ANGER MANAGEMENT - Wiley · ANGER MANAGEMENT BEHAVIORAL ... Decrease overall intensity and frequency of angry feelings and in- ... Identify pain and hurt of past or current life that

ANGER MANAGEMENT

BEHAVIORAL DEFINITIONS

1. History of explosive aggressive outbursts out of proportion to anyprecipitating stressors leading to assaultive acts or destruction ofproperty.

2. Overreaction of hostility to insignificant irritants.3. Swift and harsh judgement statements made to or about others.4. Body language of tense muscles (e.g., clenched fist or jaw, glaring

looks, or refusal to make eye contact).5. Use of passive-aggressive patterns (social withdrawal due to anger,

lack of complete or timely compliance in following directions orrules, complaining about authority figures behind their backs, ornonparticipation in meeting expected behavioral norms).

6. Consistent pattern of challenging or disrespectful treatment of au-thority figures.

7. Use of verbally abusive language.

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LONG-TERM GOALS

1. Decrease overall intensity and frequency of angry feelings and in-crease ability to recognize and appropriately express angry feel-ings as they occur.

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SHORT-TERM OBJECTIVES

1. Verbally acknowledge thathe/she is angry. (1, 2)

2. Identify targets of andcauses for anger. (2, 3, 4)

3. Verbalize increased aware-ness of anger expressionpatterns. (2, 5, 6)

4. Verbalize how influentialpeople in growing up havemodeled anger expressions.(2, 7)

5. Identify pain and hurt ofpast or current life thatfuels anger. (2, 8, 9)

6. Verbalize feelings of angerin a controlled, assertiveway. (10, 11, 12, 17)

7. Decrease the number andduration of angry outbursts.(10, 13)

8. Utilize relaxation tech-niques to cope with angryfeelings. (14)

12 THE COMPLETE ADULT PSYCHOTHERAPY TREATMENT PLANNER

THERAPEUTIC INTERVENTIONS

1. Assist patient in coming tothe realization that he/sheis angry.

2. Assign patient to read thebook Of Course You’re Angry(Rosellini and Worden) orThe Angry Book (Rubin).

3. Ask patient to keep a dailyjournal in which he/she documents persons, situa-tions, and so on that causeanger, irritation, or disap-pointment.

4. Assign and process a thor-ough list of all targets ofand causes for anger.

5. Confront/reflect angry be-haviors that occur withinsessions.

6. Refer patient to an angermanagement class or group.

7. Assist patient in identifyingways key life figures, such

2. Develop an awareness of current angry behaviors, clarifying ori-gins of and alternatives to aggressive anger.

3. Come to an awareness and acceptance of angry feelings while de-veloping better control and more serenity.

4. Become capable of handling angry feelings in constructive waysthat enhance daily functioning.

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9. Verbalize increased aware-ness of how past ways ofhandling angry feelingshave had a negative impact.(13, 15, 16)

10. Decrease verbal and physi-cal manifestations of anger,aggression, or violencewhile increasing awarenessand acceptance of feelings.(12, 17)

11. Verbalize increased aware-ness of and ability to reactto hot buttons or anger trig-gers in a nonaggressivemanner. (10, 18, 19)

12. Write an angry letter to target of anger and processthis letter with therapist.(20, 21)

13. Verbalize recognition of howholding on to angry feelingsfreezes you and hands con-trol over to others and citethe advantages of forgive-ness. (22, 23)

14. Write a letter of forgivenessto perpetrator of past orpresent pain and processthis letter with therapist.(24)

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ANGER MANAGEMENT 13

as father, mother, andteachers, have expressedangry feelings and how pos-itively or negatively theseexperiences have influencedthe way patient handlesanger.

8. Assign patient to list the experiences of life that havehurt and led to anger.

9. Empathize and clarify feel-ings of hurt and anger tiedto traumas of past.

10. Assign assertiveness train-ing classes.

11. Process patient’s angry feel-ings or angry outbursts thathave recently occurred andreview alternative behav-iors available.

12. Using role-playing tech-niques, assist patient in de-veloping non-self-defeatingways (e.g., assertive use of“I messages”) of handlingangry feelings.

13. Assign a specific exercisefrom the Anger Work OutBook (Weisinger) or similarworkbook and process exer-cise with patient.

14. Teach patient relaxationtechniques (e.g., deepbreathing, positive imagery,deep muscle relaxation,etc.) to cope with initial response to angry feelingswhen they occur.

15. Ask patient to list waysanger has negatively im-pacted him/her in daily life.Process list with patient.



16. Expand patient’s awarenessof the negative affects thatanger has on his/her body.

17. Use empty chair techniqueto coach patient in express-ing angry feelings in a con-structive, non-self-defeatingmanner.

18. Assist patient in developingthe ability to recognizehis/her hot buttons/triggersthat lead to angry explo-sions.

19. Train patient in RationalEmotive Therapy (RET)techniques for coping withfeelings of anger, frustra-tion, and rage.

20. Ask patient to write anangry letter to parents,spouse, or whomever, focus-ing on the reasons forhis/her anger toward thatperson. Process letter insession.

21. Encourage patient to ex-press and release while insession feelings of anger orrage, and violent fantasiesor plots for revenge.

22. Discuss forgiveness of per-petrators of pain as a pro-cess of letting go of anger.

23. Assign patient to read thebook Forgive and Forget(Smedes).

24. Ask patient to write a for-giving letter to target ofanger as step toward lettinggo of anger. Process letter insession.


ANGER MANAGEMENT 15

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DIAGNOSTIC SUGGESTIONS

Axis I: 312.43 Intermittent Explosive Disorder296.xx Bipolar I Disorder296.89 Bipolar II Disorder312.8 Conduct Disorder310.1 Personality Change Due to (Axis III Disorder)309.81 Posttraumatic Stress Disorder

Axis II: 301.83 Borderline Personality Disorder301.7 Antisocial Personality Disorder301.0 Paranoid Personality Disorder301.81 Narcissistic Personality Disorder301.9 Personality Disorder NOS


ANTISOCIAL BEHAVIOR


1. An adolescent history of consistent rule-breaking, lying, physicalaggression, disrespect for others and their property, stealing,and/or substance abuse resulting in frequent confrontation withauthority.

2. Consistent pattern of blaming others for what happens to him/her.3. Refusal to follow rules with the attitude that they apply to others,

not him/her.4. History of reckless behaviors that reflect a lack of regard for self or

others and show a high need for excitement, having fun, and livingon the edge.

5. Little regard for truth as reflected in a pattern of consistently lyingto and/or conning others.

6. Pattern of sexual promiscuity; has never been totally monogamousin any relationship for a year and does not take responsibility forchildren.

7. Pattern of interacting in an irritable, aggressive, and/or argumen-tative way with authority figures.

8. Little or no remorse for hurtful behavior.9. Verbal or physical fighting often initiated.

10. Failure to conform with social norms with respect to the law asshown by repeatedly performed antisocial acts that he/she may ormay not have been arrested for (e.g., destroying property, stealing,or pursuing an illegal job).

11. Pattern of impulsive behaviors, such as moving often, travelingwith no goal, or quitting a job without having another.

12. Inability to sustain behavior that would maintain consistent em-ployment.

13. Failure to function as a consistently concerned and responsibleparent.

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1. Admit to illegal and/or unethical behavior that has trampled on the lawand/or rights and feelings of others. (1, 2)

ANTISOCIAL BEHAVIOR 17

THERAPEUTICINTERVENTIONS

1. Explore the history of patient’s pattern of illegaland/or unethical behaviorand confront attempts atminimization, denial, orprojection of blame.

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LONG-TERM GOALS

1. Become more responsible for behavior and keep behavior withinthe acceptable limits of the rules of society.

2. Develop and demonstrate a healthy sense of respect for socialnorms, the rights of others, and the need for honesty.

3. Improve method of relating to the world, especially authority fig-ures; be more realistic, less defiant, and more socially sensitive.

4. Come to an understanding and acceptance of the need for limitsand boundaries on behavior.

5. Accept responsibility for own actions, including apologizing forhurts and not blaming others.

6. Maintain consistent employment and demonstrate financial andemotional responsibility for children.

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2. Verbalize an understandingof the benefits for self andothers of living within thelaws and rules of society. (3, 4)

3. Make a commitment to livewithin the rules and laws ofsociety. (4, 5, 6)

4. List relationships that havebeen broken because of dis-respect, disloyalty, aggres-sion, or dishonesty. (7, 8)

5. Acknowledge a pattern ofself-centeredness in virtu-ally all relationships. (8, 9)

6. Verbalize an understandingof the benefits for self andothers of being honest andreliable. (10, 11)

7. Make a commitment to be honest and reliable. (10, 11, 12)

8. Verbalize an understandingof the benefits to self andothers of being empatheticand sensitive to the needsof others. (3, 13, 14)

9. List three actions that willbe performed that will beacts of kindness andthoughtfulness towardothers. (3, 15)

10. List those who deserve anapology for hurtful behav-iors. (7, 8, 16, 17)

11. Indicate steps that will betaken to make amends orrestitution for hurt causedto others. (16, 17, 18)


2. Review the consequencesfor self and others of the an-tisocial behavior.

3. Teach that the basis for allrelationships is trust thatthe other person will treatone with respect and kind-ness.

4. Teach the need for lawful-ness as the basis for trustwhich forestalls anarchy insociety as a whole.

5. Solicit a commitment to livea prosocial, law-abidinglifestyle.

6. Emphasize the reality ofnegative consequences forpatient if continued law-lessness is practiced.

7. Review relationships thathave been lost due to antiso-cial attitudes and practices(e.g., disloyalty, dishonesty,aggression, etc.).

8. Confront the lack of sensi-tivity to the needs and feel-ings of others.

9. Point out the self-focused,me-first, look-out-for-number-one attitude that isreflected in the antisocialbehavior.

10. Teach the value of honestyand reliability for self asthe basis for trust and respect in all relationshipsand social approval.

11. Teach the positive effectthat honesty and reliabilityhave for others as they arenot disappointed or hurt bylies and broken promises.


12. Verbally demonstrate anunderstanding of the rulesand duties related to em-ployment. (19)

13. Attend work reliably andtreat supervisor andcoworkers with respect. (20, 21)

14. Verbalize the obligations ofparenthood that have beenignored. (22, 23)

15. State a plan to meet respon-sibilities toward children.(23, 24)

16. Decrease statements ofblame of others or circum-stances for own behavior,thoughts, and feelings. (1, 17, 22, 25, 26)

17. Increase statements of accepting responsibility for own behavior. (16, 17, 18, 24, 27)

18. Describe instances in child-hood of emotional, verbal,and/or physical abuse. (26, 28)

19. Verbalize an understandingof how childhood experi-ences of pain and aggressionhave led to an imitative pat-tern of self-focused protec-tion and aggression towardothers. (28, 29)

20. Verbalize a desire to forgiveperpetrators of childhoodabuse. (28, 29, 30)

21. Verbalize fears associatedwith trusting others. (28, 29, 31)


12. Ask patient to make a com-mitment to be honest andreliable.

13. Attempt to sensitize patientto his/her lack of empathyfor others by revisiting con-sequences of behavior onothers. Use role reversaltechniques.

14. Confront patient when rudeor not being respectful ofothers and their bound-aries.

15. Assist patient in listingthree actions that he/shewill perform as acts of ser-vice or kindness for others.

16. Assist patient in identifyingthose who have been hurtby his/her antisocial behavior.

17. Teach the value of apologiz-ing for hurt caused as ameans of accepting respon-sibility for behavior and developing sensitivity to thefeelings of others.

18. Encourage a commitment to specific steps that will betaken to apologize, makerestitution to those whohave suffered from patient’shurtful behaviors.

19. Review the rules and expec-tations that must governbehavior at the work setting.

20. Monitor attendance at work and reinforce reliabil-ity as well as respect for authority.



21. Ask patient to make a list ofbehaviors and attitudesthat must be modified inorder to decrease his/herconflict with authorities.Process list with therapist.

22. Confront patient’s avoid-ance of responsibilitiestoward his/her children.

23. Assist patient in listing thebehaviors that are requiredto be a responsible, nurtu-rant, consistently reliableparent.

24. Develop a plan with patientthat will begin to imple-ment behaviors of a respon-sible parent.

25. Confront patient whenmaking blaming statementsor failing to take responsi-bility for actions, thoughts,or feelings.

26. Explore with patient rea-sons for blaming others forown actions.

27. Give verbal positive feed-back to patient when he/sheis taking responsibility forhis/her own behavior.

28. Explore history of abuse,neglect, or abandonment inchildhood.

29. Point out that the patternof emotional detachment inrelationships and self-focused behavior is relatedto a dysfunctional attemptto protect self from pain.

30. Teach the value of forgive-ness of the perpetrators ofhurt versus holding on to

22. Practice trusting a signifi-cant other with disclosureof personal feelings. (17, 29, 32)

23. Report on the experience ofbeing more trusting in self-disclosure. (31, 32, 33)

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hurt and rage, using thehurt as an excuse to con-tinue antisocial practices.

31. Explore fears associatedwith placing trust in others.

32. Identify some personalthoughts and feelings thatcould be shared with a sig-nificant other as a means ofbeginning to demonstratetrust in someone.

33. Process the experience ofpatient making self a littlevulnerable by self-disclosingto someone.

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Axis I: 303.90 Alcohol Dependence304.20 Cocaine Dependence304.89 Polysubstance Dependence309.3 Adjustment Disorder with Disturbance of

Conduct312.8 Conduct Disorder312.34 Intermittent Explosive Disorder

Axis II: 301.7 Antisocial Personality Disorder301.81 Narcissistic Personality Disorder


ANXIETY


1. Excessive and persistent daily worry about several life circum-stances that has no factual or logical basis.

2. Symptoms of motor tension such as restlessness, tiredness, shaki-ness, or muscle tension.

3. Symptoms of autonomic hyperactivity such as palpitations, short-ness of breath, dry mouth, trouble swallowing, nausea, or diarrhea.

4. Symptoms of hypervigilance such as feeling constantly on edge,concentration difficulties, trouble falling or staying asleep, andgeneral state of irritability.

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LONG-TERM GOALS

1. Reduce overall level, frequency, and intensity of the anxiety so thatdaily functioning is not impaired.

2. Stabilize anxiety level while increasing ability to function on adaily basis.

3. Resolve the core conflict that is the source of anxiety.4. Enhance ability to handle effectively the full variety of life’s anxi-

eties.

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1. Tell the story of the anxietycomplete with ways he/shehas attempted to resolve itand the suggestions othershave given. (1, 2)

2. Identify major life conflictsfrom the past and present.(3, 4)

3. Complete anxiety home-work exercises that identifycognitive distractions thatgenerate anxious feelings.(5)

4. Complete physical evalua-tion for medications. (6)

5. Take medications as pre-scribed and report any sideeffects to appropriate pro-fessionals. (7)

6. Develop appropriate relax-ation and diversion activi-ties to decrease level ofanxiety. (8, 9, 10)

7. Increase daily social and vocational involvement. (11)

8. Identify how worries are ir-rational. (12, 13)

ANXIETY 23


1. Build a level of trust withpatient and create a sup-portive environment whichwill facilitate a descriptionof his/her fears.

2. Probe with questions (seeAnxiety Disorders and Phobias by Beck andEmery) which require thepatient to produce evidenceof the anxiety and logicalreasons for it being present.

3. Ask patient to develop andprocess a list of key pastand present life conflicts.

4. Assist patient in becomingaware of key unresolved lifeconflicts and in starting to work toward their resolution.

5. Assign patient to complete,and process with therapist,the anxiety section exer-cises in Ten Days to Self-Esteem! (Burns).

6. Make a referral to a physi-cian for a medication con-sultation.

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9. Increase understanding ofbeliefs and messages thatproduce worry and anxiety.(13, 14)

10. Verbalize insight into howpast traumatic experiencesare causing anxiety inpresent unrelated circum-stances. (15)

11. Decrease daily level of anxi-ety by developing positiveself-talk. (16)

12. Implement thought-stopping technique to inter-rupt anxiety-producingthoughts. (17)

13. List the advantages anddisadvantages of the anxi-ety. (18)

14. Verbalize positive principlesthat reduce anxiousthoughts. (19)

15. Verbalize alternative posi-tive views of reality that areincompatible with anxiety-producing views. (20)

16. Identify an anxiety copingmechanism that has beensuccessful in the past andincrease its use. (21)

17. Utilize paradoxical inter-vention to reduce anxietyresponse. (22)

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7. Monitor medication compli-ance, side effects, and effec-tiveness. Confer withphysician regularly.

8. Train in guided imagery foranxiety relief.

9. Utilize biofeedback tech-niques to facilitate relax-ation skills.

10. Assign or allow patient tochoose a chapter in Relax-ation and Stress ReductionWorkbook (Davis, Eshel-man, and McKay), thenwork with him/her to imple-ment the chosen technique.

11. Assist patient in developingcoping strategies (e.g., in-creased social involvement,obtaining employment, orphysical exercise) forhis/her anxiety.

12. Assist patient in developingan awareness of the irra-tional nature of his/herfears.

13. Analyze the fear with thepatient by examining theprobability of the negativeexpectation occurring, sowhat if it happens, abilityto control it, the worst pos-sible outcome, and the pa-tient’s ability to accept it.(See Anxiety Disorders andPhobias by Beck andEmery.)

14. Explore cognitive messagesthat mediate anxiety re-sponse and retrain in adap-tive cognitions.


ANXIETY 25

15. Reinforce insights into pastemotional issues andpresent anxiety.

16. Help patient develop reality-based, positive cog-nitive messages that will increase self-confidence incoping with irrational fears.

17. Teach patient to implementa thought-stopping tech-nique that cognitively inter-feres with obsessions bythinking of a stop sign andthen a pleasant scene. Mon-itor and encourage patient’suse of technique in daily lifebetween sessions.

18. Ask patient to complete and process with therapist“Cost-Benefit Analysis” ex-ercise (see Ten Days to Self-Esteem! by Burns) in whichhe/she lists the advantagesand disadvantages of thenegative thought, fear, oranxiety.

19. Read and process a fablefrom Friedman’s Fables(Friedman) that pertains toanxiety with the patient.

20. Reframe the fear or anxietyby offering another way oflooking at it, various alter-natives, or by enlarging theperspective.

21. Utilize a brief solution-focused therapy approach inwhich the patient is probedto find a time or situation inhis/her life when he/shehandled the specific anxietyor an anxiety in general.



Clearly focus the approachhe/she used and then encourage the patient to increase the use of this.Monitor and modify the solution as required.

22. Develop a paradoxical inter-vention (see Ordeal Ther-apy by Haley) in which thepatient is encouraged tohave the problem (e.g., anx-iety) and then schedule thatanxiety to occur at specificintervals each day in a spe-cific way and for a definedlength of time. It is best tohave it happen at a time ofday/night when the patientwould be clearly wanting todo something else.

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Axis I: 300.02 Generalized Anxiety Disorder300.00 Anxiety Disorder NOS309.24 Adjustment Disorder with Anxiety


ATTENTION DEFICIT DISORDER (ADD)—ADULT


1. Childhood history of Attention Deficit Disorder (ADD) that was either diagnosed or later concluded from by the symptoms of be-havioral problems at school, impulsivity, overexcitability, temperoutbursts, and lack of concentration.

2. Unable to concentrate or pay attention to things of low interest,even when those things are important to his/her life.

3. Easily distracted and drawn from task at hand.4. Restless and fidgety; unable to be sedentary for more than a short

time.5. Impulsive; has an easily observable pattern of acting first, think-

ing later.6. Rapid mood swings and mood lability within short spans of time.7. Disorganized in most areas of his/her life.8. Starts many projects but rarely finishes any.9. Has a “low boiling point and a short fuse.”

10. Exhibits low stress tolerance; is easily frustrated, hassled or upset.11. Chronic low self-esteem.12. Tendency toward addictive behaviors.

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1. Cooperate with and com-plete psychological testing.(1, 2, 7)

2. Cooperate with and com-plete psychiatric evalua-tion. (3)

3. Comply with all recommen-dations of the psychiatricand/or psychological evalua-tions. (2, 4, 7)

4. Take medication as pre-scribed on a regular, consis-tent basis. (5, 6)

5. Identify specific benefits oftaking prescribed medica-tions on a long-term basis.(8, 9, 10)



1. Arrange for the administra-tion of psychological testingto establish or rule out Attention-Deficit/Hyperactivity Disorder(ADHD).

2. Process the results of psy-chological testing with pa-tient to aid understandingand answer any questionswhich he/she may have.

3. Arrange for a psychiatricevaluation to make medica-tion recommendations.

4. Process results and recom-mendations of psychiatricevaluation with patient andanswer any questions thatmay arise.

LONG-TERM GOALS

1. Reduce impulsive actions while increasing concentration and focuson low-interest activities.

2. Reduce ADD behavioral interference in daily life.3. Acceptance of ADD as a chronic issue and in need of continuing

medication treatment.4. Sustain attention and concentration for consistently longer periods

of time.5. Achieve a satisfactory level of balance, structure, and intimacy to

personal life.

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6. Identify the specific ADDbehaviors that cause selfthe most difficulty. (11, 12, 13)

7. Apply problem-solvingskills to specific ADD be-haviors that are interferingwith daily functioning. (14, 15)

8. Utilize cognitive strategiesto curb impulsive behavior.(16)

9. Implement a specific, time-limited period of indulgingimpulses that are not self-destructive. (17)

10. Use “time out” to removeself from situations andthink about behavioral reaction alternatives andtheir consequences. (18)

11. Implement relaxation pro-cedures to reduce tensionand physical restlessness.(19)

12. Reward self when problembehaviors (e.g., impulsivity,inattention, etc.) are re-placed with positive alter-natives. (20)

13. Use lists, sticky notes, anddaily routines to decreaseeffects of inattention. (21)

14. Cooperate with brainwavebiofeedback to improve im-pulse control and reducedistractibility. (22, 23)

15. Introduce behaviors into lifethat improve health (e.g.,increased exercise) and/orserve others (e.g., commu-nity service). (24, 25)

ATTENTION DEFICIT DISORDER (ADD)—ADULT 29

5. Monitor and evaluate medi-cation compliance and theeffectiveness of the medica-tions on the patient’s levelof functioning.

6. Confer with psychiatrist onregular basis regarding ef-fectiveness of the medica-tion regime.

7. Conduct a conjoint sessionwith significant others andpatient to present the re-sults of psychological andpsychiatric evaluations. Answer any questions theymay have and solicit theirsupport in dealing with patient’s condition.

8. Ask patient to make a “pros and cons” spreadsheetregarding staying on medi-cations after doing well.Process sheet with therapist.

9. Encourage and support pa-tient in remaining on medi-cations and warmly butfirmly confront thoughts ofdiscontinuing when theysurface.

10. Assign patient to list thepositive effects that have occurred for him/her sincestarting on medication.

11. Assist patient in identifyingthe specific behaviors thatcause him/her the most difficulty.

12. Review the results of psy-chological testing and/orpsychiatric evaluationagain with patient to assist


16. List the negative conse-quences of the ADD prob-lematic behavior. (26)

17. Attend an ADD supportgroup. (27)

18. Use a “coach” who has beentrained by therapist to in-crease organization andtask focus. (28, 29)

19. Report improved listeningskills without defensive-ness. (30)

20. Read material that is infor-mative regarding ADD togain knowledge about thecondition. (31)

21. Decrease statements andfeelings of negativity re-garding self and life. (32)

22. Have significant other at-tend an ADD support groupto increase his/her under-standing of the condition.(33)

23. Attend a communicationimprovement group withsignificant other. (34)

24. Verbalize expectations partners have for eachother. (35)

25. Report improved communi-cation and feelings of trustbetween self and significantother. (34, 35, 36, 37)

26. Develop signals betweenpartners to act as a warningsystem to indicate whenproblematic behaviors areescalating. (38)


in identifying or in affirm-ing his/her choice of a mostproblematic behavior(s) toaddress.

13. Ask patient to have ex-tended family members andclose colaterals complete aranking of the three behav-iors they see as interferingthe most with his/her dailyfunctioning (e.g., moodswings, temper outbursts,impulsivity, restlessness,easily stressed, short atten-tion span, never completesprojects, etc.).

14. Teach (or expand) patient’sproblem-solving skills (i.e.,identify problem, brain-storm all possible options,evaluate each option, selectbest option, implementcourse of action, and evalu-ate results).

15. Assign problem-solvinghomework to patient spe-cific to identified behavior(i.e., impulse control, angeroutbursts, mood swings,staying on task, attentive-ness). Process the com-pleted assignment and giveappropriate feedback to patient.

16. Teach patient the self-control strategies of “stop,listen, think, act” and“problem-solving self-talk.”Role-play these techniquesto improve skill level.

17. Structure a “blow out” timeeach week when patient cando whatever he/she likes to



do that is not self-destructive (e.g., blastthemselves with music,gorge on ice cream, etc.).

18. Train patient to use “time-out” intervention in whichhe/she settles down bygoing away from the situa-tion and calming down tothink about behavioral al-ternatives and their conse-quences.

19. Instruct patient in variousrelaxation techniques (e.g.,deep breathing, meditation,guided imagery, etc.) andencourage patient to usedaily or when stress in-creases.

20. Design and implement aself-administered rewardsystem to reinforce and en-courage patient’s decreasedimpulsiveness, loss of tem-per, inattentiveness, and so on.

21. Assist patient in utilizingexternal structure such aslists, reminders, files, and/or daily rituals to reduce effects of inattention andforgetfulness.

22. Refer for or administerbrainwave biofeedback toimprove attention span, impulse control, and moodregulation.

23. Encourage the patient totransfer the biofeedbacktraining skills of relaxationand cognitive focusing to everyday situations (e.g.,home, work, and social).

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24. Direct patient towardhealthy addictions such asexercise, volunteer work, orcommunity service.

25. After clearance from pa-tient’s personal physician,refer patient to a physicalfitness trainer who can design an aerobic exerciseroutine for the patient.

26. Assign patient to make alist of negative conse-quences either that he/shehas experienced or thatcould result from the prob-lematic behavior. Processlist with therapist.

27. Refer to a specific grouptherapy for adults withADD to increase patient’sunderstanding of ADD, toboost his/her self-esteem,and to receive feedbackfrom others.

28. Direct patient to pick a“coach” who is a friend orcolleague to assist him/herin getting organized andstaying on task and to giveencouragement support.(See Driven to Distractionby Hallowell and Raty.)

29. Instruct coach in HOPEtechnique (i.e., Help, Obli-gations, Plans, and Encour-agement) as described inDriven to Distraction (Hal-lowell and Raty).

30. Use role-playing and model-ing to teach patient how tolisten and accept feedbackfrom others regardinghis/her behavior.



31. Ask patient to read Drivento Distraction (Hallowelland Raty), The HyperactiveChild, Adolescent and Adult(Wender), Putting On TheBrakes (Quinn and Stern);and/or You Mean I’m NotLazy, Stupid or Crazy(Kelly and Ramundo). Pro-cess reading with therapist.

32. Conduct conjoint sessions inwhich positive aspects ofthe relationship, patient,and significant other areidentified and affirmed.

33. Educate significant other onADD and encourage him/her to attend a supportgroup.

34. Refer patient and signifi-cant other to a skill-basedmarriage/relationship semi-nar (e.g., PREP, MarriageEncounter, Engaged En-counter, etc.) to improvecommunication and conflictresolution skills.

35. Ask patient and significantother to list the expectationsthey have for the relation-ship and each other. Processlist in conjoint session withfocus on identifying how ex-pectations can be met andhow realistic they are.

36. Assist patient and signifi-cant other in removingblocks in communicationand in developing new com-munication skills.

37. Assign patient and signifi-cant other to schedule aspecific time each day to



Axis I: 314.00 Attention-Deficit/Hyperactivity Disorder,Predominately Inattentive Type

314.01 Attention-Deficit/Hyperactivity Disorder,Predominately Hypersensitive-Impulsive Type

314.9 Attention-Deficit/Hyperactivity Disorder NOS296.xx Bipolar I Disorder301.13 Cyclothymic Disorder296.90 Mood Disorder NOS312.30 Impulse Control Disorder NOS303.90 Alcohol Dependence305.00 Alcohol Abuse304.30 Cannabis Dependence305.20 Cannabis Abuse


spend together communi-cating, expressing affection,having fun, or talkingthrough problems. Move assignment toward becom-ing a daily ritual.

38. Assist patient and signifi-cant other in developing asignal system as a means ofgiving feedback when con-flict behaviors begin to escalate.

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BORDERLINE PERSONALITY


1. Extreme emotional reactivity (anger, anxiety, or depression) underminor stress that usually does not last more than a few hours to afew days.

2. A pattern of intense, chaotic interpersonal relationships.3. Marked identity disturbance.4. Impulsive behaviors that are potentially self-damaging.5. Recurrent suicidal gestures, threats, or self-mutilating behavior.6. Chronic feelings of emptiness and boredom.7. Frequent eruptions of intense, inappropriate anger.8. Easily feels that others are treating him/her unfairly or that they

can’t be trusted.9. Analyzes most issues in simple terms of right and wrong (e.g.,

black/white, trustworthy/deceitful) without regard for extenuatingcircumstances or complex situations.

10. Becomes very anxious with any hint of perceived abandonment ina relationship.

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1. Verbalize the situationsthat can easily trigger feel-ings of fear, depression, andanger. (1)

2. Write a daily journal of feel-ings and the circumstancesthat triggered those feel-ings. (2)

3. Identify the negative cogni-tive interpretation patternsthat mediate the intensenegative emotions. (3, 4)

4. Verbalize realistic, positiveself-talk to replace distortednegative messages. (4, 5, 6)

5. Record and report instancesof implementing positive



1. Explore the situations thattrigger feelings of fear, depression, and anger.

2. Assign patient to record a daily journal of feelingsalong with the circum-stances that he/she was reacting to.

3. Identify the distortedschemas and related auto-matic thoughts that medi-ate anxiety response.

4. Require patient to keep adaily record of self-defeatingthoughts (thoughts of hope-lessness, helplessness,worthlessness, catastrophiz-

LONG-TERM GOALS

1. Develop and demonstrate coping skills to deal with mood swings.2. Develop the ability to control impulses.3. Learn and demonstrate strategies to deal with dysphoric moods.4. Replace dichotomous thinking with ability to tolerate ambiguity

and complexity in people and issues.5. Develop and demonstrate anger management skills.6. Learn and practice interpersonal relationship skills.7. Reduce the frequency of self-damaging behaviors (such as sub-

stance abuse, reckless driving, sexual acting out, binge eating, orsuicidal behaviors).

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self-talk and constructiveautomatic thoughts; includerewarding consequences. (6, 7)

6. List some negative conse-quences to self and others of self-defeating impulsivebehaviors. (8)

7. Verbalize an understandingof the impulse control strat-egy of “stop, look, listen,and think.” (9)

8. Record and report instancesof implementing “Stop,Look, Listen, and Think” asan impulse control strategy.(9, 10)

9. Utilize cognitive methods tocontrol impulsive behavior.(9, 11)

10. Practice deep muscle relax-ation and deep breathingexercises. (12)

11. Record and report instancesof using relaxation tech-niques to manage intensefeelings and control impul-sive reactive behavior. (13)

12. Practice assertivenessskills. (14, 15)

13. Identify situations whereassertiveness has been implemented and describethe consequences. (16)

14. Implement the use of “Imessages” to communicatefeelings without aggression.(17, 18)

15. Verbalize instances ofabuse, neglect, or abandon-ment in childhood. (19)

BORDERLINE PERSONALITY 37

ing, negatively predictingthe future, etc.), challengeeach thought for accuracy,then replace each dysfunc-tional thought with one that is positive and self-enhancing.

5. Train in revising coreschema using cognitive re-structuring techniques.

6. Reinforce positive, realisticcognitive self-talk that mediates a sense of peace.

7. Assign patient to record instances of successfullyusing revised, constructivecognitive patterns. Processand reinforce positive consequences.

8. Assign patient to list de-structive consequences toself and others of impulsivebehavior.

9. Teach the patient media-tional and self-controlstrategies (i.e., “stop, look,listen, and think”) to delaygratification and inhibit impulses.

10. Assign patient to record instances of successfully implementing “stop, look,listen, and think” to controlreactive impulses.

11. Teach patient cognitivemethods (thought stoppage,thought substitution, re-framing, etc.) for gainingand improving control overimpulsive actions.


16. Verbalize the effect thatchildhood experiences ofabuse, neglect, or abandon-ment has upon possessive-ness in relationships andsensitivity to a hint of lossof commitment by others to relationship with self.(20, 21)

17. List coping strategies todeal with fear of abandon-ment. (22)

18. Initiate enjoyable activitiesthat can be done alone orare not dependent on some-one else to do them with.Report feeling comfortablebeing alone or independent.(4, 6, 23, 24)

19. Cooperate with a referral toa physician to evaluate theneed for psychotropic medi-cation to stabilize mood.(25)

20. Take medication as pre-scribed and report as to ef-fectiveness and side effects.(26)

21. Describe the history andnature of self-mutilating be-havior. (27)

22. Verbalize the intense feel-ings that motivate self-mutilating behavior andhow those feelings are relieved by such behavior. (19, 21, 28)

23. Verbalize the history of suicidal gestures and thefeelings associated withthem. (29)


12. Using relaxation techniquessuch as progressive relax-ation, self-hypnosis, orbiofeedback; teach the patient how to relax com-pletely; then have the pa-tient relax whenever he/shefeels uncomfortable.

13. Ask patient to record in-stances of using relaxationtechniques to cope withstress rather than reactingwith anger. Reinforce suc-cessful implementation ofthis coping skill.

14. Use role-playing, modeling,and behavioral rehearsal toteach assertiveness (versuspassivity and aggressive-ness).

15. Refer patient to an asser-tiveness training group.

16. Review implementation ofassertiveness and feelingsabout it as well as the con-sequences of it.

17. Use modeling, role-playing,and behavioral rehearsal to teach the use of “I mes-sages” to communicate feel-ings directly (i.e., I feel . . .When you . . . I would pre-fer it if you . . .).

18. Reinforce the use of “I mes-sages” in place of aggres-siveness or possessivenesswhen feeling threatened.

19. Explore instances of abuse,neglect, or emotional/physi-cal abandonment in child-hood. Process the feelingsassociated with these expe-riences.


24. Verbalize a promise (as partof a self-mutilation and suicide prevention contract)to contact the therapist orsome other emergencyhelpline if a serious urgetoward self-harm arises.(30, 31)

25. Terminate all self-mutilation behavior. (21, 30, 32)

26. Identify instances wherepeople were judged in blackand white terms. (33, 35)

27. List negative consequencesof judging people so rigidlyand harshly. (34)

28. Verbalize weaknesses orfaults of those who havebeen judged to be perfectand strengths or assets ofthose people who have beenjudged to be evil, worthless,and deceitful. (35, 36)

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20. Point out the destructive ef-fect of overcontrol of othersand angry resentment whenothers pull back from rela-tionship. Encourage separa-tion of helpless, desperatefeelings of the past fromcurrent relationships.

21. Reinforce insight into theeffect of childhood experi-ences on current urges toreact with rage.

22. Teach patient to use copingstrategies (e.g., delay of re-action, “stop, look, listen,and plan,” relaxation anddeep breathing techniques,“I messages,” expanded so-cial network versus few in-tense relationships) to dealwith fear of abandonment.

23. Explore patient’s automaticthoughts associated withbeing alone.

24. Encourage patient to breakpattern of avoiding beingalone by initiating activitieswithout a companion (e.g.,starting a hobby; doing ex-ercise; attending lectures,concerts, movies; reading abook; taking a class).

25. Refer patient to a physicianfor medication evaluation.

26. Monitor and evaluate pa-tient’s medication compli-ance and the effectivenessof the medication on thelevel of functioning.

27. Probe nature and history of patient’s self-mutilatingbehavior.



28. Interpret the self-mutilationas an expression of the rageand helplessness that couldnot be expressed as a childvictim of emotional aban-donment or abuse.

29. Assess the suicidal gesturesas to triggers, frequency, seriousness, secondary gain,and onset.

30. Elicit a promise from thepatient that he/she will initiate contact with thetherapist or a helpline if the suicidal urge becomesstrong and before any self-injurious behavior.

31. Provide the patient with an emergency helpline telephone number that isavailable 24 hours a day.

32. Encourage patient to ex-press feelings directly usingassertive “I messages”rather than indirectlythrough self-mutilating behavior.

33. Ask patient to examinehis/her style of evaluatingpeople, especially in regardto his/her dichotomousthinking.

34. Teach the alienating conse-quences of judging peopleharshly and impulsively.

35. Challenge the patient inunderstanding how dichoto-mous thinking leads to feelings of interpersonalmistrust, helping him/her tosee positive and negativetraits in all people.



36. Use role reversal and mod-eling to assist patient inseeing positive and negativequalities in all people.

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Axis I: 300.4 Dysthymic Disorder296.3x Major Depressive Disorder, Recurrent

Axis II: 301.83 Borderline Personality Disorder301.9 Personality Disorder NOS


CHEMICAL DEPENDENCE


1. Consistent use of alcohol or other mood-altering drugs until high,intoxicated, or passed out.

2. Inability to stop or cut down use of mood-altering drug oncestarted, despite the verbalized desire to do so and the negative con-sequences continued use brings.

3. Blood work that reflects the results of a pattern of heavy substanceuse, for example, elevated liver enzymes.

4. Denial that chemical dependence is a problem despite direct feed-back from spouse, relatives, friends, and employers that the use ofthe substance is negatively affecting them and others.

5. Amnesiac blackouts have occurred when abusing alcohol.6. Continued drug and/or alcohol use despite experiencing persistent

or recurring physical, legal, vocational, social, or relationship prob-lems that are directly caused by the use of the substance.

7. Increased tolerance for the drug as there is the need to use more tobecome intoxicated or to attain the desired effect.

8. Physical symptoms, that is, shaking, seizures, nausea, headaches,sweating, anxiety, insomnia, and/or depression, when withdrawingfrom the substance.

9. Suspension of important social, recreational, or occupational activ-ities because they interfere with using.

10. Large time investment in activities to obtain the substance, to useit, or to recover from its effects.

11. Consumption of substance in greater amounts and for longer peri-ods than intended.

12. Continued use of mood-altering chemical after being told by aphysician that it is causing health problems.

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1. Describe the amount, frequency, and history ofsubstance abuse. (1, 3)

2. Identify the negative conse-quences of drug and/or alco-hol abuse. (1, 2, 3, 4, 13)

CHEMICAL DEPENDENCE 43


1. Gather a complete drug/alcohol history includingamount and pattern of use,signs and symptoms of use,and negative life conse-quences (social, legal, familial, and vocational)

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LONG-TERM GOALS

1. Accept chemical dependence and begin to actively participate in arecovery program.

2. Establish a sustained recovery, free from the use of all mood-altering substances.

3. Establish and maintain total abstinence while increasing knowl-edge of the disease and the process of recovery.

4. Acquire the necessary skills to maintain long-term sobriety fromall mood-altering substances and live a life free of chemicals.

5. Improve quality of life by maintaining an ongoing abstinence fromall mood-altering chemicals.

6. Withdraw from mood-altering substance, stabilize physically andemotionally, and then establish a supportive recovery plan.

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3. Make verbal “I” statementsthat reflect acknowledg-ment and acceptance ofchemical dependence. (5, 6, 7)

4. Decrease the level of denialaround using as evidencedby fewer statements aboutminimizing amount of useand its negative impact onlife. (2, 4, 6, 7)

5. Verbalize increased knowl-edge of alcoholism and theprocess of recovery. (6, 8)

6. Verbalize an understandingof personality, social, andfamily factors that fosterchemical dependence. (9, 10, 11)

7. Describe childhood experi-ence of alcohol abuse by immediate and extendedfamily members. (11)

8. Review extended family alcohol use history and verbalize an acceptance of a genetic component tochemical dependence. (11, 12)

9. Obtain a medical examina-tion to evaluate the effectsof chemical dependence.(13)

10. Identify the ways beingsober could positively im-pact life. (14)

11. State changes that will bemade in social relationshipsto support recovery. (15, 16)


resulting from client’schemical dependence.

2. Ask client to make a list ofthe ways substance abusehas negatively impactedhis/her life and process itwith therapist.

3. Administer the AlcoholSeverity Index, and processthe results with the client.

4. Assign client to ask two orthree people who are closeto him/her to write a letterto therapist in which theyidentify how they sawclient’s chemical depen-dence negatively impactinghis/her life.

5. Assign client to complete aFirst Step paper and thenprocess it with either group,sponsor, or therapist to receive feedback.

6. Require client to attend didactic lectures related tochemical dependence andthe process of recovery.Then ask client to identifyin writing several keypoints attained from eachlecture for further process-ing with therapist.

7. Model and reinforce state-ments that reflect acceptanceof chemical dependence andits destructive consequencesfor self and others.

8. Assign client to read arti-cle/pamphlet on the diseaseconcept of alcoholism andselect several key ideas todiscuss with therapist.


12. List recreational and socialactivities (and places) thatwill replace substanceabuse related activities. (16, 17)

13. Identify constructive proj-ects that will be accom-plished now that time andenergy are available in sobriety. (16, 18)

14. Agree to make amends tosignificant others who havebeen hurt by the life domi-nated by substance abuse.(16, 19)

15. Identify the positive impactthat sobriety will have onintimate and family rela-tionships. (16, 20)

16. Verbalize how living situa-tion contributes to chemicaldependence and acts as ahindrance to recovery. (10, 21, 22)

17. State the need for a morestable, healthy living situa-tion that will support recov-ery. (22, 23)

18. Make arrangements to ter-minate current living situa-tion and move to a placemore conducive to recovery.(23, 24)

19. Write a goodbye letter todrug of choice telling it whyit must go. (25)

20. Sign an abstinence contractand verbalize feelings offear, grief, or reluctance associated with signing.(26)


9. Assess client’s intellectual,personality, and cognitivefunctioning as to his/hercontribution to chemical dependence.

10. Investigate situationalstress factors that may foster client’s chemical dependence.

11. Probe client’s family historyfor chemical dependencepatterns and relate these toclient’s use.

12. Explore extended familychemical dependence his-tory and relate this to a genetic vulnerability forclient to develop chemicaldependence also.

13. Refer client for thoroughphysical examination to de-termine any physical effectsof chemical dependence.

14. Ask client to make and process a list of how beingsober could positively impact life.

15. Review the negative influ-ence of continuing old alcohol-related friendships(“drinking buddies”) and as-sist client in making a planto develop new sober friend-ships.

16. Assist the client in develop-ing insight into life changesneeded in order to maintainlong-term sobriety.

17. Assist client in planning social and recreational activities that are free fromassociation with substanceabuse.


21. Develop a written aftercareplan that will support themaintenance of long-termsobriety. (16, 17, 18, 27, 30)

22. Identify sources of ongoingsupport in maintaining sobriety. (28, 29, 30)

23. Meet with an AlcoholicsAnonymous/NarcoticsAnonymous (AA/NA) mem-ber to gain informationabout the role of AA/NA inrecovery. (29)

24. Attend AA/NA meetings on a regular basis as fre-quently as necessary to support sobriety. (30)

25. Identify potential relapsetriggers and develop strate-gies for constructively dealing with each trigger.(6, 10, 15, 17, 31, 32)

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18. Plan household or work-related projects that can beaccomplished to build self-esteem now that sobrietyaffords time and energy forsuch constructive activity.

19. Discuss the negative effectssubstance abuse has had onfamily, friends, and work re-lationships and encourage aplan to make amends forsuch hurt.

20. Assist client in identifyingpositive changes that willbe made in family relation-ships during recovery.

21. Evaluate the role of client’sliving situation in fosteringa pattern of chemical de-pendence.

22. Assign client to write a listof negative influences forchemical dependence inher-ent in his/her current livingsituation.

23. Encourage a plan for achange in living situationthat will foster recovery.

24. Reinforce a positive changein living situation.

25. Direct patient to write agood-bye letter to drug ofchoice; read it and processrelated feelings with therapist.

26. Develop an abstinence con-tract with patient regardingthe use of his/her drug ofchoice. Then process the



emotional impact of thiscontract with therapist.

27. Assign and review patient’swritten aftercare plan to ensure it is adequate tomaintain sobriety.

28. Explore with patient thepositive support system per-sonally available in sobrietyand discuss ways to developand reinforce a positive support system.

29. Assign patient to meet withan Alcoholics Anonymous/Narcotics Anonymous(AA/NA) member who hasbeen working the Twelve-Step program for severalyears and find out specifi-cally how the program hashelped him/her stay sober.Afterward, process themeeting with therapist.

30. Recommend patient attendAA or NA meetings and re-port to therapist the impactof the meetings.

31. Help patient develop anawareness of relapse trig-gers and alternative ways ofeffectively handling them.

32. Recommend the patientread Staying Sober: AGuide to Relapse Prevention(Gorski and Miller) and TheStaying Sober Workbook(Gorski).



Axis I: 303.90 Alcohol Dependence305.00 Alcohol Abuse304.30 Cannabis Dependence305.20 Cannabis Abuse304.20 Cocaine Dependence305.60 Cocaine Abuse304.80 Polysubstance Dependence291.2 Alcohol-Induced Persisting Dementia291.1 Alcohol-Induced Persisting Amnestic DisorderV71.01 Adult Antisocial Behavior300.4 Dysthymic Disorder312.34 Intermittent Explosive Disorder309.81 Posttraumatic Stress Disorder304.10 Sedative, Hypnotic, or Anxiolytic Dependence

Axis II: 301.7 Antisocial Personality Disorder


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