary part of letting go
B. Share your thoughts and feelings of grief with those who care about you
C. This is often a time of painful losses and the acknowledgment of powerlessness
D. Don't get stuck with immobilizing grief over difficult changes. Some losses
simply leave a hole in your heart that doen't go away or heal over. That does
not mean that you do not continue to move on normally in your life. It means
you will always miss that person and, if you choose, you can get in touch with
those feelings
COMMON PROBLEMS EXPERIENCED BY CAREGIVERS
1. Concerns about medical advice and expense
2. Learning how to maintain positive social supports
3. The resulting strain on a marriage and other important
relationships
4. Less time and energy for other important people in the person's life
and for himself/herself
5. Balancing the pressures of additional obligations such as work,
child care, school, managing home/yard, and so on
EFFECTIVE COPING STRATEGIES FOR THE CARETAKER
1. Find a support group of others facing similar issues
2. Selfcare
A. Time for yourself
B. Exercise
C. Adequate sleep/nutrition
D. Recreation
E. Time with people you enjoy (laughter/distraction)
F. Relaxation techniques
3. Ask for help from others when you need it
4. Be honest with your parents about
A. Realistic limitations
B. The need to feel appreciated
Caree/iving of Elderly Parents 365

TIPS FOR THE CARETAKEE
1. Obtain the best possible medical care and always get a second opinion
for serious diagnoses
2. Stay involved with friends and activities
3. Stay active mentally and physically
4. Take as much responsibility for yourself as possible
ADVICE FOR OTHERS CLOSE TO
THE SITUATION
1. Communicate
A. Talk honestly about the situation
B. Be realistic about limits
2. Problemsolve how to be supportive
3. Use available community resources
4. Maintain the mutual giving and sharing in realtionships
* Remember, at some point in our lives we are likely to experience both roles. This thought
may help to guide you in the decisions you make.
TEN WARNING SIGNS OF CAREGIVER STRESS
1. Anger and frustration. The person feels angry about the lack of effective

medical treatment and diminishing feelings of hope. Frustration develops
due to the lack of support available and insight with the experience.
2. Denial. The caregiver is in denial about the issues of loss, how things
have changed, and how an illness has affected the person being cared for.
3. Fatigue and exhaustion. Fatigue is evident by never feeling like one
adequately catches up with rest and sleep. Exhaustion makes even the
smallest daily task seem impossible to complete. This chronic tiredness and
feeling of ineffectiveness in one's own life takes a serious toll.
4. Sleep disturbance. Sleep is interfered with by continuous thoughts of what
needs to be done and ongoing concerns.
5. Social withdrawal. Withdrawal from one's own support system occurs.
What used to feel pleasurable no longer seems to matter.
6. Feeling irritable. Low frustration tolerance develops. These individuals
become moody and restless. As a result, they seem to respond to others
in a negative way more and more often. They make it clear by their tone
of voice, what they say, and their body language that they would rather
be left alone.
7. Difficulty with concentration and attention. Good concentration and
attention requires adequate rest and energy. If you cannot keep you mind
on what you are doing, it becomes increasingly difficult to get even simple
tasks completed.

8. Anxiety and stress. Anxiety begins to develop as stress is experienced
just by thinking about facing the responsibilities of another day. It is
difficult to have positive feelings and hopefulness for the future.
9. Depression. Depression affects a person's ability to cope and effectively
manage the demands of life.
10. Health deterioration. With depression, anxiety, and exhaustion, the
immune system is suppressed and a person becomes more vulnerable to
health problems.
If you are currently a caregiver to another, review these warning signs and consider the
following recommendations:
1. Maintain a strong support system

2. Maintain your own daily schedule apart from the person who is cared for
3. Join a support group for caregivers
4. Utilize therapy as a resource
5. Make an appointment with your primary care physician and get a
thorough examination
SLEEP DISORDERS
Sleep Disorders can be present due to factors such as physiological changes, changes in envi

ronment, distressing experiences, emotional difficulties, stress, or changes in daily routine.
In dealing with Sleep Disorders there is a single goal: Improved sleep accompanied by
increased feelings of restfulness.

1. Identify the nature and extent of the sleep disturbance
A. Have the individual keep a sleep journal to more accurately determine the number
of hours of sleep per night
B. Assess the need to refer to specific support resources or for further evaluation
2. Rule out presence of concomitant impairment in physiological/psychological/
emotional state which is contributing or responsible for the sleep disturbance
3. Evaluate and refer for psychopharmacological treatment
4. Devise and implement a behavioral management program for treating the sleep
disturbance
Individuals who experience sleep disturbance may develop a "phobic"type reaction

which exacerbates their sleep difficulties and further negatively impacts their coping with
lack of sleep because of selfdefeating internal dialogue. Rule out substance abuse, medica
tion reactions, menopause, pain, and excessive caffeine use.
Sleep Disorders 367

TEN TIPS FOR BETTER SLEEP
People suffer from insomnia for different reasons. Sleep disturbance can be related to phys
iological changes such as menopause, medical problems such as hyperthyroidism, emotional
distress such as depression or anxiety, changes in lifestyle such as having a baby or any other
changes which may influence daily patterns, and general life stressors. Take a few minutes
to review what may possibly be related to the difficulty that you are experiencing with sleep.
If it has been some time since your last physical examination or you think that there may be
a relationship between the sleep disturbance and physiological changes or a medical prob
lem make an appointment with your physician to identify or rule out healthrelated issues.
If healthrelated issues are definitely not a factor then consider the following ways to
improve your sleep.
If you are not able to identify the exact symptoms of your insomnia keep a sleep journal
for 2 weeks and write down your sleepwake cycle, how many hours you sleep, and all the
other details related to your sleep disturbance.
1. Establish a regular time for going to bed, and be consistent. This helps to cue
you that it is time for sleep. Going to sleep at the same time and awakening
at the same time daily helps stabilize your internal clock. Having a different
sleepwake schedule on the weekends can throw you off. For the best results
be consistent.
2. Do not go to bed too early. Do not be tempted to try to go bed earlier than
you would normally need to. If you have started doing this then identify the
reason why (depression, stress, boredom, pressure from your partner). When
people go to bed too early it contributes to the problem of fragmented sleep.
Your body normally lets you sleep only the number of hours it need. If you go
to bed too early you will also be waking too early.
3. Determine how many hours of sleep you need for optimal functioning and
feeling rested. Consider the following to determine the natural length of your
sleep cycle.
A. How many hours did you sleep on the average as a child?
B. Before you began to experience sleep difficulty how many hours of sleep per night
did you sleep on the average?
C. How many hours of sleep do you need to awaken naturally, without an alarm?
D. How many hours of sleep do you need in order to not feel sleepy or tired during
the day?
4. Develop rituals which signal the end of the day. Rituals that signal closure
for the day could be tucking the kids in, putting the dog out, and closing up
the house for the night ... then ... it's time for you to wind down by watching
the news, reading a book (not an exciting mystery), having a cup of calming
herbal tea, evening prayers, or doing something like meditation, deep
breathing exercises, or progressive muscle relaxation. All of these behaviors
are targeted for shifting your thinking from the daily stressors to closure
that the day is over and it is time for rest so that you can start a new day
tomorrow.
5. Keep the bedroom for sleeping and sex only. If you use your bedroom as an
office or for other activities your mind will associate the bedroom with those
activities which is not conducive to sleep.

6. A normal pattern of sex can be helpful. However, it is only helpful if you are
engaging sex because you are interested in being close to your partner. Sexual
stimulation releases endorphins that give you a mellow, relaxed feeling. Be
careful to avoid trying to use sex to fall asleep. It can backfire because you
are taking a pleasurable, ultimately relaxing behavior and putting expectations
on it that can lead to pressure and feeling upset.
7. Avoid physical and mental stimulation just before sleep time. Exercising,
working on projects, or house cleaning, watching something exciting on
television, or reading something that has an exciting plot just prior to going
to bed can energize you instead of helping you to have closure at the end of
the day.
8. Be careful of naps. Some people are able to take naps and feel rejuvenated
by them without interfering with their sleepwake cycle. Other people may
be overtired for various reasons and benefit from an hour nap early in the
afternoon. However, for others it can be sabotaging. If you take naps skip
them for a week. If you find that you are sleeping better without the naps
then stop napping.
9. Get regular exercise. Regular aerobic exercise like walking can decrease body
tension, alleviate stress, alleviate depressive symptoms, and contribute to an
overall feeling of wellbeing. Less stress better sleep.
10. Take a warm bath one to two hours before bedtime. Experiment with the time
to determine what works best for you. A good 20 minute soaking in a warm
bath (100102°F) is a great relaxer. It raises your core body temperature by
several degrees which naturally induces drowsiness and sleep.
Be careful not to obsess about sleep. When someone is experiencing sleep disturbance they
can become so focused on the issue of sleep that they nearly develop a phobia about not get
ting it, which creates a lot of stress and tension for them at the end of the day instead of
relaxation which is necessary for the natural sleep rhythms to be initiated. Instead, try to
relax and think about something pleasant. If, after 20 minutes, that does not work get up
and go to another room to meditate, or engage in some other ritual that you find helpful to
inducing feelings of drowsiness so you can sleep.
Ten Tips for Better Sleep 369

HEALTH INVENTORY
Use the following list to identify basic healthrelated habits:
1. Exercise regularly

2. Maintain good nutrition
3. Do not smoke
4. Avoid excessive snacking
5. Get seven to eight hours of sleep per night
6. Maintain normal weight
7. Avoid having more than three drinks in at a given time to prevent
substance abuse
8. Maintain regular health checkups
9. Avoid overeating or weight gain
10. Be aware of chronic stress or anger
Other health concerns:
Take some time to consider the impact of your selfcare/health behaviors.
1. What are your assets, and what is the current and potential benefit?
2. What are your problem areas, and what is the current and potential liabilities?
3. What areas of change are necessary?
4. What are you willing to change?
Plan:

ASSESSING LIFESTYLE AND HEALTH
A. Current Risk Factors

hypertension elevated triglycerides elevated cholesterol
overeating excess salt, sugar, fat lack of exercise
chronic stress smoking overweight
alcohol abuse sleep disturbance prescription medication abuse
B. Nutrition
When you review your diet and compare it to one year ago and five years ago, is it the
same, less healthy, or more healthy?
1. The positive changes made are
2. Changes that need to be made are
C. Stress Management
1. Current level of stress is _low _moderate _high
To the following, respond never (N), sometimes (S), often (O), or always (A):
2. In an effort to deal with stress;
a. Exercise is used to decrease tension
b. Relaxation techniques are help for for releasing tension
3. Characteristics I have in common with those who manage stress well:
a. Daily moments of peace and solitude
b. Playfulness and humor to improve mood
c. Positive relationships with family and friends
d. Distracting activities
e. Good level of frustration tolerance
f. Good ability to manage criticism
g. An ability to avoid overloaded scheduling
h. A good balance of work and pleasure
D. Answer each of the following questions regarding your negative lifestyle habits:
1. How is it a problem?
2. How did it begin and develop?
3. What could be some appropriate substitutes?
4. What do you want to change?
E. Plan of change:
Assessing Lifestyle and Health 371

ASSUMING THE PATIENT ROLE: THE BENEFITS
OF BEING SICK
With real or perceived symptoms of chronic illness, an individual may experience benefits.

To better understand yourself and your potential motivation to change, thoroughly think
through the following issues.
Accidents, illnesses, symptoms (please list)
Choose an accident, illness, or symptom from your list to complete the following statements:
1. It happens when
2. It feels like
3. It prevents
4. It results in
5. I encourages
6. It demonstrates that I have a deep need for
7. It benefits me with
8. An appropriate way to get this need met would be to
My plan for dealing with this issue:

IMPROVING YOUR HEALTH
Ready to turn your life around? It may require that you make some changes in basic health
behaviors, but the results are worth it. It's simple.
1. Eat right
2. Quit smoking
3. Decrease or eliminate alcohol consumption
4. Exercise and get fit
5. Learn to relax
6. Get adequate sleep
7. Live authentically (be honest, learn from life, and be true to yourself)
Even small changes can lead to significant health improvements. According to an article

in Time (February 2001), 50 million Americans still smoke and 60% of the American pop
ulation is obese or overweight:
1. Eating Right
Educate yourself about the types of fat and their health consequences (for
example, omega3 from cold water fish is good and certain nuts are good;
sparingly consume saturated fats, watch out for transfatty acids, which are
found in crackers and cookies)
A. Emphasize fruits and vegetables
B. Promote lowfat dairy
C. Promote highfiber grains
D. Promote modest portions of lean meat
E. Reduce sodium intake
F. Reduce alcohol intake (some studies demonstrate a health benefit
for small portions of red wine; again, take responsibility and educated
yourself)
2. Smoking
A. The day you quit smoking, carbon monoxide levels in your blood drops
significantly
B. Within one week, blood becomes less sticky and death by heart attack
declines
C. After four to five years of not smoking, risk of heart attack is decreased to
nearly the same as someone who has never smoked
3. Alcohol Consumption
First of all, clarify why you are drinking. Is a glass of wine part of enjoying a
good meal, or do you drink to relax, sleep, get high, or numb out? Be honest
with yourself, and if you are not able to substitute positive health behaviors for
selfmedication, or if you cannot decrease drinking or stop drinking on your
own, then seek professional help. Remember, some people can drink alcohol
and experience some health benefits, others, not necessarily alcoholics, cannot
tolerate alcohol use. Be honest and smart.
Improving Your Health 373

4. Exercise
A 40yearold sedentary individual who starts walking briskly for half an hour
a day, four days a week, has almost the same low risk of heart attack as the
person who has always exercised.
5. Learning to Relax
Adequate rest includes getting enough hours of rejuvenating sleep and
reconditioning your body to know what it feels like to be relaxed. With the
fast pace of life and daily demands, people sometimes forget what it feels like
to not be making lists in your head, stressing about deadlines today, and
worrying about the tasks of tomorrow. Exercise, soothing music, doing art,
hobbies, pleasure reading, formal relaxation, and meditation are all choices for
relaxing. Make sure to throw in a healthy dose of laughter every day. Genuine
laughter, smiling, and happy/pleasing thoughts are healing. Likewise, attitude
influences health, emotional functioning, and how you share your life with
others. Are you honest, friendly kind, and optimistic, or sour, angry, hostile,
and negative? Guess what is good for health and happiness and which isn't?
6. Sleep
Research continues to confirm the importance of sleep in optimal physical,
emotional, and psychological functioning. If you are experiencing difficulty
sleeping, talk with your physician to make sure that there are not any physical
reasons contributing to sleep disturbance (such as sleep apnea). Also, it is
important to have a regular schedule, which conditions your body to wind
down and prepare for sleep.
7. Living Authentically
Be true to yourself. Take responsibility for your own thoughts and feelings.
Don't live in the past or hold grudges. If there are issues that you need to
resolve do so, learn, heal, and move forward integrating whatever you learn
into your life experience—it is a part of who you are and cannot be erased.
Consciously choose how you think about things, and respond in the way that is
best for you. Selfresponsibility is the only way to successfully bring sustaining
positive changes to your life.
As you review your life and health, use a journal to record the following:
1. Identify what is good (be grateful)

2. Identify what needs to be changed
A. Why?
B. What is the goal?
C. What steps need to be taken?
D. How can changed be reinforced and maintained?
E. What will you need to selfmonitor?
3. Clarify and understand why you have chosen negative health behaviors or
emotional responses
A. Selfmedication
B. Lack of insight and awareness
C. Lack of motivation/selfresponsibility
D. What motivates the decision to change now?

4. What resources may be helpful in reaching you goals?
A. Gym, walking, jogging, cycling, exercise videos, organized sports
B. Yoga or other classes
C. People who are supportive of positive health behaviors
D. Maintaining a journal
5. Educate yourself on the role of emotions on healthful or harmful thinking or
feeling:
A. Anger
B. Hostility
C. Anxiety
HEART DISEASE AND DEPRESSION
FACTS ON DEPRESSION AND HEART DISEASE OFFERED BY

THE NATIONAL INSTITUTE OF HEALTH
1. Depression is common and treatable. Nearly 10% of the adult population
experiences depression. Unfortunately, it is often not identified.
2. Depression affects those with heart disease at a much higher rate and can
have devastating consequences
3. Among individuals with heart disease, depression occurs in 18 to 20% of
those who have not had a heart attack
4. Among those who have a history of having a heart attack, the rate of
depression is 40 to 65%
5. Major depression appears to increase disability in heart patients
A. It may contribute to a worsening of symptoms
B. It may contribute to poor adherence to cardiac treatment regimens
6. Heart attack surviviors with major depression have a three to four times greater
risk of dying within six months than those who do not suffer from depression
7. Treating depression when it occurs in heart patients can minimize or help
patients to avoid some of the serious health consequences
BENEFITS OF DEPRESSION TREATMENT
1. Treatment of depression can benefit the heart patient through
A. Improved medical status
B. Enhanced quality of life
C. Reduced pain and disability
D. Improved cooperation with treatment
2. Early treatment of depression can reduce the risk of relapse or recurrence of
depression
DEPRESSION IS OFTEN UNDIAGNOSED AND UNTREATED

1. There are several reasons why depression in cardiac patients goes untreated
A. Depressive symptoms are dismissed as temporary low mood, which is often
associated with serious illness
Heart Disease and Depression 375
B. It may be overlooked
C. It may be viewed as the sideeffects of cardiac treatment
D. If the person is older, if may be viewed simply as a part of aging
2. Major depression presents with symptoms that are more severe, last longer,
and are more disabling than the expected reaction
EFFECTIVE TREATMENT FOR DEPRESSION

1. With treatment, up to 80% of depressed individuals can improve
2. Treatment usually includes medication and psychotherapy
3. The severity of depression, the other conditions present, and the medical
treatment being used must be considered to determine appropriate
treatment
Depression can be overcome through appropriate diagnosis and treatment. Persons with a

heart disorder, their loved ones, and their physician should be alert to symptoms of depres
sion so that early treatment can be initiated.
EATING HISTORY
To increase your awareness for eating patterns and bahavioral patterns associated with eat

ing, please use the following to write your eating history. Use this as an opportunity to bet
ter understand and be honest about your loss of control in regard to food use or rituals and
practices surrounding your food use. Share your eating history with another person or with
your therapist.
Consider the following:
1. Kinds, amounts, and frequency of food use

2. Foggy memories or difficulty concentrating after eating too much
3. Feeling high after vomiting or starving.
a. Feeling powerful when "choosing to withhold food or correcting food mistakes"
by throwing up (fully of power in demonstrating this selfcontrol to self others.)
4. Behavior changes
a. Mood swings with eating/not eating
b. Withdrawal from others to eat or starve
c. How relationships change and why
5. Rituals surrounding food use
a. Overeating or binge eating on certain foods
b. Frequent eating out
c. Sneak eating/eating in secret
d. Weighing self daily or more often
e. Eating/not eating certain food(s)
6. Preoccupation
a. Thinking about eating/not eating
b. Eating for relief from problems, boredom, frustration, and so on

c. Protecting your food supply; hiding food
d. Preoccupation with body size
7. Attempts to control eating or weight
a. Doctor's diets
b. Fad diets
c. Diet pills or shots
d. Starving, vomiting, laxative use, diuretics, or manual extraction of stool
e. Diet clubs or fat farms
f. Hypnosis, acupuncture, stomach stapling, or gastric bypass surgery
g. Spending money to control eating or weight
8. Family/friend response
a. To your eating patterns
b. To changes in your appearance
HOW TO STOP USING FOOD AS A COPING MECHANISM
Some people experience difficulty expressing their emotions and resolving associated issues.

Over time, they may identify food as the source of comfort hey are looking for. By this time
it is quite possible that they are experiencing depression. Therefore, their use of food as a
mechanism to cope has (1) created a cycle of conditioned behavior that maintains depres
sion and (2) become a demonstration of selfmedication.
Emotional Internalizes Thinks about Engages in Numbs Feels

distress distress food/eating compulsion out guilty/bad"]
The irony of this cycle is that these individuals often do not even notice the taste or how

much they are eating. The distress and emptiness cannot alleviated with food. The foods
often eating under these condition are sugars and starches. These foods increase serotonin
in the brain and temporarily alleviate emotional distress. Therefore, these two issues must
be confronted: (1) reconditioning, which involves learning new ways to cope and take
care of yourself and (2) understanding the role of your specific brain chemistry. Consider the
following information as resources for developing new coping mechanisms:
1. Increase selfunderstanding and selfawareness. Keep a selfawareness journal

that records what are you doing and why are you doing it. Keep a food
journal. Write down exactly what you eat, when, and how you felt.
2. Create a habit of asking yourself why you feel like eating. If you are not
hungry, take responsibility for making a better choice. Create a list of
behaviors you can do in an effort to get redirected.
3. Identify what you are feeling. Identify what the feeling is associated with
(thoughts and experiences), and identify your choices for "dealing" with
the feeling.
4. Acknowledge that life is never without issues to deal with. Don't ruminate
about it, don't worry about it, don't procrastinate. Whatever it is, deal with it
(without food) and move on.
How to Stop Using Food as a Coping Mechanism 377

5. Be assertive about how you feel instead of using food as a coping mechanism.
Compulsive eating is a negative way of expressing feelings that are being stuffed.
6. Develop realistic expectations about working through emotional distress
that has built up over a period of time. Just because you have identified the
problem and are practicing positive health behaviors and improved coping
does not mean that everything is immediately resolved. Continue to journal
for increased clarity and problem solving, and practice appropriately and
honestly expressing your thoughts and feelings.
7. Focus on what is working in your life, use positive selftalk, and develop genuine
gratitude. Find the silver lining in clouds. What positive things have you learned
through difficult experiences? You often do not have any control over things that
happen, but you do have control in how you choose to deal with them.
8. Identify triggers. What thoughts, feelings, and situations serve as setups for
relapse. This would be a good topic for putting your journal to good use. Be
prepared and be selfresponsible. Life is about choices, so use choices that
help you.
9. Consider joining a support group that reinforces positive health behaviors and
selfcare.
10. Talk with your doctor about health changes and medications that increase
serotonin.
PREVENTING WEIGHT AND BODY IMAGE
PROBLEMS IN CHILDREN
Increased stress, everpresent media, convenience food and soda, and decreased physical
activity have led to an overconcern about physical appearance with decreased tolerance for
all the normal variations in body types, and an epidemic of obesity in children. Children
have become more concerned about their weight and body image at an earlier age (as early
as 6 to 9 years old). However, children who are obese do not necessarily have lower self
esteem than nonobese children.
Obesity among children has now become a health concern that can make some medical
issues worse and lead to others (such as diabetes, joint problems, hypertension, premature
onset on periods and irregular periods, etc.). Both genetic and environmental factors affect
a child's potential for obesity. Therefore, it may be important for both you and your child
to change some habits. Consult with your family physician or nutritional specialist, attend
nutrition classes, and educate yourself by reading about how to eat healthfully. Continuously
bringing up exercise and dieting to children and adolescents can create conflicts, resistance,
and negatively affect selfesteem. Therefore, problemsolve what changes you will make that
sets the tone for nutrition and exercise. Your children will learn from you. Be a more active
family. Make activity fun an important part of your lifestyle.
OBSESSION WITH WEIGHT
While being obsess is not necessarily related directly to lower selfesteem, there is still war
ranted concern:
1. Peer cruelty

2. Parental focus on weight

A. May cause a child to develop feelings of inadequacy
B. A develop potential precursor to eating disorders
3. Media continuously portraying the cultural perception of thin as
attractive
OBESITY AND SELFESTEEM
1. Obesity is not always related to the lowering of selfesteem
2. Selfesteem is more likely to be associated with how
A. Family members respond to weight issues
B. Social experiences
C. Development of effective coping skills
WHAT PARENTS CAN DO
1. Set a healthy example
A. Physical activity
B. Nutrition
C. Not being negatively judgmental about different body types
* Children develop adult perceptions of attractiveness as early as age 7
2. Make sure that children know and feel they are loved regardless of

their weight
1. Do not focus on their weight
2. Focus on spending time with them
3. Focus on teaching them effective lifemanagement skills
GUIDELINES TO FOLLOW IF SOMEONE YOU

KNOW HAS AN EATING DISORDER
1. Don't pretend that everything is okay when it is not. Anorexia and bulimia

are serious illnesses. These eating disorders are selfdestructive behaviors
(starving, binging, purging). They are scream for help with underlying
problems like depression, and they can become life threatening. So don't be
silentbe honest and address your concerns.
2. Approach you family member or friend in a gentle, caring manner, but be
persistent. Listen without interrupting. However, let your family member
know how concerned you are. Do not expect an admission of a problem or
changes just because you address your concern.
3. Pay attention to what you witness or experience in the way of changes in your
family member or friend, such as anorexia, which is indicated by significant
weight loss, obsessive dieting, hyperactivity, distorted body image (seeing
oneself as fat when the person is thin) or Bulimia, indicated when someone
eats a lot of food and then rushes to the bathroom, or uses laxatives.
Guidelines to Follow ij Someone You Know has an Eating Disorder 3/9
4. Do not focus on the eating habits of those you are concerned about. Instead,
try to encourage an understanding of why they are engaging in eating disorder
behaviors.
5. Encourage them to get help because of their unhappiness. If you have noticed
increased fatigue, irritability, depression, anxiety, or compulsiveness, be
supportive in their getting help.
6. Being supportive is the best that you can offer. It is important to show you
believe in them. Be emotionally available, and do not judge.
7. If possible, offer a written list of resources in your community, online, and in
books. Again, do not expect an admission of a problem, just share the
resources.
8. Do not keep this to yourself and deal with alone. Colluding with secrecy is
not helpful—things are likely to get worse. Confide in someone that you trust.
Be honest about not keeping it a secret, and say that you are speaking out
because you care.
9. Deal with your own emotions. How have you been affected by this
experience? Talk to someone about your own feelings.
10. Be clear that you are not responsible for your family member or friend. You
can only encourage these loved ones to help themselves.
Adapted from Glamour Magazine (1985, March). Conde Nast Publications.
DEALING WITH FEAR
Fear is not a character flaw. It is a survival mechanism designed to protect you. It is meant

to be a warning. However, it does more than just warn you, it makes the heart beat faster
as your body prepares itself for fight or flight. However useful fear may be at times, when it
becomes irrational and prevents you from doing normal things, it then becomes a problem.
Use the following information to appropriately manage and recover from problem fear.
1. Stop looking for the answer—it doesn't matter why you are afraid. When you
think about something that scared you as a kid (and still does), does thinking
about it take away the fear? The memory may not even be accurate. You
don't need to know exactly how or when you developed your fear to put your
fear to rest. Instead, work on ways to overcome the fear you experience.
2. End fear by knowledge. Since fear is a protective mechanism, find out what
you are afraid of. A powerful part of the experience of fear is unpredictability
or uncertainity. Therefore, when the situation becomes predictable, fear
decreases. The more accurate and realistic your information, the more
prepared you will feel in dealing with it.
3. Practice doing it. The more you know how to do something or are clear about
how you want to respond, the more fear seems to evaporate. If there is
something you want to do but are afraid, train for it so that you develop a
sense of "can do" or selfconfidence.

4. Find positive role models who you can learn from. They are
rational and accurate in what they do. Their courage is calming and
contagious.
5. Talking helps. Opening up about your fears can decrease distress even when
you can't change the situation. Likewise, trying to keep your feelings of fear a
secret isn't going to get you the help you need.
6. Use your imagination. Remind yourself that fear isn't the end of the
world. For example, fear of public speaking is the number one phobia.
There are numerous "mind tricks" for dealing with this fear, such as
imagining you are speaking to children or that something is funny about
everyone in the audience, which decreases the fear of being judged by
them. Get creative in problemsolving. How you think about a situation
may be helpful.
7. Focus on the little things. Little things are always manageable. Figure out
what you have to do and do it one step at a time.
8. Give yourself permission to get help. If the symptoms are severe, you may
have an anxiety disorder that could be treated by medication and therapy.
However, even if the symptoms are not severe, it may be useful to seek
professional help.
9. Find ways to decrease the physical and emotional stress associated with fear.
These may include exercise, positive selftalk, and progressive muscle
relaxation or meditation.
10. Develop a hierarchy of experiences that range from not causing fear
or/minimal fear leading up to the most feared experience which is the goal to
overcome. This is called systematic desensitization and a therapist can do this
technique with you. Another technique is called "flooding," whereby you are
continually exposed directly to the feared object or situation until the fear
response is diminished.
GUIDELINES FOR FAMILY MEMBERS/SIGNIFICANT
OTHERS OF ALCOHOLIC/CHEMICALLY
DEPENDENT INDIVIDUALS
1. Do not view Alcoholism/Chemical Dependency as a family or social disgrace.

Recovery can and does happen.
2. Do not nag, lecture, or preach. Chances are that they have already told
themselves everything that you might say. People tune out to what they do not
want to hear. Being nagged or lectured may lead to lying and may put them in
a position of making promises they cannot keep.
3. Be careful that you do not come off sounding and acting like a martyr. Be
aware, because you can give this impression without saying a word. Look at
your own attitudes and behavior.
4. Do not try to control their behavior with "if you loved me." Because the
individual using substances is compulsive in their behavior such pleas only
cause more distress. They have to decide to stop because it is their choice.
Guidelines for Family Members/Significant Others of Alcoholic/Chemically Dependent Individuals 381
5. Be careful to guard against feelings or jealousy or feeling left out because of
the method of recovery that they choose. Love, home, and family is not
enough to support abstinence from substance abuse. Gaining selfrespect is
often more important in the early stages of recovery than other personal
relationship responsibilities.
6. Support responsible behavior in the chemically dependent individual. Do
not do for them what they can do for themself or do what they must do for
themself. No one can do this for them, they must do it for themselves. Instead
of removing the problem, allow them to see it, solve it, and deal with the
consequences of it.
7. Begin to accept, understand, and to live One Day At A Time.
8. Begin to learn about the use of substances and what role it plays in an
individual's life and what role you have played in the life of a substance
abuser. Be willing to assume responsibility for your own life and totally
give up any attempt to control the behavior and to change the substance
abuser—even for their own good.
9. Participating in your own support group, like a 12Step meeting such as
Alanon can help you in your own recovery from the dysfunctional behaviors
in this relationship and possibly similar behaviors in other relationships
as well.
10. Recognize and accept that whatever you have been doing does not work.
Understand what your own behavior is about. Acknowledge that your life has
become as unmanageable as the substance abuser so that you can learn to be
free to make better choices instead of reacting to what is the responsibility of
someone else. Know where you end and they begin.
DETACHING WITH LOVE VERSUS CONTROLLING
One of the hardest, but most important goals for people close to an individual in recovery to

learn, is to detach from the behaviors/substance abuse process and continue to love the person.
What does detachment mean? It can sound frightening, given that everyone's life (espe
cially family members) has revolved around the chemically dependent person—always try
ing to anticipate what will happen next, covering up for them, etc. Detaching with love is an
attitude which is associated with behaviors that are not controlling.
What does controlling mean? Controlling behavior is the need to have people, places, and
things, be "my way." Expecting the world to be what you want it to be for you. Living your
life with "shoulds" and "ought to be." Not expressing your feelings honestly, but with self
centeredness and manipulation of the environment around you. Feeling okay if things are
the way you want them to be regardless of the needs or desires of others. It is a behavior that
comes from fear—fear of the unknown, of "falling apart" if people and situations are not
the way you want them to be. It is a symptom of a family or systems dysfunction. It is a
reaction to the substance abuse that evolves out of feeling increasing responsibility for the
substanceabusing person.
As the illness within the substanceabusing individual progresses so do the projections: "If
it were not for you I would not drink to drink/use other substances." Statements like this
contribute to a deterioration of selfworth with the result being that you believe that you are
the key to change this awful mess by controlling your world, and the people in it. You
become exhausted, frustrated, and resentful. Resentment comes from people not doing what
you want them to do—and resentment kills love.

You must accept that:
1. Chemical dependency is an illness.
2. You did not cause it.
3. You cannot control it.
4. You cannot cure it.
Detaching from the illness and the substanceabusing individual's behaviors allows them

to take responsibility for themselves—and allows you to be free to feel the love for the
individual.
When you begin taking care of yourself and doing and being responsible for yourself, you
have the key to peace, serenity, sanity, and really feeling good about who you are.
THE ENABLER—THE COMPANION TO THE
DYSFUNCTIONALVSUBSTANCEABUSING PERSON
Substance abuse and substance dependency can have devastating consequences for the indi
vidual using the substances as well as for those closely associated with them. Of most con
cern is the individual who may reside with the substanceabusing individual or who spends
a significant amount of time with them. Typically, they begin to react to the symptoms of
the individual, which results in the "concerned person" unsuspectingly conspiring with the
dysfunctional behavior/illness and actually enabling it to progress and get worse. This
"enabling" behavior surrounds and feeds the dependency.
How does the dysfunctional behaviors/illness affect the dependent individual? For the
substancedependent individual they completely lose their ability to predict accurately when
they will start and stop their substance use. Because of this they become engaged repeatedly
and unexpectedly in such behaviors as:
1. Breaking commitments that they intended to keep.
2. Spending more money than they planned.
3. Driving under the influence (DUI) violations.
4. Making inappropriate statements to friends, family, and coworkers.
5. Engaging in arguing, fighting, and other antisocial behaviors.
6. Using more of the substance(s) than they had planned.
These types of behaviors violate their internal value system resulting in feelings of guilt,

remorse, and selfloathing. However, these feelings get blocked by rationalizations and pro
jections. The rationalization is that "last night wasn't that bad." The projection causes the
individual to believe that "anyone would be doing what I am doing if they had to put up
with what I do." The effects of such use of defenses is to progressively lead the individual
to be out of touch with reality. This distortion becomes so solid that the individual using
substances or engaging in other dysfunctional behaviors is the last to recognize that their
behavior represents any type of personal problem.
What is an enabler? It is the person who reacts to the above symptom of illness/dysfunctional
behavior in such a way as to shield and protect them from experiencing the consequences
of their problem. Thus, they lose the opportunity to gain insight regarding the severity of
The Enabler—The Companion to the Dysjunctional/SubstanceAbusing Person 383

their behavior. Without this insight they remain a victim of the defenses and are incapable
of recognizing the need to seek appropriate and necessary help. Tragically, the enabler's well
intentioned behavior plays an increasingly destructive role in the progression of the illness/
dysfunctional behaviors.
The enabler continues their behavior because they see all that they have done as a sincere
effort to help. While they see the negative behavior as isolated attempts to cope with difficult
situations or something that just got a little out of hand, their behavior serves to reinforce the
issues of rationalization, denial, and projections related to the substance abuse/dysfunctional
behaviors.
The enabler may be in denial themselves about the significance or severity of the problem.
Their thinking may be that the problem does not really exist or that it will disappear as soon
as the real problem disappears. This makes the enabler highly vulnerable to developing beliefs
and attitudes which victimize the individual engaging in substance abusing/dysfunctional
behaviors. The rationalizations of both persons are now supporting each other's misunder
standing of the true nature of the problem. The result is that they are both engaged in a suc
cessful selfdeception which allows the disease to remain hidden and to progress to a more
serious stage.
The substance abuse/dysfunctional behaviors continue to have an increasingly adverse
effect on both individuals. To understand the progression of the type of thinking that the
individual engaged in substance abuse/dysfunctional behavior has it is important to under
stand what a successful defense system projection serves:
1. They take the unconscious and growing negative feelings about the self and put

them onto other people and situations. This relieves some of stress that they
feel inside and allows them to continue to live in an increasingly painful
situation. The individual does not have any insight, and as a result they
continue to experience more pain which leads to further projections or putting
it off on other—What a vicious circle.
2. As the individual with the substance abuse/dysfunctional behavior problem
continues to verbalize their projections on the other person, there is no
realization from either party that this is being said out of hatred. Both believe
that the individual hates the enabler and for good reason (because of the view
that they are the source of the problem). The consequence is that they now
both focus on the enabler's behavior and this allows the problem behavior to
continue to go unseen as the central issue.
It is easy to see how this defense can have a significant emotional affect on the enabler.
This becomes a pivotal point in the process of enabling. As the pain from the projections
becomes more painful and uncomfortable, the enabler reacts by feeling hurt, injured, and
guilty. The result is avoidance behavior. Less and less is expected of the individual with
the substance abuse/dysfunctional behaviors because of the distress that it causes. These
avoidant reactions only allow the progression of the problem. The individual with substance
abuse/dysfunctional behaviors remains out of touch with reality, does not receive honest
feedback of the behaviors causing the difficulties at home, work, school, etc. What develops
is a "no talk" rule. By the enabler not directly expressing the issues, the individual with sub
stance abuse/dysfunctional behaviors becomes more removed from any insight into their
behaviors and its harmful consequences.
The enabler is not always able to avoid the individual with substance abuse/dysfunctional
behaviors. Where relationships are very close, then the increasing projections create in the
enabler a growing feeling of guilt and blame. They begin to feel responsible for the individ
ual's selfdefeating and selfdestructive behavior. These feelings of selfdoubt, inadequacy,
and guilt continue to increase with the progression of the severity of the problem.

Unfortunately, the tendency is for the enabler's controlling behavior to escalate. The only
way for them to feel positive to "try to make sure that the behavior does not get out of con
trol." "If there are things that I did to cause this, then I can make it go away." Most of their
efforts are manipulative. They do things indirectly in an effort to get the behavior they want.
These manipulations are destined to fail. Nothing is being confronted and dealt with. As
the enabler's feelings of low selfworth increase, it triggers even more desperate attempts of
control. The cycle continues and escalates as both parties become increasingly alienated and
dysfunctional.
The way to break the cycle is through knowledge and understanding:
1. Learn about the dynamic of chemical dependency and other dysfunctional

behaviors.
2. Learn about the dynamics of being an enabler and the importance of selfcare.
3. Become aware of the personal identification with the compulsive behavior of
enabling.
With the development of this knowledge and insight the enabler can begin to respond to

an individual with substance abuse/dysfunctional behavior in a meaningful and honest way
versus control and manipulation. This will help the enabler let go of the responsibility for the
behavior of others. The result is that the enabler become a person who lives life consciously
and takes responsibility for themselves, thus becoming an agent of change who no longer
reinforces dysfunctional behaviors through control and manipulation. This allows them to
intervene directly in functional ways which promotes change not maintains the status quo.
SUBSTANCE ABUSE/DEPENDENCE
PERSONAL EVALUATION
1. Age of first drug use?

2. What drug did you use?
3. Who introduced you to drugs?
4. What drug(s) did you go on to use after that?
5. What was your reason for using drugs?
6. Did you ever try to stop?
7. If so, what is it like when you aren't using?
8. Do your friends use?
9. Are you easily influenced by others?
10. Family history of substance abuse?
11. Do you and your significant other use together?
12. How has drug abuse affected your life?
13. What do you see as your options?
14. What do you have to do to abstain from drug abuse?
15. Have you been to a treatment program before or attended 12Step meetings?
16. What do you feel like when you are using?
17. How do you think you benefit from using/or what do you get out of it?
18. How do you view drug screening in the workplace/school?
Substance Abuse/Dependence Personal E v a l u a t i o n 385

LIST OF SYMPTOMS LEADING TO RELAPSE
1. Exhaustion. Allowing yourself to become overly tired. Not following through

on selfcare behaviors of adequate rest, good nutrition, and regular exercise.
Good physical health is a component of emotional health. How you feel will
be reflected in your thinking and judgment.
2. Dishonesty. It begins with a pattern of small, unnecessary lies with those you
interact with in family, socially, and at work. This is soon followed by lying to
yourself or rationalizing and making excuses for avoiding working your
program.
3. Impatience. Things are not happening fast enough for you. Or, others are not
doing what you want them to do or think they should do.
4. Argumentative. Arguing small insignificant points which indicates a need to
always be right. This is sometimes seen as developing an excuse to drink.
5. Depression. Overwhelming and unaccountable despair may occur in cycle. If
it does, talk about it and deal with it. You are responsible for taking care of
yourself.
6. Frustration. With people and because things may not being going your way.
Remind yourself intermittently that things are not always going to be the way
that you want them.
7. SelfPity. Feeling like a victim, refusing to acknowledge that you have choices
and are responsible for your own life and the quality of it.
8. Cockiness. "Got it Made." Compulsive behavior is no longer a problem. Start
putting self in situations where there are temptations to prove to others that
you don't have a problem.
9. Complacency. Not working your program with the commitment that you
started with. Having a little fear is a good thing. More relapses occur when
things are going well than when not.
10. Expecting Too Much From Others. "I've changed, why hasn't everyone else
changed too?". All that you control is yourself. It would be great if other
people changed their selfdestructive behaviors, but that is their problem.
You have your own problems to monitor and deal with. You cannot expect
others to change their lifestyle just because you have.
11. Letting Up On Discipline. Daily inventory, positive affirmations,
12Step meetings, therapy, meditation, prayer. This can come from
complacency and boredom. Because you cannot afford to be bored
with your program, take responsibility to talk about it and problem
solve it. The cost of relapse is too great. Sometimes you must accept
that you have to do some things that are the routine for a clean and
sober life.
12. The Use Of MoodAltering Chemicals. You may feel the need or
desire to get away from things by drinking, popping a few pills, etc.,
and your physician may participate in thinking that you will be responsible
and not abuse the medication. This is about the most subtle way to
enter relapse. Take responsibility for your life and the choices that
you make.

WHAT IS CODEPENDENCY?
Codependency is defined as when someone becomes so preoccupied with someone else that
they neglect themself. In a way it is believing that something outside of themselves can give
them happiness and fulfillment. They payoff in focusing on someone else is a decrease in
painful feelings and anxiety.
Some people are in an emotional state of fear, anxiety, pain, or feeling like they are going
crazy, and they feel these emotions strongly almost all the time. These people tend to think
they can make those around them happy, and when they can't, they feel somehow less than
others, they feel like they have failed.
These are people who tend to hold things in and then at inappropriate times they overre
act, or they just have a tendency to overreact (e.g., something frightening happens and
instead of experiencing normal fear they panic or experience anxiety attacks).
Codependency is when people operate as if they are okay only if they please the people
around them.
They live with the false belief that the bad feelings they have can be gotten rid of if
they can just "do it better" or if they can win the approval of certain important people in
their life. By doing this they make those people and their approval responsible for their own
happiness.
Often codependent people appear gentle and helpful. However, in this situation, two dif
ferent things may be going on:
1. They may be struggling with a strong need to control and manipulate
those around them into giving them the approval they believe they need to
feel okay.
2. They minimize their emotions until they hardly experience any emotion at all.
No fear, pain, anger, shame, joy, or pleasure. They just exist from one day to
the next—numb.
It was actually the families of alcoholics and other chemically dependent people who
brought these two clusters of symptoms to the attention of professionals.
What is Codependency? 387

THE CLASSIC SITUATION
The codependents' efforts were apparently to get the alcoholic or chemically dependent per

son sober and free from drugs. If they could help the alcoholic the family members would
be free of pain, shame, fear, and anger.
But they found that that doesn't really work because even when the alcoholic got sober
the family stayed sick and sometimes even appeared to resent the sobriety. Sometimes they
sabotaged it.
It was as if the family needed the addict to stay sick and dependent on them so that they
could maintain their dependence on the addict as a way of explaining their own experience
and how they felt.
In other words, the addict and the codependent are trying to solve similar basic symptoms
of the same disease: the addict with alcohol or drugs and the codependent with the addic
tive relationship.
Codependency may be difficult to see from the outside because people who suffer from
codependency generally appear adequate and successful. This is because they are involved in
things to win them the all important approval they need.
It's a vicious cycle of addiction because it is common for the codependent to at some point
turn to drugs to numb their discomfort. Codependents are set up to be alcoholics or other
kinds of addicts.
As you read these examples what do you identify with?
SOME CHARACTERISTICS OF C ODEPENDENCE
1. My good feelings about who I am stem from being liked by you and receiving

approval from you.
2. Your struggles affect my serenity. I focus my mental attention on solving your
problems or relieving your pain.
3. I focus my mental attention on pleasing you, protecting you, or manipulating
you to "do it my way."
4. I bolster my selfesteem by solving your problems and relieving your pain.
5. I put aside my own hobbies and interests. I spend my time sharing your
interests and hobbies.
6. Because I feel you are a reflection of me, my desires dictate your clothing and
personal appearance.
7. My desires dictate your behavior.

8. I am not aware of how I feel. I am aware of how you feel.
9. I am not aware of what I want. I ask you what you want.
10. If I am not aware of something, I assume (I don't ask or verify in some
other way).
11. My fear of your anger and rejection determines what I say or do.
12. In our relationship I use giving as a way of feeling safe.
13. As I involve myself with you, my social circle diminishes.
14. To connect with you, I put my values aside.
15.1 value your opinion and way of doing things more than my own.
16. The quality of my life depends on the quality of yours.
17. I am always trying to fix or take care of others while neglecting myself.
18. I find it easier to give in and comply with others than to express my own
wants and needs.
19. I sometimes feel sorry for myself, feeling no one understands. I think about
getting help, but rarely commit or follow through.
SUGGESTED DIAGNOSTIC CRITERIA
FOR CODEPENDENCE
1. Continued investment of selfesteem in the ability to control both oneself and

others in the face of adverse consequences.
2. Assumption of responsibility for meeting other's needs to the exclusion of
acknowledging one's own needs.
3. Anxiety and boundary distortions around intimacy and separation.
4. Enmeshment in relationships with personalitydisordered, chemically dependent
and impulsedisordered individuals.
5. Exhibits at least three of the following.
A. excessive reliance on denial
B. constriction of emotions (with or without outbursts)
C. depression
D. hypervigilance
E. compulsions
F. anxiety
G. alcohol or other drug abuse
H. recurrent victim of sexual abuse
I. stressrelated medical illnesses
J. has remained in a primary relationship with an actively mistreating or abusing
person for at least 2 years without seeking outside support.
Adapted from Cermak (1986). Cermak believes that approximately 95% of the population

grew up in a dysfunctional home, and that 5% of those individuals fit this diagnostic criteria.
Another model describing codependence is called the "iceberg model." Again this model
depicts the codependent as growing up in a dysfunctional family of origin as well as living
in an unhealthy society with two major criteria at the foundation: abandonment and shame.
Suggested Diagnostic Criteria for Codependence 389

As children they feel many things; there is a dominance of emptiness. In many ways their
life journey is an effort to fill the emptiness. This may result in experiencing painful conse
quences which include: depression, anxiety, chemical dependence, eating disorders, other
compulsions, relationship addiction, and stressrelated disorders.
Codependency can be thought of as the growth stopping behaviors that occur between
two people. Such behavior is on a continuum from infrequent and not particularly signifi
cant to frequent and destructive.
Examples that might exist on a continuum are:
1. A father who is contacted by the school about his teenage son being absent.

The father covers for the teenager so that he won't get in trouble. This
prevents the son from experiencing the consequences of making bad choices.
The result is that it creates an opportunity to reinforce poor decisionmaking
skills.
2. The house always needs to be picked up, but instead of making everyone
responsible to pick up after themselves the oldest daughter always does it "to
avoid an argument."
3. The alcoholic who has a hangover and can't make it to work every other
Monday never is confronted with the consequences of his substance
dependence because his wife always calls in the office that he is sick. This is
just one of the ways she protects him. However, there are also enumerable
fights about her wanting him to quit drinking.
In each situation you have somone trying to control what another person's experience will
be. As a result the person is denied being put in a situation in which they have no choice but
to deal with the consequences of their behavior are. Additionally, each person has the risk
or tendency to become more embedded in their role.
Others
HOW DOES CODEPENDENCY WORK
Codependency creates a set of rules for communicating and interacting in relationships.
1. It's not okay to talk about problems.

"Don't air your dirty laundry in public."
Never hear mom and dad arguing but there is often a lot of tension.
This results in learning to avoid problems

2. Feelings are not expressed openly.
Taking pride in being strong and not showing emotion.
"Big boys don't cry."
The result is coming to believe it is better (safer) not to feel, eventually we get so cut
off from self that we are unsure what we feel.
3. Communication is often indirect, with one person acting as a messenger
between two others.
Dad tells son "I wish your mom was more understanding" (he talks to mom) Using
someone else to communicate for you results in confusion, misdirected feelings,
and an inability to directly confront personal problems.
4. Unrealistic expectations: be strong, good, right, perfect, makes us
proud.
Doing well and achieving is the most important thing.
Enough is never enough.
Results in creating an ideal in our head about what is good or right or
best that is far removed from what is realistic and possible. This leads to
us punishing others because they don't meet our expectations. We may
even blame ourselves for not pushing someone enough to meet our
expectations.
5. Don't be selfish.
Views self as wrong for placing their own needs before the needs of others.
End up trying to feel good by taking care of others.
6. Do as I say ... not as I do.
This rule teaches us not to trust.
7. It's not okay to play.
Begin to believe that the world is a serious place where life is always difficult and
painful.
8. Don't rock the boat.
The system seeks to maintain itself. If you grow and change you'll be alone.
THE RULES OF CODEPENDENCY
1. It's not okay to talk about problems.
2. Feelings are not expressed openly.
3. Communication is often not direct, having a person act as a messenger
between two other people.
4. Unrealistic expectations: be strong, good, right, perfect. Make us
proud.
5. Don't be selfish.
6. Do as I say, not as I do.
7. It's not okay to play.
8. Don't rock the boat.
HOW CODEPENDENCY AFFECTS ONE'S LIFE
1. When I am having problems feeling good about myself and you have an
opinion about me that I don't want you to have, I try to control what you
feel about me so that I can feel good about myself.
How Does Codependency Work 391

2. I can't tell where my reality ends and someone else's reality begins. Leads to
making assumptions, belief that you can read the thoughts of others, and as a
result choosing your behavior based on your perception of what the other
person's opinion of you is.
3. Have trouble getting my own needs and wants met.
4. Resenting others for the pain or losses they have caused you. This
can lead to obsessively thinking about them and how to get back or
punish them.
5. Avoid dealing with reality to avoid unpleasant feelings.
6. Difficulty in close or intimate relationships. Relationship implies sharing—one
person giving and the other receiving (without trying to change each other).
Also affects how we parent our own children.
SYMPTOM/EFFECT IN CHILDREN OF CODEPENDENTS

Difficulty with selfesteem/inability to appropriately esteem our children.
Difficulty setting boundaries/inability to avoid transgressing our children's boundaries.
Difficulty owning and expressing our own reality and imperfections/inability to allow our
children to have their reality and be imperfect.
Difficulty taking care of adult needs and wants/inability to appropriately nurture our chil
dren and teach them to meet their needs and wants.
Difficulty experiencing and expressing our reality/inability to provide a stable environ
ment for our children.
WHAT CAN YOU DO
First of all, it is necessary to examine objectively your life to see if you have codependent
behaviors. If you do, but generally not that often (like a parent who occasionally covers for
their teenager) then just understanding the impact of the behaviors may be enough to cause
change. However, more chronic use of codependent behaviors warrants more intervention
to understand what is happening, how it got started, and what the choices are. This can be
accomplished in various ways which include:
1. Education. There are many selfhelp books written on the subject.

2. Selfhelp groups such as Codependents Anonymous.
3. Male/Female Support Groups (facilitated by a licensed therapist).
4. Individual therapy.
STAGES OF RECOVERY

1. The process actually begins by seeing yourself where you are right now. Before
you start recovery you are in the mode of "survival and denial." This is
existing, not living. There is a denial of having any problems or that behaviors
are selfdefeating.
2. Acceptance for the realization that you cannot change others and learning to
deal with it.
3. Identifying and working through personal issues. This is where you see and
understand more about yourself.
Awareness is increasing. There is an understanding of the past, but living in
the present.

4. Reintegration. Learning to be okay with yourself—not identifying yourself by
what you do for others. This prepares you for taking responsibility of selfcare
and getting your own needs met.
5. A new beginning. Living a new, emotionally healthy way of life.
CHARACTERISTICS OF ADULT CHILDREN
OF ALCOHOLICS
Adult children of alcoholics appear to have characteristics in common as a result of being

raised in an alcoholic home. Review the characteristics listed. If you identify with these char
acteristics then seek appropriate sources of support to understand and resolve them. You will
find many books at the bookstore on this subject. Additionally, there is Adult Children of
Alcoholics 12Step selfhelp community meeting, individual therapy, and group therapy
facilitated by a therapist.
1. Isolation, fear of people, and fear of authority figures.

2. Difficulty with identity issues related to seeking constantly the approval of
others.
3. Frightened by angry people and personal criticism.
4. Have become an alcoholic yourself, married one, or both. A variation would
be the attraction to another compulsive personality such as a workaholic. The
similarity is that neither is emotionally available to deal with overwhelming
and unhealthy dependency needs.
5. Perpetually being the victim and seeing the world from the perspective of a
victim.
6. An overdeveloped sense of responsibility. Concerned about the needs of others
to the degree of neglecting your own wants and needs. This is a protective
behavior for avoiding a good look at yourself and taking responsibility to
identify and resolve your own personal difficulties.
7. Feelings of guilt associated with standing up for your rights. It is easier to give
into the demands of others.
8. An addiction to excitement. Feeling a need to be on the edge, and risktaking
behaviors.
9. A tendency to confuse feelings of love and pity. Attracted to people that you
can rescue and take care of.
10. Avoidance of feelings related to traumatic childhood experiences. Unable to
feel or express feelings because it is frightening and/or painful and
overwhelming. Denial of feelings.
11. Low selfesteem. A tendency to judge yourself harshly and be perfectionistic
and selfcritical.
12. Strong dependency needs and terrified of abandonment. Will do almost anything
to hold onto a relationship in order to avoid the fear and pain of abandonment.
13. Alcoholism is a family disease which often results in a family member taking
on the characteristics of the disease even if they are not alcoholics (para
alcoholics). Dysfunctional relationships, denial, fearful, avoidance of feelings,
Characteristics of Adult Children of A l c o h o l i c s 393

poor coping, poor problem solving, afraid that others will find out what you
are really like, etc.
14. Tendency to react to things that happen versus taking control and not being
victim to the behavior of others or situations created by others.
15. A chameleon. A tendency to be what others want you to be instead of being
yourself. A lack of honesty with yourself and others.
GUIDELINES FOR COMPLETING YOUR FIRST STEP
TOWARD EMOTIONAL HEALTH
The first step is simply an honest look at how your life experiences have affected you. This

includes how you perceive things, how you react and respond to various situations and other
people, your coping ability, problemsolving skills, conflict resolution skills, what motivates
you, and the ability to form healthy relationships.
Answer all of the questions that follow as thoroughly as possible, citing specific incidents,
the approximate date, how you felt, what you thought, and how you responded. It may be
an emotional experience for you to review your life experiences in detail, but remind your
self that there is nothing that you will write about that you haven't already experienced and
survived. This writing will help you understand yourself better, clarify what the problems
are, and find what you need to do to solve these problems.
1. Describe in detail your childhood home life. Include descriptions of

relationships with family members, and extended family members that you
view as significant.
2. What is your earliest memory? What emotion(s) does this memory
evoke?
3. Share two of your happiest/pleasant and two of the most painful life
experiences that you have had. Be specific in describing the experiences.
4. How did these experiences affect you?
5. What did you learn from your family about:
A. What it means to be a family member.
B. How to be a partner to someone.
C. How to resolve conflicts and problem solve issues.
D. How to deal with anger and other emotions.
6. How do you function in social relationships?
A. Are you friendly, reserved, distrustful, easily hurt?
B. How do you respond to the ideas or opinions of others?
C. Do you easily form acquaintances/friendships?
D. Are you able to maintain relationships?
E. Do you have any behaviors or attitudes which create difficulties for you?
7. How did your early life experience affect selfesteem and selfconfidence?
8. When did you become aware that you have emotional and behavioral
difficulties that contribute to negative life experiences?
9. Explain how your difficulties have prevented you from reaching desired
goals and having fulfilling relationships.

10. What are your fears, and how do they affect your life?
11. Do your difficulties increase during times of stress or discomfort resulting
from job, family, or personal problems? Give examples of each.
12. Discuss how your emotional and behavioral difficulties have had negative
impact on significant relationships, intimacy, trust, caused you social
problems, such as loss of friends, inability to perform sexually, unreasonable
demands on others, allowing yourself to be taken advantage of, etc.
Tell how they interfered with your relationships. How do you feel about
that now?
13. How have your emotional and/or behavioral difficulties affected your
health?
14. List the emotional and behavioral problems that you have attempted to
resolve. How successful have you been?
15. Review all that you have written. Use this information to take responsibility
for your life. No matter what has happened to you or what others have done
it is up to you to make yourself and your life what you want them to be. This
requires that you live consciously maintaining a good awareness for what you
are doing and why you are doing it. Marketing things right is an active
process not just a thinking exercise.
Guidelines for Completing Your First Step Toward Emotional Health 395
RELATIONSHIP QUESTIONNAIRE
This questionnaire is intended to estimate the current satisfaction with your relationship.
Circle the number between 1 (completely satisfied) to 10 (completely unsatisfied) beside each
issue. Try to focus on the present and not the past.
1. List the things that your partner does that please you:

2. What would you like your partner to do more often?
3. What would your partner like you to do more often?
4. How do you contribute to difficulties in the relationship?
5. What are you prepared to do differently in the relationship?
6. Is there a problem of alcohol/substance abuse?
7. Do you often try to anticipate your partners wishes so that you can please them?
8. What are your goals or what do you hope to accomplish?
completely completely
satisfied unsatisfied
General Relationship 1 2 3 4 5 6 7 8 9 10
Personal Independence 1 2 3 4 5 6 7 8 9 1 0
Spouse Independence 1 2 3 4 5 6 7 8 9 1 0
Couples Time Alone 1 2 3 4 5 6 7 8 9 1 0
Social Activities 1 2 3 4 5 6 7 8 9 1 0
Occupational or 1 2 3 4 5 6 7 8 9 1 0
Academic Progress
Sexual Interactions 1 2 3 4 5 6 7 8 9 1 0
Communication 1 2 3 4 5 6 7 8 9 1 0
Financial Issues 1 2 3 4 5 6 7 8 9 1 0
Household/Yard 1 2 3 4 5 6 7 8 9 1 0
Responsibility
Parenting 1 2 3 4 5 6 7 8 9 1 0
Daily Social Interaction 1 2 3 4 5 6 7 8 9 1 0
Trust in Each Other 1 2 3 4 5 6 7 8 9 1 0
Decision Making 1 2 3 4 5 6 7 8 9 1 0
Resolving Conflicts 1 2 3 4 5 6 7 8 9 1 0
Problem Solving 1 2 3 4 5 6 7 8 9 1 0
Support of One Another 1 2 3 4 5 6 7 8 9 1 0
HEALTHY ADULT RELATIONSHIPS: BEING A COUPLE
Because people change over time so do their relationships. When two people initially get
together there is the excitement and passion of a new relationship. Then they make a com
mitment to one another. During this time of commitment each person has an expectation
that things will feel wonderful forever. This period of relationship development lasts for 1 to
2 years. During this time they begin to notice that there are differences in beliefs and how
each would like to handle various situations. However, they continue to put their best foot
forward, feeling close and enjoying one another.
As this period of discovery continues there are disagreements and differences of opinion,
but they don't talk about it. They tend to hold back fearing an increase in disagreements.
They are struggling to find a way to go beyond being two people in a relationship to being
two people who are sharing their lives together and building a future.

Unfortunately, avoiding conflicts make them go away. In fact, if issues are being talked
about a lot but it is not accompanied by problem solving there can be increased frustration
and distancing from one another. The two people struggling to be a couple earlier may be
doing things separately now. With this drifting there are questions which arise regarding the
stability of the relationship. This leads to a fork in the road for them. They can choose one
of two courses of action: (1) being disillusioned and pulling away from one another more
and ending it in a separation, or (2) recognize that they have not been making the necessary
efforts to strengthen their relationships and make a commitment to invest themselves in cre
ating a successful partnership.
With a recommitment to each other a couple feel as if they have found that excitement
that they originally experienced. They have found out some very important things:
1. To feel good about your partner you must have positive thoughts about them

in your heart and in your head.
2. For a successful relationship there must be an enduring commitment to get
through the good and the bad together.
3. There must be an effort to share your lives cooperatively.
4. As you leave your family of origin to begin your own new family:
A. Recognize that now it is your partner who comes before others.
B. From the positive perspective your parents have gained your partner not lost you.
Make sure they include your partner as they would you.
5. Since life is very hectic make sure that you are spending adequate time together,
focusing on one another and your relationship.
6. Validate your partner. Listen without interrupting when your partner is talking
to you. Reflect to them your understanding of what they have shared. Accept
and acknowledge how they feel.
SPECIAL CIRCUMSTANCES
1. If you are a single parent you need to have a strong support system. This
includes supportive family and one or more very good friends to talk to and
have fun with. Strive to keep some balance in your life.
2. If partners get together where there have been children from a previous
relationship there are different difficulties that they must deal with. Couples in
a blended family have to work harder to maintain their life together.
HOW TO PREDICT THE POTENTIALLY

VIOLENT RELATIONSHIP
At the core of any violent relationship is the use of power and control. Women often express
interest in how they might be able to predict if a potential partner may be someone who is
emotionally, sexually, or physically abusive. Consider the following points in increasing
awareness for concern.
1. Controlling behavior. Where they are allowed to go, who they are allowed
to see or talk to, how they dresses, and how they do their hair and makeup.
How to Predict the Potentially Violent Relationship 397

This behavior tends to escalate under the guise of trying to be protective or to
prevent someone from being harmed by their poor judgment—therefore, they
need to be told what to do and how to do it.
2. Jealousy. Expresses jealousy as a sign of love and concern. There may be
accusations of flirting or questioned for talking to someone. They are often
isolated from family and friends. As jealousy intensifies, they will be
monitored by frequent phone calling and will not be allowed to make
personal decisions. Ultimately, they may not be allowed to do anything
without the permission of their partner.
3. Neediness. Insecurity is expressed as " I have never felt like this about anyone
or "I have never been able to talk to someone or trust someone like you."
There is pressure to commit quickly to an exclusive relationship. There may
be pressure to have sex or to move in together.
4. Isolation. There is an attempt to isolate the abused person from family and
friends. There will likely be efforts to sabotage close relationships and accuse
others of causing difficulties in the relationship. There may also be efforts to
limit phone contact, use of a car, or even from going to school or work.
5. Projecting blame onto others. Almost anything that goes wrong will be
blamed on the woman or other people.
6. Unrealistic expectations. Expectations of the perfect wife, who has nothing
out of place and will be his everything. He will have the expectation that all
needs will be met in this relationship.
7. Blaming others for the abuser's feelings. Does not take responsibility for their
own emotions. Blames the woman or others for how they feel and may use it
as a means to manipulate. Makes light of abuse through minimizing, denying,
and blaming.
8. Verbal and emotional abuse. Saying things to be hurtful and cruel—
minimizing ability, accomplishments, and overall degradation. There may be
awakening during the night out of sleep to be verbally assaulted, questioned,
and called names. There may be added manipulation such as threats to end
the relationship, harm themselves, abandonment, or kick the person out of
their home. There is game playing, resulting in the abused experiencing low
selfesteem and feeling crazy.
9. Rigidly traditional roles. Expectation of the woman being in the home, being
the central caretaker, being submissive, being unable to make decisions
independently and seen as inferior. This can be a part of economic abuse. The
abused may become totally financially dependent on the abuser. This is also
where children can be used to make the abused feel guilty for won strivings or
using children to relay messages. Using male privilege, treating her like a
servant, creating the rules for men and women.
10. Coercion and threats. Cruelty to children or pets. Having unrealistic
expectations about children's abilities. Pets may be harmed or even killed.
11. Using force sexually. Desires to act out fantasies during sex in which the
woman is forced, bound, or hurt. There is little concern about what the woman
wants or needs. They may use manipulative behavior such as withdrawal, anger,
or guilt to get the woman to comply. There may be no empathy for illness, and
they may make demands for sex or initiate sex while the woman is sleeping.

12. Using force during conflicts. The use of force such as being prevented from
leaving a room, held down or restrained. Being held against one's will.
13. History of violence in a relationship. History of physically hurting a past
partner but blames them for what happened.
14. Threats of violence. Making or carrying out threats of harm, threatening to
leave, or harm self. Coercing someone into illegal behavior. This is meant to
control. There may be excuses later, such as "I was just upset because of what
you did. I wouldn't do that."
15. Throwing or breaking things. This behavior is threatening and is often used as
a punishment and to terrorize another person into submission.
16. Mood swings. This is the confusing behavior where one minute the person is
nice and the next minute the person is upset, angry, or out of control.
DOMESTIC VIOLENCE: SAFETY PLANNING
MOST IMPORTANT TO REMEMBER
1. Help is available
2. You are not alone
3. You are not to blame
*No one deserves to be hit!
Even if you do not believe that there will be a "next time," decide now what you will do and
where you will go.
DOCUMENT THE ABUSE
1. Keep a journal. Make sure that it is hidden in a secret place
2. Take photos of any physical harm to yourself or to property
3. If you are physically harmed, show bruises or injuries to a friend, neighbor
or family member
4. Make the following copies and keep them in your secret place
A. Hospital bills
B. Property damage bills
FIND A SAFE PLACE TO GO
1. A shelter
A. Know how to get there
B. Memorize the phone number
2. Make arrangements to stay with family or a friend
A. Make friends with a neighbor
B. Ask neighbors to call the police if they hear suspicious noises from your home
Domestic Violence. Safety Planning 399

3. Decide ahead of time if you plan to take the children with you. Always
try to take the children in order to get yourself and them out of an unsafe
environment. An abusive environment may teach your children things
about behavior and relationships that you don't want them to learn.
4. Develop a code word with your children, neighbor, friends, or supportive family
that lets them know that you need to get out or you need them to call the police
*If there have been serious threats to your safety and you are fearful, contact local law
enforcement.
CREATE A SAFE ROOM IN YOUR HOME
1. Choose a room with a window
2. Get a cordless phone for that room
3. If possible, arrange a signal system for help with a neighbor
4. Plan a barricade
5. Install interior locks on the door (ask about locks at the local hardware store)
6. Make sure that there are not any weapons in the room
7. Call the police immediately should you need to use the safe room
*If things are building up, try to leave immediately to prevent the situation from getting out

of control. If you can't get out, don't get backed into a corner. Try to keep your back toward
an opening such as a door or window.
HAVE MONEY AND KEYS
1. Make duplicate keys for your vehicles, house, safety deposit box,
post office box, and so on
2. Start hiding money in amounts that will not be missed
3. Open your own bank account
4. Save pay stubs and other important receipts
CREATE A FILE WITH YOUR IMPORTANT DOCUMENTS
(IF YOU ARE TAKING YOUR CHILDREN, ALSO PUT
THEIR DOCUMENTS)
1. Temporary restraining order
2. Driver's license
3. Car title and registration
4. Social security card(s)
5. Birth certificate(s)
6. Immigration paper(s)
7. Social services documents
8. Prescriptions
9. Tax records/receipts for property purchases
10. Bank statements
11. Address book

PACK A SUITCASE
1. Pack basic clothing
A. Shoes
B. Socks
C. Underwear
D. Nightclothes
E. Change of clothes
F. Toiletries
G. Special children's needs such as diapers
2. Pack keepsakes that cannot be replaced
A. Photos
B. Documents
3. Hide it in a safe place
A. At a neighbor's house
B. Under the bed
C. At church
D. In the garage
E. In a public locker
F. At a family member's home
KNOW WHEN AND HOW TO LEAVE
1. Leave while the offender is away
2. Ask the police to help you
3. If your children are in danger, contact child protective services or the police
4. Consult an attorney or legal resource at a shelter about your parental rights if
you are leaving your children while you seek safety
* Safety is the priority.
WHY VICTIMS OF DOMESTIC VIOLENCE STRUGGLE
WITH LEAVING
1. Fear in general. Often they have been cut off from all of their resources and

have lived under threat and control, not being able to rely on their own
decision making.
2. Low selfesteem. People who have been emotionally beaten down over a
period of begin to see themselves as failures at everything they do. Offenders
reinforce this belief to maintain their control.
3. Selfblame/responsibility. Victimized people blame themselves for the abuse.
This is constantly reinforced by the offenders who blame them for the abuser's
violent behavior.
4. Holding the family together. Women are raised and socialized to see
themselves as the center of family cohesiveness—for keeping their families
Why Victims of Domestic Violence Struggle with Leaving 401

safe and together. Women often believe they must do this at any cost to
themselves, while at the same time questioning their parenting abilities.
5. Fear of being crazy. When you are told you are crazy often enough you begin
to believe it. As a result, these victims question their ability to cope with all of
the responsibilities of the outside world.
6. Dependence. Victim of domestic violence have likely had their worlds made
very small so that they could be controlled. As a result, they lack experience
in making their own decisions and acting independently.
7. Isolation. One of the most common things done to victims of domestic
violence is to isolate them from family and friends, physically and
emotionally. The more isolated they are , the less likely they will seek
help or be aware of the help available in their community.
8. Traditional values. Traditional malefemale roles are in conflict with separation
and divorce and support the notion of "keeping the family together at all costs."
There may also be a strong religious influences and unsupportive family members
that reinforce a victim's belief that she must stay in an abusive relationship.
9. Learned behavior. When you live in an isolated and abusive environment,
over time the experience takes on a normalcy because there is nothing else to
compare it to. When combined with a lack of belief in oneself, the victim may
come to believe that the situation is impossible to change. This may be further
embedded if the victim grew up in an abusive home.
10. The honeymoon stage and promises of change. Victims often love their
partners and want a good marriage and a stable family life for their children.
With the promise of change is the hope that all of these things are possible.
In the hopes that the promise of change will be kept, the victims will forgive
and give the relationship another chance for a new beginning.
Deal with what is, not what if. If things were going to change on their own they would have.
If there is to be any chance of hope for change, for the victim and the victim's family, it is
necessary to take action.
IMPROVED COPING SKILLS FOR HAPPIER COUPLES
There is no way to eliminate all conflicts between two people. However, by improving your

coping skills, you can go a long way to alleviate the distress of seeing things differently. By
evaluating your problems, learning effective ways to resolve them, and knowing when to
seek professional help you, and your partner can ensure the lifelong loving relationship you
want. Keep in mind, both people must be prepared to take responsibility, work at becoming
aware of their contribution to positive and negative outcomes, and be prepared to make
changes when needed. This is a demonstration of mutual respect and responsibility.
EVALUATE THE PROBLEM
Just bringing two lives together quickly highlights basic differences:
1. Style
2. Beliefs

3. Process of how to accomplish tasks
4. Parenting
5. Family expectations
6. Traditions
7. Priorities
8. Goals (short/long term, personal development, and family achievements)
Differences may initially result in mutual attraction, but over time become sources of frus

tration. Therefore, while differences or complimentarity may bring you together, it is the
sharing of common goals that keeps you together.
PROBLEM RESOLUTION
Every couple has differences in opinion. However, people who feel respected, loved, and
appreciated experience less conflict. Make it a point every day to say positive and support
ive things to your partner. Simply saying, "I love you" is reassuring and feels good. Give
compliments about how the other looks or what he/she has done. Compliments are a nice
way to say, "I noticed," "I am aware of all that you do."
Talk to each other about fears, concerns, plans, goals, ideas, and financial management.
Explore different solutions to the issues that confront you. That will give you more infor
mation into the discussion of what the two of you can do to reach your desired outcome.
Use the basic problemsolving outline for approaching issues:
1. Identify the problem (agree on what the problem is)

2. Generate all the different ways that are available for resolving the problem
3. Make a mutually agreed on method for resolving the problem
4. Do it!
5. Be supportive and prepared to go to plan B with out blaming if it is
necessary
If you have baggage from the past that you (as an individual) have seen interferes with
positive outcomes, take responsibility for working through it. If there are couple's issues that
you don't seem to be able to resolve to your satisfaction or feel that there is increasing dis
tance in what was a loving and sharing relationship, seek professional help. Also check into
community presentations or activities that may improve your functioning as a couple. Many
churches also offer helpful groups or programs to the community. Do whatever you need to
in order to give your relationship the opportunity to get back on track.
COUPLE'S CONFLICT: RULES FOR FIGHTING FAIR
1. Do not use threats during the argument. Stay focused on the issue(s).

2. Do not use blanket or labeling judgments such as "You never..." or "You are
thoughtless." Doing and saying hurtful things is not helpful. Be respectful and
treat others as you wish to be treated.
3. Stay on the topic. Save other topics for a later discussion. Focus on specific
problem, behaviors or situations that you are striving to resolve.
Couple's Conflict. Rules for Fighting Fair 403

4. It is not fair to interrupt. Stay at the same eye level. Take responsibility for
being a good listener and being sure that you understand what the message is
before you respond with your own thoughts and feelings. How you act will be
a demonstration of your own agenda or goal. Do you want to work through a
problem and resolve it or keep the conflict going?
5. Do not use "always" or "never." Be realistic and honest. Exaggerating
prolongs and intensifies a conflict.
6. Stay in the present tense. Bringing up past issues is usually utilized to "win"
or prove a point. Just because someone acted in a certain or behaved in a
certain way in the past does not mean that person will always do the same
thing. What is in the past cannot be changed. Also, if you are held hostage by
the past, your partner may start to think that no matter what he/she does, it
will not make a difference. This does not mean, however, that one should not
take responsibility for past actions and make amends.
7. Do not argue in the dark or in bed.
8. It is not fair to walk away or leave the house while you are in the midst of a
conflict. Be respectful and responsible for your own behavior. If tempers are
escalating, then make a mutual decision to cool off and come back to resolve
the conflict.
9. Avoid finger pointing, which will seem like lecturing. Pay attention to your
body language. People pay more attention to how a message is delivered than
the words said. What do you want to communicate?
10. Take responsibility for change. Always do your part. Take the high road.
Be true to yourself.
11. Take responsibility for your own feelings. Rather than saying, "You make me
mad," take responsibility for your emotions by saying, " I am mad." You are
responsible for your own thoughts, feelings, and behaviors.
12. If you suspect that a conflict is brewing, write down the issue or problem
before it evolves into an emotional volcano. This helps a couple to stay in
control and more effectively problemsolve the issues at hand. Also, taking the
time to write it down can slow the building of tension and clarify the
problem.
13. Drama and exaggeration is not helpful. Being dramatic is likely to escalate the
situation. Take responsibility to do your part honestly and in a straight
forward manner.
14. Both partners have the right to take time to calm themselves and to think
about their thoughts and feelings so that they can express them appropriately.
15. Be sure that you know what you are having conflict about. What is the real
issue? Choose your battles carefully. Don't sweat the small stuff. What is
worth fighting about?
16. Approach conflict with a problemsolving attitude. Be honest about your own
agenda and take responsibility for how you choose to deal with it.
17. Don't say things that are critical, hurtful, or attacking that offers your partner
no recourse but to avoid or retaliate. You can't erase hurtfulness.
18. Don't store up feeling and then erupt like a volcano with your accumulated
resentments. This is overwhelming and confuses the current issue. Deal with
important issues as they come up.

19. Be honest even when it hurts. Avoid making assumptions. When you make
assumptions, you run the risk of totally being off base 50% of the time. It is
always easier to see what is wrong with the other person than it is to see what
is wrong with yourself. Be honest about your own shortcomings and
contributions to relationship difficulties. People grow and change. Also, just
because someone loves you does not mean that the person knows what you
want or need. It is your responsibility to express your wants and needs
directly, clearly, and respectfully.
20. Does it matter who is right? Is it about winning? If you answered yes
to either of these questions, you are not investing yourself in a conflict
resolution process that is best for your partnership. You are investing
yourself in what you think is best for you. When you approach conflict
resolution, it must be from a position that both partners just win, both must
benefit, and neither will be harmed. When issues are resolved, it is a winwin
situation. You are going to have to decide if you are two teams or one. With
two teams, each has its own agenda. A single team works together toward a
common goal.
Be Clear About 1. Everyone should occasionally take the time to review where they are with

What You Want consideration to goals, interests, and friendships.
2. Consider goals, interests, and friendships as an individual.
3. Consider goals, interests, and friendships as a couple.
Be Clear in 1. A successful couple is one that works hard at making decisions that are

Communicating acceptable to both parties.
What You Want 2. Establish a good time to talk over issues.
3. Remain on one topic until it has been resolved. Then move on to the next
topic of discussion.
4. Avoid criticizing, judging, or coercing your partner into what you want
and they don't. It may feel like you get what you want in the short run,
but you will both pay for it later because your partner will feel hurt and
cheated.
5. Avoid stating things from a position of what you don't want. Instead, state
what your goals are.
6. Stay focused, respectful, and concentrate on the discussion topic.
7. Avoid bringing up negative experiences from the past. Remain focused on the
here and now.
How Can Both of 1. If there is a difference in what you both want be prepared to negotiate.
You Get What 2. If there is something you need or want from your partner, request it, don't
You Want make a demand for it.
3. When negotiating be prepared to offer something that your partner
wants if you want them to give you what you want. There must be
balance. Both partners must feel that they get out what they put into the
relationship.
Couple's Conflict: Rules for Fighting Fair 405

4. Don't hold back waiting to see how your partner is going to help you. Instead,
show them how you can assist in completing any task. Remember, balance.
Each must feel like they get out what they put in.
5. Selfmonitor. Make shortterm agreements with a builtin time for reviewing
what has been accomplished.
6. Always reinforce the efforts and accomplishments of your partner in assuring
that your needs are met. Therefore, when you get what you want make sure
you let them know in a loving and appreciative manner.
PARENTING A HEALTHY FAMILY
CREATING EFFECTIVE FAMILY RULES

1. Rules hold the family together. They create a foundation for learning
responsibility, developing mutual respect, and encouraging ageappropriate
independence.
2. Create rules from a positive perspective. Make rules which facilitate what
you want.
3. Have as few rules as possible, be clear, and be specific.
4. Choose consequences that are logical, and that you are willing to
enforce.
5. Take the time to educate the child of each rule and the associated
consequences. Life is about choices, and early on this is how a child learns
responsibility.
6. Have the child reflect to you in their own words and understanding of the rules
and consequences.
7. Whenever possible and appropriate include children in making rules as well as
other decisionmaking situations.
8. Be consistent in adhering to rules.
9. Be aware when it is appropriate to change a rule because of developmental
changes and increased maturity, in order to facilitate responsible
behavior.
EFFECTIVE COPARENTING
1. Make rules together. Agreement on the rules is important so that children
receive consistent information from both parents.
2. If you don't agree on certain rules negotiate until there is agreement.
3. Be supportive of each other. Remember, this was a joint decision and
children will be confused if there is conflict between parents over rules.
Not being consistent and supportive can lead to manipulation and power
struggles.
4. If one parent intervenes in a situation and the other disagrees with the
intervention do not voice the disagreement and undermine the intervening
parent. Instead, discuss and resolve later.

MAINTAIN THE PARENT ROLE
1. Be specific in telling a child exactly what actions are expected.
2. Be flexible in how a child accomplishes a task. If you aware of different
ways of doing something show them to the child. It is important for the child
to work effectively, to have accomplishments, and to master their
environments.
3. Don't lecture. Talk less, act more.
4. Give positive feedback, rewards, and reinforcement for efforts and
accomplishment of the behaviors you want.
5. Be consistent, and don't argue.
6. Follow through with rewards and consequences to shape the behaviors
you want.
BE AN ACTIVE PARENT
1. Help your child learn by teaching how to do things "their way." Don't expect
them to have the same level of expertise as someone older.
2. Be aware that you are always a role model to a child. They learn by watching
and copying what they see.
3. Demonstrate your love through actions. Words lack meaning and value if a
child does feel the love from a parent through attention and affectionate and
caring behaviors.
4. Develop routines. Routinely create an environment that feels dependable and
safe to a child.
5. As part of the family routine have regular one to one time with a child.
A HEALTHY FAMILY MEANS ALL OF ITS MEMBERS
ARE INVOLVED
1. The development of selfesteem is an active process. Empower children by
their demonstrated importance in family functioning.
2. The best way to teach values and build skills is by doing things with a child.
3. Identify a child's contributions to family life.
4. Laugh and be playful with a child.
5. Include a child in appropriate family decision making.
ENCOURAGE COMMUNICATION
1. Be interested in a child's life and their experiences. It is through talking about
things that happen that children are able to learn valuable lessons and better
understand themselves.
2. Encourage a child to talk to you about things that are important to them.
3. When a child shares their experiences, thoughts, and ideas with you actively
listen and encourage their problem solving of issue.
4. Avoid criticizing and giving directions. Respect them. Ask them what they
think.
5. Give a child the time and attention required to understand their point of view.
They are individuals. Expect them to have their own ideas.
Parenting a Healthy Family 407

6. Use active listening behaviors (face them and use eye contact) and reflect to
them what you hear them saying. When you repeat to them what you think
they are saying it demonstrates interest, respect, and that they are important.
7. When there is an opportunity to teach values to a child in a meaningful way
take advantage of it. It will feel natural instead of contrived.
GUIDING YOUR CHILD TO APPROPRIATELY
EXPRESS ANGER
Everyone is familiar with the devastating situations in which children have killed other chil

dren as an expression of their extreme anger with being treated badly and being humiliated.
While it is imperative that bullies and cruel social behaviors be dealt with, it is also impor
tant that children be taught how to appropriately express feelings of anger. Learning how to
effectively problemsolve and deal with difficult emotions is a preventive measure for posi
tive mental health and preventing violent behavior. Young people turn to violence when they
don't see other ways of managing difficult situations. They may be reacting to the moment
without anticipating the consequences of their actions. The following tips can help a child
to learn internal management, use of resources, and selfresponsibility.
1. Be a good listener. Pay attention to what your children are saying about what

they feel and how they are thinking about things in their life. Unfortunately,
children are confronted at an earlier age about more adultoriented issues such
as relationships, sex, and romanticizing. Failure and rejection are also difficult
issues to deal with. Young people are not prepared mentally or physically to
effectively manage many of these issues and can find themselves overwhelmed
and in trouble.
2. Be comforting and reassuring. Tell your children that you care about what they
think and feel. Show confidence in them by helping them to explore their
choices for managing the issues confronting them.
3. Normalize the experience of anger. Everyone gets angry. Share the positive
ways that you have found to deal with anger and other difficult feelings.
4. Encourage children to express their feelings honestly and appropriately and
then to move on to fun and interesting activities. Distracting oneself with other
activities helps to refocus on other things and not get stuck and miserable
with anger.
5. Teach problemsolving and conflict resolution skills. Give your children some
ideas about how to deal with difficult situations and encourage them to talk
about what they try to do in those situations, what works, what doesn't, and
what they may do next time they are confronted with a similar situation.
6. Catch them being good. It is always important to reinforce good behavior by
acknowledging it. When your children deal with their anger in positive ways,
reinforce their positive choices. Use every opportunity to build and reinforce
strengths and skills.
If you do not feel that your efforts are successful, talk to a professional about community
resources (such as anger management classes) and therapy.

THE FAMILY MEETING
The Family Meeting is a regularly scheduled meeting of all family members. It creates the
opportunity to promote healthy family functioning by:
1. Providing time for clarifying rules or establishing new rules as a family goes

through new stages of growth and change.
2. Making decisions and problem solving. List any family problems. Choose
one to solve. State the result that is desired. List and discuss all possible
solutions. Choose one solution and make a plan to carry it out. Set a date
to review it.
3. To acknowledge and appreciate good things happening in the family.
4. Identifying strength of individual family members, and of the family as a
whole.
5. To list fun activities for the family.
6. To encourage all family members to share their ideas. Try to see and
understand each other's point of view.
7. A time to practice assertiveness and democracy. Role model respectful and
effective communication. Parents should role model the skills of reflective
listening, "I" messages, and problem solving so that children can learn.
8. To promote commitment of all family members to the functioning of the
family.
9. To provide an opportunity for all family members to be heard.
10. Expressing feelings, concerns, and complaints.
11. Distributing chores and responsibilities fairly among family members.
12. Expressing positive feelings about one another and giving encouragement.
GUIDELINES
1. Meet at a regularly scheduled time which is convenient for everyone.
2. Share the responsibility of the meeting by taking turns in chairing the meeting.
3. Reserve an hour for the family meeting. If the children are young, try 20 to
30 minutes.
4. Each person has a chance to speak.
5. One person speaks at a time.
6. Listen when others are speaking.
7. No one is forced to speak, but participation is encouraged.
8. No criticism or teasing. Do not allow the meeting to become a regular gripe
session.
9. All family members must have an opportunity to bring up what is important
to them.
10. Focus on what the family can do as a group rather than on what any one
member can do.
11. Share things that are going well. Recognize efforts and accomplishments.
The Family Meeting 409

12. The goal of the family meeting is communication and agreement. Be sure to
accomplish plans for family fun.
13. End the meeting by summarizing the decisions and clarifying commitments.
Thank everyone for respectfully attending and participating.
DEVELOPING POSITIVE SELFESTEEM IN

CHILDREN AND ADOLESCENTS
1. Demonstrate a positive perspective rather than a negative one. "Catch"
your children doing something good. This communicates love, care, acceptance,
and appreciation. Be careful not to undo a positive statement. For example,
"you did a great job of cleaning your room, too bad you don't do it more
often."
2. Keep your promises. This facilitates trust in parents, while they are role
modeling being respectful and responsible. Consistency is important.
3. Create opportunities out of your children's mistakes. For example, "what did
you learn? What would be helpful next time?"
4. Show appreciation, approval, and acceptance. Listen for the feelings behind
the words. Active listening to what a child says shows respect and is a way to
reflect their worthiness. Being genuinely interested fosters mutual care and
respect.
5. Have reasonable and appropriate consequences. Discipline should be a part of
learning and encouraging responsible behavior. If a consequence is too long or
severe it creates feelings of hopelessness, and a feeling that they have nothing
to lose. As a result, it is likely to lead to more opposition and acting out.
6. Ask your children for their opinions, involve them in family problem solving
and decision making whenever possible and appropriate.
7. Help your children develop reasonable ageappropriate goals for themselves
and help them recognize their progress toward goals.
8. Avoid making comparisons between siblings or peers. Each person is unique
and has something special to offer. Recognizing individual attributes is a good
thing because it helps a child or adolescent to become more aware of their
strengths or assets.
9. Support your children in activities in which they feel accomplished and
successful. Everyone feels good about themselves when they are successful.
10. Spend time doing things with your children. The amount of time as well as
the quality of time is important. Remember, your children grow quickly and
time that has past can never be recaptured. Be sure to take time to have fun
and enjoy your children.
11. Encourage your children's efforts and accomplishments. Genuine
encouragement of efforts, progress, and accomplishments promotes positive
selfesteem. Children learn to accept themselves, identify their assets and
strengths, build selfconfidence, and develop a positive selfimage.
12. Communicate your love by saying it and demonstrating it. Feeling loved is
feeling secure. Love is communicated by mutual respect, which is a
cornerstone in the development of independence and responsibility.
13. Accept your children for who they are. This facilitates selfacceptance, self
like, and selflove.

14. Have faith in your children so that they can learn to expect the best in
themselves.
15. Focus on contributions, assets, and strengths so that children feel that they
are important and have something to offer. Let them know that what they
offer counts.
UNDERSTANDING AND DEALING WITH LIFE

CRISES OF CHILDHOOD
Everyday family life is full of stressors, crises, and necessary adjustments. An aspect of gen

eral growth and development includes the experience of being exposed to difficult/stressful
situations and learning to cope with them. Growing up means learning to cope effectively
with a full range of life experiences—both good and bad. Your child's ability to effectively
cope with any given situation is related to the amount of distress it elicits, if they previously
have experienced anything similar in which they were able to resolve, and how supportive
parents and other adults are in facilitating the effective management of stressors. As an
adult, you probably have had years of experience in dealing with all kinds of crises and
have probably learned to cope with them. If this is not the case it is recommended that you
consult with a therapist on the issues of problem solving, conflict resolution, and crisis
resolution. If you are unable to cope effectively with stressors and crises it will be very dif
ficult for you to help a child to successfully resolve and learn to cope with the stressors in
their life.
A central task for all parents is teaching your child how to deal with stressors, pressures,
and demands so that as they move into their adult life they are able to cope effectively. How
your child responds to difficult circumstances will be influenced by how you help them deal
with life crises they experience. While crises are often associated with emotional distress it is
also a time of opportunity. It is a time of learning. The very essence of a crisis demands that
a person search and explore new methods of coping and developing alternatives for dealing
with it. As a result, a crisis presents a person, child or adult, an opportunity for growth and
increased effectiveness in coping.
Parents are confronted with two major problems in helping children face and cope with
stress:
1. To deal with your own reactions to the stress.

2. Facilitate optimal coping of the child by giving adequate support, encouraging
and helping with the development of alternatives to deal with difficult
situations, and by giving positive feedback and reinforcement for efforts toward
management and resolution of stressors and crises.
WHAT IS A CRISIS?
A crisis can be defined as a person's evaluation of an experience as dangerous, threatening,

traumatic, outside of anything they have ever experienced, and with an uncertainty of how
they will handle it. A crisis is unique to the individual. What is experienced as a crisis for
one person will not necessarily be a crisis for another person. It involves a person's inter
pretation and feelings about an experience along with speculation and questions about why
it happened and what the consequences of it will be.
Wbai is a C r i s i s ? 41 1

Losses such as death, divorce, relocation, and job change, and new or frightening experi
ences such as a physical trauma or hospitalization are frequently thought of in terms of what
a crisis means. However, some positive events such as a marriage, birth of a child, job pro
motion, and acceptance to a desired college can also be experienced as a crisis. With any
experience that is new there is some level of stress, expectation of performance, concern of
how to deal with it, and questions about what may happen as a result of it. This can be just
as overwhelming for a person as an event interpreted as a negative experience. When a per
son experiences a crisis in relation to a positive experience they may also feel guilty or upset
with themselves expressing that they are confused because this should be a happy or pleas
ing experience.
Recognizing and understanding that the crisis is not the event, but the individual's inter
pretation of the event allows insight into why two different people may react differently to
the same event. One child may begin school confident, secure, and grown up, while another
child may feel fearful, rejected, or punished. Other events that may trigger a crisis include
loss, loneliness, independence, sexuality, high expectations of performance (by self or oth
ers), and feeling overwhelmed by a situation that is interpreted as being out of their control.
Therefore, everyone has different areas of vulnerability of sensitivity resulting from their
past experiences which will influence their interpretation and response to situations. There
is not an issue or event that across the board will be interpreted as a crisis for every person.
Each person will interpret and react to life experiences in their own unique manner as a
result of personality, disposition, coping ability, support, issues of emotional security, and
previous life experiences will all work together as a person responds to a crisis event.
WHAT HAPPENS DURING A CRISIS
When an event precipitates a crisis there is a disruption in equilibrium and stability. Anxiety
and tension begin to rise. The person tries to understand what is happening and why
it is happening. The less a person is able to understand the situation, the more tension and
anxiety they experience. This can lead to feeling overwhelmed, out of control, and helpless.
With this psychological and emotional experience there may also be feelings of shame,
depression, anger, or guilt. A child may be unable to verbally express their fears or may be
afraid to express them. The confusion of fear, anxiety, and other emotions is the crisis.
When preparing yourself to help children deal with life events that they may interpret and
experience as a crisis, it is helpful to consider the following:
1. Children tend to be selfcentered. This is especially true of young children and

adolescents. They seem to interpret things as if the world revolves around
them—everything is taken personally. Because of this they may interpret
themselves as being the cause of something that they have no power or
control of, which can be overwhelming.
2. Children tend to interpret things in a literal or concrete manner. This can
cause a crisis via misunderstanding. For example, telling a child that death is
like sleep, or having a medical or dental procedure won't hurt because they
will be knocked out. What the parent means and what the child interprets such
statements as meaning are likely to be different.
3. Fantasy is reality for young children. This could be a situation in which one
parent is seeking divorce and the child fears that they will also be abandoned
or divorced by this parent. Sometimes a child experiences a form of fantasy
called magical thinking, which means that a child has a belief that they had the
power to make something happen by thinking it. An example of this is when a

child is angry and thinks or says "I wish you were dead" and someone is
harmed in some way. They may believe that harm came to the person because
of their thoughts or wish.
4. The effect of childhood loss or separation. Most of the crises experienced by a
child involve a loss or separation of some kind. The loss or separation can be
fantasy or real. There are direct losses such as divorce or death, or indirect
losses such as starting school, a hospitalization, or staying for a brief period
with a relative. Losses are a threat to feeling safe and secure. Losses can involve
feelings such as sadness, depression, loneliness, rejection, abandonment, anger,
guilt, and confusion.
Because life has a normal level of stress and changes, it would be impossible to hide from

children the problems that confront a family. Children are very sensitive and can feel when
things are not right at home. Therefore, instead of allowing a child to interpret what is going
on it is belter to give them ageappropriate information in a manner that helps them main
tain their feelings of safety and security.
CRISIS RESOLUTION
1. Promoting objectivity. Help the child see the situation for what it is. For

example, while the child is at school mom/dad won't forget about them, or
parents did not divorce because the child was bad, etc.
2. Validate feelings. Recognize and accept how the child feels about a given
situation. Denying their feelings is a rejection and is also confusing. When
feelings are denied it leads to a misinterpretation of feelings later on.
3. Elicit their thoughts and feelings about what has happened. Encourage
them to vent their thoughts and feelings appropriately instead of keeping
them inside.
4. Facilitate problem solving and taking appropriate action. This means
identifying exactly what the problem is, what the alternatives are for managing
it or resolving it, and then taking action. It also includes utilizing resources and
selfcare behaviors such as getting adequate rest/sleep, nutrition, exercise, and
balance in their life—not just being focused on the crisis.
Helping the child to understand what has happened, why it happened, how it is happen

ing, what it means to them, how it affects them are the objectives for facilitating resolution
of the crisis for the child. The efforts of understanding and support to the child early in life
when faced with crises pays off later because it lays the foundation of coping skills for deal
ing with crises later in life.
WHAT DO YOU NEED TO DO TO HELP A CHILD

1. As with any relationship interaction you need to be the best you can be before
you can offer healthy support, guidance, and facilitate problem solving for
effective coping. This means that you need to understand and cope with your
own reactions to events before you can help a child learn to cope. When a
Crisis Resolution 413

child experiences a crisis parents experience their own personal reactions.
Additionally, the body language or nonverbal communication your child
experiences from you will have a significant impact on how they interpret
an event. A child tends to reflect their parents reaction to an event.
2. Attempt to understand the child's experience of the event. Remember the
tendency of the child to be selfcentered. This will give you insight into how
the child might personalize a given experience. Is the child fearing a loss or
rejection and abandonment? Is the situation frightening or do they feel that
they are to blame for what has occurred? What kind of feelings might the child
be trying to express?
3. Validate the child's feelings. Acknowledge and accept the feelings that the child
is experiencing. In order for the child to master the situation they must be able
to understand and effectively express what it is they are feeling. Reflecting the
child's emotional experience ("I understand that you feel sad because we could
not keep the kitten") because it offers acceptance and a label to their emotion
which allows them to connect their feelings to the event and lets them know
that having such a feeling for that experience is okay.
4. Understand the stage of loss that a person experiences, which are a series
of feelings which people go through when working through a loss and/or
death.
A. Denial that the event is happening.
B. Anger that the event happened, or that they have been abandoned.
C. Depression (and guilt) often experienced as sadness and loneliness associated with
the object, or feeling guilty that something has happened to another and harboring
a belief that somehow they could have prevented it.
D. Bargaining in an attempt or as a plea to not accept what has happened, or being
willing to do anything to take it back.
E. Acceptance of the reality of what has occurred.
People do not necessarily go through these stages in the sequence that they are given, or

go through a stage and never return to that stage again. Everyone goes through these stages
in their own unique way based on how they grieve and cope. However, everyone seems to
go through this sequence of feelings in coping with a loss, and children seem to go through
these stages in general when coping with a crisis.
5. Accept the child's efforts to deal with the crisis. Be careful to not put them
down or shame them. Instead, offer acceptance and support to facilitate the
resolution of the crisis. In other words, meet the child where they are at
emotionally and guide them by responding appropriately to what they need in
moving toward resolving the crisis.
6. Make an effort to hear what the child is trying to express.
7. Respond verbally to the child at their level of understanding. Be direct and
keep it simple.
8. Don't push the child to talk about the event. This can result in distressing the
child more and leading to withdrawal.
9. Be empathic. Try to understand what the child's experience is. Often, a child
experiences a crisis because they believe that they are somehow responsible
for what has happened (divorce, death), that they are being punished for

being bad (a new baby takes their place in the family, they are sent to school),
or they are being rejected and abandoned. Be consistent and reassuring by
what you say and what you do. Give the child adequate time and support to
work it out.
10. Whenever possible, prepare a child for a difficult event such as an impending
change, loss or death. It is much easier to cope with something when there is
some expectation and understanding for what is happening. This will often
reduce the intensity of the crisis or avert it all together. A child can be
prepared by talking with them, using ageappropriate books, drawing, dolls,
etc. Also, if possible avoid too many changes within a given period of time.
This would be overwhelming for an adult with good coping skills, let alone a
child who is striving to develop the skills necessary to adequately cope with
difficult situations.
YOUR CHILD'S MENTAL HEALTH
When a parent has any health concerns, he/she seeks medical advice. Mental health prob

lems may be more difficult to recognize. According the Center for Mental Health Services,
one in five children has a diagnosable mental, emotional, or behavioral problem. Sometimes
these problems lead to family conflict, school problems and academic failure, violence, or
suicide. Even though help is available, twothirds of the children with mental health prob
lems do not get the help that they need.
Don't confuse normal responses with an illness. It is common for children to at times feel
sad or to behave badly. However, if you are not sure, talk to a therapist about your concerns.
Overall, if you see severe and persistent troubling behaviors, immediately seek help. The fol
lowing questions will help to clarify if there is a problem and help you to effectively com
municate your concerns to a therapist.
1. Is the child extremely fearful? Is this worry and fear is excessive in

comparison to other children your child's age?
2. Does the child want to be alone all the time?
3. Do he or she avoid family and friends?
4. Does the child seem to have lost interest in things he or she formerly
enjoyed?
5. Is the child angry most of the time?
6. Does he or she cry a lot?
7. Does the child overact to things?
8. Is the child easily distracted and does he or she seem to have poor
concentration?
9. Does he or she have trouble making decisions?
10. Has the child's school performance gone down?
11. Is the child obsessed about his or her looks?
12. Are there unexplained changes in the child's sleeping or eating habits?
13. Does he or she complain about headaches, stomachaches, or other physical
problems?
Your Child's Mental Health 415

14. Does the child feel that life is too hard to manage or is he or she easily
overwhelmed?
15. Does the child talk about suicide?
*If you answered yes to any of these questions, seek professional help.
WARNING SIGNS OF TEEN MENTAL HEALTH PROBLEMS
The teen years can be tremendously fun and interesting. They can also be tough for both the
parent and child. Adolescents experience a lot of stress:
1. To be liked
2. To do well in school
3. To get along with their family (when they are trying to separate)
4. To define who they are
5. To plan their future
6. To manage negative peer pressure (substance use, etc.)
7. To deal with continual physical and emotional changes
Most of these pressures cannot be avoided, and worrying about them is natural. However,
if your teen is feeling sad and depressed, hopeless, worthless, or overwhelmed, these could
be warning signs of a mental health problem. These problems are real, painful, and can
become severe. They can lead to increased difficulty and stress, such as family conflict,
school problems, and academic failure. Consider the following review of possible problems:
1. Experiences significant changes

A. Grades go down
B. Loses interest in things usually enjoyed
C. Wants to be alone all the time
D. Avoids family and friends or doesn't get things done
E. Daydreams a lot
F. Feels that life is too hard and is overwhelmed
G. Talks about suicide
H. Hears voices
I. Is not taking care of his/her hygiene
J. Is giving prize possessions away
K. Is very moody
2. Emotional changes
A. Feels extremely sad and hopeless without reason
B. Is angry a lot of the time
C. Is often tearful
D. Overreacts to things
E. Feels worthless or guilty

F. Worries excessively
G. Has excessive anxiety
H. Cannot get over grief from a death of someone he/she was close to
I. Is extremely fearful
J. Is overly concerned about physical appearance
K. Is overly concerned about physical problems
L. Is fearful of his/her own thinking
M. Feels like he/she is out of control (his/her mind is out of control/someone is
controlling him/her)
N. Has poor concentration
O. Has difficulty making decisions
P. Worries excessively
Q. Is constant fidgeting
R. Has difficulty remaining seated
S. Has a fear of harming self or others
T. Displays compulsive, ritualistic behavior
1. Need to wash/clean things
2. Hand washing
3. Need for specific order
4. Other similar behaviors
U. Has racing thoughts
V. Has persistent nightmares
W. Has a sleep disturbance
X. Has a appetite disturbance
3. Selfdefeating behaviors
A. Substance use
B. Truancy
C. Lying/stealing
D. Eating excessive amounts of food
E. Forced vomiting
F. Abusing laxatives
G. Excessive exercise/dieting
H. Obsessiveness about weight (bonethin)
I. Destroying property
J. Breaking the law
K. Hurting people or animals
L. Fascinated with fire/starts fires
M. Engaging in risky, lifethreatening activities
If you identify any of these issues of concern, seek professional help for your teen.
TALKING TO CHILDREN
A parent communicating with their child is an important interaction. It is also complex
because of the opportunity that it holds for the child in the way of building selfesteem,
encouragement, feeling understood, and feeling accepted.
Talking to Children 417

Accept the child as a unique individual separate from yourself. They have their own ideas
and special way of looking at things. When a child experiences your acceptance they are
more open to you, your support, and your interventions for problem solving. In other words,
they feel respected.
Acceptance can be communicated verbally as well as nonverbally. If your verbal communi
cation is accepting but your nonverbal communication is not it will be confusing to the child.
Ways of demonstrating your acceptance include:
1. Taking an interest in the child's activities, hobbies, and interests.

2. Listening to the child, and encouraging them to give details, to express their
thoughts and feelings about it, and reflecting to them what you are hearing.
3. Allow and encourage the child to do thing for themselves. They are capable
beings.
4. Be careful to avoid lecturing, repeating, ordering, preaching, criticizing, and
shaming.
Always make an effort to hear what the child has to say. This means taking the time to
listen. If you are in a hurry or have limited time let the child know and make sure that you
follow up later to complete the conversation. For example, the morning can be rushed try
ing to get everyone ready for work and school. If this is not a good time for discussing things
or sharing then clarify and offer other time frames for quality sharing.
Be accepting of the child's feelings. Treating a child as a unique, worthwhile person
requires genuine positive regard, respect, and acceptance.
RULES FOR LISTENING
1. When a child is talking to you be facing them physically and use eye contact.
2. Avoid shaming, criticizing, preaching, nagging, threatening, or lecturing.
3. Treat a child in the respectful manner that you would treat a friend.
4. Be accepting and respectful of their feelings.
5. Restate in your own words the child's feelings and beliefs. Reflective listening is
a demonstration of interest and understanding in what they are saying.
6. Be open and encouraging.
7. Allow and facilitate the child's learning. Resist jumping in with your own
solutions.
8. Encourage a child to identify their own solution to problems. This encourages
selfesteem.
RULES FOR PROBLEM SOLVING AND EXPRESSING YOUR

THOUGHTS AND FEELINGS TO CHILDREN
1. Communicate your feelings with "I" messages. When you use "I" messages you
are making a statement about how their behavior affects you and how you feel
about it. "You" messages are blaming and disrespectful.
2. When there is a conflict:
A. Decide who owns the problem.
B. Limit your talking to perception of feelings and answering questions.
C. Initiate problem solving. Invest the child in understanding the conflict and what to
do about it.

3. Communicate belief in the child by what you say, how you say it, and with
body language.
4. Always be encouraging. People learn from their mistakes. Encourage the child
to learn from all of their experiences.
5. Be patient. Allow children the time to think and to express their responses to
what it is you are sharing with them.
6. Admit that as an adult you do not have all the answers, but together you can
explore alternatives and find solutions to their questions or difficult situations.
7. Engage in purposeful conversation, talking with one another to understand
what the other means. They are worthy of your time.
8. Offer a non judgmental attitude which demonstrates respect.
9. Avoid pressure, sarcasm, ridicule, putdowns, and labeling.
DO'S
take an interest in what the child is interested in
allow the child to do things for himself
encourage the child to try new things
be accepting of their feelings
encourage their expression of thoughts and ideas
talk to the child honestly, simply, and at their level
ask one question at a time, and listen to their answer
DONTS
do not tell a child that their fears are stupid
do not lie or make false promises
do not invade their privacy. Don't push them to talk about something that causes them
to clam up more.
do not redo tasks that they have completed. Be encouraging.
do not deny their feelings, "you shouldn't feel that way"
do not be controlling. Clarify rules, boundaries/limits, and safety issues. Children need
room to grow.
GUIDELINES FOR DISCIPLINE THAT
DEVELOPS RESPONSIBILITY
For discipline to be a learning experience that shapes positive, appropriate, and responsible

behavior requires that the consequences be:
1. logically related to the misbehavior.
2. given in a manner that treats a person with dignity. Also separate the behavior
from the person.
3. based on the reality of the social order with clarification on its importance for
community living.
4. concerned with present and future behavior, not bringing up the past.
5. verbally expressed in a way that communicates respect and goodwill.
Guidelines for Discipline that Develops R e s p o n s i b i l i t y 419

6. tied to choices, i.e., all choices have a consequence, some are positive and some
are negative. Choosing a certain behavior is acknowledging a willingness to
accept the associated consequences.
7. a defining factor for telling the difference between a privilege and a right.
HELPFUL HINTS
1. Don't look at discipline as a win or lose situation. The goals are:
A. to provide the opportunity to make one's own decisions and to be responsible for
their own behavior.
B. to encourage children to learn the natural order of community life (rules are
necessary to promote optimal freedom of choice for all and to maintain safety).
C. to encourage children to do things for themselves for the development of self
respect, selfesteem, and taking responsibility for their own behavior.
2. Be both firm and kind.
3. Don't lecture. Be brief, clear, and respectful.
4. Don't fight.
5. Don't be worn down or manipulated.
6. Be consistent.
7. Be patient. It takes time for natural and logical consequences to be effective.
8. Don't be reactive. Parents' responses often reinforce children's goals for power,
attention, revenge, or displays of inadequacy. Be calm and respectful when you
intervene.
STEPS IN APPLYING LOGICAL CONSEQUENCES
1. Provide choices and accept the child's decisions. Allow them the space and
time to learn. Use a friendly tone of voice that communicates respect and
goodwill.
2. As you follow through with a consequence be assuring that they may be able to
try again at a later time. Encourage them to express the purpose of the
consequence for demonstrated mutual understanding.
3. If the misbehavior is repeated, extend the time that must elapse before the child
is given another opportunity. Be careful not to make the mistake of initially
choosing a time frame which is too long. Children do not share your concept of
time, and the purpose of the consequence may be lost.
SURVIVING DIVORCE
Divorce is one of the most stressful life experiences to endure. However, as with all times of

crisis it can also be a time of opportunity and new beginnings. It is a time to learn, to grow
personally, and to develop new relationships and discover community resources. The first
step in learning how to deal with divorce to understand how it is affecting you emotionally
and physically. Once you have an increased awareness for how you are being affected, you
can then acknowledge and accept your feelings, which becomes a springboard of learning
new ways to take care of yourself. This is a very stressful time, but you will learn that you
can deal with such a big change in your life and even go on to thrive.

PHYSICAL STRESS
Whenever a person goes through a stressful experience, the body is affected. Ongoing stress
can even lead to physical illness. Some physical experiences include headaches, stomach
upset, sleep disturbance, appetite disturbance, and exacerbation of preexisting illnesses such
as asthma or back pain. Pay attention to you body and take care of yourself.
EMOTIONAL STRESS
Many difficult emotions are associated with divorce. You may experience feelings of
1. Failure
2. Anger
3. Resentment
4. Worry
5. Depression
6. Loss
7. Sadness
8. Fear
9. Frustration
10. Loneliness
11. Helpless
In addition to such feelings, there is also the fact that you miss sharing your life with
someone. You miss the warmth, friendship, financial security, and intimacy you had or
hoped you would have had. If you have children, that job also becomes more difficult. Often,
parents who have divorced find that the level of demand in caring for their children signifi
cantly increases because they are no longer sharing those responsibilities in the same home.
There is less time to spend with children during a time that their needs are greater. If you are
not the one who wanted the divorce, you may be struggling with feeling angry and you may
be resentful for having such changes and losses forced on you. You have to be careful to not
put the children in the middle of your anger and grief. There may also be conflict stressors
associated with custody and child support. You may have worries about your children being
alienated from you. Divorce is even more painful if is seems like everyone around you seems
to be happily married or you get little or no support from family and friends.
SELFCARE
1. Recognize your feelings and find positive ways to deal with them
2. Reach out to other, use your social resources
3. Find social support in your community with groups dealing with divorce and
other activities
4. Take good care of your body (sleep, nutrition, laughter, exercise)
5. Take risks by trying new activities and getting distracted from your
problems
6. Nurture yourself, do things that feel good and do not have a harmful side
Doing these things can make you stronger, more confident, and more content.
Surviving Divorce 421

SUCCESSFUL STEPFAMILIES
Differences between Biological Families and Stepfamilies
Biological family Stepfamily
Marriage is a new beginning Marriage brings together two families

Traditions and history develop Different traditions and history—not shared
Couple's relationship comes before Biological parentchild relations come before
relationship with children new marital relationship
Family lives in same home Children spend time in two parental homes
Couple develops parenting role and skills Couple brings their own individual parenting
gradually and together ideas and skills to marriage
Since approximately 50% of first marriages and approximately 60% of second marriage

end in divorce, understanding what happens in marriage is important if you want to improve
the outcome of your marriage when it is complicated by stepfamily issues. As with all mar
riages, the factors necessary for success are the following:
1. Honor
2. Validation
3. Respect
4. Responsibility
5. Communication
6. Discipline
7. Parentcentered structure
HONOR
Honor embodies the meaning of marriage vows. It is the feeling demonstrated to a marital
partner that he/she is the most important person in your life.
VALIDATION
Validation means to listen, acknowledge, and accept that everyone is entitled to their own
thoughts and feelings. There are few things that feel as bad as when we share our thoughts
and feelings and they are denied as real, accurate, or important by someone important.
RESPECT
One never minimizes how their choices and behavior affect the people that they love, espe
cially their life partner. Treat others as you desire to be treated. Respect is the foundation
of trust.
RESPONSIBILITY
Responsibility describes how one thinks and behaves in a way that demonstrates doing what
is right. It is the recognition that we have obligations and values, which clarifies how to take
care of and nurture a couple's relationship.

COMMUNICATION
Open and honest communication is the foundation of a successful stepfamily. Do not avoid
talking about difficult issues. Instead problemsolve the issues that confront you as a couple
and your family (children) together.
DISCIPLINE
It is imperative that a couple approach parenting issues as a team. The children in a family
need the consistency offered by the team approach. Likewise, the couple benefits from being
able to depend on an alliance with their team member.
PARENTCENTERED STRUCTURE
A couple's bond needs to be strong. When there is a healthy couple relationship, there is
greater success in dealing with difficult family issues.
HELPING CHILDREN COPE WITH
SCHEDULING CHANGES
A schedule change could be a return to work following a long leave of absence, change from

a traditional lifestyle (Mom has been at home), or family/parent adjustments of any kind,
which present a disruption to a child's schedule or learned expectation of parental contact.
The following are some suggestions to consider:
1. Talk with your child in ageappropriate terms. Talk factually about the change

and explain in ageappropriate language what that means. Remain focused on
the positive aspects and consider that even what you view as a negative may
not be experienced in the same manner by your child. Likewise, what you see
as positive may be stressful to your child. Explain what you will be doing and
how important it is.
2. If possible, take your children to your place of work (or familiarize them with
whatever is associated with change) so that they have a picture of where you
will be or what is involved. If there is a receptionist, introduce them for added
comfort should there be a time they need to call you. If at all possible, call
them at predetermined times to check in.
3. Outline changes that will improve your lives and make things easier. This is an
opportunity to develop positive family behaviors. Family members should all
have a contribution in selfresponsibility and home maintenance. Children are
likely to feel empowered when they feel that they have positive contributions.
Think of ageappropriate ways that children can help around the house and
develop a reward system for reinforcing the development of selfresponsibility.
4. Make sure that your children know that you are thinking of them without
repeatedly reinforcing how much you miss them or how sad you are. They
may begin to feel responsible for making you happy or develop other negative
feelings about work or change. Instead, do sweet things like leaving them fun
notes.
Helping Children Cope with Scheduling Changes 423

5. Be emotionally available to your children when you are with them. Sitting in
front of the television or being busy with chores when you are home is not a
demonstration of taking the time to be with them. Talk to and listen to your
children. Keep the lines of communication open so you will know what is
happening in their lives and how they feel about it. This way you will know
what are they interested in, what do they like at school, what are they
struggling with, who their friends are, and so forth.
6. Each day, allot specific child time where there is no phone, no television, no
interruptions of any kind. Even if it is only a short period of time, you are
telling your children how important they are, which reinforces positive self
esteem. This is an investment in your child. One thing you can do is it read to
your child. Reading with children is a special time; it fosters reading as being
enjoyable, a quiet time, and it can be used as a nonstressful means for
working on difficult issues. Think of the possibility that reading may facilitate
children to be more open to learning life lessons.
7. Demonstrate a focus on the positives and what is working. Demonstrating
genuine gratitude for what one has improves coping with limitations and
encourages letting go or accepting what cannot be changed.
8. If you feel that your child is keeping difficult emotions inside or you just want
to stimulate the sharing of thoughts and feelings, play the "finish the
sentence" game. Create sentence stems where the child gets to complete the
sentence. This game not only creates the opportunity to understand what your
child is thinking and feeling, it is also an opportunity for your child to find
out that you have similar feelings about some things. Examples include the
following
A. "I Wish..."
B. "I feel happy when..."
C. "I feel unhappy when..."
D. "I don't understand..."
E. "When I grow up I will never..."
F. "When I grow up I will..."
9. Even when you find yourself tired and frustrated, don't give into blaming your
significant other for hardships created by the changes associated with
necessary adjustment. If you talk in terms of feeling punished for taking
responsibility for what needs to be done, consider the effect on children and
how they may be reinforced to view their own issues of responsibility.
10. Remember, you are the role model for positive selftalk and selfcare. Your
child is learning from watching you:
A. How to interact with the world
B. How to simply do what needs to be done without negativity and procrastination
C. How to problemsolve and resolve conflicts
D. How to appropriately get needs met

IS YOUR BEHAVIOR IN THE BEST INTEREST OF
YOUR CHILDREN?
Though we often consider a separation or divorce to be a time when parents engage in
behaviors that may be emotionally and psychologically damaging to children, the concern of
children could be expanded in general to marital distress as well. Therefore, carefully con
sider the following, and if you do any of the things listed, stop immediately. Try to put your
self in the shoes of your child, who needs a healthy relationship with both parents.
1. Do not put your child in the middle

A. Children should not be placed between two parents communicating information
from one to the other. Parents need to act like adults and communicate directly.
2. Do not put your child in the position of having to choose to be with one parent
over the other
A. Parents are supposed to be in the family leadership role. This means that children are
supposed to be able to rely on parents to make the decisions that are best for them.
B. Allow your children to be children, not to take on adult worries and stress
C. Parents are supposed to protect, nurture, and encourage children
3. Do not use your child as a confidant
A. Do not speak to your children about the adult issues that you struggle with
B. Do not speak to your children about your view of the faults of other parents
C. Do not try to get children "on your side" against the other parent
4. Do not allow your child to be responsible for you emotionally
A. When your children are exposed to your emotional displays of sadness, fear, anger,
and so on, they may come to believe that they are responsible for protecting you
and making you feel better because they
1. See you as fragile and unable to fulfill all aspects of your parent role
2. See you as a victim of the other parent
If you are doing any of these behaviors, then something is wrong. As a parent, you need

to stop thinking about yourself and your needs and take responsibility for what you are
doing to your children. If you need support, understanding, and to problemsolve how to
deal with your own difficult feelings, get help so that you can learn to do things differently
before you damage your children and their relationship with the other parent.
Your children are entitled to the following:
1. To be a carefree child who does not have to worry about you or adult issues.

2. To have a healthy relationship with both parents.
3. To be able to trust that their parents will protect them and their emotions.
4. To be encouraged and supported in their lives.
Is Your Behavior in the Best Interest of Your Children? 425
THE RULES OF POLITENESS
The Do's The Don'ts
Give sincere and positive appreciation. If you Don't complain or nag.

have an issue to resolve, sit down and discuss it
in a constructive manner to manage your differences.
Be courteous and considerate. Don't be selfish.
Express interest in the activities of others. Try Don't hog the conversation.
to listen and ask questions.
Give others a chance to finish speaking. Don't suddenly interrupt.
Speak honestly and in a caring way. Don't put others down.
Critique your ideas, but don't criticize yourself. Don't put yourself down.
Focus on the present situation. If you have an issue, Don't bring up old resentments.
sit down and discuss some constructive solutions.
Think of the needs and wants of others. Be Don't think only of your own needs
empathic. If you have an issue to resolve, sit and wants.
down and work out a constructive solution.
Be sensitive to others as you choose topics to discuss. Don't embarrass or humiliate others.
SELFMONITORING
Selfmonitoring is the process of observing and recording your thoughts, feelings, and behav
iors. It is used to:
1. Define or redefine the problem or target of change as needed.

2. Increase or decrease desired target behaviors, thoughts or feelings.
3. Evaluate the progress toward your goal(s).
Selfmonitoring is important for increasing your awareness for which management skills

and behaviors have been most helpful, and in planning the steps you will take to ensure con
tinued progress and success. Initiate selfmonitoring by:
1. Identify
A. Target behaviors, thoughts, and/or feelings to be changed
B. Desired Behaviors
C. Goals
2. Identify methods supportive of making desired changes and reaching your goals
A. Objectives
B. Strategies
3. What has been most helpful, and how do you plan to maintain positive changes
QUESTIONS TO ASK YOURSELF
1. Suppose someone who used to know you well, but has not seen you for some
time sees you when you complete the program. What would be different about
you then than now?

2. When you are successful, what will you be doing differently?
3. How would you like to benefit from the program, and how will you make that
happen?
4. What do you want to be thinking, feeling, and doing?
5. How much control do you have over making this happen?
6. What changes will these goals require of you?
7. Can these goals be achieved without the help of anyone or anything else?
8. To whom is this goal most important?
9. Who, specifically, is responsible for making this happen?
It is important that goals be feasible and realistic.
Part of selfmonitoring includes:
1. Goal Setting

2. Accomplishment
3. Listing Strengths
4. Resources
GOAL SETTING
In order to accomplish the tasks that will make the most difference in the quality of your life

experience it is required that you develop appropriate goals. To successfully reach your goals
requires that you develop a plan using objectives or steps which will lead to the completion
of your selected goal(s).
1. Goal:
Objective:
2. Goal:
Objective:.
3. Goal:
Objective:.
4. Goal:
Objective:.
Goal Setting 427

5. Goal:
Objective:.
ACCOMPLISHMENTS
From the time that you begin your program of change and personal growth it is important

to keep a log of what you accomplish in how you think, how you manage your feelings and
the difficulties in your life, and behavioral changes.
STRENGTHS
As you continue to work toward your goals of personal growth you will learn more about

yourself, your abilities, and your assets. These are your strengths. As you identify them write
them down. Your strengths contribute significantly to how you manage your life. When you
combine your strengths with your skills and your resources you will experience yourself as
much more effective in how you choose to live your life.
1.
2.
3.
4.

5.
6.
7.
8.
9.
10.
RESOURCES
Developing a list of resources can be very helpful. It will have to be updated from time to
time. Write down whatever resources you are aware of at this time and continue to add to
it as you go through this program. Examples of resources include trusted individuals, com
munity meetings, sponsors, etc.
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
TEN RULES FOR EMOTIONAL HEALTH
1. Take care of yourself. Take time to relax, exercise, eat well, spend time with

people you enjoy and activities which you find pleasurable. When you are the
best you can be the best that you can be in relationships.
2. Choose to find the positives in life experiences instead of focusing on the
negatives. Most clouds have a silver lining and offer opportunities for personal
understanding and growth. When you accept that things are
difficult and just do what you need to do then it doesn't seem so hard.
Ten Rules for Emotional Health 429

3. Let go of the past. If you can't change it and you have no control over it then
let it go. Don't waste your energy on things that cannot benefit you. Forgive
yourself and others.
4. Be respectful and responsible. Don't worry about other people; do what you
know is right for you. When you take care of business you feel good. Don't
get caught up in blaming others.
5. Acknowledge and take credit for your successes and accomplishments. Avoid
false modesty.
6. Take the time to develop one or two close relationships in which you can be
honest about your thoughts and feelings.
7. Talk positively to yourself. We talk to ourselves all day long. If we are saying
negative and fearful things then that is the way we feel.
8. Remove yourself from hurtful or damaging situations. Temporarily walk away
from a situation that is getting out of control. Give yourself some space and
problem solve a positive approach to dealing with it.
9. Accept that life is about choices and is always bringing change to you to
which requires adjustment.
10. Have a plan for the future. Develop long range goals for yourself, but work
on them one day at a time.

Chapter 4
Professional Practice Forms

Clinical Forms
Business Forms
Although there is some similarity to several of the forms in each section, there are minor
variations which allow them to be used to meet more specific needs. For example, there are
several variations of assessment forms which have been designed to be utilized for different
reasons and offer slightly different information.
Overall, the forms offer a basic selection of the breadth of forms used in a general men
tal health practice. At the same time there are some forms whose use does not necessarily
fall under the general practice expectation, but may fulfil needs of expectation as a reviewer
of someone else's work or working toward the development of a new specialty or service.
431
Clinical Forms
CASE FORMULATION
If you are preparing to consult with a treatment team, insurance case reviewer, or referring

physician, consider the following informational format:
If the consult is with a case reviewer, the initial information presented should include
the following:
1. Identifying information

A. Provider name and identification (ID) number (Social Security number or tax ID)
B. Member name, identification, and date of birth (DOB)
2. Treatment modality
A. Type of session (individual, conjoint/family, or group)
B. Number of sessions to date and session frequency
C. Number of additional sessions needed to complete treatment
GENERAL CONSULT INFORMATION
1. Diagnostic information
A. Multiaxial diagnosis
1. On Axis IV, be specific. General examples include the following:
a. Problems with primary support group
b. Economic problems
c. Housing problems
d. Educational problems
e. Occupational problems
f. Problems with access to health care
g. Problems in interaction with legal/criminal system
h. Problems related to social environment
i. Problems related to stage of life issues
j. Other psychosocial and environmental problems
2. Medical presentation
A. Psychotropic medications
B. Substance abuse
C. Elaboration on Axis III issues presenting
1. Management problems
2. Medical instability
3. Factors influencing emotional/psychological functioning
3. Clinical presentation

A. Crisis issues
1. Harm to self
2. Harm to others
3. Child abuse/neglect
4. Other related issues
B. Symptoms/behavior
C. Stability and compliance
D. History of abuse/neglect/assault
E. Treatment history (including hospitalizations) and course of assoc. treatment
E Family history and involvement in treatment
Case Formulation 435

4. Relevant history of presenting problem(s)
5. Current status
A. Descriptive current level of functioning
B. Situational issues impeding or facilitating improvement
6. Treatment goals and objectives
A. Integrating empirically supported treatments
GENERAL CLINICAL EVALUATION
The general clinical evaluation systematically reviews all domains associated with understand
ing an individual and his/her level of functioning. Depending on the presentation of a given
area, the assessment will vary in intensity as needed. Areas of evaluation include the following:
1. Presenting problem/reason for evaluation
2. Referral source with associated information
3. History of the presenting problem
4. Psychiatric history
A. Chronology of episodes of mental illness and associated course of treatment
including medication, treatment programs, and treatment providers
B. Responses to prior treatment (medication, dosage, duration, side effects,
benefits, complaints)
5. Medical history
A. Medical illness (medication(s), treatment, procedures, hospitalizations)
B. Undiagnosed health problems
C. Injuries, trauma
D. Sexual/reproductive history
E. Headaches/chronic pain
F. Allergies/drug sensitivities
G. Disease(s), infection
H. Healthrelated behaviors (exercise, nutrition, use of substances, etc.)
6. Substance use history
A. Specific substances
B. Frequency/amount
C. Route of administration
D. Pattern of use (episodic/continual/single/recreational/mood management)
E. Association between substance use and mental illness
F. Perceived benefits
7. Personal history
A. Developmental milestones/stageoflife experiences
B. Response to transitions/adjustments
C. Genetic influences (inherited/consequences, potential of passing on to children)
D. Psychosocial issues
1. Family (experiences and genogram)
2. Education
436 4. Professional Practice Forms Clinical Forms Business Forms

3. Religion/spiritual beliefs
4. Culture/ethnicity (immigration, political repression, war experience,
natural disaster)
5. Legal issues (past, current)
E. Current level of functioning
1. Mood management
2. Family (marriage, parenting)
3. Personal relationships/resources
4. Work
5. School
6. Social environment
F. Past level of functioning
1. Mood management
2. Family (marriage/parenting)
3. Personal relationships/resources
4. Work
5. School
6. Social environment
8. Mental status examination (MSE)
A. The MSE is a systematic review of observed information collected
during the interview
1. Appearance, grooming, general behavior
2. Facial expressions
3. Mood
4. Affect
5. Characteristics of speech and language
6. Movement (rate, repetition, posturing, purposeful, unusual
movements)
7. Thoughts and perception
a. Spontaneous thoughts (concerns, worries, impulses, perceptual
experiences)
b. Cognitive/perceptual distortions (hallucination, delusions, ideas of
reference, obsessions, compulsions)
c. Issues of risk (danger to self, danger to others, violent, selfinjurious)
(insight, judgment, impulse control)
8. Associations (loose or idiosyncratic associations, contradictory
statements)
9. Understanding/insight of the current situation
10. Cognitive status
a. Level of consciousness
b. Orientation
c. Attention and concentration
d. Memory (short term, intermediate, long term)
e. Language function (naming, fluency, comprehension, repetition,
reading, writing)
f. Fund of knowledge
g. Calculation
h. Abstract reasoning (explaining similarities, explaining proverbs)
i. Executive functions (judgment, resisting distraction, inhibition of impulsive
answers, recognizing contradictions)
General Clinical Evaluation 437

9. Diagnostic tests
A. There may be the use of paperandpencil tests or inventories, which may used
later to assess improvement in patient functioning or to monitor other areas of
progress
10. Initial diagnostic impression and diagnoses to be ruled out
11. Initial treatment plan
12. Recommendations or requests of the treatment team members are to follow
up on in establishing a comprehensive treatment plan

TREATMENT PLAN
Name: Date:
DOB: SS#:
Referral source:
Current medications:
(and purpose of medications) Prescribing physician:
Primary care physician:
Current health problems:.
Date of last physical exam:
Approximate date and time frame of treatment
Prior inpatient and/or outpatient treatment (Reason for treatment, Provider, Outcome of

treatment) physical and emotional reasons
Is there a family history of the following? (If yes, explain)
Alcoholism:
Drug abuse/dependency:
Emotional/psychological problems:
Health issues (hypertension, diabetes, cardiac, others):
Do you use substances (daily basis, binging/party, other patterns, how much)?
Treatment Plan 439

Is there a history of sexual abuse or sexual assault?
Is there a history of anger problems or domestic violence?
DIFFICULTIES EXPERIENCED
Thoughts/Feelings/Mood
Depression Intrusive thoughts . Dissociation
Anxiety Anger/frustration . Depersonaliztion
Sadness Not liking self . Derealization
Fear Not liking others . Thoughts of hurting others
Fatigue Sudden mood changes . Excessive worry/stress
Euphoria Obsessive/ruminative thoughts . Negative thoughts
High energy Thought of hurting yourself . Believing you are better
Financial stress Legal worries/problems than others
Hear things other people . Confusion
don't . Memory difficulties
. Difficulty with attention and
concentration
. Suspicious(Distrustful)
. See things other people don't
Behaviors
Compulsive behavior/rituals Angry/hostile _ Lying
Difficulty with daily routine Withdrawal from other Stealing
Difficulty getting to appt. on time Isolation Reactive
Let others take advantage of you Self destructive/sabotaging Avoidant
Using alcohol/drug to cope Abuse of others Controlling
Dependency upon others Hyperactivity Argumentative
Not able to relax Decrease/lack of sexual
interest
Preoccupation with sex
Experience in Workplace
Pattern of tardiness . Negative feelings about work
Absenteeism . Difficulty with supervision
General performance Difficulty with coworkers
General satisfaction . History of work problems
Physical Functioning
_ Ulcers Hyperventilation Hypertension
Bowel problems/changes in habit Shortness of breath Hypoglycemia
Abdominal pain/vomiting Easily fatigued Thyroid dysfunction
Changes in urinary patterns Back pain Sleep disturbance
Changes in menstrual problems Joint pain Appetite disturbance
Colitis/irritable bowl Swelling legs/ankles/feat Hypoglycemia
Headache Chest pain Skin problems
Hearing/vision problems Shakiness/trembling
Sweating/flushes
440 4.Professional Practice Forms Clinical Forms Business Forms

Presenting problem identified by client (why is the person coming to therapy and why now?):
As stated by client
PRESENTING PROBLEMS PERCEIVED BY CLINICIAN

Personal Addictions Crisis Issues
Depression Alcohol Suicidal ideation/ death wish
Anxiety Smoking H/o suicide attempts
Stress Amphetamine Self destructive behavior
Grief Cocaine Homicidal ideation
Selfesteem Hallucinogens H/o violent behavior
Huffing Potential for violent behavior
Interpersonal Opeatis Child abuse
Significant other Sedatives Domestic violence
Marital Tranquilizers Dependent adult abuse/neglect
Family Eating Elder abuse
Child Gambling
Divorce Sex
Friendships Stealing
Work/School Health
Career/vocational Weight
Performance Appetite
Interpersonal Sleep
Authority Pain
Other
DSM IV Diagnosis
Axis I
Axis II
Axis III
Axis IV
Axis V
Treatment Plan 441

Problem Goal Interventions Time frame to complete goal How progress monitored
1
2
3
4
5
6
Therapist's signature Date
Client's signature Date
MENTAL STATUS EXAM
The mental status exam serves as the basis for diagnosis and understanding of the dynamic

elements which contribute to an individual's current level of psychological and emotional
functioning.
A satisfactory assessment should include objective behavioral observation as well as infor
mation elicited through selected questioning of the individual. Sensitivity, tact, and respect
to the individual and their reactions will facilitate cooperation.
The following outline for the mental status exam breaks down the type of information
needed for a thorough evaluation. In order to foster feelings of interest and compassion from
the therapist it is best to begin the evaluation by discussing the present difficulties or primary
complaint and then proceed in a natural manner. This is accomplished by blending specific
questions into the general flow of the interview.
CONTENTS OF EXAMINATION
1. Appearance, Behavior, and Attitude
A. Appearance—apparent age, grooming, hygiene/cleanliness, physical characteristic
(build/weight, physical abnormalities, deformities, etc.), appropriate attire. The
description of appearance should offer adequate detail for identification. It should
take into consideration the individual's age, race, sex, educational background,
cultural background, socioeconomic status, etc.
B. Motor Activity—gait (awkward, staggering, shuffling, rigid), posture (slouched,
erect), coordination, speed/activity level, mannerisms, gestures, tremors, picking on
body, tics/grimacing, relaxed, restless, pacing, threatening, overactive or
underactive, disorganized, purposeful, stereotyped, repetitive.
C. Interpersonal—rapport with the interviewer. Evaluation process, cooperative,
opposition/resistant, submissive, defensive.
D. Facial Expression—relaxed, tense, happy, sad, alert, daydreamy, angry, smiling,
distrustful/suspicious, tearful.
E. Behavior—distant, indifferent, evasive, negative, irritable, labile, depressive,
anxious, sullen, angry, assaultive, exhibitionistic, seductive, frightened, alert,
agitated, lethargic, somnolent.
442 4. Professional Practice Forms Clinical Forms B u s i n e s s Forms

2. Characteristics of Speech
A. Descriptors—normal, pressured, slow, articulate, amount, loud, soft, dysarthric,
apraxic, accent, enunciation.
B. Expressive Language—normal, circumstantial, anomia, paraphasia, clanging,
echolalia, incoherent, blocking, neologisms, perseveration, flight of ideas, mutism.
C. Receptive Language—normal, comprehends, abnormal.
3. Mood and Affect
A. Mood—a symptom as reported by the individual describing how they feel
emotionally, such as: normal, euphoric, elevated, depressed, irritable,
anxious, angry.
B. Affect—observed reaction or expressions. Range of affect includes: broad,
restricted, blunted, flat, inappropriate, labile, mood congruent, mood incongruent.
4. Orientation and Intellectual Ability
A. Orientation—time, person, place, and self. The individual should be asked
questions such as the day of the week, the date, where he lives, where he is at, and
if he knows who he is.
B. Intellectual Ability—above average, average, below average
1. General information—the last four presidents, governor of the state, the capital
of the state, what direction does the sun set, etc.
2. Calculation—serially subtracting 7 from 100 until he can go no further. Simple
multiplication word problems such as, "if a pencil costs 5 cents, how many
pencils can you but with 45 cents?"
3. Abstract Reasoning—proverbs. This is the ability to make valid generalizations.
Responses may be literal, concrete, personalized, or bizarre. Example, "Still
waters run deep", "A rolling stone gather no moss".
4. Opposites—slow/fast, big/small, hard/soft.
5. Similarities—door/window, telephone/radio, dog/cat, apple/banana.
6. Attention—digit span, trials to learn four words.
7. Concentration—months of the year or days of the week backward.
8. Reasoning and Judgment—is able to connect consequences to choices and
behaviors.
5. Memory—immediate (10 to 30 sec)
short term (up to 11/2 hours)
recent (2 hours to 4 days)
recent past (past few months)
remote past (6 months to lifetime)
6. Thought Processes/Content—deals with organization and composition of
thought. Examples include: normal, blocking, loose associations, confabulation,
flight of ideas, ideas of reference, illogical thinking, grandiosity, magical
thinking, obsessions, perseveration, delusions, depersonalization, suicidal
ideation, homicidal ideation.
7. Hallucination—none, auditory, visual, olfactory, gustatory.
8. Insight—good, fair, poor. Understanding, thought, feeling, behavior.
9. Impulse Control—good, fair, poor. The ability/tendency to resist or act on
impulses.
A Mental Status Exam review form can be a helpful adjunct to the initial assessment
report.

MENTAL STATUS EXAM
Appearance: Grooming Normal Disheveled Unusual

Hygiene Normal Body Odor Bad Breath
Other
Motor Activity Relaxed Restless Pacing Sedate
Threatening Catatonic Posturing
Mannerisms Psychomotor Retardation
Tremors Tics Other
Interpersonal Cooperative Oppositional/Resistant
Defensive Other
Speech Normal Pressured Slow Dysarthric Apraxic
Expressive Language Normal Circumstantial Anomia
Paraphasia Clanging Echolalia
Incoherent _Neologisms
Receptive Language Normal Abnormal
Mood Normal Euphoric Elevated Depressed Angry
Irritable Anxious
Affect Broad Restricted Blunted Flat
Inappropriate Labile
Orientation Normal Abnormal
Estimated IQ Above Average _Average Below Average
Attention Normal Distractible Hypervigilant
Concentration Normal Brief
Memory Recent Memory Normal Abnormal
Remote Memory Normal Abnormal
Thought Processes Normal Blocking Loose Associations
Confabulation Flight of Ideas
Ideas of Reference Grandiosity
Paranoia Magical Thinking Obsessions
Perseveration Delusions
Depersonalization Suicidal Ideation
Homicidal Ideation Other
Hallucination None Auditory Visual Olfactory
Gustatory
Judgment Good Fair Poor
Insight Good Fair Poor
Impulse Control Good Fair Poor
444 4. Professional Practice Forms C l i n i c a l Forms Business Forms

MENTAL STATUS EXAM
Date: General Body Movements
Accelerated
Name: Slowed
Appropriate
INITIAL INTERVIEW Inappropriate
Speech (speed and volume)
Presenting Problem: Increased/loud
Decreased/slowed
Normal
Mute
Atypical
Relationships with Others
Domineering
Submissive
Provocative
Suspicious
Sleep patterns:
Uncooperative
Cooperative
Appetite change:
Physically/emotionally abusive
Drug/alcohol use:
FEELINGS (AFFECT AND MOOD)
Appropriate
Marital status:
Inappropriate
Range of Affect
Marriage quality:
Broad
Restricted
Children:
Lability of Affect
Labile
APPEARANCE
Stable
Clothing
Prominent Mood
Clean
Euphoria
Dirty
Hostility
Disheveled
Anxiety
Atypical
Sadness
Physical Hygiene Fearful
Good Other
Fair
Poor PERCEPTION
Illusions
BEHAVIOR Present
Posture Absent
Normal Hallucinations
Slumped Absent
Rigid Present
Unsteady Visual
Atypical Olfactory
Facial Expression Tactile
Anxious Responding to hallucinations
Sad Not responding to hallucinations
Hostile Thought processes
Cheerful Orientation
Inappropriate Disoriented
Other X4 Person/place/time/situation
Menial Status Exam 445

Memory Depersonalization
Impaired Suicidal ideation
Not impaired Homicidal ideation
Immediate Delusions
Recent No thought disorder
Remote Sexually preoccupied
Comments: Associational Disturbance
Thought content Present
Obsessions Absent
Compulsions Judgment
Phobias Impaired
Dearealization Not impaired
Comments:
Therapist Date

INITIAL CASE ASSESSMENT
Name: Date of 1st Contact: Date of 1st Session:

IDENTIFYING INFORMATION:
PRESENTING PROBLEM:
SITUATION STRESSORS:
MENTAL STATUS EXAM:
SYMPTOMS OF IMPAIRED FUNCTIONING:
PATIENT'S STRENGTHS AND ASSETS:
I n i t i a l Case Assessment 447

DIAGNOSIS:
AXIS I: AXIS IV:
AXIS II: AXIS V: CURRENT
AXIS III: PAST:
DIAGNOSTIC COMMENTS:
TREATMENT GOALS:
TREATMENT PLAN:
THERAPIST DATE

INITIAL EVALUATION
Person(s) present at interview:
1. Presenting Problem
A. Presenting problems and precipitating events
B. History of problems
C. Medications/Prescribed by whom
D. Primary Care Physician (PCP)
2. Interpersonal Relationships
A. Current living arrangement
B. Present family relationships
C. Relationships in FamilyofOrigin (past emphasis)
D. Marital/significant other relationships (past and present)
E. Peers and social relationships
3. Medical and developmental history
4. Vocational and educational information
5. Other mental health and community agency involvement (past and present)
6. Diagnostic impression

A. Client mental status
B. Strengths and weaknesses
C. Diagnosis
Axis:
I
II
III
Initial Evaluation 449

IV
V
D. Observations about other family members and relationships
7. Treatment Disposition
A. Goals (what will be accomplished)
B. Objectives (what interventions to reach goals)
Date

BRIEF MENTAL HEALTH EVALUATION REVIEW
Name: DOB:
Date first examined: Type of Service
Outpatient
Case management
Date of most recent visit:
Presenting Problem:
Diagnosis
Axis I
Axis II
Axis III
AxisIV
Axis IV Current Last year
Medications:
Current Mental Status Examination (circle and comment on abnormal findings)

Appearance and Behavior
Grooming: wellgroomed disheveled eccentric poor hygiene
Motor activity: normal tremor, retarded agitated hyperactive
Speech: normal slow rapid pressured slurred mute delayed soft
loud tuttering aphasia
Interview behavior: cooperative guarded evasive
Behavior disturbance: none irritable aggressive violent/poor impulse contol
manipulative apathetic
Comment:
Sensorium and Cognitive Functioning
Orientation: oriented x4 disoriented (person, place, time, situation)
Concentration: intact slight distracted impaired (mild, moderate, severe)
Memory: normal impaired (immediate, recent, remote) and degree (mild,
moderate, severe)
Intelligence: above average average below average borderline mental
retardation
Comment:
Brie/ Mental Health Evaluation Review 451

Mood and Affect
Mood: normal anxious depressed fearful elated euphoric angry
Affect: appropriate labile expansive blunted flat
Perception
Hallucinations: none auditory visual olfactory gustatory
Illusions: none misidentified
Thought Processes
Associations: goal directed blocking circumstantial tangential loose
neologisms
Contentdelusions: none persecution somatic broadcasting grandiosity
religious nihilistic ideas of reference
Judgment: good fair poor
Insight: good fair poor
Impulse control: good fair poor
Comment:
Substance Abuse
Current alcohol use: none social abuse (occasional, binge, pattern, daily)
Specify type, amount, frequency:
Current illicit drug use: none abuse (occasional, episodic, daily) cannabis

cocaine heroin amphetamines sedatives
hallucinogens hypnotic inhalants
Specify drug, amount, frequency:
History of substance abuse:
Detox, treatment program, tox screen (specify date):
History of Sexual Abuse or Assault:

Suicidal Ideation: __Yes No
Homicidal Ideation: _Yes No
Progress in Treatment and Prognosis:
Therapist name Title/license number
Address
Phone FAX/email
Brief Mental Health Evaluation Review 453

LIFE HISTORY QUESTIONNAIRE
The purpose of this questionnaire is to obtain a comprehensive understanding of your life

experience and background. Completing these questions as fully and as accurately as you
can will benefit you through the development of a treatment program suited to your specific
needs. Please return this questionnaire when completed, or at your scheduled appointment.
PLEASE COMPLETELY FILL OUT THE FOLLOWING PAGES
Date
Name
Address
Telephone numbers (day) (evenings).
DOB Age Occupation
By whom were you referred?
With whom are you now living? (list people).
Where do you reside? house hotel room apartment other
Significant relationship status (check one)

single
engaged
married
separated
divorced
remarried
committed relationship
widowed
If married, husband's (or wife's) name, age, occupation?
1. Role of religion and/or spirituality in your life:

A. In childhood
B. As an adult
2. Clinical
A. State in your own words the nature of your main problems and how long they have
been present:

B. Give a brief history and development of your complaints (from onset to present):
C. On the scale below please check the severity of your problem(s):

mildly upsetting
moderately severe
very severe
extremely severe
totally incapacitating
D. Whom have you previously consulted about your present problem(s)?_
E. Are you taking any medication? If "yes"> what, how much, and with what results?
3. Personal Data
A. Date of birth Place of birth
B. Mother's condition during pregnancy (as far as you know):
C. Check any of the following that applied during your childhood:

Night terrors Bedwetting Sleepwalking
Thumb sucking Nail biting Stammering
Fears Happy childhood Unhappy childhood
Any others:
D. Health during childhood?
List illnesses ,
E. Health during adolescence?
List illnesses
F. What is your height? Your weight
G. Any surgical operations? (Please list them and give age at the time)
H. Any accidents:

I. List your five main fears:
1.
2.
3.
4.
5.
J. Underline any of the following that apply to you:

headaches dizziness fainting spells
palpitations stomach trouble anxiety
bowel disturbances fatigue no appetite
anger take sedatives insomnia
nightmares feel panicky alcoholism
feel tense conflict tremors
depressed suicidal ideas take drugs
unable to relax sexual problems allergies
don't like weekends overambitious shy with people
and vacations
can't make friends inferiority feelings can't make decisions
can't keep a job memory problems home conditions bad
financial problems lonely unable to have a good time
excessive sweating often use aspirin concentration difficulties
or painkillers
Please list additional problems or difficulties here.
K. Circle any of the following words which apply to you:

Worthless, useless, a "nobody," "life is empty"
Inadequate, stupid, incompetent, naive, "can't do anything right"
Guilty, evil, morally wrong, horrible thoughts, hostile, full of hate
Anxious, agitated, cowardly, unassertive, panicky, aggressive
Ugly, deformed, unattractive, repulsive
Depressed, lonely, unloved, misunderstood, bored, restless
Confused, unconfident, in conflict, full of regrets
Worthwhile, sympathetic, intelligent, attractive, confident, considerate
Please list any additional words:
456 4. Professional Practice Forms C l i n i c a l Forms Business Forms

L. Present interests, hobbies, and activities.
M. How is most of your free time occupied?
N. What is the last grade of school that you completed?.
O. Scholastic abilities: strengths and weaknesses
P. Were you ever bullied or severely teased?
Q. Do you make friends easily?
Do you keep them?
4. Occupational Data
A. What sort of work are you doing now?
B. List previous jobs.
C. Does your present work satisfy you? (If not, in what ways are you dissatisfied?)
D. How much do you earn?
How much does it cost you to live?.
E. Ambitions/Goals
Past
Present
5. Sex Information
A. Parental attitudes toward sex (e.g., was their sex instruction or discussion in the

home?)
B. When and how did you derive your first knowledge of sex?
C. When did you first become aware of your own sexual impulses?

D. Did you ever experience any anxieties or guilt feelings arising out of sex or
masturbation? If "yes," please explain.
E. Please list any relevant details regarding your first or subsequent sexual experience.
F. Is your present sex life satisfactory? (If not, please explain).
G. Provide information about any significant heterosexual (and/or homosexual) reactions.
H. Are you sexually inhibited in any way?
6. Menstrual History
Age of first period ?_
Were you informed or did it come as a shock?.
Are you regular? Duration.
Do you have pain? Date of last period
Do your periods affect your moods?

7. Marital History
How long did you know your marriage partner before engagement?.
How long have you been married?
Husband's/Wife's age
Occupation of husband or wife.
A. Describe the personality of your husband or wife (in your own words)
B. In what areas is there compatibility?
C. In what areas is there incompatibility?
D. How do you get along with your inlaws? (This includes brothers and

sistersinlaw.)
How many children do you have?
Please list their gender and age(s).

E. Do any of your children present special problems?
F. Any history of miscarriages or abortions?
G. Comments about any previous marriage(s) and brief details.
8. Family Data
A. Father
Living or deceased?
If deceased, your age at the time of his death.
Cause of death.
If alive, father's present age.
Occupation:
Health:
B. Mother
Living or deceased?
If deceased, your age at the time of her death.
Cause of death.
If alive, mother's present age.
Occupation:
Health:
C. Siblings
Number of brothers: Brothers' ages:
Number of sisters: Sisters' ages:
D. Relationship with brothers and sisters:
Past:
Present:
E. Give a description of your father's personality and his attitude toward you
(past and present):
Li/e History Questionnaire 459

F. Give a description of your mother's personality and her attitude toward you
(past and present):
G. In what ways were you punished by your parents as a child?
H. Give an impression of your home atmosphere (i.e., the home in which you grew up,

including compatibility between parents and between parents and children).
I. Were you able to confide in your parents?
J. Did your parents understand you?
K. Basically, did you feel loved and respected by your parents?
If you have a stepparent, give your age when parent remarried:
L. Describe your religious training:
M. If you were not raised by your parents, who did raise you, and between what years?
N. Has anyone (parents, relatives, friends) ever interfered in your marriage,

occupation, etc.?
O. Who are the most important people in your life?
P. Does any member of your family suffer from alcoholism, epilepsy, or anything

which can be considered a "mental disorder"?
Q. Are there any other members of the family about whom information regarding

illness, etc., is relevant?
R. Recount any fearful or distressing experiences not previously mentioned?

S. What do expect to accomplish from therapy, and how long do you expect therapy
to last?
T. List any situations which make you feel calm or relaxed.
U. Have you ever lost control (e.g., temper or crying or aggression)? If so, please describe.
V. Please add any information not brought up by this questionnaire that may aid your

therapist in understanding and helping you.
9. SelfDescription (Please complete the following):
A. I am a person who
B. All my life
C. Ever since I was a child
D. One of the things I feel proud of is
E. It's hard for me to admit
F. One of the things I can't forgive is
G. One of the things I feel guilty about is
H. If I didn't have to worry about my image
I. One of the ways people hurt me is
J. Mother was always
K. What I needed from mother and didn't get was
L. Father was always
M.What I wanted from my father and didn't get was
N. If I weren't afraid to be myself, I might
O. One of the things I'm angry about is
P. What I need and have never received from a woman (man) is
Q. The bad thing about growing up is
R. One of the ways I could help myself but don't is
10. A. What is there about your present behavior that you would like to change?
Lift History Questionnaire 461

B. What feelings do you wish to alter (e.g., increase or decrease)?
C. What sensations are especially:
1. pleasant for you?
2. unpleasant for you?
D. Describe a very pleasant image of fantasy.
E. Describe a very unpleasant image of fantasy.
F. What do you consider your most irrational thought or idea?
G. Describe any interpersonal relationships that give you:
1. joy
2. grief
H. In a few words, what do you think therapy is all about?
11. With the remaining space and blank sides of these pages, give a brief

description of you by the following people:
A. Yourself
B. Your spouse (if married)
C. Your best friend
D. Someone who dislikes you
This has been adapted from Lazarus (1977).

ADULT PSYCHOSOCIAL
IDENTIFYING INFORMATION (age, gender, ethnicity, marital status):
Presenting Problem:
Current Social Information:
1. Describe the present living arrangements (include with whom you are living

with, and a brief description of these relationships):
2. How long have you been married/dating/living together? Describe this

relationship (include occupation and age of significant other):
3. How many children do you have? (name, sex, age):
4. Are there any significant problems with any of these children? (describe):
5. Give details of previous relationships/marriages:
Adult Psycbosocial 463

6. Any history of abuse (emotional, physical, sexual) in current or previous
relationships:
FAMILY HISTORY
1. Describe your childhood and adolescence (include home atmosphere,
relationship with parents):
2. Any history of significant life events such as death, abuse (physical, emotional,

sexual) divorce, separation, other?:
3. List mother and father by age, include occupation:
4. List siblings by age and describe how you relate to them (past and present):
5. Have any family members been treated for/have emotional problems? Describe:

DRUG AND ALCOHOL ABUSE
1. Any family history of drug and/or alcohol usage? List and describe:
2. Any personal history of drug/alcohol usage? List and describe:
EDUCATIONAL HISTORY
1. Describe all school experiences, high school, college, vocational school. Were
there any problems with truancy, suspensions, special education, vocational
training, etc.?:
EMPLOYMENT HISTORY
1. Present employment status and where (positive and negative aspects of what is
going on at work):
2. If on leave of absence or disability, will you return to present job?:
SOCIALIZATION SKILLS
1. List clubs and organizations you belong to:
2. What do you do for pleasure and relaxation?:
Adult Psycbosocial 465

SUMMARY
This year old (include sex, marital status, ethnicity) is currently participating in

outpatient treatment for (summary of reasons for treatment).
1. What/who seems to be placing the most stress on you at this time?:
2. Are there any legal issues pending? Yes No (describe):
3. Are you having financial problems at this time?:
4. Describe your plans regarding any help you would like to have with yourliving
arrangements:
TREATMENT PLANS AND RECOMMENDATIONS

1.
2.
3.
4.
Therapist Date

CHILD/ADOLESCENT PSYCHOSOCIAL
IDENTIFYING INFORMATION
Date of assessment:
Name of child . Sex: (M) (F) _
Birth date Place of birth Age
Address (number and street)
(city) (state) (zip code)
Telephone ( ) Religion (optional)
Education (grade) Present school
Referral Source:
I give permission for (therapist) to contact (physician/teacher/etc.) regarding treatment

issues, symptoms, behaviors or other information necessary for the treatment of (minor
patient).
Parent Signature Date
CHIEF COMPLAINT:
Presenting Problems: (check all that apply)
_Very unhappy _Impulsive _Fire setting
Irritable _Stubborn .Stealing
__Temper outbursts _Disobedient Lying
_Withdrawn _Infantile _Sexual trouble
Daydreaming _Mean to others .School performance
Fearful _Destructive _Truancy
Clumsy Trouble with the law _Bed wetting
Overactive _Running away .Soiled pants
Slow _Selfmutilating _Eating problems
Short attention span _Head banging .Sleeping problems
Distractible _Rocking _Sickly
Lacks initiative _Shy _Drugs use
Undependable _Strange behavior .Alcohol use
Peer conflict _Strange thoughts Suicide talk
_Phobic
Explain:
How long have these problems occurred? (number of weeks, months, years)
What happened that makes you seek help at this time?

Problems perceived to be: very serious serious not serious
What are your expectations of your child?
What changes would you like to see in your child?
What changes would you like to see in yourself?
What changes would you like to see in your family?
PSYCHOSOCIAL HISTORY:
CURRENT FAMILY SITUATION.
Mother—Relationship to child natural parent .relative
stepparent .adoptive parent
Occupation
Education Religion
Birthplace Birth date
Age
Father—Relationship to child natural parent .relative

stepparent .adoptive parent
Occupation
Education Religion
Birthplace Birth date
Age
Marital History of Parents:
Natural Parents: married when _ age.
separated when _
divorced when _
deceased M or F
Stepparents: married when _
If child is adopted:

Adoption source:
Reason and circumstances:

Age when child first in home:
Date of legal adoption:
What has the child been told?
LIVING ARRANGEMENTS: Places Dates
Number of moves in child's life
Present Home renting buying

house apartment
Does the child share a room with anyone else? Yes No
If yes, with whom?
If no, how long has he/she had own room?.
Was the child ever placed, boarded, or lived away from the family? _Yes No
Explain:
What are the major family stresses at the present time, if any?
What are the sources of family income?
BROTHERS and SISTERS: (indicate if stepbrothers or stepsisters)

Living Use drugs Treated for
School or Present at home or alcohol drug abuse
Name Age Sex Occupation Grade (yes or no) (yes or no) (yes or no)
1.
2.
3.
4.
5.
6.
List all other extended family members by their relation to the patient who have drug and/or
alcohol problems (legal or illegal), history of depression, selfdestructive behavior, or legal
problems.
1.
2.

3.
4.
5.
6.
Others living in the home (and their relationship):

1.
2.
HEALTH OF FAMILY MEMBERS: (excluding patient)
Name Relationship to child Type of Illness When Occurred Length of Illness
1.
2.
3.
4.
Does or did any member of the child's family have any problems with:

reading spelling math speech
(if yes, please explain.)
Is there any history in the child's family of:

mental retardation epilepsy birth defects schizophrenia
(if yes, please explain.)
CHILD HEALTH INFORMATION:
Note all health problems the child has had or has now.
AGE AGE
High fevers Dental Problems

Pneumonia _Weight Problems
Flu _Allergies
Encephalitis Skin Problems
_Meningitis Asthma
Convulsions Headaches
Unconsciousness Stomach Problems
Concussions Accident Prone
Head Injury Anemia
Fainting High or Low Blood Pressure
Dizziness Sinus Problems
_Tonsils Out Heart Problems
Vision Problems Hyperactivity
Hearing Problems Other Illnesses, etc.
Earaches (Explain)
Has the child ever been hospitalized? __Yes No

If yes, please explain.
4/0 4. Professional P r a c t i c e Forms Clinical Forms Business Forms

Age How Long Reason
Has child ever been seen by a medical specialist? Yes No

Age How Long Reason
Has child ever taken, or is he/she taking presently any
prescribed medications? _Yes No
Age How Long Reason
Name of Primary Care Physician,
DEVELOPMENTAL HISTORY.
Prenatal—Child wanted? Yes No Planned for? Yes No
Normal pregnancy? Yes No
If mother ill or upset during pregnancy, explain:
Length of pregnancy:
Paternal support and acceptance: (explain)
BIRTH:
Length of active labor: hrs. Easy Difficult
Full term: Yes No
If premature, how early:
If overdue, how late:
Birth weight: Ibs. oz.

Type of delivery: spontaneous cesarean with instruments
head first breech
Was it necessary to give the infant oxygen? _Yes No If yes, how long:
Did infant require blood transfusions? _Yes No
Did infant require Xray? _Yes No
Physical condition of infant at birth:
(If yes explain) anorexia Yes No
trauma _Yes No
other complications _Yes No
Did mother abuse alcohol/drugs during pregnancy? _Yes No
NEWBORN PERIOD:
How Long
irritability Yes No
vomiting Yes No
difficulty breathing __Yes No
difficulty sleeping _Yes No
convulsions/twitching _Yes No
colic Yes No
Child/Adolescent Psycbosocial 471

normal weight gain _Yes _No
was child breast fed Yes No
DEVELOPMENTAL MILESTONES:
Age at which child:
sat up:
crawled:
walked:
spoke single words:
sentences:
bladder trained:
bowel trained: _
weaned:
Describe the manner in which toilet training was accomplished:
EARLY SOCIAL DEVELOPMENT:
Relationship to siblings and peers:
individual play group play
competitive cooperative
leadership role a follower
Describe special habits, fears, or idiosyncrasies of the child:
EDUCATIONAL HISTORY:
Dates attended: Grades completed
Name of School City/State from to at this school
preschool
elementary.
junior high.
high school.
Types of classes: regular learning disability continuation

_emotionally handicapped ...opportunity _other
Did child skip a grade? _Yes No Repeat a grade? _Yes No
(If yes, when and how many years appropriate grade level at present time?

Did child have any specific learning difficulties? _Yes _No
Has child ever have a tutor or other special help with school work? _Yes _No
Does child attend school on a regular basis? _Yes _No
Does child appear motivated for school? _Yes _No
Has child ever been suspended or expelled? _Yes _No
ACADEMIC PERFORMANCE:
Highest grade on last report card?
Lowest grade on last report card?
Favorite subject?
Least favorite subject?
Does child participate in extracurricular activities? __Yes No (explain)
In school, how many friends does child have: a lot a few none
What are child's educational aspirations? quit school

graduate from high school
go to college
Has child had special testing in school? (If yes, what were the results?)
Psychological Yes _No Vocational _Yes No
List child's special interests, hobbies, skills:
Has the child ever had difficulty with the police? _Yes _No (if yes, explain)
Has child ever appeared in juvenile court? __Yes No (if yes, explain)
Has child ever been on probation? _Yes No
From To Reason Probation Officer
Has child ever been employed? _Yes _No

Job Employe How long
Child/Adolescent Psycbosocial 473

ADDITONAL COMMENTS:
Therapist Date

PARENT'S QUESTIONNAIRE
Name of child: Date:
Name of parent (filling out form):
Answer all of the questions by indicating the degree of the problem. Write "N" for never,

"S" for sometimes, or "O" for often in front of the number for each question.
QUESTION
1. Picks at things (nails, fingers, hair clothing)
2. Talks back to authority figures (attitude)
3. Has problems with making or keeping friends
4. Excitable, impulsive
5. Wants to run things
6. Sucks or chews (thumb, clothing, blankets, etc.)
7. Cries easily/often
8. Emotionally reactive
9. Has a chip on his/her shoulder
.10. Tendency to daydream
11. Difficulty learning
12. Always squirming, restless, and moving around
13. Experiences fear and anxiety in new situations/meeting new people
14. Breaks things/destructive
15. Lies, makes up stories
16. Does not follow rules
17. Gets into trouble more than peers
18. Shy and does not assert self
19. Has problems with speech (stuttering, hard to understand, baby talk)
20. Denies mistakes and is defensive
21. Blames other for mistakes
22. Steals
23. Argumentative
24. Disrespectful
25. Pouts and sulks
26. Obeys rules but is resentful
27. When hurt or angered by someone, holds a grudge
28. Develops stomachache or headache when stressed
29. Worries unnecessarily
30. Does not finish tasks
31. Emotionally sensitive and easily hurt
32. Bullies others
33. Cruel and insensitive
Parent's Questionnaire 475

34. Clingy and in need of constant reassurance
35. Easily distracted
36. Frequent headaches or stomachaches
37. Rapid mood changes
38. Fights a lot and creates conflicts
39. Power struggles with authority
40. Childish or immature (wants help when should be able to do it
independently)
41. Does not get along well with siblings
42. Easily frustrated
43. Perfectionism prevents trying new things
44. Problems with sleep
45. Problems with eating
46. Has bowel problems
47. Vomiting, nausea, or other complaints of pain or physical distress
48. Feels he/she is treated differently in the family than siblings
49. Passive and gets pushed around
50. Selfcentered, brags, little understanding of others

SELFASSESSMENT
What is happening in your life which resulted in this appointment?
What would you like to see accomplished in therapy?
CHIEF COMPLAINT (CHECK ALL THAT APPLY TO YOU):

Depression Feeling that you are not real
Low energy Feeling that things around you are not real
Low selfesteem Lose track of time
Poor concentration Unpleasant thoughts won't go away
Hopelessness Anger/frustration
Worthlessness Easily agitated/annoyed
Guilt Defies rules
Sleep disturbance (more/less) Blames others
Appetite disturbance (more/less) Argues
Thoughts of hurting yourself Excessive use of drugs and/or alcohol
Thoughts of hurting someone Excessive use of prescription medications
Isolation/social withdrawal Blackouts
Sadness/loss Physical abuse issues
Stress Sexual abuse issues
Anxiety/panic Spousal abuse issues
Heart pounding/racing Other problems/symptoms:
Chest pain
Trembling/shaking
Sweating
Chills/hot flashes
Tingling/numbness
Fear of dying
Fear of going crazy
Nausea
Phobias
Obsessions/compulsive behaviors
Thoughts racing
Can't hold onto an idea
Easily agitate
Excessive behaviors (spending,
gambling)
Delusions/hallucinations
Not thinking clearly/confusion
Previous outpatient therapy? Yes _No, with
What was accomplished?
medications, list:
Previous hospitalization? Yes No Number of hospitalizations ECT?
If yes, when
SelfAssessment 477
BRIEF MEDICAL HISTORY
Name: Age: DOB: Date:
Primary Care Physician:
Last medial exam:
List any medical problems that you are currently experiencing:
Name of the physician monitoring this condition(s):
List any medications you are currently taking:
Who prescribed the medication(s): _
Have you ever seen a psychiatrist or counselor before?
Yes No When:
Please Explain:
Check any of the following problems that you experience:
lack of appetite sleep disturbance depression
excessive drinking headaches bowel problems
anger management sexual problems bladder control problem
problem drug use appetite disturbance difficulty relaxing
nervousness stomach problems fears/phobia
fatigue pain (where) obsessive thoughts
panic attacks low selfesteem compulsive behaviors
anxiety relationship problems marital/family problems
loneliness difficulty concentrating poor impulse control
nightmares feelings of unreality confusion
intrusive thoughts flashbacks difficulty trusting
4/8 4. Professional Practice Forms Clinical Forms B u s i n e s s Forms

ILLNESSES AND MEDICAL PROBLEMS
Please mark with an "X" any of the following illnesses and medical problems you have had

and indicate the year when each started. If you are not certain when a illness started, write
down an approximate year or ago it occurred.
ILLNESS X YEAR N/A ILLNESS X YEAR N/A
Eye or Eyelid Infection Venereal Disease

Glaucoma Genital Herpes
Other Eye Problems Breast Disease
Ear Condition Nipple Drainage
Deafness or Decreased Hearing Headaches
Thyroid Problems Head Injury
Strep Throat Stroke
Bronchitis Convulsions/Seizures
Emphysema Black Outs
Pneunomia Dizziness
Allergies, Asthma, or Hayfever Mental Problems
Nose Bleeds Arthritis
Tuberculosis Gout
Other Lung Problems Cancer or Tumors
Difficulty Breathing Bleeding Tendency
High Blood Pressure Diabetes
High Cholesterol Measles/Rubeola
Arteriosclerosis (hardening of arteries) . German Measles/Rubella . . . .
Heart Attack . . . Polio
Chest Pain Mumps
Irregular Heart Beat Scarlet Fever
Heart Murmur Chicken Pox
Other Heart Conditions Mononucleosis
Stomach/Duodenal Ulcer Eczema
Nausea Psoriasis
Vomiting Skin Rash
Weight Loss Open Wounds
Weight Gain Infection
Difficulty Swallowing Muscle Stiffness
Diverticulosis Muscle Weakness
Colitis Muscle Pain
Other Bowel Problems Bone Fracture
Blood in Stools Bone Stiffness
Diarrhea Others
Hemorrhoids
Easily Fatigued
Hepatitis . .
Liver Problems
Gallbladder Problems
Hernia
Kidney or Bladder Disease
Prostate Problem (male only)
Ovarian Problem (female only)
Last menstrual period
Last Pregnancy
Menstrual Flow Pattern
Illnesses and Medical Problems 4/9

MEDICAL REVIEW CONSULT REQUEST FOR
PRIMARY CARE PHYSICIAN OF AN EATING
DISORDER (EDO) PATIENT
Dear Attending Physician:
This patient has presented for psychological treatment for an eating disorder. In order for
effective, comprehensive treatment to be rendered, all professionals involved must share
information, including the screening and monitoring of medical complications associated
with the eating disorder. Before psychological treatment proceeds, a physical examination is
required, which includes the following routine lab work. If abnormalities are presented, a
list of selected studies may be required. Please forward the results of your examination and
lab studies. Your consultation is appreciated.
Laboratory Studies for Evaluation of Eating Disorders
Routine:
Complete blood count
Electrolytes, glucose, and renal function tests
Chemistry panel
Liver function tests
Total protein and albumin
Calcium
Amylase
Hormones
Thyroid function tests
A.M. plasma cortisol
Luteining hormone
Follicle stimulating hormone
Estrogen (female)
Testosterone (male)
Chest xray
Electrocardiogram
Dual photon absorptiometry
Selected:
Magnetic resonance imaging for brain atrophy
Abnormal xray for severe bloating
Lower esophageal sphincter pressure studies for reflux
Lactose deficiency tests for dairy intolerance
Total bowel transit time for severe constipation
Regards,
Signature
Adapted from E. Anderson (1991). Medical complications of eating disorders.
480 4.Professional Practice Forms Clinical Forms B u s i n e s s Forms

SUBSTANCE USE AND PSYCHOSOCIAL QUESTIONNAIRE
(To be filled out by client)
Client Name:
Sex: Date of Birth Age: Marital Status: M/D/S
Living Arrangements:
Referral Source:
Presenting Problems:
1. Use of alcohol and/or drugs

Type How used Age started Amount Frequency Last time used
2. Has there been any change in the pattern of alcohol/drug use in the last

6 months to 1 year _Yes No. If yes, describe:
3. Preferred alcohol or drug:
4. Preferred setting for alcohol/drug use (home, work, bars, alone, with friends):
5. Longest period of time you have gone without using alcohol or drugs?
Substance Use and Psychosocial Questionnaire 481

6. What medication(s) are you currently being prescribed, what are you taking it
for, and who is prescribing it?
7. Do you use alcohol or drugs to get started in the morning?
8. Have you ever felt annoyed when other people criticize your substance use?
9. Has your physician ever told you to cut down or stop using alcohol/drugs?
10. Have you ever felt the need to cut down on the use of alcohol/drugs (if yes,
explain):
11. Has the use of alcohol/drugs caused you to be late to or miss work?
12. Has the use of alcohol/drugs affected your home life or relationships?
13. How do you feel about your use of alcohol/drugs?
14. Have you ever attended AA/NA meetings?
TREATMENT HISTORY
1. Number of attempts to stop alcohol/drug use . By what means?
2. Length of time you abstained from alcohol/drug use:
Why did you start again?
3. Previous experiences with detox:
482 4, Professional Practice Forms Clinical Forms B u s i n e s s Forms

4. Previous treatment experiences (list problems, type of treatment, location, and
what you learned and accomplished):
FAMILY HISTORY
1. Alcoholism and/or drug dependence of mother, father, siblings or grandparents?
2. High blood pressure?
3. Diabetes?
4. Liver disease?
SOCIAL HISTORY
1. Occupation:
2. Level of education completed:
SYMPTOMS (If Yes, Please Explain) Yes/No Explain
Depression
Fatigue/decreased activity level
Sleep problems
Appetite problems or changes
Memory problems/changes
Suspicious
Anxiety
Fever, sweaty
Shortness of breath
Chest pain/discomfort
Palpitations
Dizziness
Indigestion/nausea
Vomiting (with blood)
Abdominal pain
Diarrhea
Black "tarry" stools
Trouble getting an erection
Tremors
Blackouts
Substance Use and Psycbosocial Questionnaire 483

SYMPTOMS (If Yes, Please Explain) Yes/No Explain
Periods of confusion
Hallucinations
Staggering/balance problems
Tingling
Headaches/vision changes
Muscle weakness
Suicidal attempts/thoughts
MEDICAL PROBLEMS
Has your physician told you that you have any of the following:
Diabetes Yes No
Cirrhosis Yes No
Hepatitis Yes No
Anemia Yes No
Gout Yes No
High blood pressure _Yes No
Delirium tremens _Yes No
Gastritis Yes No
Pancreatitis _Yes No
Goals of participating in treatment at this time?
484 ^Professional Practice Forms Clinical Forms Business Forms

CHEMICAL DEPENDENCY PSYCHOSOCIAL ASSESSMENT
Date: Age:
S.O. Name Phone:
Religious/ethnic/cultural background:
Marital Status: Children:
Living with Whom:
Present Support System (family/friends):
Chemical History:
Age Last Dose? Length
Chemical Use Route Started Amt. Freq. Last Used of Use
Description of Presenting Problems (patient's view):
Previous Counseling:
When Where Therapist/Title Response To
Familv/S.O. Relationships/History of Chemical Use:
S.O. Relationships and History of Chemical Use:
Chemical Dependency Psychosocial Assessment 485

Effects of on Family/Support System:
Daily Activities that: A. support abstinence:
B. encourage usage:
History of Sexual/Physical Abuse (victim/abuser):
Sexual Orientation:
Education:
Vocational History:
Leisure/Social Interests:
Current Occupation:
Current Employer:
Impact of on Job Performance:
EAP? Yes_ No_ Name: Phone:
Socioeconomic/Financial Problems:
Legal: DWI: Yes_ No_ Court Ordered: Yes_ No_
Patient's Perceptions of Strengths and Weaknesses:
Preliminary Treatment Plan: List presenting problems based on initial assessment of the

client's physical, emotional, cognitive, and behavioral status.
Detox: Yes No Explain:
Rehab: Yes No Explain:

Problem #1:
Problem #2:
Problem #3:
Immediate treatment recommendations to address identifying problems:
Therapist Date
Chemical Dependency Psycbosocial Assessment 487

INITIAL EVALUATION CONSULTATION NOTE TO
PRIMARY CARE PHYSICIAN
Date:
Name:
Primary Care Physician:
Reason for Referral:.
(Presenting Problem)
Medications currently prescribed:
Medical problems currently experiencing:
Previously seen by therapist or psychiatrist:
Symptoms:
depression _anxiety .hopeless/helpless
tearful _fears/phobias .anger/frustration
sleep disturbance _shakiness/trembling _depersonalization
appetite disturbance .palpitations _derealization
difficulty concentrating .sweating/flushes/chills .obsessive thoughts
memory problems _dizziness/nausea .compulsive behaviors
social isolation .fatigue .relationship problems
activity withdrawal jrritability/on edge .family problems
headaches Jiypervigilance .issues of loss
abdominal distress .intrusive thoughts .stress
suicidal ideation _bowel problems .difficulty relaxing
homicidal ideation .asthma/allergies .work problems
sexual abuse/assault _mania .legal/financial problems
eating disorder .school problems/truancy .hyperactive
defies rules _annoys others .easily annoyed
spiteful/vindictive .blames others .argues
uses obscene language .excessive drinking .drug use
somatic concerns
History of Current Problem (Relevant History, Reason for Treatment):

Mental Status:
Mood Normal Depressed Elevated Euphoric Angry Irritable
Anxious
Normal Broad Restricted Blunted Flat Inappropriate
Labile
Memory Intact Shortterm Problems Longterm Problems
Processes Normal Blocking Loose Associations Confabulations
Flight of Ideas Ideas of Reference Grandiosity Paranoia
Obsession Perseverations Depersonalization
Suicidal Ideation Homicidal Ideation
Hallucinations None Auditory Visual Olfactory Gustatory Somatic
__Tactile
Judgment Good Fair Poor
Insight Good Fair Poor
Impulse Control Good Fair Poor
Initial Diagnostic Impression:
Axis I.
Axis II.
Axis III.
Axis IV.
Axis V.
Initial Treatment Plan:
Brief psychotherapy Medication evaluation with PCP
Supportive psychotherapy Medical referral
Decreased symptomatology Improve coping
Stabilize Utilization of Resources
Cognitive restructuring Social skills training
Specialized group Problem solving/conflict resolution
Child Protective Services Stress management
AA/Alanon Behavior modification
Chemical dependency treatment Pain management
Selfesteem enhancement Suicide alert
Parent counseling Impatient care/Partial hospitalization
Grief resolution Legal alert
Psychological testing Potential violence
Next Appointment
Therapist
I n i t i a l Evaluation Consultation Note to Primary Care Physician 489

BRIEF CONSULTATION NOTE TO PHYSICIAN
Dear Dr.
was seen on
Purpose of visit:
Preliminary findings reveal:
I tentative diagnosis:
Return appointment:
If you have further questions please feel free to contact me.
Sincerely,

OUTPATIENT TREATMENT PROGRESS REPORT
Name: Date:.
SS#: DOB:
Date of initial interview: Number of sessions:
Describe treatment motivation and compliance:
Current Risk Factors

Suicidality: None Ideation Plan Intent w/o means Intent with means
Homicidality: None Ideation Plan Intent w/o means Intent with means
If risk exists: Client is able to contract not to harm: Self Others
Impulse control: Sufficient Moderate Minimal Inconsistent Explosive
Substance abuse: None A b u s e D e p e n d e n c e Unstable Remission
Medical risks: Yes No If "yes," explain:
Risk History (Explain significant history of behaviors that may affect the current level
of risk.)
Functional Impairments (Explain how symptoms impact current functioning or place client
at risk.)
Diagnosis
Axis I—Primary Secondary
Axis II—
Axis III—
Axis IV— (Identify Stressors)
Axis V (GAP) Current Highest in past 12 months
Current Medication
None Psychiatric Medical No information
Specify (include dosage, frequency, and compliance}:

A: Measurable Behavioral Goals with Target Dates for Resolution
1.
2.
3.
B: Planned Interventions
1.
2.
3.
C. Objective Outcome Criteria by Which Goal Achievement Is Measured
1.
2.
3.
D. Progress Since Last Update
E. Referrals
F. Discharge Planning
Comments:

Therapist Date
Patient

PROGRESS NOTE FOR INDIVIDUAL WITH ANXIETY
AND/OR DEPRESSION
Symptoms List: Check off any symptoms that have been most bothersome or have occurred

frequently during the past week.
Date:
Name:
G aieral Symptoms
Fever
Repetitive, senseless thoughts
Repetitive, senseless behaviors
Fainting or feeling faint
Tremors, trembling, or shakiness
Seizures
Easy bruising
Skin rash
Violent behavior
Constant worry Section 1: If constant worry plus three other
Irritability symptomsin Section 2 are checked,
Tension consider a diagnosis of persistent
Headache anxiety.
Feeling in a dreamlike state
Fearful feelings
Fear of losing control
Jumpiness
Restlessness
Sweating
Dizziness/lightheadedness
Keyed up/on edge
Agitation Section 2: If any symptoms are checked in this
Nervousness section, plus either of the first two
Trouble concentrating symptoms in Section 3, consider a
Insomnia/trouble sleeping diagnosis of depression with
Decrease in sex drive associated anxiety.
Trouble making decisions
Sad/depressed/down in the dumps Section 3: If six or more symptoms in
Lack of/loss of interest in things this area are checked, consider a
Helpless feelings diagnosis of depression.
Fatigue, lack of energy
Weakness
Increase or decrease in appetite
Increase or decrease in weight
Frequent crying or weeping
Frequent thoughts of death or suicide
Worthless feelings
Excessive feelings of guilt
Hopeless feelings
Feeling life is not worth living
Sleeping too much
Frequent negative thinking
Memory problems

Fear of doing something uncontrollable
Fear of dying
Chills
Seeing or hearing things that are not real
Fear of going crazy
Please list medications and dosages

Do you smoke? _No _Yes. How much?
Do you drink or use other substances? _No _Yes. How much and how often?
Do you have thoughts of harming yourself?
Do you have thoughts of harming another person?
*May be used as a progress note. Have patient check off symptoms. Remove the printing on
the right side of page and line to write progress note.
Adapted from Bristol Meyer Squibb Well Being Chart.
Progress Note for Individual with Anxiety and/or Depression 495

CLINICAL NOTES
1. Mental Status:

A. Appearance: WNL Unkempt Dirty Meticulous Unusual
B. Behavior: WNL Guarded Withdrawn Noncompliant Hostile.
Uncooperative Provocative Manipulative Hypoactive,
Hyperactive Suspicious Cooperative Pleasant
Underthe influence
C. Mood/Affect: WNL Flat Depressed Euphoric Anxious
Fearful Irritable Angry Labile Incongruent
D. Cognitions: WNL Loose Scattered Blocked Illogical
Dilusional Paranoid Hallucinations Grandiose
Fragmented Somatic
E. Safety: Danger to self/others? Yes No
If yes, describe:
Safe to return home? Yes No
If no, state planned intervention below.
2. Intervention and/or Teaching:
3. Patient Response/Participation:
Signature: Date:
1. Mental Status:

A. Appearance: WNL Unkempt Dirty Meticulous Unusual
B. Behavior: WNL Guarded Withdrawn Noncompliant Hostile,
Uncooperative Provocative Manipulative Hypoactive_
Hyperactive Suspicious Cooperative Pleasant
Underthe influence
C. Mood/Affect: WNL Flat Depressed Euphoric Anxious
Fearful Irritable Angry Labile Incongruent
D. Cognitions: WNL Loose Scattered Blocked Illogical
Dilusional Paranoid Hallucinations Grandiose
Fragmented Somatic
E. Safety: Danger to self/others? Yes No
If yes, describe:

Safe to return home? Yes No
If no, state planned intervention below.
2. Intervention and/or Teaching:
3. Patient Response/Participation:
Signature: Date:
Printed by permission from Cosette TaillacVento, LCSW
WNL=Within Normal Limits
C l i n i c a l Notes 497
DISABILITY/WORKER'S COMPENSATION
Patient Name: Sex M F DOB.
Address:
Work Phone: Home Phone:
Occupation:
SS#: Date Last Worked:
Date Disability Commenced On:
Approximate date patient may resume work:
Has patient previously been treated at this office? Yes No
If yes, give dates/circumstances:
Description of patient complaint:
Symptoms experienced:
Diagnosis (including DSMIV/CPT code):
Type of treatment rendered and frequency:
Referral to Residential Treatment Facility: Yes No
If yes, where and for what purpose:
Profession: Practice in the State of:
Name on License: License #:
Signature: Date:
Address:
Phone: Fax:

SOCIAL SECURITY EVALUATION MEDICAL SOURCE
STATEMENT, PSYCHIATRIC/PSYCHOLOGICAL
Please evaluate, give examples, and provide comments on the patient's ability in the follow

ing categories:
1. Ability to relate and interact with supervisors and coworkers.
2. Ability to understand, remember, and carry out an extensive variety of

technical and/or complex job instructions.
3. Ability to understand, remember and carry out simple oneortwo step job

instructions.
4. Ability to deal with the public.
5. Ability to maintain concentration and attention for at least 2 hour increments.
6. Ability to withstand the stress and pressures associated with an 8 hour

workday and daytoday work activity.
7. Please comment on the patient's ability to handle funds.
8. Please comment on expected duration and prognosis of patient's impairments.
9. Please comment on the onset and history of the patient's impairments, as well

as response to treatment.
10. Specify any side effects from medication and restrictions related thereto.
11. Does patient require any additional testing or evaluations? Please specify.
Therapist Date
Social Security Evaluation Medical Source Statement, P s y c h i a t r i c / P s y c h o l o g i c a l 499

WORKER'S COMPENSATION ATTENDING
THERAPIST'S REPORT
Employee: Claim Number:
Employer: Date of Injury: Date of Next Appt:
Date of This Exam: Patient Social Security No:
Current Diagnosis:
PROGRESS
Since the last exam, this patient's condition has:
Progressed as expected progressed slower than expected
not progressed significantly worsened
plateaued. No further progress expected been determined to be nonwork related
Briefly describe any change in objective or subjective complaint:
TREATMENT
Treatment Plan: (only list changes from prior status): No change Patient is/was
discharged from care on:
Est. Discharge Date: Medications:
Therapy Type Duration Times per Week
Diagnostic Studies:
Hospitalization/Surgery:
Consult/Other Services:
WORK STATUS
The patient has been instructed to:
return to full duty with no limitations or restrictions
remain off the rest of the day and return to work tomorrow
with no limitations with limitations listed below
return to work on
Work limitations:
Remail off work until
Estimated date patient can return to full duty:

DISABILITY STATUS
Patient discharged as cured
Please supply a brief narrative report if any of the following apply:
Patient will be permanently precluded from engaging in his/her usual and customary
occupation
Patient's condition is permanent and stationary
Patient will have permanent residuals Patient will require future medical care
Therapist Name: Address:
Signature:
Date: Telephone:
Worker's Compensation Attending Therapist's Report 501

BRIEF PSYCHIATRIC EVALUATION
FOR INDUSTRIAL INJURY
Date:
Name: Type of service
Outpatient psychotherapy
Date of first examination: Intensive Outpatient
Urgent care
Date of most recent visit: Case Management
Frequency of visits:
Diagnosis (axis I):
Medication
1. 2.
3. 4.
CURRENT MENTAL STATUS EXAM (circle and comment if abnormal findings)
Appearance and Behavior

Grooming: Wellgroomed, disheveled, eccentric, poor hygiene
Motor activity: Normal, tremor, retarded, agitated, hyperactive
Speech: Normal, slow, rapid, pressured, slurred, mute, delayed, soft, loud, stuttering, aphasia
Interview behavior: Cooperative, guarded, evasive
Behavioral disturbance: None, irritable, aggressive, violent, poor impulse control, manipu
lative, apathetic
Comments:
Sensorium and Cognitive Functioning

Orientation: Oriented in all spheres, disoriented (person, place, time, situation)
Concentration: Intact, slightly distracted, impaired (mild, moderate, severe)
Memory: Normal, impaired (immediate, recent, remote) and degree (mild, moderate, severe)
Intelligence: Above average, average, below average, borderline, mental retardation
Comments:
Mood and Affect

Mood: Normal, anxious, depressed, fearful, elated, euphoric, angry
Affect: Appropriate, labile, expansive, blunted, flat
Comments:

Percepion
Hallucinations: None, auditory, visual, olfactory
Illusions: None, misidentification
Specify:
Thought Process
Associations: Goal directed, blocking, circumstantial, tangential, loose, neologisms
ContentDelusions: None, persecution, somatic, broadcasting, grandiosity, religious, nihilistic,
ideas of reference
Contentpreoccupations: None, obsessions, compulsions, phobias, sexual, suicidal, homicidal,
depersonalization
Comments:
Judgment: Intact, impaired (mild, moderate, severe)
Comments:
PROGRESS IN TREATMENT AND PROGNOSIS:
ALCOHOL AND DRUG ABUSE

Current alcohol use: None, social, abuse (occasional, binge pattern, daily)
Current illicit drug use: None, social, abuse (occasional, binge pattern, daily)
Detox, drug program, or tox screen: (Specify dates and results)
History of alcohol/drug abuse:.
CURRENT WORK-RELATED SKILLS
(Comment on reason for limitation and degree of limitation, if there is impaired ability.)
Able to understand, remember and perform simple instructions:
Able to understand, remember and perform detailed, complex instructions:
Able to maintain concentration for twohour periods:
Able to interact with coworkers and supervisors:
Able to sustain an ordinary routine without special supervision:
Brief Psychiatric Evaluation for Industrial Injury 503

Able to handle the responsibilities common to a basic work environment:
Do you believe this patient is capable of managing funds in his/her own best interest?
Yes No Comments:
Name of reporting doctor:
Address: Signature:.
City, state: Title:
Telephone number: Date:.

BRIEF LEVEL OF FUNCTIONING REVIEW FOR
INDUSTRIAL INJURY
Name: Date
DOB: SS#: _
Mental Status Assessment based on last office visit

Provide assessment based on last office visit. Circle response.
1. Sensorium: Alert Clear Clouded Drowsy Other
2. Orientation: Normal Disoriented as to: Time Place Person Situation
3. Behavioral attitudes: Cooperative Hostile Withdrawn Guarded/Resistant
Indifferent/Passive
4. Appearance: Wellgroomed Adequate Unkempt Inappropriate
Other
5. Attention and concentration: Good Fair Distractible Other
6. Speech: Rate Normal Slow Rapid Halting Pressured
Other
Quality Clear Mumbled Slurred Other
Tone Normal Low Inaudible Loud Other
7. Psychomotor activity: Normal Retarded Accelerated Restless Agitated
8. Mood: Euthymic Depressed Elevated Hypomanic Manic
Anxious Angry Irritable Labile
9. Affect: Congruent w/mood & thought Incongruent w/mood & thought
Intensity: Full Bland Blunted Flat
Range: Constricted Normal
10. Thought Process: Goal Directed/Relevant Tangential Circumstantial
Loose Associations Flight of ideas
11. Thought Content Obsessions Preoccupations Grandiose Paranoid
Somatic religious Phobia Fears
Hallucinations: Auditory (Command Type Y N) Visual
Tactile Olfactory
Delusions:
Suicidal Ideation: No Yes Plan/Intent: No Yes
Risk: Low Moderate High
Homicidal Ideation: No Yes Plan/Intent No Yes
Risk: Low Moderate High
12. Insight &c psychological mindedness Excellent Good Fair Poor
13. Evidence of possible organic/neurological pathology No Yes Comments:
14. Vegetative symptoms:
Brief Level of Functioning Review for Industrial Injury 505

Circle the response that applies to the patient's ability to perform ADL's
Performance Areas ADL's Performance of ADL's

1 Mathematical skills Balance checkbook Yes No N/A ?
2 Word processing Operate personal computer at home Yes No N/A ?
skills Write letters Yes No N/A ?
3 Problem Schedule day Yes No N/A ?
solving/judgment Schedule children's day Yes No N/A ?
Driving Yes No N/A ?
4 Attention/ Read newspaper or books Yes No N/A ?
concentration Follow movie/TV shows Yes No N/A ?
Shopping Yes No N/A ?
5 Initiate work Planning/cooking meals Yes No N/A ?
Initiate and complete domestic Yes No N/A ?
chores (washing dishes, laundry,
yard work, etc.)
Remember doctor's appointments Yes No N/A ?
6 Memory Recalling phone conversations Yes No N/A ?
Remembering medications/dosages Yes No N/A ?
Socialize with family/friends Yes No N/A ?
Attend social outings/church Yes No N/A ?
7 Social interactions Pariticipate in hobbies Yes No N/A ?
Participate in exercise /sports Yes No N/A ?
Take trips/vacations Yes No N/A ?
Bathe/shower regularly Yes No N/A ?

8 Maintain personal Neat grooming Yes No N/A ?
hygiene Dressed appropriately Yes No N/A ?
9 Supervise others Supervise children/family members Yes No N/A ?

Organize home activities Yes No N/A ?
10 Understand and Medication compliant Yes No N/A ?
carry out Manage physical health needs Yes No N/A ?
instructions Return phone calls Yes No N/A ?
How are these functions assessed?
506 4. Professional P r a c t i c e Forms Clinical Forms B u s i n e s s Forms

What are the treatment plan target dates?
Goal: Target date:
Goal: Target date:
Goal: Target date:
What are the current: Medications / Dosage Frequency / Response
DSM IV AND ICD 9 code of Diagnostic Categories for which the patient is being treated:

a. Axis I (ICD or billing codes)
b. Axis II
c. Axis II
d. AxisIV
e. Axis V
Current symptoms GAF= GAF=

current past year
Released to return to work: or Estimate for return to work:
The patient is unable to return to work at this time because he/she is unable to perform the

following jobrelated duties:
Brief Level of Functioning Review for I n d u s t r i a l Injury 507

The reason(s) that he/she is unable to return to work:.
Circumstances that have contributed to the patient's recovery taking longer include the
following:
The person could return to work with the following modifications or restrictions:.
Signature of Therapist License number
Address Phone

OUTLINE FOR DIAGNOSTIC SUMMARY
DIAGNOSTIC SUMMARY
Date:
Patient Name:
Date of Birth:
Sources of Information (includes but not limited to, mental status exam, history and physical,

psychiatric evaluation, psychosocial and treatment plan).
Identification of the Patient (demographic information, include but not limited to, age, race,

marital status, etc.):
Presenting Problems (includes, but not limited to, why was the patient hospitalized, drug of

choice, route of admission, frequency of use, pattern of use, medical problems, mood, affect,
mental status, legal problems, etc.):
Treatment Plan/Recommendations/Goals (includes problem list, therapeutic interventions

and goals):
O u t l i n e for Diagnostic Summary 509

Discharge Plan (includes, but not limited to, followup with therapy, a physician, a sponsor,
a 12step recovery program, vocational guidance, etc.):
Therapist Date

DISCHARGE SUMMARY
NAME OF PATIENT:
IDENTIFICATION OF PATIENT:
PRESENTING PROBLEM:
TREATMENT GOALS: WERE GOALS MET? (yes/no}
DISPOSITION/CONSULTS/REFERRALS/PROGNOSIS:
INITIAL DIAGNOSIS: DISCHARGE DIAGNOSIS:

Axis I Axis I
Axis II Axis II
Axis III Axis III
Axis IV Axis IV
Axis V Axis V
Date of 1st session: Date of last session: # of sessions:
Date Therapist
Discharge Summary 511

Bwsmess Forms
513
PATIENT REGISTRATION
(PLEASE PRINT) Today's Date: __/__/_
Patient's full name: SS#:
Home Address: City: State: Zip:
Home Phone: ( ) Sex: Age: Date of Birth: __/__/_
Patient Employer: Phone Number: ( )
If Student: H.S. College:
Family Physician: Referred By:
Person to Contact in Emergency: Phone:
INSURED/RESPONSIBLE PARTY INFORMATION
Please complete this section regardless of insurance coverage.
Full Name of Insured: Relationship: Occupation:
Home Address: Phone: ( )
Employer and Address: Phone:
Insured's SS# Driver's License No. State.
Full Name of spouse: SS#:
Spouse's Employer: Phone:
Insured's Primary Ins. Co.: I.D.No.: Group NO.:
Secondary Ins. Co.: No __Yes; Company: Policy No.:
Job Related InjuryWorkmens Comp. Co.: No __Yes; Company:
OFFICE BILLING AND INSURANCE POLICY

1. I authorize us of this form on all of my insurance submissions.
2. I authorize the release of information to my insurance company(s).
3. I understand that I am responsible for the full amount of my bill for services
provided.
4. I authorize direct payment to my service provider.
5. I hereby permit a copy of this to be used in place of an original.
Name: I.D.#
Signature: Date:
Patient Registration 515

It is your responsibility to pay any deductible amount, copay, coinsurance amount or
any other balance not paid by your ins. the day and time serviced provided.
There will be a $25.00 service charge on all returned checks.
In event that your account goes to collections, there will be a 20% collection fee added
to your balance.
There is a 24hour cancellation policy which requires that you cancel your appointment
24 hours in advance between the hours of Sam to 4pm Monday through Friday to avoid
being charged.
Signature Date

CONTRACT FOR SERVICES WITHOUT
USING INSURANCE
Financial Agreement
I have agreed to pay privately for my therapy.
The agreed upon charge is $ for the first visit and then $ per session

thereafter. Paperwork or other requests will be a separate cost if not done during the allot
ted time. Additionally, I acknowledge that my insurance will not reimburse me for my deci
sion to see privately. is not to bill my insurance.
Name: Date:
FEE AGREEMENT FOR DEPOSITION AND
COURT APPEARANCE
Date:
To:
From:
Re:
When served with a subpoena duces tecum for my appearance in person or a deposition sub
poena for my appearance, the following fee policies will be in effect. This is the case unless
you receive a signed, written amendment from me.
My fee for scheduled appearance is $ /hour paid in advance. The fee is due with the

subpoena. If the fee is not paid at that time, arrangements for payment are the duty of the
party requesting the appearance and must be made on receipt of this communication.
The fee is required for my scheduling the day or any fraction of the day. The fee is due
whether or not I am actually called on that day. The fee is due even if the appearance is can
celed by anyone other than me for any reason and at any time. These are my usual and cus
tomary fee arrangements.
Fee Agreement for Deposition and Court Appearance 51 /

Further required attendances will be charged at additional daily rates under the same cir
cumstances. These terms are not negotiable.
Please determine the number of days you need me, specify same, and send me a check for
$ per day by return mail if you want me to obey your subpoena. Then I will get back
to you with my availability.
For payment purposes, my Federal Tax Identification Number or my Social Security Number
is .
Signature of Therapist

LIMITS ON PATIENT CONFIDENTIALITY
We are required to disclose confidential information if any of the following conditions exist:
1. You are a danger to yourself or others.

2. You seek treatment to avoid detection or apprehension or enable anyone to
commit a crime.
3. Your therapist was appointed by the courts to evaluate you.
4. Your contact with your therapist is for the purpose of determining sanity in a
criminal proceeding.
5. Your contact is for the purpose of establishing your competence.
6. The contact is one in which your psychotherapist must file a report to a public
employer or as to information required to be recorded in a public office, if
such report or record is open to public inspection.
7. You are under the age of 16 years and are the victim of a crime.
8. You are a minor and your psychotherapist reasonably suspects you are the
victim of child abuse.
9. You are a person over the age of 65 and your psychotherapist believes you are
the victim of physical abuse. Your therapist may disclose information if you
are the victim of emotional abuse.
10. You die and the communication is important to decide an issue concerning a
deed or conveyance, will or other writing executed by you affecting as interest
in property.
11. You file suit against your therapist for breach of duty or your therapist files
suit against you.
12. You have filed suit against anyone and have claimed mental/emotional
damages as part of the suit.
13. You waive your rights to privilege or give consent to limited disclosure by
your therapist.
14. Your insurance company paying for services has the right to review all records.
*If you have any questions about these limitations, please discuss them with your therapist.
Signature: Date:
I am consenting to my (or my dependent) receiving outpatient treatment.
Signature: Date:
RELEASE OF INFORMATION
I authorize to contact my primary care physician (name)
regarding an appointment being made for followup, as well as information pertaining to
psychological and emotional function.
Signature: Date:
Limits on Patient Confidentiality 519

TREATMENT CONTRACT
The therapist and I have discussed my/my child's case and I was informed of the risks,
approximate length of treatment, alternative methods of treatment, and the possible conse
quences of the decided on treatment which includes the following methods and interven
tions: For the purpose of
Stabilization
Decrease and relieve symptomatology
Improve coping, problem solving, and use of resources
Skill development
Grief resolution
Stress management
Behavior modification and cognitive restructuring
Other
While I expect benefits from this treatment I fully understand and accept that because of fac

tors beyond our control, such benefits and desired outcomes cannot be guaranteed.
I understand that the therapist is not providing emergency service and I have been
informed of whom/where to call in an emergency or during the evening or weekend hours.
I understand that regular attendance will produce the maximum possible benefits but that
I or we am/are free to discontinue treatment at any time in accordance with the policies of
the office.
I understand that I am financially responsible for any portion of the fees not covered or
reimbursed by my health insurance.
I have been informed and understand the limits of confidentiality, that by law, the thera
pist must report to appropriate authorities any suspected child abuse or serious threats of
harm to myself or another person.
I am not aware of any reason why I/we/he/she should not proceed with therapy and
I/we/he/she agree to participate fully and voluntarily.
I have had the opportunity to discuss all of the aspects of treatment fully, have had my
questions answered, and understand the treatment planned. Therefore, I agree to comply
with treatment and authorize the above named clinician(s) or whomever is designated to
administer the treatment(s) to me or my child.
Name of Patient:
Signature of Patient/Parent/Guardian:
Therapist Signature: Date:

CONTRACT FOR GROUP THERAPY
1. As a group member I expect to benefit from participation, I recognize that

I have rights and responsibilities as a group member.
2. The goals of this group are:
A.
B.
C.
3. I will attend all group meetings and be on time. If there is an emergency which
prevents me from attending I will contact the group facilitator as soon as
possible. If for some other reason I am not able to attend a group meeting I
will let the group know at least one week in advance.
4. If for some reason I decide to not continue to participate in group or I am
unable to, I will let the group know 2 days before the last group meeting
that I attend.
5. I agree to not socialize with group members outside of group.
6. I have been informed and understand the limits of confidentiality, that by law,
the group facilitator must report to appropriate authorities any suspected child
abuse and any serious threats of harm to myself or another person.
7. The cost of group is $ , or $ per session, which
begins at am/pm and ends at am/pm on
days. The first group meeting is scheduled for .
8. Respectfully and with full understanding I accept the following rules:
A. Only first names will be used.
B. There will be no side conversations or comments, whoever is speaking will be given
full attention and respect.
C. Children or other unauthorized visitors are not allowed in group.
D. Recording of the group meetings is not allowed.
E. I agree to not disclose information/problems of any group member outside
of group.
F. I will not disclose the identity of any group member outside of group.
G. No food or drink will be allowed in group.
H. I will not abuse any substances on the day of a group meeting.
Name: Date:
Contract for Group Therapy 521

RELEASE FOR THE EVALUATION AND TREATMENT
OF A MINOR
As parent or legal guardian of .

I authorize his/her evaluation and treatment. As parent or legal guardian, I have the right to
request information concerning the above minor's evaluation and treatment.
Signature Date
Witness Date
AUTHORIZATION FOR THE RELEASE OR
EXCHANGE OF INFORMATION
Patient Name: DOB:
Information To Be Released By Or Exchange With:
Name:
Address:
Information To Be Released By Or Exchanged:

History and Physical Exam Court/Agency Documents Family Systems Eval
Discharge Summary Mental Status Nursing Notes
Psychiatric Evaluation Treatment Plans Consultation Reports
Psychological Test Results Progress Notes Educational Records
Chemical Recovery History Therapist Orders EducationalTests and
Dates of Hospitalization Diagnoses Reports
Crisis Intervention Attendance Record
Reports Psychosocial Report
Medical Records Lab results
Other (specify)
Date:
Patient Signature

CLIENT MESSAGES
InChart Log
Client's name:
Phone calls/messages
Date: Time: am/pm
Content:
Response:
Date: Time: am/pm
Content: _
Response:
Date: Time: am/pm
Content:
Response:
Date: Time: am/pm
Content:
Response:
Client Messages 523

AFFIDAVIT OF THE CUSTODIAN OF MENTAL HEALTH
RECORDS TO ACCOMPANY COPY OF RECORDS
I, declare that:
(custodian of records)
1. I am the (a) duly authorized custodian of the mental health records of and have

the authority to certify said records; and
2. The copy of the mental health records attached to this affidavit is a true copy
of all the records described in the subpoena duces tecum; and
3. The records were prepared by in the ordinary course of business; and
4. The documents contained herein are subject to privilege and may be subject to
confidentiality provisions. They are to be reviewed by a judge of competent
jurisdiction prior to further distribution.
I declare under penalty of perjury that the foregoing is true and correct.
(Signature of custodian)

REFERRAL FOR PSYCHOLOGICAL
Evaluation Testing Therapy (circle one)
Date:
Client: Age: Sex:
Telephone # (H) ( ) (W) ( )
Address:
Referral Sources: Agency
PSYCHIATRIC HISTORY
1. Nature and length of client involvement with referral source:
2. Background information regarding client and family:

A. Household members and ages.
B. Behavioral description of client/family interactional style.
3. Is client presently taking medications: Yes No DK
If yes, specify medication:
Dosage level:
Medical/Psychiatric condition:
4. Behavioral description of client:
Referral for Psychological 525

5. Questions to be addressed by, and purpose of this referral?
6. What has client been told about this referral?
7. What is the client's attitude toward and expectation of this referral?
8. List other agencies involved:
Therapist

RELEASE TO RETURN TO WORK OR SCHOOL
Date
This is to certify that has been under my care and has
been unable to attend work/school since . They are released to return
to work/school on .
Remarks/Limitations/Restrictions:
Therapist
Release to Return to Work or School 527

NOTICE OF DISCHARGE FOR NONCOMPLIANCE
OF TREATMENT
Date:
Dear :
This letter is to inform you that I am discharging you from further professional attendance
because you have not complied with appropriate recommendations throughout the course
of your treatment.
Since you have the need of professional services it is recommended that you promptly seek
the care of another mental health professional to meet your needs. If for some reason you
are unable to locate another mental health practitioner, please let me know and I will try to
assist you.
Effective 14 days from the date, I will no longer be available to attend to your mental
health needs. This period will give you ample time to find another mental health profes
sional.
When you have selected another mental health professional, I will, upon your written
authorization, provide a summary of your chart to the new provider.
Sincerely,

DUTY TO WARN
Although confidentiality and privileged communication remain rights of all clients of men

tal health practitioners according to the law, some courts have held that if an individual
intends to take harmful acts or dangerous action against another human being, or against
themselves, it is the practitioner's duty to warn the person or the family of the person or the
family of the person who is likely to suffer the results of harmful behavior, or the family of
the client who intends to harm himself of such an intention.
I, as a mental health practitioner, will under no circumstances inform such individuals
without first sharing that intention with the client, unless it is not possible to do so. Every
effort will be made to resolve the issue before such a breach of confidentiality takes place.
Therapist
I have read the above statement and understand the therapist's social responsibility to
make such decisions when necessary.
Name Date
Duty to Warn 529

MISSED APPOINTMENT
It appears that circumstances have prevented you from meeting with me for an appointment
on at . Please
contact me if you are interested in rescheduling the appointment. If I do not hear from you
I will assume that you are not interested in my services at this time. In that event, please feel
free to call again in the future if I can be of service to you.
Sincerely,

RECEIPT
(letterhead)
RECEIPT
Date of service:
Name:
DOB: SS#:
Service provided:
Diagnosis code:
Amount paid:
Receipt 531
RECEIPT
(letterhead)
RECEIPT
Date of service:
Name:
Service provided:
Amount paid:
532 4. Professional Practice Forms Clinical Forms B u s / n e s s Forms

BALANCE STATEMENT
Date
Name
Our records show that you have a balance due for
in the amount of
Date of service was
Please bring your account current.
Balance Statement 533

CLIENT SATISFACTION SURVEY
To be completed by client or parent/guardian if client is a minor.
1. The problems, feelings, or situation that brought me to the therapist are:

__Much improved
Improved
About the same
Worse
__Much worse
2. Because of therapy, I understand the problems well enough to manage
them in the future:
Strongly agree
Agree
Not certain
Disagree
Strongly disagree
3. My therapist was:
__Very helpful
Somewhat helpful
Neither helpful nor unhelpful
Somewhat unhelpful
_Very unhelpful
4. If I needed help in the future, I would feel comfortable calling this
therapist:
Definitely yes
Probably yes
Maybe
Probably not
Definitely not
5. I would recommend this therapist to others that need help:
Definitely yes
Probably yes
_Maybe
Probably not
Definitely not
6. The interest shown by my therapist in helping me to solve my
problems was:
__Very satisfactory
Satisfactory
Neither satisfactory nor unsatisfactory
Unsatisfactory
__Very unsatisfactory
7. How long has it been since your last visit?
Less than 1 month
1 or 2 months
3 to 5 months
6 months or more (how many)

8. Treatment ended with this therapist because:
The concerns which brought me to the therapist were worked out to my satisfaction.
Most of the significant concerns which brought me to seek therapy were worked out
satisfactorily. There are some minor problems which we can now handle.
—We reached the number sessions set by the therapist at the beginning of treatment.
Significant problems remained that were not dealt with adequately.
I felt that more treatment would not be helpful at this time, even though significant
problems remained.
_The therapist felt that more treatment would not be helpful at this time, even though
significant problems remained.
There was a change in a work or school schedule that made it impossible to arrange
further appointments.
9. After you received counseling with this therapist, have you or any members
of your family received any counseling elsewhere for the same problems you
came here for?
YES NO
10. Additional Comments:
THANK YOU FOR YOUR TIME.
SIGNATURE (OPTIONAL) DATE
Client Satisfaction Survey 535

FORM FOR CHECKING OUT AUDIOTAPES,
VIDEOTAPES AND BOOKS
Date:
has borrowed the following:
The tape(s) will be returned by . It is understood that for each tape

or book not returned during this period of time I will be charged $10.00.
Signature

QUALITY ASSURANCE REVIEW
Patient Number:
Therapist Number:
Initial Assessment Date:
Termination Date:
INITIAL ASSESSMENT
1. Presenting problem __Yes No
2. Relevant history Yes No
3. Reason for treatment __Yes No
4. Mental status _Yes No
5. Current medications Yes No
6. DSM IV diagnosis __Yes No
7. Treatment plan __Yes No
PROGRESS NOTES
1. Do progress notes relate logically to assessment, diagnosis, and
treatment plan Yes No
2. Does each progress note express:
Client concern/problem _Yes No
Therapist Intervention __Yes No
Client response to intervention Yes No
3. Treatment plan _Yes No
Other Issues
1. Signed release of information __Yes No
2. Something relating to limits of confidentiality Yes No
3. Client agreement with therapist (fee, office policy) __Yes No
4. Discharge summary __Yes No
Quality Assurance Review 537

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INDEX
A predicting a potentially violent
Abuse relationship 397
neglect and child abuse 195 stage model 191
indicators 196 systems model 191
prevention 195 Accomplishments 428
treatment 197 Activities of daily living (ADL's) 128
psychoactive substances care of environment and chore
abstinence 38 responsibilities 129
addiction 37 child care 129
assessment, chemical dependency financial 129
psychosocial 185 level of required assistance 129
somatic 185 living situation 129
categories of pharmacological meals 129
intervention 41 selfcare skills 128
checklist, withdrawal symptoms 185 shopping 129
chemical use history 186 transportation 130
common drugs of abuse 4344 ADHD/ADD 174, 177
denial 38 Adjustment disorder, see also Disorders 81
developmental model 37 adjusting and adapting 298
obsessivecompulsive 37 treatment 82
pathways of use 37 Adult children of alcoholics 393
selfcontrol 39 Adult psychosocial 403465
symptoms leading to relapse 42 Affidavit for custodial records 524
treatment settings 41 Alzheimer's disease, ten warning signs 632
spousal/partner (Domestic Violence: DV) eating history 169
assessing 187, 192 mood eating scale 169
assessing lethality 188 medical review consult request for primary
counseling victims 194–195 care physician for eating disorder
cycle of domestic violence 190 patient 480
domestic violence, safety planning 399 Anxiety disorder 65
create a file of important documents 400 anxiety assessment 111
create a safe room 399 cycle of anxiety provoking emotional
documentation 399 disturbance 69
evaluate the problem 402 cycle of phobic anxiety 124
important to remember 398 how your body reacts to stress and
know when/how to leave 401 anxiety 351
money and keys 400 managing anxiety 242
pack a suitcase 400 obsessional disorders 125
problem resolution 403 assessment of 125
safe place to go 399 overanxious disorder 16
struggle with leaving 401 treatment, 6669
intervention 193194 progress note for anxiety 494
553
Anxiety disorder (continued) stage model of domestic violence 191
PTSD 346 structured interview for depression 112
separation anxiety 13 suicide 115
trauma response 70 the patient with psychosomatic illness
treatment 6669, 345 who has an underlying personality
what is panic anxiety 344 disorder 165
Anger 283289, 408 visitation rights report 211
Antidepressant medication and other withdrawal symptoms checklist 185
treatment 63 Assuming the patient role, benefits 372
Assertive communication, see also Skills 257 Authorization for release or exchange of
development 261 information 522
practice assertive responses 263 Avoidant personality disorder 89
saying no 264265
steps of positive assertiveness 263 B
Assessing lifestyle and health 371 Behavior
Assessing special circumstances 109222 affect, of inappropriate 99, 101
activities of daily living 128130 appropriate boundaries, lack of 101
ADHD behavioral review 177 autonomy difficulties 18, 92
adult ADD screening 174 avoidant 14, 88
assessment of phobic behavior 139 bipolar disorder, hypersexuality 101
chemical dependency assessment 179 body image, 20, 24, 73
chemical dependency psychological bonding 199, 201
assessment 182 bulimia nervosa, see also Disorders, eating
child abuse and neglect 195 physical symptoms 22
child custody evaluation 198 psychological symptoms 22
chronic mental illness 130 defensive 10
chronic pain, assessment and intervention 182 dependent 92
counseling the individual in a medical isolative 14, 97
crisis 147 manipulative 101
crisis evaluation 132 oversensitive 89, 92
crisis intervention 133 responses, negative 94, 101
cycle of depression 113 selfdestructive, see also Harm 101
cycle of phobic anxiety 124 social interaction, dramatized 99
dangerousness 119 Borderline personality disorder 101
dealing with the challenges of long term
illness 151 c
dispositional review: foster/temporary Caregiver of elderly patients 363366
placement 211 Caregiver stress 34
eating disorder evaluation Case conceptualization xxvi
anorexia 170 Characteristics of adult children of
bulimia 172 alcoholics 393
eating disorder screening questionnaire 167 Chemical dependency, see Evaluation, skills
eating history 167 Child Abuse and neglect 195
evaluation and disposition considerations Child custody evaluation
for families where parental alienation ability of the child to bond 199
occurs 207 ability of the parents to bond 199
forensic evaluation 219 other pertinent information 199
gravely disabled 127 bonding study versus custody evaluation 201
identifying traumatic stress 135 dispositional review
obsessional disorders, overview 125 foster/temporary placement 211
pain identification 160162 report outline 212
parental alienation syndrome 202206 guidelines for psychological evaluation 198
treatment 209 interaction between parentchild(ren) 201
postpartum depression and anxiety parental alienation 202209
141144 visitation rights report 211
professional guidelines for crisis Chronic mental illness (CMI), see also
intervention 145 Disorders, schizophrenia 130
psychiatric work related disability general guidelines for assessment 131
evaluation 213 Chronic Pain
psychological preemployment assessing and measuring pain 157
evaluation 217 assessment and intervention 157
report outline 220 clinical interview 158
selfcare behaviors 142 factors affecting experience of pain 157
somatic problem 164 identification chart 160
spousal/partner abuse 187 interventions 162
554 Index
management scale 161 Dependent behaviors, see Behavior
six stages of treatment 162 Dependent personality disorder 92
Codependency see also Skills 383, 387, 388, Depression, see also Disorders
389, 390 5152, 324
Common axis I and axis II diagnosis xxvii additional considerations 64
Communication, see also Skills causes 314
of difficult feelings 266 children 61
Competency evaluation, see also cooccurring with other illnesses
Evaluation 220 5657
Compulsive overeating, see also Disorders, decreasing the intensity of 313
eating elderly 64
physical symptoms 23 management of 314
psychological symptoms 23 mood 314
Compulsive personality disorder 90 recognizing stages of 313
Counseling the individual in a medical risk of relapse 118
crisis 147 suicide risk 52
central crisis issues 149 surviving the holiday blues 317
dealing with the challenges of longterm symptoms checklist 315
illness 151 treatment of 5256, 63
treatment framework and Desensitization 357
conceptualization 147 Differences xxiii
working through the challenges of longterm Differentiation
illness 154 emotional states, internal sensations 21
Couples 396397, 402403, 406, 422 Disorders
Criminal evaluation, see also Evaluation 220 adjustment 81
Crisis anxiety 65
what happens during 412 attention deficit hyperactivity 7
what is a crisis 411 avoidant 14
Crisis intervention 133 disruptive behavior 7
assessment of phobic behavior 139 dissociative 78
childhood, life crises 411 eating 18
critical incident stress debriefing (CISD) 134 first evident in infancy, childhood or
effects of time 137 adolescence 1
how does treatment affect someone 136 identity 26
identifying traumatic stress 135 impulse control 84
professional guidelines 145 mood 51
recovery from traumatic stress 135 organic mental syndrome 31
screening for survivors 135 overanxious 16
trauma and vehicular accidents 137 personality
Crisis resolution 413 avoidant 89
Critical problem solving 247249 borderline 101
Crosscultural issues 6162 compulsive 90
dependent 92
D histrionic 99
Daily activity schedule 322 narcissistic 100
Daily living skills, see also Skills passiveaggressive 94
activities of daily living (ADL) 128 paranoid 95
Dangerousness, see also Violence, schizotypal 97
potential for schizoid 98
assessment 119 physical factors affecting psychological
assessment outline 120 functioning 104
objectives and treatment focus 122 psychoactive substance abuse 37–41
Decision making, see also Skills 272 schizophrenia, delusions and related
Decision tree xxi psychotics 4549
Defense mechanisms, see also Skills 282 disorders 45–49
Delirium 3536 separation anxiety 13
Delusional 45 sexual 80
Dementia 31, 3235 sleep, see also Skills 367
conditions somatoform 72
causing dementia that are not Disabled, gravely 127
reversible 359 daily living, activities 128
causing reversible symptoms 358 indicators, behavioral 129
diagnosis 359 Dispositional review 212
symptoms 358 Disruptive behavior disorder 7
what is dementia 358 Dissociative disorder 78
Index 555
Domestic violence 398 initial evaluation 449
create a file with important documents 400 initial evaluation consultation note to
create a safe room in your home 400 primary care physician 488
document the abuse 399 worker's compensation attending therapist
find a safe place to go 399 report 500
have money and keys 400
know when and how to leave 401 F
most important to remember 399 Factitious disorder 77
pack a suitcase 401 Family meeting, see also Skills 409
struggle with leaving 401 Fatigue or sleep deprivation 344
Duty to warn 529 Forensic evaluation 219
Fear
bad memories 341
Elderly, caregiver of parents 363 dealing with 380
advise for those close to the situation 366 Forms
common problems of 365 affidavit of the custodian of mental health
coping strategies 365 records to accompany copy of
tips for the caretaker 366 records 524
Education authorization for release/exchange of
family 23, 6, 8, 13, 16, 17, 21, 2526, 41, information 522
47, 55, 68 balance statement 533
teacher 9, 14, 17 client messages 523
Effective management of stress 229 client satisfaction survey 534
Emotional IQ 237 clinical
Enabler, the companion to the dysfunctional/ adult psychosocial 463
substance abusing person 383 brief consultation note to physician 490
Ethics brief level of functioning review for
educational guidelines xx, xxi, xxv industrial injury 505
professional practice xx, xxi, xxv brief medical history 478
Evaluation brief mental health evaluation review 451
ADHD behavioral review 177 brief psychiatric evaluation for industrial
adult ADD screening 174 injury 502
adult psychosocial 463 case formulation 435
anorexia 170 chemical dependency psychosocial
bulimia 172 assessment 485
brief consultation note to physician 490 child/adolescent psychosexual 467
industrial 505 clinical note 496
brief medical history 478 disability/worker's compensation 498
brief mental health evaluation review 451 discharge summary 511
chemical dependency psychosocial 485 duty to warn 529
chemical dependency psychosocial general clinical evaluation 435
assessment 182 illness and medical problems 475
child custody life history questionnaire 454
bond ability, child 199 medical review consult request for primary
bond ability, parent 199 care physician of an eating disorder
custody versus bonding study 201 (EOO) patient 480
dispositional review 211 mental status at time of offense 220
parentchild interaction 201 mental status exam 442, 444, 445
psychological guidelines 198 notice of discharge for noncompliance of
report outlines 200 treatment 528
visitation rights 211 outpatient treatment progress report 491
chronic pain 157 outline for diagnostic summary 509
client satisfaction survey 534 parent's questionnaire 475
clinical notes 496 progress note for individual with anxiety
competency 220 or depression 494
compulsory psychosocial evaluation 218 self assessment 477
criminal evaluation 220 social security evaluation, medical source
disability, workers compensation 498 statement, psychiatric/psychosocial 499
discharge summary 51 substance use and psychosocial
domestic violence 182, 192 questionnaire 481
duty to warn 529 family history 483
forensic evaluation 219 medical history 484
general clinical evaluation 436 social history 483
illness and medical problems 479 treatment history 482
initial case assessment 447 treatment plan
556 Index
contract for group therapy 521 how does traumatic stress affect
contract for services without using someone 136
insurance 515 identifying traumatic stress 135
fee agreement for disposition and court medical crisis 147
appearance 517 recovery from traumatic stress 135
form for checking out audiotapes response pattern 133
and books 536 screening for survivors 135
limits on patient confidentiality 519 selfcare behavior 146, 235
missed appointments 530 vehicular accidents 137
notice of discharge for noncompliance of critical issues xxi
treatment 528 level of functioning xix, xxii
receipt 531, 532
referral for psychological evaluation 525 J
treatment contract 520 Journal
quality assurance preview 537 writing 22, 267, 308
steps 14 308
G steps 515 309
Geriatric (elderly) xxi, 31, 66
Goal development 273
Goals 427 L
Gravely disabled xxi, 127 Loss, see Grief
activities of daily living 128
chronic mental illness 130 M
guidelines for discipline that develops Malingering 77
responsibility 419 Management
Grief anxiety, see also Skills, managing anxiety
cycle of 303 65, 144, 238, 274, 278279, 281,
grief 304 319, 334345, 347, 351353,
history of losses graph 307 355357, 367, 368
life changes 298 depression, see also Skills, depression
losses/opportunities 301 52, 274, 278279, 281, 301, 303304,
Guidelines 310, 312315, 318, 319, 322327,
professional practice xxi 329330, 334, 342, 344, 357,
Guilt 327 367368
stress, see also Skills, stress management
H 226, 229231, 235, 238, 249, 274,
Harm xxi, xxii, xxix, 18 278279, 281, 298, 301, 308, 319,
Tarasoff, see also Duty to warn 529 334, 351, 366368, 370371, 373
Health inventory 370 time, see also Skills, time management 92,
Healthy adult relationship 396 270, 271
Heart disease and depression 375 Mania, see also Disorders 58, 62
Helping children cope with scheduling Medical causes of psychiatric illness 106
changes 423 Medical crisis counseling 147
History of loss graph 307 central crisis issues 149
Histrionic personality disorder 99 challenges of longterm illness 151
How does codependency work 390 treatment framework and
How to build a support system 312 conceptualization 148
How to handle angry people 295 working through longterm illness issues 154
How to predict the potentially violent Medication
relationship 397 compliance with 45, 48, 55, 59
How to stop using food as a coping evaluation of 8, 41, 53, 63, 66, 84
mechanism 377 side effects of 32, 36, 48, 55, 60, 66, 69
Meditation 245
I Mental retardation 1
Identify feeling states 20, 21 Mental states 442, 444, 445
Identity 26, 80 contents of exam 442
Imaging, mental/visual 239 Modalities, treatment xxiii, xxix
Impulse control 7, 84 Mood disorders 5164
Interventions additional treatment considerations 64
crisis antidepressant medication 63
common responses 133 bipolar hypersexuality 62
critical incident stress debriefing (CISD) 134 depression 52
early intervention 133134 depression cooccurring with other illness 56
effects of time 137 mania 58
guidelines, professional 145 Mood eating scale 169
Index 557
N Placement, foster/temporary 211
Narcissistic personality disorder 100 Plan of action for dealing with anxiety 353
Nonverbal communication 260 Positive attitude 318
checklist 255 Postpartum depression and anxiety 141
Nurturing, self 334 definitions of 141
how to break the postpartum cycle 144
o psychosis 143
Post traumatic stress disorder (PTSD) 346
Obesity and self esteem 379
Obsession with weight 378 Power of positive thinking 318
Obsessional disorder 125 Practice reframing how you interpret
assessment 125 situations 281
Occupational history 214 Preventing
Organic mental syndromes 31 body weight and body image problems in
Outline for diagnostic summary 509 children 378
Outpatient treatment progress report 491 violence in the workplace 289
Overanxious disorder 16 bully in the workplace 291
dangerous employee 290
p how to handle angry people 295
Pain, chronic assessment and intervention 157 negative work environment 290
Pain identification chart 160 what management can do to minimize
Pain management 233 employee stress 296
interventions 161 workplace violence 291
pain management scale 161 Problem solving diagram 249
Panic anxiety, what is it 344345 Professional care guidelines for crisis
Parent questionnaire 475 intervention 145
Parental alienation syndrome Progress note for individual with anxiety
behaviors and/or depression 496
children 205 Psychiatric workrelated disability evaluation 213
parents 204 description of client
child's own scenarios 203 at time of interview 213
criteria for establishing primary custody 203 current complaints 213
evaluation and disposition considerations 207 developmental history 215
family dynamics and environmental/ family history 214
situational issues 203 findings from psychological assessment 215
parental programming 202 history of present illness 213
subtle and unconscious influencing 202 identifying information 213
three categories of parental alienation 206 interviews with collateral sources 216
treatment 209 occupational history 214
Parenting a healthy family 406 past psychiatric history and relevant medical
a healthy family means all of its members history 214
are involved 407 review
be an active parent 407 of medical records 215
creating effective family rules 406 employment or personnel records 216
effective coparenting 406 social history 215
encourage communication 407 summary and conclusions 216
maintain effective family rules 406 Psychoactive substance abuse disorders 37
Patient registration 515 categories of pharmacological
Patient with psychosomatic illness who has an interventions 41
underlying personality disorder 165 substance abuse and/or dependence 38
Personal bill of rights 262 treatment settings 41
Personality disorders Psychological factors affecting physical
avoidant 89 condition 86
borderline 107 Psychological preemployment
compulsive 90 evaluation 217
dependent 92 Psychosomatic illness with underlying
histrionic 99 personality disorder 165
narcissistic 100
paranoid 95 Q
passiveaggressive 94 Questionnaire
schizoid 98 parent's 475
schizotypal 97 relationship 396
Pervasive development disorder 5 substance use and psychosocial 481
Physical factors affecting psychological Questions to ask yourself 426
functioning 104 Quotient
stages of adjustment 105 emotional IQ 237
558 Index
R affirmations for building selfesteem 334
Rational thinking anger
realistic selftalk 279 barriers to expressing anger 288
refraining 277 decreasing the intensity of 287
reframing your interpretation 281 handling, general principles regarding
selftalk 274 anger 286
thinking distortions 278 how to handle angry people 295
thought stopping 276 inappropriate expression 288
Recognizing the stages of depression 313 management of 283
Recommendations for family members of penalties for not expressing 288
anorexic individuals 25 recognizing the stages of 287
Registration, patient 515 steps for letting go of 289
Relationship taking responsibility 284
graph 307 understanding your experience of 285286
questionnaire 396 ways to deal with
Relaxation exercises 238 areas of potential conflict 268
brief progressive relaxation 241 list of potential conflicts 268
confronting the provocation 245 assertive communication 257, 262
deep breathing 238 assertive inventory 258
guide to meditation 245 consequences of saying yes 265
it's time to talk to yourself 245 developing assertiveness 261
mental imagery 239 nonverbal assertive behavior 261
mental relaxation 239 overcoming guilt of saying no 264
preparing for the provocation 244 personal bill of rights 262
progressive muscle relaxation 242 practicing assertive responses 263
tensing the muscles 239 saying no 264
Resources 429 the steps of positive assertiveness 263
Risk, situations in practice xxiii verbal assertive behavior
Rules assessing lifestyle and health 371
for emotional health 429 assuming the patient role, benefits of
of politeness 426 being sick 372
bad memories and fear 341
caregiver of elderly parents 363
Saying no 264 advice for others close to the situation 366
Schizophrenia see also Disorders common problems experienced by
phases of treatment 49 .caregivers 365
summary of treatment recommendations 49 tips for the caretaker 366
thought disorder 45 warning signs of caregiver stress 366
treatment setting 49 characteristics
understanding 359360 of adult children of alcoholics 393
Seasonal anniversary of losses 342 of high selfesteem 338
Self assessment 477 of low selfesteem 336
Selfcare chemical imbalance 329
behaviors 146 codependency
plan 235 characteristics 388
Selfesteem classic situation 388
affirmations 334 enablers 383
boosters 333 how does it work 390
characteristics effects on children of codependents 392
of high selfesteem 338 how it affects one's life 391
of low selfesteem 336 rules 391
low 330 stages of recovery
review 332 what can you do 392
selfnurturing 334 suggested diagnostic criteria 389
Self monitoring 318, 426 what is codependency 387
Separation anxiety 13 communication
Setting priorities 274 components of effective communication 253
Sexual disorders see also Disorders 80 active listening 253
Shyness 339 effective listening 257
Skills how to present yourself 256
adjusting/adapting 298 how to say it 256
developmental perspective 299 improving communication skills 256
life changes 298 I statements 253
accepting no for an answer 265 nonverbal communication checklist 255
accomplishments 428 reflection 254
Index 559
Skills (continued) feeling
confronting and understanding suicide 323 like your life is out of control 326
couple's conflict, rules for fighting fair 403 overwhelmed and desperate 325
crisis resolution 413 goals
what do you need to do to help steps for developing 273
a child 413 goal setting 427
critical problem solving grief
developing good problem solving acceptance 306
skills 248 bargaining 305
managing intervention during problem depression 305
solving 248 never happened 304
preparing to learn problemsolving grief cycle 273
skills 248 guiding your child to appropriately express
stages of problem solving 248 anger 408
steps for problem solving 249 guidelines
daily activity schedule 322 for completing your first step toward
dealing with fear 380 emotional health 399
decision making for discipline that develops
steps for 272 responsibility 419
defense mechanisms 282 helpful hints 420
definitions of 283 steps in applying logical consequences 420
definition, the natural emotional response to for family members/significant others of
the loss of a cherished idea, person or alcoholic/chemically dependent
thing 303 individuals 381
dementia to follow if someone you know has an
conditions causing dementia that is not eating disorder 379
reversible 359 guilt 327
conditions causing reversible health inventory 370
symptoms 358 healthy adult relationships 396
diagnosis 359 heart disease and depression 375
symptoms 358 helping children cope with scheduling
what is dementia 358 changes 423
depression 324 how does codependency work 390
symptom checklist 315 how to
detaching with love versus controlling 382 get the most out of your day 236
developing and utilizing social supports 310 build and keep a support system 312
characteristics of a supportive predict the potentially violent
relationship 310 relationship 396
domestic violence (DV) stop using food as a coping
create a file with your important mechanism 377
documents 400 how your body reacts to stress and
create a safe room in your home 400 anxiety 351
document the abuse 399 improved coping skills for happier
find a safe place to go 399 couples 402
have money and keys 400 improving communication skills 256
most important to remember 399 body language, how to present
pack a suitcase 401 yourself 256
predicting potentially violent effective listening 257
relationships 397 quality of voice, how to say it 256
safety planning 399 improving your health 373
struggle with leaving 401 is life what you make it 308
eating history 376 is your behavior in the best interest of your
effective management of stress 229 children 425
assertiveness 230 journal writing 308309
conflict resolution 230 learning history 300
critical problem solving 229 list of feeling words
selfcare 230 difficult/unpleasant 269
time management 230 pleasant 269
tips 230 list of symptoms leading to relapse 386
emotional IQ 237 loneliness 329
family meeting 409 losses/opportunities
developing positive selfesteem in finding the solution, the five stages of
children and adolescents 410 recovery loss 302
guidelines 409 how do you know you are ready 302
fatigue or sleep deprivation 344 how you deal with loss 302
560 Indtx
other ways 302 selfnurturing, a component of
what are the myths of dealing with loss 302 selfesteem 334
what is meant by resolving grief/loss 301 setting priorities 274
why are people not prepared to deal with sleep disorders 367
loss 301 treatment focus and objectives 367
low self esteem 330 some examples of individual time
managing anxiety 347 management options 234
what do you do 349 standing up to shyness 339
pain management 233 socializing 340
panic anxiety stress
symptoms 345 what is stress 223
treatment 345 review 225
what is panic anxiety 344 stress management 226
parenting a healthy family 406 busting stress 229
a healthy family means all of its early warning signs 228
members are involved 407 signals of 228
be an active parent 407 substance abuse/dependence personal
creating effective family rules 406 evaluation 385
effective coparenting 406 successful stepfamilies
encourage communication 407 communication 423
maintain the parent role 407 discipline 423
personal bill of rights 262 humor 422
plan of action for dealing with anxiety 353 parentcentered structure 423
post traumatic stress disorder (PTSD) 346 respect 422
power of positive attitude 315 responsibility 422
practice reframing how you interpret validation 422
situations 281 survey of stress symptoms 350
preventing body weight and body image estimate your stress level 350
problems in children 378 physical symptoms 350
preventing violence in the workplace 289 psychological symptoms 350
bully in the workplace 291 surviving divorce 420
negative work environment 290 systematic desensitization 357
the dangerous employee 290 talking to children 417
workplace violence 291 do's 419
problem solving diagram 249 don'ts 429
rational thinking 274 rules
reframing 277 for listening 418
selftalk 274 for problem solving and expressing your
thought stopping 276 thoughts and feelings to children 418
realistic selftalk 279 ten
recognizing the stages of depression 313 rules for emotional health
relationship graph 307 selfesteem boosters 333
relaxation exercises 238 steps for giving feedback 264
brief progressive relaxation 241 steps for letting go of anger 289
brief relaxation 241 tips for better sleep 368
confronting the provocation 245 warning signs of Alzheimer's disease 362
deep breathing 238 warning signs of caregiver stress 366
guide to meditation 245 ways of responding to aggression 265
it's time to talk to yourself 245 the classic situation 388
mental imagery 239 thinking distortions 278
mental relaxation 239 time management
preparing for the provocation 244 four central steps to effective time
progressive muscle relaxation 242 management 270
tensing the muscles 239 how to start your own time management
resources 429 program 270
risks 252 tips
saying no 264 for stress management 230
overcoming guilt of 264 to simplify your life 231
consequences of saying yes 265 how to improve planning 233
seasonal anniversary of losses 342 ten signs that you need to simplify your
selfcare plan 235 life 232
selfesteem review 332 understanding
selfmonitoring and dealing with life crises of childhood 411
checklist 319 anger 285
questions to ask yourself 426 schizophrenia 359
Index 561
utilizing your support system 315 Systematic desensitization
warning signs of relapse 356 the ten steps of 357
warning signs of teen mental health
problems 416 T
what happens during a crisis 412
Talking to children, see also Skills 417
what is a crisis 412
Ten
what management can do to minimize
rules for emotional health 429
employee stress 295
selfesteem boosters 333
what motivates me 339
steps for giving feedback 264
why victims of domestic violence struggle
steps for letting go of anger 289
with leaving 401
tips for better sleep 365
writing 267
warning signs of Alzheimer's disease 362
Sleep disorders
ways of responding to aggression 265
fatigue or sleep deprivation 344
The classic situation 388
tips for better sleep 368
Thinking distortions 278
treatment and objectives 367
Time management, see also Skills 270
Social security evaluation, see also
Tips
Forms 499
for stress management 230
Solution focused approach to treatment xxv
to simplify your life see also Skills 231
Solving problems 247, 249
Traumatic stress and vehicular accidents 137
Somatic problems 164165
Treatment contracts 520
Somatoform disorder, see also Disorders 72
Treatment plan xxiv, 439
Spousal/partner abuse 187
assessing abuse 187
Stage model of domestic violence 191 u
Standing up to shyness, see also Skills 339 Understanding
Steps for letting go of anger 289 and dealing with life crises of children 411
Strengths 428 anger 285
Stress 223 schizophrenia 359
management 229230 potential for violence 360
what is stress 223 suicide 360
Structural interview for depression 112 symptoms and perceptual disturbance 360
Substance abuse/dependence personal what causes schizophrenia 360
evaluation 385 Utilizing your support system 318
Substance use and psychosocial questionnaire 481
family history 483 V
medical problems 484
Violence, potential for 119121
social history 483
Visitation rights report 211
treatment history 482
Successful stepfamilies, see also Skills 422
communication 423 w
discipline 423 Warning signs
humor 422 of relapse 356
parentcentered structure 423 of teen mental health problems 416
respect 422 What management can do to minimize
responsibilities 422 employee stress 298
validation 422 What motivates me 339
Suggested diagnostic criteria for Why victims of domestic violence struggle with
codependence 389 leaving 401
Suicide 115,360 Withdrawal symptoms
adolescent 116 checklist 185
assessment outline 115 psychological 185
depression and suicide risk relapse 118 somatic 185
treatment focus and objectives 117 Worker's compensation
Summary, treatment plans and attending therapist's report 500
recommendations 466 disability status 500
Survey of stress symptoms, see also progress 500
Skills 350 treatment 500
Surviving divorce, see also Skills 420 work status 500
Surviving the holiday blues 317 Writing 267
562 Index

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Therapist's Guide to

Permissions may be sought directly from Elsevier's Science & Technology Rights

Library of Congress Catalog Card Number: 2003109372

International Standard Book Number: 0­12­386588­3

PRINTED IN THE UNITED STATES OF AMERICA

THIS second edition, like the first, is intended to serve as a comprehensive resource tool.

Level of functioning Treatment goalsa Focus of treatment Possible treatment modalities

1. Patient demonstrates adaptive Increase Self efficacy Didactic/educational Groups

5. Patient demonstrating Provide safe environment Stabilization Increased OP therapy contact

1. Child Custody Cases

Printed by permission from Allan Hedberg, Ph.D.

Depressive Disorders Adjustment Disorders

Treatment Planning­. Goals,

Goals 1. Establish developmentally appropriate daily living skills

Treatment Focus 1. Daily Living Skills (waking by alarm, dressing, hygiene/personal care, finances,

2 1. Treatment Planning­. Goals, Objectives, and Interventions

Additional During Assessment

Levels of mental retardation by Intelligence Test Range

Behavior Competency Expectations Associated with Degree of Mental

The most common intrauterine causes of mental retardation are the following:

Disorders Usually First Evident in Infancy, Childhood, or Adolescence 3

Dual Diagnosis Jacobson (1982a, 1982b) surveyed retarded children from infancy to adolescence and found

Parents and siblings must be evaluated in association with their own risk for significant dif­

Parents Increased risk for depression

Siblings Behavioral problems

4 1. Treatment Planning Goals, Objectives, and Interventions

1. Reciprocal Social Interaction: not aware of others' feelings, doesn't imitate,

Goals 1. Child will not harm self

Treatment Focus 1. Risk of Self­Harm

Disorders Usually First Evident in Infancy, Childhood, or Adolescence 5

Medical 1. History

6 i. Treatment Planning: Goals, Objectives, and Interventions

Developmental 1. Preschool

Goals 1. Assess for referral for medication evaluation

Treatment Focus 1. Evaluate for Referral for Medication Evaluation

Disruptive Behavior Disorders 9

10 i. Treatment Planning: Goals, Objectives, and Interventions

Disruptive Behavior Disorders I 1

1. Inquire about the possibility of lead intoxication and malnutrition

12 i.Treatment Planning: G o a l s , Objectives, and Interventions

However, children with Bipolar Disorder also exhibit

Goals 1. Support and educate parents regarding age­appropriate separation issues

Treatment Focus 1. Educating Parents Regarding Age­Appropriate Emotional Separation

Disruptive Behavior Disorders 13

While separation anxiety is seen as a normal response in young children, when it inter­

Additional For children residing in inner­city settings there may be legitimate issues of safety associated

Goals 1. Correct irrational thinking

14 1. Treatment Planning­. Goals, Objectives, and Interventions

Treatment Focus 1. Explore Fears and Irrational Beliefs

Disruptive Behavior Disorders 15

Additional 1. Assess parental response to new people and situations

Goals 1. Correct irrational thinking

Treatment Focus 1. Irrational Beliefs

16 1. Treatment Planning­. Goals, Objectives, and Interventions

According to Peterson and Brownlee­Duffeck (1989)

1. Fears and anxieties of family members constitute a factor in whether or not to

International Standard Book Number: 0123865883

Treatment Planning. Goals,

2 1. Treatment Planning. Goals, Objectives, and Interventions

Parents and siblings must be evaluated in association with their own risk for significant dif

Treatment Focus 1. Risk of SelfHarm

Goals 1. Support and educate parents regarding ageappropriate separation issues

Treatment Focus 1. Educating Parents Regarding AgeAppropriate Emotional Separation

While separation anxiety is seen as a normal response in young children, when it inter

Additional For children residing in innercity settings there may be legitimate issues of safety associated

14 1. Treatment Planning. Goals, Objectives, and Interventions

16 1. Treatment Planning. Goals, Objectives, and Interventions

According to Peterson and BrownleeDuffeck (1989)

Additional If an eating disorder is suspected of an individual from a culturally diverse group, it is impor

22 1. Treatment Planning. Goals, Objectives, and Interventions

Obesity and 1. Obesity is not always related to the lowering of selfesteem

28 1. Treatment Planning. Goals, Objectives, and Interventions

OralSensory Trust versus Primary caretaker Trust and optimism

Muscularanal Autonomy versus Parents Selfassertion, selfcontrol,

Locomotorgenital Initiative versus Family Sense of initiative,

Anal (13 yrs.) Anal region Toilet training Fixation produces anal

30 1. Treatment Planning. Goals, Objectives, and Interventions

The various Organic Mental Syndromes and Disorders are manifested in disturbances of cog

34 1. Treatment Planning. Goals, Objectives, and Interventions

Brown's (1985) developmental model for the stages of recovery offer's a conceptual frame