Definition of Anger Many definitions of anger exist, and anger must be separated from irritation, hostility aggression and violence.1. Anger is defined as a strong, uncomfortable emotional response to a provocation that is unwanted and incongruent with ones values, beliefs, or rights. - Anger can involve feelings of disapprovals of others. - Anger can involve feelings of being blocked from obtaining something. - It usually involve interpretations of being provoked by others. - It usually occurs as a result of a perceived injustice and involves blaming others (involving an element of self-justification). - Anger may be situational and occasional (state anger). - Anger may be persistent, long-standing, cross-situational and a reflection of a stable interpretive belief system (trait anger). - Anger may involve positive adaptive responses designed to correct a wrong, or solve an injustice that has been done.
Definition of Irritability and Hostility2. Irritability is defined as minor annoyances that occur in a person’s daily routine, and the reactions (or overreactions) to these perceived minor annoyances.3. Hostility is defined as a chronic antagonistic and mistrustful negative attitude toward people and the world. - It involves a personal set of expectations and beliefs in which one frequently attributes harmful intent to the actions of others. - This chronic negative attitude usually involves the devaluation of work and motives of others, the expectations that others are source of a given wrongdoing, and a desire to inflict harm upon others, or see that others are harmed by a third party.
Definition of Aggression and Violence4. Aggression and Violence are defined as the actual or intended harming of another with flagrant forceful and destructive acts. Literature supports 2 types of aggression:1. Reactive aggression – unplanned aggressive acts which are either unprovoked or out of proportion to the provocation. This type of aggression involves retaliatory intent independent of premeditated cognitive processes.2. Proactive aggression – instrumental, premeditated, or predatory aggression that is related to personal or social gain, or to the expression of domination over others, or to the achievement of some goal. Proactive aggression can occur without anger.
Characteristics of Reactive Aggressors• People characteristically have “hot tempers” or “short fuses”, are easily riled into anger-aggression at the slightest provocation.• People usually evidence less self control over emotional reactions.• They manifest aggressive behavior in response to being teased or perceived provocation.• They tend to be hyper vigilant and misinterpret social cues (they tend to use fewer social cues and tend to focus on aggressive cues).• They tend to attribute hostile intention to the actions of others.• They tend to attack someone when feeling bad, angry or bored (even when they may not benefit from such feelings or even when they may pay a price for their own aggressive behaviors).• They are more likely to mull over and have a longer maintenance of grudges and have a desire for revenge.
Characteristics of Proactive Aggressors• Their behavior is carried out for an extrinsic purpose, or to achieve some personal goals.• They tend to evidence less observable emotions (and may not evidence anger).• They tend to use physical force to dominate others, and to achieve their personal goals.• They may also tend to get others to gang up on peers in order to achieve their personal goals.• They evidence leadership skills and qualities, and evidence an agreeable sense of humor.
The DSM-IV-TR and Anger• Intermittent Explosive Disorder – 1) Several discrete episodes of failure to resist aggressive impulses that result in serious assaultive acts or destruction of property. 2) The degree of aggressiveness expressed during the episodes is grossly out of proportion to any precipitating psychosocial stressors. 3) The aggressive episodes are not better accounted for by another mental disorder (or a substance disorder or general medical condition): • Antisocial Personality Disorder – anger featured in disorder • Borderline Personality Disorder – anger featured in disorder • Conduct Disorder – anger featured in disorder • Psychotic Disorder • Manic Episode • Attention Deficit/Hyperactivity Disorder Other Disorders that Feature Anger • Oppositional Defiant Disorder • Adjustment Disorder with Disturbance of Conduct • DSM-5 - Disruptive Mood Dysregulation Disorder
History of Treating Anger Various treatment approaches have been developed to help individuals with anger management difficulties to change their experience and expression of anger. The most effective have been cognitive-behavioral in nature. Earlier psychoanalytically trained therapists supported the use of catharsis. Empirical evidence supports that venting anger alone does not automatically reduce its intensity, and that anger reduction is brought about only if cognitive processes such as reinterpretation of the triggering events or regaining a sense of control are involved.
Myths About Dealing with Your Anger Myth #1: Actively expressing your anger reduces it. Errors include:1. Expressing your rage reduces risks to your health.2. Letting your anger out will make you feel less angry.
Myths About Dealing with Your Anger Myth #2: Take time out when you feel angry. Problems with the time out theory include:1. You are not addressing problems that need to be solved. Running away from problems will not make them disappear and could cause them to continue to grow.2. Avoiding feelings stops you from being able to better manage them, and situations in which they occur.
Myths About Dealing with Your Anger Myth #3: Insights into your past decreases your anger.1. While it can be important that you learn how you developed your anger problem. Practicing new ways of thinking and behaving will help reduce your anger problem.2. It is good to have insight into what you’re doing wrong, in regards to your anger. Knowing how you came to have a problem controlling anger doesn’t necessarily lead to anger reduction.
Myths About Dealing with Your Anger Myth #4: Outside events make you angry.1. It is not the outside events that make you angry, it is your beliefs regarding the events that determine your emotional response.2. Unfair situations, difficult people and great frustrations help with anger provoking situations, however you largely create what you feel.3. Accepting this responsibility is the crucial first step in dealing effectively with your anger.
Situations That Make People Angry1. Interruptions – interruptions of planned activities and obstacles to goal-directed behaviors. The closer a person is to a goal, the greater the frustration (and anger) when interrupted.2. Implications – of noncompliance (short-term, long-term, and future implications of another person not complying).3. Concern – about possible injury to another or to oneself, also concern over what might have happened.4. Expectations – violated expectations. Something another person “should” or “should not” be doing, that is breaking implicit shared rules.
Situations That Make People Angry5. History – history repeating itself over and over. Patterns of annoying behaviors that accumulate over time.6. Overload – overload of the individual (fatigue and stress that can lower the frustration tolerance level of a person).7. Personal Peeve – violation of personal rules and values by another. For example, being disrespected in front of another.8. Embarrassment – noncompliant behavior by another that occurs in public places in front of others.
Anger Assessment Exercise #1 Joanie has been married to Chachi for over 7 years, and they have been together for over 15. They have 4 children, ages 14, twins who are 9, and 7. Joanie was in treatment at your agency and successfully completed outpatient treatment 8 months ago. During that time, she reported having domestic problems with Chachi, a few of which led to physical altercations where Joanie would hit her husband. She stated her husband never hit her back, but would often infuriate her because he would not engage in the verbal argument she was looking for. She would often get into an angry altercation with her husband over matters of finances, or the restrictions that were currently placed on the relationship (her husband is currently on parole, and stipulations of parole affect his curfew, which in turn restricts their ability to have time together outside of the house). The last physical altercation that occurred was while Joanie was in treatment was her anger at not being able to go out on a date with her husband because of these restrictions. This led Joanie to continue to argue with Chachi, and when Chachi would no longer engage in the argument, Joanie repeatedly hit him.
Anger Assessment Exercise #1 Joanie has come back to see you on the advice of her DYFS worker, who learned of the latest incident that occurred just last week. Joanie was arguing with Chachi over finances. This argument had started on Wednesday, but Joanie would not let it go, and continued the arguing into Thursday morning right before both went to work. According to Joanie, Chachi refused to continue the conversation, stating he had to get the kids ready for school. She stated this just infuriated her more, and as he was finally leaving for work, she told him he could not go until she finished having her say. He started walking out to go to work and she threw a fully loaded Zen Garden at Chachi, hitting him in the head, and causing him to go to the hospital, where he received 22 stitches. Joanie stated she did not accompany her husband to the hospital and didn’t even apologize until three days later. “I just couldn’t stop being mad at him over all this.” This incident led to her husband losing two days of work, which caused further financial strain on the family, as he is a temp worker with no sick days. When asked about this, she was unable to see the connection between her actions and it leading the worsening of the financial problems.
Anger Assessment Exercise #1 When first working with Joanie and assessing her anger patterns and history, she reported her anger is similar to her mother’s anger pattern. She stated that her mother and father were separated for two years when she was a teenager. As an adult she asked her mother about this, and her mother stated Joanie’s father left her due to repeated anger/aggression bouts in their marriage. She comes to you today, on the advice of her DYFS worker, but also with real concern that Chachi is going to leave her if things continue the way they are. When asked if Joanie relapsed at any time during all of these, she stated no, she has remained sober since leaving treatment at your agency. Joanie did state she knows she needs help with her anger problem and wants to come back to work with you on this issue.1. What type of aggressor does Joanie appear to be, reactive or proactive, and please justify your answer with supportive information.2. In the 8 different types of situations that make people angry, which ones fit Joanie? Why?3. Given the information what would your recommendation be? Since she is requesting you as her counselor, how do you handle her request?
Client Education Regarding Anger In cognitive-behavioral interventions, education is seen as most effective by using an ongoing collaborative, discovery based Socratic process (i.e., education naturally built into the therapy process as opposed to specific didactic lecture style client education). Examples of client education:1. Giving clients material to read as homework assignments, or personalized handouts (specific to their issues of anger control problems).2. Introducing conceptual frameworks and have the client discover how these frameworks apply to their own anger-aggression behaviors.3. Analysis of homework assignments.4. Videotape modeling (showing clients video tapes of individuals who become angry, analyzing the components of the anger cycle that is contributing to their anger, then (if possible) showing the same clients using their coping skills to handle the exact same provocation).5. Group feedback.
Anger-Aggression Cycle 1. STIMULUS EVENTS/INITIAL APPRAISALS/TRIGGERING THOUGHTS 5. 2. CONSEQUENCES FEELINGS (IMMEDIATE/LONG-TERM) PRE-ANGER STATE/OUTSETINTERPERSONAL (SOCIAL)/SELF FEELINGS/DURING/AFTER (HEALTH, MOOD) EPISODE/SECONDARY EMOTIONS 4. 3. FORMS OF EXPRESSION VERBAL/NONVERBAL/BEHAVIORAL THOUGHTS / PHYSIOLOGICAL (INWARD THINKING ERRORS/AUTOMATIC ANGER) THOUGHTS/IMAGES & MEMORIES/ BELIEFS/PERSONAL & CULTURAL RULES AND NORMS Taken directly from: Meichenbaum, D. (2001). Treatment of Individuals with Anger-Control Problems and Aggressive Behaviors: A Clinical Handbook. Clearwater, Fl: Institute Press.
Anger-Aggression Cycle – Box 11. Stimulus Events – Events, People, Behaviors. Initial Appraisals Triggering Thoughts Intentional “On purpose” Unjustified “Nobody has a right to do this to me” Undeserved/Unwarranted “I don’t have to put up with this” Preventable/Controllable “This doesn’t have to happen” Unreasonable “Stupid rule”, “Dumb system”, “They were asking for it”, “They deserved to be punished” Disrespectful “I feel dissed”, “Dishonored” – possible cultural expectations violated
Anger-Aggression Cycle – Box 21. Feelings – High arousal and tense state. Pre-Anger State Triggering Feelings Irritable “On edge, short fuse, keyed up, stressed, overwhelmed” Exhausted “Fatigued, at wits end, hungry, tired” Mood “Depressed, anxious, bored, jealous” Low Frustration Tolerance “Frustrated, disappointed, cynical, hostile” Trait Features “Argumentative”2. Feelings at OUTSET of Episode – Furious, enraged, pissed off.3. Feelings DURING the Episode (Can exacerbate anger) – feeling trapped, locked in, having no other options available.4. Secondary Emotional Triggers (Can exacerbate anger – feeling humiliated, scared, anxious, depressed, rejected, ashamed, embarrassed, hurt.
Anger-Aggression Cycle – Box 31. Thoughts Thinking Errors Automatic Thoughts Catastrophic Interpretation Use dramatic terms: Awful, Can’t stand it Demanding Language “Shoulds, oughts, have to, need to” Overgeneralization “Always, never, completely hopeless” Categorical Thinking “Stupid, nerd, typical of those types” Inflammatory Thinking “SOB, Asshole, fill in your own here” Misattribution “They did it on purpose” Mind Reading “The should know how I feel”, “I know what you’re up to” Black/White – either-or thinking “My soul mate or I want a divorce”2. Images & Memories – memory of wrongdoing, images of getting even3. Beliefs – Justified, lack responsibility (“Not my fault), Violates personal (narcissistic) rules of living (“It’s my home, you do it my way”), Authority challenged (“No lip from you”), Disrespectful and/or dishonorable, Unable to control anger (“Once a fuse is lit, it blows”, “I’m not able to stop it”).
Anger-Aggression Cycle – Box 41. Forms of Expression Verbal Verbal assault, argumentative, relationship aggression, gossip, lie. Non-verbal Glares, gives dirty looks, gestures, threatening posture, threatening acts. Behavioral Physical assault against others or objects: Follow cultural (anger/aggression) display rules. Physiological Arousal, tenseness, biochemical changes. “Anger In” Suppress anger, turn anger in on self (self injury, self-critical).
Anger-Aggression Cycle – Box 51. Consequences (Immediate and Long Term) Interpersonal (Social) Elicit counter-aggression, alienate others, rejection from others, damaged relationships, self- destructive behaviors, leaving problems unresolved. Self Feelings – guilty, depressed, fearful, inadequate, puzzled, dismayed. Health – increased coronary heart disease, hypertension, possible increase in general health (such as increases in getting sick or catching colds).
Guidelines for Assessing and Working WithAngry Clients1. What is the client’s usual proneness to react angrily (hot headed vs. slow to respond angrily)?2. How intense is the angry emotionality?3. What is the duration of the typical anger episode? Seconds, minutes, hours, days?4. How does the client usually express anger? Is it suppressed or directed outward in physical actions or verbal behavior? How does the client feel about his/her style of anger expression? What are some of its consequences?5. Does the person ruminate about the grievance, rekindling the anger over and over again?6. Are there irrational beliefs fueling the anger (beliefs about the way other people should behave or about the way a fair world ought to operate)?7. If the anger is kept to oneself, what barriers prevent it from being expressed?
Guidelines for Assessing and Working WithAngry Clients8. If the anger is projected outward, does the person make a clear, forthright declaration of the anger to the person who provoked it?9. Does the person engage in yelling, screaming, threats or profanity when angry?10. What triggers the anger? What is it about? What are the recurrent themes/patterns?11. What strategies are used to cool down and control ones temper? Humor? Meditation? Physical exercise?12. To what degree is anger creating problems for this client in the workplace or in intimate relationships? Has the client ever harmed self or others when angry?13. What defense mechanisms come into play? Intellectualization, projection, isolation?14. How does the current angry behavior compare the person’s usual pattern.
Guidelines for Assessing and Working WithAngry Clients15. What did the client learn about anger while growing up? Rules for anger display vary greatly from culture to culture. Gender role socialization is another strong influence.16. Is anger somaticized in headaches, gastric distress, or other physical ailments?17. Is the discomfort of anger medicated through alcohol, drugs, nicotine, or food binges?18. With whom does the anger most frequently occur? Are there any commonalities with provocateurs? Are transference phenomena evident?19. In a situation of recurrent conflict, what would the client like to be different? Is it possible for the client to understand the other person’s position on the issue?20. Who will support the client’s efforts to try new anger behaviors? Who will attempt sabotage? How will the client handle saboteurs?
Imminent Danger Defined Imminent danger is a concept used to describe problems that can lead to dire consequences for the client (and others). Imminent danger is defined as the following 3 components:1. A strong probability that certain behaviors (such as continued alcohol or drug use or continued self harm) will occur.2. The potential for such behaviors to present a significant risk of serious adverse consequences to the individual and/or others.3. The likelihood that such harmful events will occur in the near future.
New Jersey Duty to Warn & Protect Law N.J. Stat. 2A:62A-16 Medical or counseling practitioners immunity from civil liability a. Any person who is licensed in the State of New Jersey to practice psychology, psychiatry, medicine, nursing, clinical social work or marriage counseling, whether or not compensation is received or expected, is immune from any civil liability for a patients violent act against another person or against himself unless the practitioner has incurred a duty to warn and protect the potential victim as set forth in subsection b. of this section and fails to discharge that duty as set forth in subsection c. of this section. b. A duty to warn and protect is incurred when the following conditions exist: (1) The patient has communicated to that practitioner a threat of imminent, serious physical violence against a readily identifiable individual or against himself and the circumstances are such that a reasonable professional in the practitioners area of expertise would believe the patient intended to carry out the threat; or
New Jersey Duty to Warn & Protect Law N.J. Stat. 2A:62A-16 Medical or counseling practitioners immunity from civil liability (continued) (2) The circumstances are such that a reasonable professional in the practitioners area of expertise would believe the patient intended to carry out an act of imminent, serious physical violence against a readily identifiable individual or against himself. c. A licensed practitioner of psychology, psychiatry, medicine, nursing, clinical social work or marriage counseling shall discharge the duty to warn and protect as set forth in subsection b. of this section by doing any one or more of the following: (1) Arranging for the patient to be admitted voluntarily to a psychiatric unit of a general hospital, a short-term care facility, a special psychiatric hospital or a psychiatric facility, under the provisions of P.L.1987, c.116 (C.30:4-27.1 et seq.);
New Jersey Duty to Warn & Protect Law N.J. Stat. 2A:62A-16 Medical or counseling practitioners immunity from civil liability (continued) (2) Initiating procedures for involuntary commitment of the patient to a short-term care facility, a special psychiatric hospital or a psychiatric facility, under the provisions of P.L.1987, c.116 (C.30:4-27.1 et seq.); (3) Advising a local law enforcement authority of the patients threat and the identity of the intended victim; (4) Warning the intended victim of the threat, or, in the case of an intended victim who is under the age of 18, warning the parent or guardian of the intended victim; or (5) If the patient is under the age of 18 and threatens to commit suicide or bodily injury upon himself, warning the parent or guardian of the patient. d. A practitioner who is licensed in the State of New Jersey to practice psychology, psychiatry, medicine, nursing, clinical social work or marriage counseling who, in complying with subsection c. of this section, discloses a privileged communication, is immune from civil liability in regard to that disclosure.
New Jersey Duty to Warn & Protect Law N.J. Stat. 2A:62A-17 Court order required for certain disclosures When a duty to warn and protect arises from the receipt of a privileged communication from a patient in a drug or alcohol abuse program governed by federal law, a licensed practitioner of psychology, psychiatry, medicine, nursing, clinical social work or marriage counseling may be required to obtain a court order authorizing disclosure prior to disclosure of information about the patient including the patients threat of violence, in accordance with 42 U.S.C. 290dd-3 and 42 U.S.C. 290ee-3 and regulations promulgated thereunder. * See also: McIntosh v. Milano, 168 NJS 466 (Law Div. 1979) * The regulations are the federal Confidentiality of Alcohol and Drug Abuse Patient Records; Final Rule, 42 CFR Part 2
42-CFR-Part 2 – Exceptions to Confidentiality § 2.22 Notice to patients of Federal confidentiality requirements. The confidentiality of alcohol and drug abuse patient records maintained by this program is protected by Federal law and regulations. Generally, the program may not say to a person outside the program that a patient attends the program, or disclose any information identifying a patient as an alcohol or drug abuser Unless: (1) The patient consents in writing: (2) The disclosure is allowed by a court order; or (3) The disclosure is made to medical personnel in a medical emergency or to qualified personnel for research, audit, or program evaluation. Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Violation of the Federal law and regulations by a program is a crime. Suspected violations may be reported to appropriate authorities in accordance with Federal regulations. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities.
42-CFR-Part 2 – Exceptions to Confidentiality § 2.22 Notice to patients of Federal confidentiality requirements. Federal law and regulations do not protect any information about a crime committed by a patient either at the program or against any person who works for the program or about any threat to commit such a crime. Federal laws and regulations do not protect any information about suspected child abuse or neglect from being reported under State law to appropriate State or local authorities. § 2.14 Minor patients (d)(2) The applicants situation poses a substantial threat to the life or physical well being of the applicant or any other individual which may be reduced by communicating relevant facts to the minors parent, guardian, or other person authorized under State law to act in the minors behalf.
42-CFR-Part 2 – Exceptions to Confidentiality § 2.63 Confidential communications. (a) A court order under these regulations may authorize disclosure of confidential communications made by a patient to a program in the course of diagnosis, treatment, or referral for treatment only if: (1) The disclosure is necessary to protect against an existing threat to life or of serious bodily injury, including circumstances which constitute suspected child abuse and neglect and verbal threats against third parties; (2) The disclosure is necessary in connection with investigation or prosecution of an extremely serious crime, such as one which directly threatens loss of life or serious bodily injury, including homicide, rape, kidnapping, armed robbery, assault with a deadly weapon, or child abuse and neglect; or (3) The disclosure is in connection with litigation or an administrative proceeding in which the patient offers testimony or other evidence pertaining to the content of the confidential communications.
Duty to Warn VignettePaul is referred to your organization for domestic violence. The domestic violence wastowards a girlfriend who was attempting to break up with him. Paul and the girlfriendhave since broken up, and she has a restraining order against him (which he states heabides by). Both clinicians with experience with this type of client are full and cannotaccept anymore clients. As the clinical director you decide to give this case to an intern,who is supervised by one of your master’s level clinicians. The intern is assigned thecase and not much happens for a few months that you are aware of. One week insupervision, your clinician comes to you to inform you that a situation has happened withthis client.You come to find out that Paul has been increasingly making threatening statementstowards other drivers on the road when he travels to work. He describes how he gets“infuriated” by other drivers who cut him off, or don’t move out of the fast lane when he isbehind them. At first “altercations” were just gestures back and forth between he and theother driver at the time. However, in the past week he followed another driver all the wayto that person’s job, and proceeded to fight him in the parking lot.
Duty to Warn Vignette When asked if anybody was hurt, Paul replied that the other person was “a bit bloody” when Paul left him on the parking lot grounds. Paul confided to the intern that he has now started carrying a gun in the car. He at first played with the intern by stating the gun was there for his “protection”, but later hinted that it might “come in handy” on his way to work. When pressed, Paul stated that he would only wave the gun at a potential “highway offender” to scare him/her. He also stated he is licensed to carry the gun, and the gun is loaded. The final piece of information that the clinician tells you is the nature of the domestic violence towards the ex-girlfriend was Paul hitting this woman on the face with the barrel of a gun. Paul has been diagnosed with Intermittent Explosive Disorder (DSM-IV-TR 314.32). Paul is employed full-time at Home Depot and works as the customer service manager for returns. Basically his job consists of being the returns and complaints manager at the Home Depot.
Duty to Warn Vignette Questions What are your obligations, if any? If you find you have obligations, who are you obliged to warn?
(Duty to Warn) Anger Vignette 2 – “Manfound guilty of serial HIV assaults” From CNN.com, 11/09/2004 During the trial in Thurston County OLYMPIA, Washington (AP) -- court, an Oklahoma prison official A man was convicted by a testified that Whitfield was judge Monday on charges he diagnosed with HIV while deliberately exposed 17 incarcerated in 1992. women to HIV by having unprotected sex with them. Two women testified that Whitfield Five of the women have once said, seemingly in jest, that if tested positive for the virus, he had HIV, he would give it to as which causes AIDS. many people as he could. Anthony E. Whitfield, 32, faces a Defense lawyer Charles Lane said minimum sentence of 137 years in Whitfield was addicted to prison on the 17 counts of first- methamphetamine and used degree assault with sexual women for shelter, money and Anthony E. Whitfield, motivation and other charges. sex but never meant to inflict right, is handcuffed by a "great bodily harm" as required for Thurston County Health officials said as many as him to be convicted of first-degree corrections officer 170 people may have been assault. Monday. exposed to the virus because of Whitfields actions, counting subsequent partners of women he slept with. No additional people have tested positive for HIV, but 45 http://www.cnn.com/2004/LAW/11/09/hiv.assault.ap/index.ht refused to be tested or couldnt be ml found.
HIV Reporting As of 2009, 28 states (including NJ) now have HIV reporting for both adults and adolescents. Under great security, NJ stores names and addresses of individuals who are infected with the virus that causes AIDS. Residents have the option of learning their HIV status without their names being reported (by being tested anonymously), if they go to 1 of 15 state-financed HIV testing and counseling sites. The approximately 200 residents per year who choose this option are identified by a number, and the state receives only demographic information like age, sex and race. New Jersey’s system of notifying partners is voluntary. Spouses or other partners of infected people are not notified without the consent of the infected person. A person with HIV or AIDS who knowingly infects another (which in NJ law the other person has to be unaware that their partner was infected), is given a 3rd “degree diseased person” charge. A lesser 4th degree charge is reserved for sexually transmitted diseases other than HIV or AIDS. 2009 – Leadership Seminar: “Guide to Mental Health Law in NJ and PA.” Leadership Seminars, 4020 N. MacAuthor Blvd, Ste. 122, Irving, Tx. (800) 443-6912.
Motivation Interviewing and Anger MI uses the term resistance when dealing with anger statements from clients. MI defines resistance as an observable behavior that occurs in treatment, and shows that the client is moving away from the direction of change. Resistance is powerfully determined by therapist style. Therefore, your style as a therapist will determine how much resistance is elicited by the client. Resistance occurs when the counselor uses strategies inappropriate for the client’s current stage of change. An important goal of Motivational Interviewing is to avoid eliciting or strengthening resistance. A more empathic style is associated with lower resistance and better long-term change. 41
Dealing with Resistance – 4 Types1. Arguing – The client contests the accuracy, expertise or integrity of the clinician.2. Interrupting – The client breaks in and interrupts the clinician in a defensive manner.3. Denying – The client expresses an unwillingness to recognize problems, cooperate, accept responsibility, or take advice.4. Ignoring – The client shows evidence of ignoring or not following the clinical advice. 42
Strategies for Handling Resistance Simple Reflection This is responding to resistance with non-resistance. A simple acknowledgement of the client’s disagreement, emotion, or perception can permit further exploration rather than defensiveness. CLIENT: “While this may be somewhat interesting, I’d really like to get out of this lecture at 2:30 p.m.” COUNSELOR: “While your not totally disinterested in the topic Ms. White, you’d like to be able to leave early.” 43
Strategies for Handling Resistance (cont.) Amplified Reflection Reflecting back what the client has said in an exaggerated form, to state it in an even more extreme form than the client did. These responses must be straightforward and supportive, not in a tone of sarcasm or impatience. CLIENT: I’ve heard a lot about this Drug Court, and I know I need help and would be open to going to a treatment program, I’m not willing to go to AA meetings for the next 5 years because I’ve tried them before and they suck.” COUNSELOR: “So what I hear you saying is the only thing you need to help in your recovery process is therapy and nothing else will work for you.” 44
Strategies for Handling Resistance (cont.) Double-Sided Reflection This is acknowledging what the client has said, and add to it the other side of the client’s ambivalence. This may require material that the client has offered previously. CLIENT: “I know my job has expressed concern, and while they may be honest in their concern I can’t help but believe that they are pushing their own agenda regarding my right to do what I want in my own private life.” COUNSELOR: “You feel that what you do on your own time is none of your company’s business, but on the other hand you do see that they may have genuine concern for you.” 45
Strategies for Handling Resistance (cont.) Shifting Focus This is shifting the client’s attention away from what seems to be a stumbling block standing in the way of progress. Such detouring can be a good way to defuse resistance when encountering a particularly difficult issue. CLIENT: “I came here for my alcohol problem, and you want to contact my physician because he prescribes me Vicodin for my back pain, that’s not going to happen.” COUNSELOR: “You don’t feel that your problem with alcohol has anything to do with your prescription for pain from your doctor and you don’t want to sign this release. We do feel it is very important to communicate with all professionals involved with our clients, however, lets move to another part of this assessment and we can come back to that later.” 46
Strategies for Handling Resistance (cont.) Emphasizing Personal Choice and Control This works in working with resistance that comes from reactance. When people think their freedom of choice is being threatened, they tend to react by asserting their liberty. Antidote for reactance is to assure the client it is he/she who determines what happens. CLIENT: “I know my job has expressed concern, and while they may be honest in their concern I can’t help but believe that they are pushing their own agenda regarding my right to do what I want in my own private life. What I do in my private life is none of their business and they, and you can’t force me to change.” THERAPIST: Nobody has the power to change your drug usage but you, it’s totally your choice to either stop using or continue using. 47
Handling Resistance - Siding with the Negative This is where the Clinician presents, or takes up, the negative voice in the discussion … the voice of precontemplation and status quo. This works well with clients still in contemplation, and needing to elicit self- motivational, change oriented statements but needs help doing so. Taking the negative side can evoke a response of the positives for change from the client, thus the client would be making your argument for you. This is often times called a “paradoxical intervention” or “prescribing the problem”. COUNSELOR: “From what I hear you saying, you don’t have a problem, everything is functioning perfectly well in your life, and yet you stated you cut down on your drinking 6 months ago. I don’t see a reason why you needed to do that.” CLIENT: “Well there have been some problems, I do have 1 DWI, my wife has been complaining recently because of my drinking away from home, and my kids have made comments to me, so I wouldn’t go so far to say there is “no problem.” 48
REBT and Anger Control1. C – The emotional or behavioral consequence: in this case your anger.2. A – The activating experience or adversity.3. B – Our beliefs about the activating experience. These beliefs largely influence “C”. It is our irrational beliefs that lead to the emotional reactions of anger.4. D – Disputing irrational beliefs by challenging their accuracy and usefulness. Replacing irrational beliefs with rational ones can help you to experience more healthy negative feelings such as disappointment and avoid unhealthy feelings such as rage.
REBT and Anger Control1. Healthy negative feelings – disappointment, regret, frustration, sadness.2. Unhealthy negative feelings – rage, depression, panic, self-pity, low frustration tolerance. Although REBT does not make clear strict definitions for these categories, they report that healthy negative feelings and behaviors will help you cope with and overcome troubles and problems.
REBT and Anger Control REBT focuses on control and choice. While you may have developed your irrational anger problems from your parents, you still choose to maintain these irrationalities. As an adult, you can control your ideas, attitudes, and actions. You largely can arrange your life according to your own dictates – if you work at doing so. REBT insight includes your need to discover and minimize your goal inhibiting irrational beliefs (these irrational beliefs that lead to the unhealthy negative feelings).
REBT and Anger Control REBT lists 4 Irrational Beliefs that generalize a majority of how people create their anger:1. How awful or terrible that you treat me like this!2. I can’t stand your irresponsible behavior!3. You should not and must not act in that bad manner towards me!4. Because you behave as you should not and must not, you are a rotten person and should be severely punished! (Awfulizing, Can’t-stand-it-itis, Damnation, All or nothingism, overgeneralization) These statements hold for anger, but not necessarily for other things such as anxiety and depression. REBT contends that anxiety usually stems from the irrational beliefs you hold about yourself, while anger stems from the irrational beliefs that you hold about others. Depression creating irrational beliefs sometimes puts the world conditions down.
REBT Insights1. Insight #1: Your present anger may have some connection with your past. However your present adversities and your current beliefs about them are more important than past connections.2. Insight #2: However you may have originally acquired your self- defeating irrational beliefs, you now keep them alive by repeating them to yourself, reinforcing them in various ways, acting on them, and refusing to challenge them.3. Insight #3: REBT states that in order to change your disturbed feelings and behaviors and the irrational beliefs that create them, you almost always have to do a great deal of work and practice.
Disputing Your Irrational Beliefs Disputing can be broken down into three distinctive tasks:1. Detection – raising your awareness of what your irrational beliefs are. Detection alone is not enough to enact change from an irrational belief system to a rational one.2. Discrimination – this is the ability to discriminate irrational beliefs from rational beliefs.3. Debating – powerfully and consistently challenging and changing your core belief about a certain event.
From Irrational Beliefs to Rational Ones1. Irrational Belief: “You absolutely must not treat me with this verbal abuse. You never should act in that bad way towards me!” Rational Response: “I hate your treating me with verbal abuse and I strongly prefer that you stop it!”2. Irrational Belief: “Because you are treating me unfairly with your verbal abuse, you absolutely must not; you are a rotten person who should be damned to Hell and severely punished!” Rational Response: “Because you are treating me unfairly with your verbal abuse, your behavior is wrong and poor, and it may benefit you to correct it!”
From Irrational Beliefs to Rational Ones3. Irrational Belief: “It is awful and terrible when you verbally abuse me, as you must not! Nothing could be worse than this!” Rational Response: “It is highly unpleasant when you verbally abuse me, and I prefer you to stop it and I feel bad about it!”4. Irrational Belief: “I find it so unpleasant when you irresponsibly abuse me verbally, as you must not, that I can’t stand it, can only feel anguish, and am unable to enjoy myself at all in any way!” Rational Response: “I find it so unpleasant when you irresponsibly abuse me verbally that I want to stay away from you as much as I can!”
Effective New Philosophy After persistently and successfully debating irrational beliefs, you can choose to believe effective new philosophies (E):1. “I can stand this unfairness, though I’ll never like it.”2. “It is quite bad, but it is not awful and terrible.”3. “It is highly preferable that people treat me fairly, but they obviously don’t have to do so.”4. “They are not rotten people but people who sometimes treat me rottenly.” Behavioral Effect (E) of this new cognitive effect or new philosophy: Loss of anger, relief, and return to the healthy negative consequences (feeling of sorry and disappointment).
Elements of Effective Anger Management Complete elimination of angry emotionality is neither possible nor desirable, because anger has self-protective functions such as maintaining boundaries and mobilizing courage to correct injustices. The ability to handle anger effectively fits within the category of "emotional intelligence," which has been defined as the capacity to perceive emotion, integrate it in thought, and understand and manage it Intelligent anger management means that one can: (a) modulate excessive physiological arousal (b) alter irrational antagonistic cognitions (c) decrease environmental stimuli (d) modify maladaptive behaviors that do not lead to problem solving.
Stress Inoculation for Anger Control1. Step 1: Mastering Relaxation Skills – mastering relaxation skills such as progressive muscle relaxation and special place visualization.2. Step 2: Developing an Anger Hierarchy A. Get a blank piece of paper and begin writing down as many anger situations as you can think of. Think of a full range of provocations, from mild irritations to things that make you lose your temper. This list should include 20 – 30 situations. B. On another sheet of paper, write at the top of the sheet, the item that makes you the most angry, and at the bottom, the item that makes you the least angry. C. Now choose between 10 – 15 items that fit in the middle (with graduated intensity. Make sure the increments of anger between each item are approximately equal throughout. If some increments are larger than others, you may need to put in additional items where the gaps are. D. Once the hierarchy is done, rank your items from 1 (lowest) to the highest.
Stress Inoculation for Anger Control3. Step 3: Developing Coping Thoughts – you should develop two or more coping thoughts as you get ready to visualize each new scene in your hierarchy. A. Briefly visualize the scene, making it as real as possible. Notice what you see, hear, and even how you feel physically. Now listen to your trigger thoughts. - Are you blaming the other person or people involved for deliberately harming or hurting you? - Do you see their behavior as wrong and bad, as violating basic rules of conduct?
Blaming Trigger Thoughts If your trigger thoughts fall into the category of blame, here are some suggested coping responses to control you anger:1. I may not like it, but they’re doing the best they can.2. I’m not helpless – I can take care of myself in this situation.3. Blaming just upsets me – there’s no point in getting mad. Don’t assume the worst or jump to conclusions.4. I don’t like what they’re doing, but I can cope with it.
Broken Rules Trigger Thoughts If your trigger thoughts fall into the “broken rules” category, where the offending person(s) appears to be violating standards of reasonable behavior, some of the following coping thoughts can be helpful:1. Forget shoulds, they only upset me.2. People do what they want to do, not what I think they should do.3. No one is right, no one is wrong. We just have different needs.4. People change only when they want to.5. No one is bad; people do the best they can.
Other Generic Coping Thoughts1. Take a deep breath and relax.2. Getting upset won’t help me.3. I’m not going to let them get to me.4. I can find a way to say what I want without anger.5. No matter what is said I know I’m a good person.6. Their opinion isn’t important, I won’t be pushed into losing my temper.7. It’s just not worth it to get so angry.8. Anger means its time to relax and cope.9. This is funny if you look at it a certain way.10. I can manage this; I’m in control.11. I don’t have to take this so seriously.12. I’ll stay rational, as anger won’t solve anything.
Stress Inoculation for Anger Control4. Step 4: Applying Anger-Coping Skills: A. Take ten to fifteen minutes to get relaxed using relaxation techniques. B. Visualize the first (or next) item in your anger hierarchy. Try to bring the scene alive by visualizing the situation, feeling the tension building up. Remind yourself of the trigger thoughts, the blame towards others, and/or unfairness of the offense. When you feel the anger move onto step C. C. Start to cope. Once the scene is clear and anger response occurring, start relaxing and start using your coping thoughts you developed for the situation. Use quick relaxation methods such as deep breathing or visualization of peaceful scenes. D. Rate your anger. Rate your anger in the scene (from 1 meaning little or no anger, to 10 being the worst anger imaginable), just before you cut your anger off. Re-examine your coping thoughts. Did they work? If not, dump them and come up with new coping thoughts that will help you.
Stress Inoculation for Anger Control5. Step 5: Practicing anger-coping skills in real life. If your hierarchy includes items that occur frequently or predictably in real life, you’ll find many opportunities to practice. - The key to real life practice of your relaxation and anger- coping thoughts is to recognize the first signs of anger. - The earlier you intervene with brief relaxation interventions and coping thoughts (e.g., deep breathing exercising, picturing yourself relaxed, telling yourself a coping thought), the more likely you are to maintain control.
Dialectical Behavior Therapy Dialectical Behavior Therapy (DBT) – Originally devised by Marsha Linehan at the University of Washington in Seattle for the treatment of Borderline Personality Disorders, DBT combines standard cognitive-behavioral techniques for interpersonal effectiveness, emotion regulation and reality- testing with concepts of distress tolerance, acceptance, and mindfulness. DBT was developed initially to treat suicidality in adults with borderline personality disorder; however, it now is being used effectively in adolescents with similar self-harm behaviors as well as other co-occurring psychiatric illnesses such as depression and anxiety. DBT is an empirically supported technique, meaning that it has been clinically tested for its effectiveness in adolescents and adults.
Dialectical Behavior Therapy The spirit of a dialectical point of view is never to accept a proposition as a final truth or indisputable fact. In the context of therapeutic dialogue, dialectic refers to bringing about change by persuasion and to making strategic use of oppositions that emerge within therapy and the therapeutic relationship. In the search for the validity or truth contained within each contradictory position, new meanings emerge, thus moving the patient and therapist closer to the essence of the subject under consideration. The patient and therapist regularly ask, “What haven’t we considered?” or “What is the synthesis between these two positions?”
Dialectical Behavior TherapyThe treatment includes five essential functions:1.Improving patient motivation to change,2.Enhancing patient capabilities,3.Generalizing new behaviors,4.Structuring the environment, and5.Enhancing therapist capability and motivation.
Dialectical Behavior TherapyLike other behavioral approaches, DBT classifies behavioral targetshierarchically. The DBT target hierarchy is to decrease behaviors that are:1.Imminently life-threatening (e.g., suicidal or homicidal);2.Reduce behaviors that interfere with therapy (e.g., arriving late or notattending therapy, being inattentive or intoxicated during the session, ordissociating during the session);3.Reduce behaviors with consequences that degrade the quality of life (e.g.,homelessness, probation, Axis I behavioral problems, or domestic violence);and increase behavioral skills.In any given session, a DBT therapist will pursue a number of these targets butwill place the greatest emphasis on the highest order problem behaviormanifested by the patient during the past week.
Dialectical Behavior Therapy "What" skillsObserve - This is used to non-judgmentally observe one’s environment withinor outside oneself. It is helpful in understanding what is going on in any givensituation.Describe - This is used to express what one has observed with the observeskill. It is to be used without judgmental statements. This helps with lettingothers know what you have observed.Participate- This is used to become fully involved in the activity that one isdoing. To be able to fully focus on what one is doing.
Dialectical Behavior Therapy "How" skillsNon-judgmentally - This is the action of describing the facts, and not thinkingabout what’s “good” or “bad”, “fair”, or “unfair.” These are judgments becausethis is how you feel about the situation but isn’t a factual description. Being non-judgmental helps to get your point across in an effective manner without addinga judgment that someone else might disagree with.One-mindfully- This is used to focus on one thing. One-mindfully is helpful inkeeping your mind from straying into emotion mind by a lack of focus.Effectively- This is simply doing what works. It is a very broad-ranged skill andcan be applied to any other skill to aid in being successful with said skill.
Dialectical Behavior Therapy Distress toleranceMany current approaches to mental health treatment focus on changing aperson’s thoughts, feelings and/or belief systems regarding distressing eventsand circumstances.They have paid little attention to accepting, finding meaning for, and toleratingdistress.Dialectical behavior therapy emphasizes learning to bear pain skillfully.The goal is to become capable of calmly recognizing negative situations andtheir impact, rather than becoming overwhelmed or hiding from them.
Dialectical Behavior Therapy Distress toleranceDistractwith ACCEPTS - This is a skill used to distract oneself temporarilyfrom unpleasant emotions. 1. Activities - Use positive activities that you enjoy. 2. Contribute - Help out others or your community. 3. Comparisons - Compare yourself either to people that are less fortunate or to how you used to be when you were in a worse state. 4. Emotions (other) - cause yourself to feel something different by provoking your sense of humor or happiness with corresponding activities. 5. Push away - Put your situation on the back-burner for a while. Put something else temporarily first in your mind. 6. Thoughts (other) - Force your mind to think about something else. 7. Sensations (other) – Do something that has an intense feeling other than what you are feeling, like a cold shower or eating a spicy food.
Dialectical Behavior Therapy Distress tolerance Self-soothe - This is a skill in which one behaves in a comforting, nurturing, kind, and gentle way to oneself. You use it by doing something that is soothing to you. It is used in moments of distress or agitation. IMPROVE the moment - This skill is used in moments of distress to help one relax. Imagery, Meaning, Prayer, Relaxation, One thing in the moment, Vacation (brief) - Take a break from it all for a short period of time, and Encouragement Pros and cons - Think about the positive and negative things about not tolerating distress.
Dialectical Behavior Therapy Distress tolerance Radical acceptance - Let go of fighting reality. Accept your situation for what it is. Turningthe mind - Turn your mind toward an acceptance stance. It should be used with radical acceptance. Willingness vs. willfulness - Be willing and open to do what is effective. Let go of a willful stance which goes against acceptance. Keep your eye on the goal in front of you.
Dialectical Behavior Therapy Emotional RegulationDialectical behavior therapy skills for emotion regulation include: 1. Identify and label emotions 2. Identify obstacles to changing emotions 3. Reduce vulnerability to emotion mind 4. Increase positive emotional events 5. Increase mindfulness to current emotions 6. Take opposite action than that emotion that the situation evoked 7. Apply distress tolerance techniquesOther skills of emotional regulation include understanding the story of theemotion, addressing ineffective health habits, mastering one skill at a time,problem solving when emotions are justified and learning to observe andexperience your emotion and let it go.
Mindfulness Exercises1. Observing Your Breath Exercise (being in the moment, push out distractions) Have clients focus on something in the room. While they are doing this, have them become mindful of their breath. Tell them to count their breath. Breath in, that’s one. Breath out, that’s two. Breath in, that’s three. Breath out, that’s four and so on. Have them go all the way to ten and then start back at one. Tell your clients that if a thought, urge, distraction, etc. comes into their mind, just notice it and turn their mind back to counting their breath. If they lose count, start back at one. If they count over ten, just notice that and return their mind back one.2. Defining Moment Exercise (interpersonal effectiveness, distress tolerance, emotional regulation insights) Have clients get a piece of paper and something to write with. Each client should write about an event that was their defining moment in their life. It is a moment that has shaped them to be who they are and how they look at life now.
Mindfulness Exercises3. Walking Mindfully (focusing on the present, blocking out past and future) Have clients stand up and get in a single file line. Have them focus solely on each step as they walk around the room. Be mindful to the feelings they get on the bottom of their feet. If they loose track of their step, tell them to stop and turn their mind back to their step before they continue to walk. Be mindful to all the thoughts that come in, but don’t get stuck on them. Turn the mind back to your step. You can have them focus on different aspects of walking such as how one’s pants shift on each leg, breathing patterns, etc.4. Describe Mindfully (attributions, judgments, assumptions) Bring different objects to group. Place one object at a time on the table and have clients DESCRIBE the object by using only the facts! Be mindful to clients who assume or judge. Get them to describe the objects by using only what they do know and nothing more.
Anger/Aggression Exercise #3 Joanie has come back to you, stating her anger is worse than before, and angry at you because you decided to refer her to “some stupid ass bitch” whom she doesn’t believe was helpful. She feels this person is trying to ruin her family, and she feels this person reports back everything she states in session to her DYFS worker. She is agitated, pacing the room and verbally assaulting this other therapist and you, for making the referral and not working with her.1. Joanie is in an obvious crisis situation. Work together with your team to come up with some strategies to de-escalate Joanie WITHOUT LOOKING AHEAD IN YOUR HANDOUTS.
De-escalating Angry Clients Breathe Deeply, Remain Calm, and Be Aware - In confrontational situations, staff must be aware of their own frustration and anger. Only then is it possible to put the other party first, saving the processing of personal feelings until the incident is over. Separate the Problem From the Person - Do not take insults or abusive language personally. When anothers behavior is allowed to adversely impact the workplace, one gives away power, reinforcing the disrespectful behavior and accompanying negative feelings. Take Complaints Seriously - When clients complain to staff, it is important to give them an opportunity to present their grievances by listening attentively.
De-escalating Angry Clients Respect Personal Space - When a person is angry, it is important to be close enough to command attention but not so close as to invade personal space and create more tension. Use Respectful Language - Most angry individuals are seeking respect and dignity. One needs to choose words carefully. Respect and caring can be shown through an interaction such as, "I respect you and your right to feel the way you do. You know that this is my job, and I cannot allow you to threaten others. That would cause you more trouble and I want what is best for you." Acknowledge Feelings - It is essential for the counselor to recognize their feelings. For example, one might say, "I can see that youre frustrated. Id probably feel angry, too." Acknowledging feelings does not mean there is agreement about the cause of the persons feelings or the appropriateness of their behavior.
De-escalating Angry Clients Use Listening Skills - It is imperative one understands the individuals message. It is important to reassure the client that the problem can be solved and it is important to reflect what you have heard the angry client say. Accept Their World View - To emotionally aroused persons, their perceptions of reality are real. Denial of this reality only increases their frustration and anger. Observe Body Language - The goal is for ones body language to reflect calmness and balance. Keeping hands relaxed and at ones sides while maintaining an open and balanced stance. You need to appear self assured, but not threatening.
De-escalating Angry Clients Reinforce Decision Making Ability - Praise and acknowledgment are great defusers. It is calming to appeal to an angry persons strengths. It is important to reassure client’s they can and will make a good decision. Know How to Handle Verbal Attacks - Agreeing with a verbal attack deflates anger and often ends the attack. 1. When individuals are verbally abusive, they are often frustrated and afraid; most feel powerless or isolated. 2. Agreement acknowledges they have value as human beings. 3. It does not indicate agreement with everything said.
Anger Management Training Anger Management training is delivered customarily to groups, because anger is such an interpersonal emotion (interestingly enough, a review of the literature shows that group work with anger is less effective than individual work with angry clients). Techniques such as the "empty chair" do not permit individuals to maintain eye contact with another human while learning to control their breathing and other physical reactions of being angry. Clients best learn to express their angry feelings when others are available to support, empathize, provide feedback, and role-play problematic conflicts in encounters. Behavioral practice in the safety of a group gives clients greater confidence that they can enact new anger behaviors in real-world situations. Concurrent introspection, using an anger journal or log, usually is recommended as well.
Purpose and Goals in Anger ManagementTraining The purpose of an anger management program is to enhance the coping skills of the clients so they can express their anger constructively and respond appropriately to anger directed at them. Upon completion of the program, the participants are expected to be able to:1. Explain the differences between anger and aggression.2. Describe the positive and negative functions of anger.3. Identify personal response to anger including physiological and emotional responses.4. Analyze anger-provoking situations in terms of triggering event, thought, emotion, behavior response and consequence.5. Perform anger control strategies such as positive reframing, use of positive reminders, and brief stress reduction techniques in response to anger provoking situations.6. Perform problem solving skills and conflict resolution skills.7. Perform assertive communication skills.
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Bibliography Meichenbaum, D. (2001). Treatment of Individuals with Anger- Control Problems and Aggressive Behaviors: A Clinical Handbook . Clearwater, Fl: Institute Press. Spielberger, C. D., Reheiser, E. C., & Sydeman, S. J. (1995). Measuring the experience, expression and control of anger. In H. Kassinove (Ed.), Anger Disorders. Washington, DC: Taylor & Francis. Tang, M. (2001). Clinical outcome and client satisfaction of an anger management group program. The Canadian Journal of Occupational Therapy, 68(4), pp. 228 – 239. Thomas, S. (2001). Teaching healthy anger management. Perspectives in Psychiatric Care, 37(2), pp. 41 – 48.
Bibliography Swanson, A. J., Pantalon, M. V., & Cohen, K. R. (1999). Motivational interviewing and treatment adherence among psychiatric and dually diagnosed patients. Journal of Nervous and Mental Disease, 187, 630- 635. Stress Inoculation Therapy - http://www.mentalhelp.net/poc/view_doc.php?type=doc&id=15683&cn=117 . Accessed 02/18/13. Wikipedia: Dialectical Behavior Therapy. http:// en.wikipedia.org/wiki/Dialectical_Behavior_Therapy Mindfulness Exercises Created and Designed by: Josh Smith, MSW, LMSW, “The DBT Center of Michigan, PLLC” 89