Courses: 0

Total: $00.00

Client, Family and Community Education Performance Domain Back to Course Index



The solution for the escalation of mental health issues and substance abuse requires educating clients and their families.  As professionals in the industry, we must rally families, employers, the government, medical leaders, and the community to recognize signs and combat these issues with practical strategies of prevention and treatment.  




In school, kids learn because they are placed in an environment that pushes them to do so. They are placed in a classroom, matched with other students who are roughly the same age and the same level of expertise and expected to do nothing but learn for the majority of the time they are there. Most of the motivation is external, meaning that children go through this process because of direction from their parents, teachers, and community.

Once we graduate, things are different. When adults choose to learn something, it is more so because they see value in those things. For example, we might pick up a hobby because we find it exciting or relaxing. Or we might learn a skill that will help us advance in our careers. It’s our interests and ambitions that drive learning.

When attempting to educate a population about something like mental health and substance abuse, there is a blend of those that are genuinely interested in the subject and those that are blindsided and entirely resistant regarding having to learn about such things.   The model of education used should take into account the differences between how individuals learn and also how to engage both those that are and those that are not interested in the topic.

  • After spending years in school, adults don’t want to have “homework” in the form of training courses.

  • Adults have different levels of expertise, and so any classroom will have some learners who are struggling to keep up, and some who are bored because they already know the material.


Adult Learning Theories

There are several different adult learning theories in the research literature. Some of these include:

  • Transformative learning. Authentic learning experiences should somehow change the individual—at least, that’s the central claim of transformative learning approaches. In practice, it recommends starting with learning experiences that appeal to your specific audience and then moving on to activities that challenge assumptions and explore other points of view.

  • Self-directed learning. This approach acknowledges that the majority of the learning that adults do is outside the context of formal training, and so the emphasis is on augmenting those informal learning experiences. This can be through providing content, helping individuals plan their learning, or evaluating learning experiences after the fact.

  • Experiential learning. Experiential learning makes the case that the essence of adult learning is making sense of experiences. Adults learn best when they learn by doing. Learning activities thus make heavy use of role-playing, simulations, and so on.

  • Andragogy. Andragogy combines many of the insights from the above theories. This approach starts by recognizing the differences between adults and children and designs learning experiences from there. For example, learning experiences are created with the assumption that adults come to the table with their own set of life experiences and motivations, can direct their own learning, tend to learn better by doing, and will want to apply their knowledge to concrete situations sooner rather than later.

There are more, and many variations on these, too. It is a mistake to think of any one of these as the correct theory. Each provides insight into how adults learn. Conversely, not all adults learn in the same way, and it is important to find approaches that blend several theories so that they can work for the majority. 

To tie together the principles of adult learning with the nuts-and-bolts of creating educational content for clients, families, and communities on substance abuse and mental health issues you can utilize methodologies above including the techniques such as:

  • Use video content seeks to engage learners where they are, slowly building on prior knowledge and bringing in new facts and points of view, ending up with sustainable changes in behavior—much like transformational learning.

  • Allow for the flexibility needed for self-directed learning as well as instructor-led discussions.

  • Use concrete examples, with information that learners can use immediately, as emphasized in experiential learning.

  • Use visuals wisely.  Too many visuals can overwhelm what is being said (and why). Irrelevant visuals will interrupt learning, also. However, visuals increase learning outcomes when used appropriately.
  • Be conversational with content that offers the ability to relate, is engaging, and is lively.  
  • Be consistent with the format.
  • Provide supplementary materials.  Some people can learn just by listening, but for others, it helps to take notes or review written materials afterward. Provide prepared notes and materials for ongoing understanding.



We are taught throughout our lives that anger is bad.   When someone feels angry, they also frequently feel shame, guilt, hurt, or embarrassed. Getting mad is scary… and potentially dangerous. We learn that anger should be avoided. That expectation is not only challenging but actually can be unhealthy. 

As mental health and substance abuse professionals, we will run into our share of anger.  Families are angry, clients are angry, even we sometimes find ourselves battling feelings of anger.  Anger may contribute to the development of a host of unhealthy patterns in relationships.

Anger is a powerful, natural feeling. At some time or another, everyone feels it, and we have the right to feel that way. It’s what someone does with the anger that makes the difference.

As clinicians, it is our goal to help clients learn effective ways to manage their anger. In this section, we will explore:

  • Anger and Its Causes
  • Common Approaches to Anger
  • The Problems with Anger
  • The Positive Aspects of Anger
  • Exploring Anger Management


Anger and Its Causes

Anger is a natural emotional reaction. It affects the entire body, creating energy. When someone begins to anger, adrenaline and other chemicals, enter the bloodstream. The heart pumps faster, and the blood flows more quickly. The muscles tense. This biological reaction is frequently in preparation for a behavioral response, conscience, or not. That behavioral response can be out of protection or aggression.

Anger is an emotional-physiological-cognitive internal state; it is separate from the behavior of aggression it might prompt. Aggression, different from anger, is action. It is intended to harm. It can be a verbal attack–insults, threats, sarcasm, or physical punishment.

Just how widespread is hostility? Psychology Today asked, “If you could secretly push a button and thereby eliminate any person with no repercussions to yourself, would you press that button?” 69% of responding males said yes, 56% of women said yes. Emotion usually triumphs over reason.

Much of our learned behavior is learned young in life. By the time we are five years of age, we have learned to be kind and caring, or aggressive.

Is anger innate? Certainly, most three-year-olds can throw a temper tantrum without any formal training. They learn this reaction, usually even without observing a model. Is the behavioral response to anger learned? Why are the abused sometimes abusers? Does having a temper and being aggressive yield payoffs? You bet.

The causes of anger vary from person to person and from situation to situation.

Research has shown that stimulation of certain parts of animals’ brains leads to aggression. Stimulation of other parts stops aggression. Even back in 1966, we learned through Charles Whitman, who killed his wife and mother because “I do not consider this world worth living in…”, then climbed a tower on the University of Texas campus and fired his rifle at 38 people. He killed 14 before being killed. An autopsy revealed a large tumor in the limbic system of his brain (where the aggression “center” is in animal brains).  

In epileptic patients with implanted electrodes, in rare cases, violence follows the stimulation of certain parts. Abnormal EEG’s have been found among repeat offenders and aggressive people. So, aggression may sometimes have a physical basis. More recently, scientists have learned to use neuro-imaging to see the living, thinking, feeling human brain at work. Neuro-imaging tools include functional magnetic resonance imaging (MRI), which uses magnetic fields and radio waves to elicit signals from the brain, and positron emission tomography (PET), which uses low doses of a radioactive tracer to obtain messages from the brain. Both of these technologies have been designed to reveal signals that correlate with human brain activity. These approaches have been used to study the pathways in the brain involved in sensory processes such as vision, and a variety of cognitive processes.

Other physiological factors seem to be involved. Examples: high testosterone (male sex hormone) is associated with more unfaithfulness, more sex, more divorce, more competitiveness, and anti-social behavior. It is also known that a viral infection, called rabies, causes violent behavior. About 90% of women report being irritable before menstruation believed to be due to hormones. Furthermore, 50% of all crimes by women in prison occurred during their menstrual period or premenstrual period. By chance, only 29% of crimes would have happened during those eight days. Hypoglycemia (low blood sugar) increases during the premenstrual period, and it causes irritability.

  • Stress-related to work, family, health and money problems can frequently make someone feel anxious and irritable
  • Frustration when someone fails to reach a goal or when they feel as if things are out of their control.
  • Fear can cause anger. Anger is a natural response to threats of violence, or physical or verbal abuse.
  • Irritation can escalate anger and lower someone’s tolerance.
  • Disappointment can trigger anger when expectations and desires aren’t met.
  • Resentment can cause anger when someone feels hurt, rejected, or offended.
  • Whether anger is learned, due to an issue in the brain, physiological ,or a combination of these with the inability to control such feelings comes problems.


The Problems with Anger 

Poorly handled anger can cause many problems. Some individuals try to pretend they aren’t angry. Other people feel as if their anger is out of their control. Ignoring anger or giving up control over it can lead to:

Physical Health Problems

  • Headaches
  • Sleep Problems
  • Digestive Problems
  • High Blood Pressure
  • Heart Problems

Poor Decision Making

  • Anger can make it hard to think clearly. A person may have trouble concentrating or may use poor judgment. This can lead to accidents, injuries, and other problems.

Problems with Relationships

  • If a person cannot control their anger, they may end up insulting, criticizing, or threatening those close to them. They may respond with anger or resentment. Getting angry may also keep them from telling others how they feel.

Low Self-Esteem

  • If someone has difficulty managing anger, they may feel bad about themselves.


  •    Anger that is kept bottled up can affect a person’s thoughts and feelings.

Alcohol or other Drug Problems

  • Alcohol and other drugs dull strong feelings. They can become a crutch to help someone avoid the negative consequences of an angry outburst.  
  • Uncontrolled anger can lead to aggression, as we discussed earlier. The result of unchecked
  • anger may include verbal attacks or physical assaults, abuse, and other criminal behavior.


The Positive Aspects of Anger

With all of this being said, learning to recognize and express anger appropriately can have very positive consequences in a client’s life. Sometimes, anger can gain attention when nothing else will. Anger can be a tool for change. It can serve as a motivator and energizer. It signals to us that “this does not work for me” “this is not pleasurable or right for me.”

As we provide treatment services to clients, we want to remember that positive aspects of anger do exist. We also want to remember that for our clients to function at an optimum level, becoming “un-angry” is not the goal. Finding productive ways to use their anger is the goal of effective anger management.


Theoretical Approaches to Anger 

Some theorists believe anger just naturally results from frustration. This is called the frustration-aggression hypothesis. As noted earlier, several physiological reactions accompany frustration, including higher blood pressure, sweating, and more considerable energy. At times, mainly when the cost of anger is high, for example, getting hurt or fired, most individuals can learn to control their anger, but as a primary drive, it remains there seeking some expression.

A common approach to dealing with anger is to express it. In the popular movie Pretty Women, the leading man expressed that it took ten months of therapy to learn how to say, “I am angry at my father.” The belief is that clients benefit when given a forum to express their anger in therapy. Individuals must acknowledge their anger, vent their anger, and manifest their rage both emotionally and physically. Methods include letting out their anger during individual or group therapy, hitting punching bags when angry, yelling, or exhibiting some extreme display of emotional or physical release. The obvious downfall of this technique is that aggression is a habit. The goal in therapy should be to learn effective ways to manage anger without violent physical release. A preferred approach might be creating the venting habit of intense exercise in reaction to anger. People who tend to lose control of their physical behaviors should not practice “punching” as a method of letting it all out. Most clients in therapy for anger issues don’t have difficulty venting their anger; moreover, that is what got them to treatment in the first place.

Some in the mental health field argue that aggression is learned in two primary ways:

(1) from observing aggressive models and

(2) from receiving and/or expecting payoffs following aggression.

The payoffs may be in the form of:

(a) stopping aggression by others,

(b) getting praise or status or some other goal by being aggressive

(c) getting self-reinforcement and private approval, and

(d) reducing tension.

Treatment would include cognitive processes, like rational problem-solving, “trial runs” in fantasy to see what might happen if I did _____, and the self-control procedures of self-observation, self-evaluation, and self-reinforcement.

Therapy, whatever the theoretical basis, should see anger as a normal human emotion. Treatment should help clients eliminate self-defeating behaviors or behaviors that are destructive or harmful to others. A client is entitled to their feelings, and they are responsible for their actions.


Exploring Anger Management

When focusing on the management of angry feelings, an individual can:

(a) prevent it, i.e. keep anger from welling up inside, or

(b) control it, i.e. modify our aggressive urges after anger erupts inside.

As discussed, although someone can decrease the frequency and volatility with which they feel and express anger, they cannot prevent it entirely. Then they must learn to control it.


Potential Signs of Anger Issues

If an individual has an anger problem, he or she may be aware of it but not know what to do. That individual may also not be aware of his or her anger; the nature of anger may lead those experiencing extreme anger to deny they have any responsibility for the problems to which they contribute.

Potential signs of anger issues include:

  • Persistent feelings of frustration toward oneself or others.
  • An inability to enjoy life or the company of others.
  • A hot temper or a tendency to yell or argue with others.
  • Physical signs such as headaches, rapid breathing, or a pounding heart.


Anger, as an emotion, begins as an inner twinge. A person can sense something long before it explodes into an emotional tirade. If someone can listen to this twinge, the emotional outburst is frequently not needed. Clients can learn to stop, choose the best outcome, and act accordingly. For this to work, a client needs to learn to recognize the signs that they are getting angry before the behaviors escalate beyond control. Two techniques frequently used in treatment include the Warning Signs Checklist and/or Anger Journal listed below.

What are your warning signs?

Check the warning signs you often have when you get angry.

Write in signs that aren’t listed.

___Tense muscles

___Tight fists

___Clenched jaw

___Sweaty palms

___Racing heartbeat

___Fast breathing

___Trembling or feeling shaky

___Feeling warm or flushed

___Upset stomach

___Loud or mean voice


 Anger Journal

Date/Time  Trigger   Warning Signs   Anger Rating     Response   How I felt afterward





Once a client can get ahead of the anger by recognizing what is coming they can learn techniques and coping strategies to employ to reduce the negative consequences of uncontrolled anger.

Thoughts that create angry feelings frequently begin with should, must, or ought statements. These statements can be noted in the Trigger section of the journal.

During my work with clients who were mandated to treatment due to a crime involving violence, we would work on the concept of seeing the loss of control when angry as giving their power away. If they could see that allowing another person to control their feelings and “make me lose my temper,” then they were letting the other person to have their power. To stay in control begins to look like maintaining control rather than escalating the argument.


Cognitive Shift 

As a parent of two children, I have seen a “survival of the fittest” type of mentality in children. It creates a self-centered approach to life during this phase. “If I don’t take it, there won’t be enough for me.” It is an interesting shift to watch occur when they begin to realize that others have feelings and also want to go down the slide and have a turn. Making that cognitive shift is to correct the error belief system they previously held. To become secure in the rightness of the situation. A client who has anger issues might have faulty belief systems such as, “if I do not yell, nobody will listen,” ” anger is the only way I can protect myself from becoming emotionally hurt,” “because my anger is justified, my behavior should not have consequences.”   These beliefs need to be challenged. There is a three-stage process for a client to challenge and change their cognitive errors:

1) Recognize

2) Remove

3) Replace

The first step involves helping our clients to recognize their cognitive errors. This can be done through confrontation, through the process of following conclusions to their erroneous logical extremes, and through the creation of new experiences, which experientially change an individual’s belief.

Once this cognitive error is recognized as false, the most effective way to remove it is by implementing a third strategy, which is to replace those cognitive errors with the new truth.

Another essential aspect of effective anger management is to help clients find healthy ways to express their anger.

  • Teaching them to practice skills such as remembering to calm down and think carefully before they speak.
  • Teaching them to name the problem, clearly and calmly explaining why they are angry or what the problem is.
  • Teaching them to use I statements. The use of I statements in describing how they feel helps the listener feel less blamed or criticized.
  • Teaching them to identify solutions focusing on what they would like to change or see happen in the future.
  • Teaching them to use positive self-talk.


Increasing Tolerance or Decreasing Volatility 

The goal of therapy is not to teach clients to avoid anger, but rather how to have an increased tolerance for those situations that are going to make them upset. One method for teaching clients to tolerate higher levels of anger is using therapeutic relaxation training exercises. Therapeutic breathing exercises and progressive muscle relaxation exercises can help a person take physical control over the emotions that they experience.

Allowing and fostering clients to be a part of creating their treatment plan gives them control over their progress. In the throes of a control issue, this is very important. One of the approaches to give them power is to have them complete an Anger/Rage Safety Plan. They can complete it with steps that will help them personally. Here is an example:


Safety Plan

1.) Take a Deep Breath and Sit Down.

2.) Stop Drinking Alcohol.

3.) Exit by going outside or to another room. Take three deep breaths.

4.) Call ______________ @ ______-___________. Talk for five minutes.

5.) Write out what is bothering you on a piece of paper.

6.) If you are still feeling angry, go to this place: _____________________.

7.) If you are still unable to control your rage, or if you feel like killing yourself or others, call_______________ @ ___- _______ and tell whoever answers that,

I feel like killing myself or others, and I want help.


Outside of the Box Tools to Use With Clients:

  • Strategies Sandwiches

These creative sandwiches can be used with younger clients that need to learn better ways to recognize and deal with their anger.  Use paper cut into the shape of bread, tomato, lettuce, etc. to represent the ingredients.  These ingredients represent the things that you talked about trying when the anger starts to overwhelm.

  • Candle and Flower

This strategy distracts and teaches deep breathing.  Bring to session a candle and a flower.  Instruct your client to take a deep breath through their nose as the smell the flower.  When they are breathing in the flower, have them focus on breathing in good, calm feelings.  Instruct them to hold their breath for two seconds then release their breath by slowly blowing out the candle, pretending that they are breathing out the out to control angry feelings.  Repeat.

  • Say what?

Help your client create a flip chart of ways of calming down through verbalizing how they feel and what they need the other person to understand.  It sometimes takes longer than they think to separate their anger from what they are trying to say.

  • Fuse

Clients who get angry easily can be shown pieces of string, cut to various lengths from very short to long, with an explanation that a person with a very short fuse tends to get angry and explode (yell, scream, fight, get into trouble) more quickly than someone with a longer fuse.

The counselor discusses with the client what happens when they get angry.  How fast they get that out of control feeling, showing the shorter string then asking what would be different if their fuse what longer giving them more time to process and think about the situation.  The counselor would then proceed with teaching how the client’s self-talk leads to the increased anger response and how changing her self-talk can allow for a calmer, more rational response to stimuli that would have previously resulted in an angry outburst. The counselor would keep emphasizing that the client’s more rational, different, self-talk leads to a longer fuse. 

  • Pop Bottle to Water Bottle

At times, clients who suffer from angry outbursts can relate to the build-up of anger inside of them like pressure in a shaken pop bottle. Counselors who use this analogy find that when helping clients understand this concept, actually showing them a bottle of pop that is about to explode lends a visual reference point to the client’s anger.

What is the difference between a pop bottle and a water bottle?   One will explode if shaken and then opened, and one won’t.  Giving this visual can help a client to understand how anger can bottle up and then get out of control.  Help the client understand that they need to be clear thinking. The counselor then proceeds with teaching the client from a cognitive-behavioral framework to understand his behavior as it relates to his self-talk. 


Theoretical Approaches to Treating Anger

Uncontrolled anger can affect your client’s relationships, their job, and their health. Rage can take over their life and result in depression, violence, and suicidal feelings.  Clients must get the support they need to develop effective management strategies.  Many theoretical approaches can be employed when working with this population.

Modern therapeutic strategies are targeted and effective, often offering results in as little as six to eight weeks.  Frequently used approaches include:

  • Cognitive-behavioral therapy
  • Improvements in communication skills
  • Focus on problem-solving
  • Avoidance of problematic situations
  • Humor and self-deprecation


Cognitive Behavioral Therapy

One of the most common types of psychotherapy is cognitive-behavioral therapy. The purpose of the treatment is to help an angry person recognize the self-defeating negative thoughts that lie behind anger flare-ups. Patients work with a mental health professional to learn how to manage stressful life circumstances more successfully.

The cognitive-behavioral approach has many benefits. Patients learn to:

  • Cope better with difficult life situations
  • Positively resolve conflicts in relationships
  • Deal with grief more effectively
  • Mentally handle emotional stress caused by illness, abuse or physical trauma
  • Overcome chronic pain, fatigue, and other physical symptoms

Cognitive therapies are structured and may offer quicker results than other approaches. Better yet, the results are lasting, with patients showing significantly decreased relapse rates.

This sort of treatment tends to focus on specific problems and personal triggers. They should learn how to deal with their particular issues using conscious, goal-centered strategies. The specific steps in cognitive behavioral therapy include:

  • Identification of situations or circumstances in their life that lead to trouble
  • Awareness of their thoughts and emotions surrounding anger triggers
  • Acknowledgment of inaccurate, negative thought patterns
  • Relearning of healthier, positive thought patterns

Several effective cognitive-behavioral techniques are outlined below:


Enhanced Personal Awareness

Angry individuals often do not have a clear sense of their anger. They don’t understand where it comes from or what is happening to them when they are angry. There are many ways you can learn about the elements of anger episodes. These include detailed discussions with your therapist, role-playing of anger causing situations, and self-monitoring (making a record of) anger in day-to-day living. Whatever approach is chosen, the goal is to help you become more aware of the anger in your life, by addressing the following issues:

Where and when does the anger occur? Why does anger occur (what events or situations lead to the anger)? What kinds of memories or images trigger the anger? How do you feel when you become angry (emotionally and physically)? What are you thinking when you are angry? How do you handle the situation that made you angry? Do you always behave the same way? If not, why not? What do others do when you become angry?

Answering such questions will help you become aware of the nature, reasons, and results of anger. The answers will also eventually help you develop a greater sense of self-worth and personal control and the ability to use anger-management and problem-solving skills. Although enhanced personal awareness is rarely all that is needed, it is often very helpful.


Anger Disruption by Avoidance and Removal

These techniques lead to interruption of anger by removing you, mentally or physically, from the situation. For example, it might be wise to simply get up and leave a situation when anger develops. This might even be negotiated with a spouse, friend, or business associate in advance. It might be wise to delay responding by asking for time to think about angering issues or to gather additional information before responding. It might be wise to seek an alternative mode of response, such as a written or email answer, instead of an immediate spoken one. These techniques may decrease or even prevent anger altogether.

Doing a distracting non-angry activity is also an alternative. One mother, with an anger problem, chose to plan meals and do the laundry instead of arguing and insulting her teenage daughter about homework. Other individuals may count to ten or may provide themselves with a brief, non-damaging physical distraction, such as pressing their fingers together very firmly or leaving to take a shower or work in the garden.

These few examples are simple strategies that can disrupt anger and give the individual some time and distance to calm down, then approach the situation differently, at a later time. As with enhanced self-awareness, these strategies are rarely sufficient alone but are an essential part of treatment.


Relaxation Coping Skills

Anger is often marked by increased emotional and physical excitement. Relaxation coping skills target this excitement and can help you calm down when angered. You can learn to become aware of the triggers for anger, and you can use relaxation to lower it. Relaxation skills include slow deep breathing, slowly repeating a calming word or phrase, picturing a personal relaxation image, or focusing on muscle tension and consciously letting it go. These skills are practiced at home until you can relax quickly. Then, as you become better at using relaxation, it can be used to lower anger within the therapy session. For example, the therapist may ask you to imagine an angering event, experience the anger, and then assist you in the relaxation skills to lower the anger. Over the course of a few sessions, as the therapist’s assistance decreases, you can learn to handle increasing levels of anger. If successful in the therapy sessions, you can begin to use relaxation for anger management in daily living, freeing yourself to approach situations more calmly.


Attitude and Cognitive Change

When angry, people often make bad situations worse by the way they think about them. For example, angry individuals tend to demand that things should be, ought to be, or have to be, their way—rather than just wanting or preferring them to be a certain way. Often, they call other people insulting, sometimes obscene, names. The problem situation is often seen as awful or catastrophic, rather than merely difficult, frustrating, or genuinely disappointing. By thinking about bad situations in this way, natural frustrations hurt, and disappointments seem much more significant, leading to increases in anger.

Attitude and cognitive change techniques focus on identifying anger-producing thoughts and replacing them with more reasonable ways of thinking. As with relaxation skills, many different methods may be employed. For example, therapists could use the careful exploration of thinking errors, role-playing, self-monitoring, and self-debating strategies, and trying out new behaviors. You and your therapist will work together in session using one or more of these techniques to become aware of, and change, attitudes, and images that increase anger. Then, you practice the new and more reasonable thought patterns (habits) for anger reduction in the real world.

Silly Humor

Another cognitive change technique is silly humor. This does not mean that you will be taught to laugh away problems. Instead, the goal is to use silly humor, rather than hostility, as a partial cure. This is particularly helpful with certain types of angering thoughts. For example, adult drivers may make themselves angrier by calling other drivers “asses.” The client might be asked to define this term correctly. This usually leads to a definition of the burro. Then, they might be asked to draw a picture of this definition and to picture this image when they use the term. Rarely is silly humor the primary therapy technique, but it often helps people chuckle at themselves, take a step back, and approach the situation in a less angry way.


Acceptance and Forgiveness

Many things that others do simply can not be helped. For example, children spill drinks; they commonly argue with each other, then pout or shout, and they are always testing the boundaries of “no.” In industry, economic conditions sometimes lead to layoffs. Spouses sometimes forget about issues that are important to their partners.

But thinking that others have intentionally set out to cause problems is almost always wrong. Thinking that they could have acted differently, if they really wanted to, ignores other causes of behavior. Sometimes, for example, spouses or colleagues just didn’t hear what you said, or your friend just forgot. Thinking that the bad behavior of others is always intentional just increases anger and does little to solve problems. Understanding that some behaviors are caused by biology or genetics, or normal development, or economic stress, is more realistic. Acceptance and forgiveness interventions help you to understand these realities. The goal is to improve relations with others while reducing needless and repetitive lecturing and blaming.


Skill Enhancement

Some people experience anger because they do not have the necessary skills to negotiate common interpersonal hassles and conflicts. They may fight with a spouse because they don’t know how to communicate well about family budgets; become furious and yell at a child because they don’t know how to handle the child’s misbehavior, or become angry and intimidating when dealing with coworkers because they don’t know how to be assertive. Anger escalates because of insufficient skill in resolving the situation.

Although the needed skills vary greatly from individual to individual, skill training can help you approach negative situations in a calm, direct, problem-solving manner. You and your therapist identify the needed skills and rehearse them during therapy sessions until you are comfortable with them. Then, you work together to transfer these skills from the office into the real world. Over time, you will learn general principles and strategies that can be adapted to many anger-causing situations. This leads to a reduction in anger because the skills stop or lessen conflict and tension with others.

Very few risks are associated with cognitive behavioral therapy, and the benefits are plentiful. The client will likely explore painful feelings and emotions, but they will do it in a safe, guided manner.

Cognitive therapy is considered a short-term approach and generally lasts about 10 to 20 sessions depending upon your specific disorder, the severity of your symptoms, the amount of time you’ve been dealing with anger symptoms, their   rate of progress, their current stress levels, and the amount of support they receive from friends and family.


Communication Skills

Teaching communication skills is also an effective treatment for anger management. The way we communicate or the style we use to communicate is often learned from much earlier experiences in our lives when our language skills were newly formed. Most individuals tend to communicate in a way that was adaptive in the environment we grew up, but problematic in our lives today. For many, our style of communication can leave someone with unmet needs, unexpressed emotion, and damaging effects on individuals around them.

Eric told his counselor that in his family, they typically yell at one another to get the point across. Eric recently got into a relationship with a woman who told him that his anger scares her when he gets upset. Eric’s reply was that he was not upset; this was just the way he is used to expressing himself when he gets upset; this is normal for him.

The reality is that what might be normal for a client’s family of origin may not be the norm in terms of communicating effectively with others.

Eric’s style of communication is aggressive, but he didn’t realize the impact it had on his girlfriend. Eric had to learn about his style of communication as well as other styles of communication to understand the kind of changes he needed to make. By learning to become more assertive, Eric felt better, his needs got met more of the time, and his girlfriend no longer feared him when he did get upset.

It is important to understand that there are many different communication styles, yet only one that tends to yield the results we are seeking. Learning to express primary feelings and needs clearly, calmly, with good eye contact, is what assertive communication is all about.

Good communication skills are an essential ingredient to anger management because poor communication causes untold emotional hurt, misunderstandings, and conflict. Words are powerful, but the message we convey to others is even more powerful and often determines how people respond to others.


Prescription and Over the Counter Medications

Because anger is a psychological issue, it is possible to treat symptoms with medication. While the goal of treatment programs will be to eventually make the patient self-sufficient, particular medicines can be helpful in the treatment phase.

Antidepressants such as Prozac, Celexa, and Zoloft are commonly prescribed for anger issues. These drugs do not specifically target anger within the body, but they do have a calming effect that can support control of rage and negative emotion. Epilepsy medicines are sometimes indicated, particularly when a patient’s seizures result in anger reactions.

The client should speak with their doctor about whether or not prescription medicines can help them with their anger issues. They should pay particular attention to potential side effects and any risks of addiction. The purpose of medications is to complement their healing, not to complicate it.

A number of over-the-counter medications and supplements can also be used to improve mood and support anger management therapy. These include:

  • Valerian
  • Primal Calm (formerly Proloftin)
  • Benadryl
  • Passionflower
  • Chamomile

Benadryl is an anti-allergy medication that also helps to reduce anxiety. Valerian and Primal Calm are herbal extracts that purportedly promote lowered stress levels and calm feelings. Passionflower and chamomile are usually consumed in either tea or tablet form to support mood and reduce anxiety.


Employing Self-Help Methods

Our goal is to help our clients help themselves. The following are some tips that can be used by the client to help avoid and de-escalate potential problems:

(1) Avoid frustrating situations by noting where you got angry in the past.

(2) Reduce your anger by taking time, focusing on other emotions (pleasure, shame, or fear), avoiding weapons of aggression, and attending to other matters.

(3) Respond calmly to an aggressor with empathy or mild, unconfrontational comments or with no response at all.

(4) If angry, concentrate on the undesirable consequences of becoming aggressive. Tell yourself: “Why to give them the satisfaction of knowing you are upset?” or “It isn’t worth being mad over.”

(5) Reconsider the circumstances and try to understand the motives or viewpoint of the other person.

(6) Train yourself to be empathetic with others; be tolerant of human weakness; be forgiving (ask yourself if you haven’t done something as bad); and follow the “great lesson of mankind: to do as we would be done by.”


Case Examples

  • Anger and domestic violence: Claude, 43, is referred to therapy for anger issues by a court after being arrested for beating up his girlfriend and her teenage son. Claude feels regret for his actions, which signifies to the therapist that he may be successful in treatment. Therapy quickly reveals that Claude has a tremendous, irrational fear that his girlfriend will leave him. Claude realizes that it is his angry behavior and violence that may, in fact, lead her to leave, but, with the help of his therapist, he discovers that his fears actually stem from childhood, when his mother, for reasons Claude denies knowing, left his father to care for Claude and his four siblings. Claude realizes he still feels great anger toward both his parents for this event. Later, in a couples session, he reveals this about himself to his girlfriend, establishing a level of intimacy and trust he has never achieved with anyone else. Claude still finds himself angry more often than he would like, but he becomes able to express his emotions more readily and avoid violence or aggression.


  • Depression manifesting as anger: Linda, 23, seeks treatment for depression and is soon angry with her therapist because her mood does not quickly improve. She is demanding in treatment and has poor insight into her actions, blaming others, and their shortcomings for everything wrong in her life. Her therapist reframes her disclosures, focusing not on her complaints but on what Linda wants and needs but lacks: intimacy, a sense of purpose in her life, and self-forgiveness for past mistakes. The therapist also identifies some biological tendencies toward mood swings. Linda is able to express her sadness and fear, and she gains insight into the ways she causes herself to be isolated from others by always criticizing or arguing with them. She soon begins to work on communicating more assertively and less aggressively, rediscovers her childhood love of painting and music, enrolls in college, and begins apologizing to friends for her past actions. Her anger, while still sometimes a challenge for her, is under control.


  • Anger and loss of control:  Art feels like Gina could be his soulmate and just wishes she would allow their relationship to improve getting back to how they were when the first got together.  Gina just can’t let her guard down.  “When Art gets angry is so irrational!”  When Art fights with Gina, the argument, over the simplest thing, ends up in him turning the utilities off at the house or throwing her clothes into the guest room.  After one argument, he drove home, leaving Gina and her kids in a hotel in another state.  She says the relationship is over if he can’t get his “out of control” behavior under control.  “We should be able to fight without him resorting to “craziness.”  The counselor is able to help Art and Gina establish “rules” for arguments, including the ability for Art to walk away and calm down then return after 15 minutes.  Once they began communicating the need to escalate the situation was no longer as necessary for either of them.

In summary, anger and arguments are normal parts of healthy relationships. However, anger that leads to threats or violence, such as hitting or hurting, is not normal or healthy. The goal of anger management is to reduce both the emotional feelings and the physiological arousal that anger causes. An individual can’t get rid of, or avoid, the things or the people that enrage them, nor can they change them, but we can help them learn to control their reactions.



Co-dependency is an emotional and behavioral condition that affects an individual’s ability to have a healthy, mutually satisfying relationship. It is also known as “relationship addiction” because people with codependency often form or maintain relationships that are one-sided and emotionally destructive.  It also can describe a relationship that enables another person to maintain their irresponsible, addictive, or underachieving behavior.

The term codependency has been around for decades. It originally applied to spouses of alcoholics (first called co-alcoholics).  We have learned over time that the characteristics of codependents were much more prevalent in the general population than had been previously understood. Many raised in dysfunctional families and those that had an ill parent could frequently become codependent.

It has also been found that codependent symptoms got worse if left untreated. 

Co-dependents have low self-esteem and look for anything outside of themselves to make them feel better. They find it hard to “be themselves.” Some try to feel better through alcohol, drugs, or nicotine – and become addicted. Others may develop compulsive behaviors like “workaholism,” gambling, or indiscriminate sexual activity.

They have good intentions. They try to take care of a person who is experiencing difficulty, but the caretaking becomes compulsive and defeating. Co-dependents often take on a martyr’s role and become “benefactors” to an individual in need. A wife may cover for her alcoholic husband; a mother may make excuses for a truant child, or a father may “pull some strings” to keep his child from suffering the consequences of delinquent behavior.

The problem is that these repeated rescue attempts allow the needy individual to continue on a destructive course and to become even more dependent on the unhealthy caretaking of the “benefactor.” As this reliance increases, the co-dependent develops a sense of reward and satisfaction from “being needed.” When the caretaking becomes compulsive, the co-dependent feels choiceless and helpless in the relationship but is unable to break away from the cycle of behavior that causes it. Co-dependents view themselves as victims and are attracted to that same weakness in love and friendship relationships.

Characteristics Of Co-Dependent People Are:

  • An exaggerated sense of responsibility for the actions of others

  • A tendency to confuse love and pity, with the tendency to “love” people they can pity and rescue

  • A tendency to do more than their share, all of the time

  • A tendency to become hurt when people don’t recognize their efforts

  • An unhealthy dependence on relationships. The co-dependent will do anything to hold on to a relationship; to avoid the feeling of abandonment

  • An extreme need for approval and recognition

  • A sense of guilt when asserting themselves

  • A compelling need to control others

  • Lack of trust in self and/or others

  • Fear of being abandoned or alone

  • Difficulty identifying feelings

  • Rigidity/difficulty adjusting to change

  • Problems with intimacy/boundaries

  • Chronic anger

  • Lying/dishonesty

  • Poor communications

  • Difficulty making decisions


Codependence vs. dependence

In codependency, one person has their needs prioritized over the others.

It is important to know the difference between depending on another person — which can be a positive and desirable trait — and codependency, which is harmful.

The following are some examples that illustrate the difference:

Dependent: Two people rely on each other for support and love. Both find value in the relationship.

Codependent: The codependent person feels worthless unless they are needed by — and making drastic sacrifices for — the enabler. The enabler gets satisfaction from getting their every need met by the other person.

The codependent is only happy when making extreme sacrifices for their partner. They feel they must be needed by this other person to have any purpose.

Dependent: Both parties make their relationship a priority, but can find joy in outside interests, other friends, and hobbies.

Codependent: The codependent has no personal identity, interests, or values outside of their codependent relationship.

Dependent: Both people can express their emotions and needs and find ways to make the relationship beneficial for both of them.

Codependent: One person feels that their desires and needs are unimportant and will not express them. They may have difficulty recognizing their own feelings or needs at all.

One or both parties can be codependent. A codependent person will neglect other important areas of their life to please their partner. Their extreme dedication to this one person may cause damage to:

  • other relationships
  • their career
  • their everyday responsibilities

The enabler’s role is also dysfunctional. A person who relies upon a codependent does not learn how to have an equal, two-sided relationship and often comes to rely upon another person’s sacrifices and neediness.

Treating Co-dependency

Treatment for codependency allows the individual to rediscover themselves and identify behavior patterns that are self-destructive. The goal of treatment is to allow individuals to feel their full range of emotions and get in touch with feelings that may have been buried. Because co-dependency is usually rooted in a person’s childhood, treatment often involves exploration into early childhood issues and their relationship to current destructive behavior patterns. Treatment includes education, experiential groups, and individual and group therapy through which co-dependents rediscover themselves and identify self-defeating behavior patterns. Treatment also focuses on helping patients getting in touch with feelings that have been buried during childhood and on reconstructing family dynamics. The goal is to allow them to experience their full range of feelings again.

Changing co-dependent behaviors takes time and involves:

Abstinence. Abstinence or sobriety is necessary to recover from codependency. The goal is to bring attention back to the individual. To have an internal, rather than external, “locus of control.” This means that actions are primarily motivated by the individual’s values, needs, and feelings, not someone else’s. The individual must learn to meet these needs in healthy ways.  Perfect abstinence or sobriety isn’t necessary for progress, and it’s impossible with respect to codependency with people. The client needs and depends upon others and therefore gives and compromises in relationships. Instead of abstinence, they learn to detach and not control, people-please, or obsess about others. They become more self-directed and autonomous.

If they are involved with an abuser or addict or grew up as the child of one, they may be afraid to displease their partner, and it can require great courage to break that pattern of conceding their power to someone else.

Awareness.  It’s said that denial is the hallmark of addiction. This is true whether the client is an alcoholic or in love with one. Not only do codependents deny their own addiction – whether to a drug, activity, or person – they deny their feelings, and especially their needs, particularly emotional needs for nurturing and real intimacy.  They may have grown up in a family where they weren’t nurtured, their opinions and feelings weren’t respected, and their emotional needs weren’t adequately met. Over time, rather than risk rejection or criticism, they learned to ignore their needs and feelings and believed that they were wrong. Some decided to become self-sufficient or find comfort in sex, food, drugs, or work.

All this leads to low self-esteem. To reverse these destructive habits, they first must become aware of them. The most damaging obstacle to self-esteem is negative self-talk. Most people aren’t aware of the internal voices that push and criticize them.

Acceptance.  Healing essentially involves self-acceptance. This is not only a step but a life-long journey. People come to therapy to change themselves, not realizing that the work is about accepting themselves. Ironically, before someone can change, they have to accept the situation. Accepting reality opens the doors of possibility. Change then happens. New ideas and energy emerge that previously stagnated from self-blame and fighting reality.

Self-acceptance means that they don’t have to please everyone for fear that they won’t be liked. They honor their needs and unpleasant feelings and are forgiving of themselves and others. This goodwill allows them to be self-reflective without being self-critical. Their self-esteem and confidence grow, and consequently, they don’t allow others to abuse them or tell them what to do. Instead of manipulating, they become more authentic and assertive and are capable of greater intimacy.

Action.  Insight without action only gets someone so far. In order to grow, self-awareness and self-acceptance must be accompanied by new behavior. This involves taking risks and venturing outside of someone’s comfort zone. It may involve speaking up, trying something new, going somewhere alone, or setting a boundary. Instead of expecting others to meet all of their needs and make them happy, they learn to take action to meet their own needs and do things that give them fulfillment and satisfaction in their life. 

Words are actions. They have power and reflect the client’s self-esteem. Becoming assertive is a learning process and is perhaps the most powerful tool in recovery.




 Historical documents often refer to the United States as a great cultural experiment or a melting pot as diverse peoples are molded and shaped into the American Way of Life.  This undertaking has yielded various shades of success as new citizens adapt to a common language, habits, and values.  The final outcome of the great culture experiment will be determined over the next several generations.  A common view hs4is that we the people have made a lot of progress toward accepting people based on their individual merits, but we have a long way to go to overcome all of the cultural barriers.   Recent trends appear to be toward cultural pluralism and diversity as concepts being advanced to promote the co-existence of various cultural groups, all of who may simultaneously maintain some of their distinctive characteristics.  However, there are other conflicts between ethnic and cultural groups, and there is inequality in the social and economic resources available to different groups.  There are also different general acceptances, power, and prestige issues between ethnic and cultural groups, as well as differences with the majority cultures.   These have a significant impact on minority persons who may also have a social or community need.  It is often difficult to separate socioeconomic, ethnic, gender, age, and other variables that influence the behavior and attitude of members of these sub-populations.   Consequently, they often experience multiple jeopardizes, including minority status, parenting problems, physical and mental challenges, age, lifestyles, and other factors.

Individuals who are disadvantaged and sometimes disenfranchised are sometimes labeled as hidden populations and include individuals such as the homeless, chronically mentally ill, criminal and juvenile offenders, prostitutes, runaways, and others.  It follows that less personal and research data are available on these groups due in part to their migratory lifestyles and loss of identity.  They are generally omitted from surveys because they are not living in typical homes, are not attending school, and choose to not cooperate with interviewers.   However, many members of these groups have a greater need for social services, medical, food, shelter, and other services than the general population.

The United States remains a nation in which ethnic minorities and other disadvantaged groups (elderly, females, etc.) are often subjected to prejudicial treatment, as well as having to continuously deal with negative life experiences including language, religion, family relationships, value system, and community norms.  Minority groups and other special sub-populations are disproportionately represented among the economically disadvantaged.  They are more likely to live in urban centers that have higher crime rates, poorer schools, substandard housing, and fewer employment opportunities.  

imgres-1 Ethnic populations are set apart from the mainstream culture by differences in language (whether a foreign language or an English dialect) and create communication difficulties.  The language barrier (includes reading, writing, and verbalizing) increases stress, interferes with psychosocial functioning, and increases the difficulty associated with getting the help they need to successfully integrate themselves into the mainstream of society.   Consequently, additional services are often needed to overcome previous deficiencies and also to accelerate the interventions needed for complex social problems.

It should be noted that many ethnic group members, and other special populations, often demonstrate remarkable strengths despite many obstacles and hardships.  In some cases, powerful religious beliefs help sustain members through difficult situations.  Although family relationships and values may be different, supportive bonds may be formed through extended family members (may include non-related individuals) that are not typically found in the mainstream culture.


The Melting Pot   images-9

The Statue of Liberty is the symbol of freedom that greeted Europeans that enter the US at Ellis Island.  The Golden Gate Bridge served the same purpose for Chinese and other Asians who arrived at San Francisco.   The number of Asian immigrants arriving in the US during the 19th Century was significantly lower than immigrants from other parts of the world.  However, thousands did migrate due to political oppression and to take advantage of the economic opportunities that existed in the US.   The following are some of the major immigration movements to the US:


Over 25,000 Japanese (the vast majority were farmers and farm laborers) immigrated to Hawaii during the late 1800s due to large-scale unemployment, bankruptcies, and other civil discord in their homeland.   Also, there was a concurrent boom in the Hawaiian sugar industry that created a need for additional farm-workers.  Most Japanese immigrants choose to remain in Hawaii because race relations were better there than in the mainland US. Initially, the Japanese gained acceptance into society by working as agricultural laborers for lower wages.  The natural process of acculturation was interrupted on December 9, 1941, when the Japanese attacked Pearl Harbor. 

Post World War II Japanese immigration is a different story.  The so-called second generation of Japanese Americans has gained acceptance in all professions at an accelerated rate.   With increased education (or a higher focus on education), the Japanese sought lucrative professions. Consequently, by the 1990s, the Japanese had surpassed the national average per-family income by over 30%.  This economic progress resulted in more acculturation and social acceptance.  For example, by this timeframe, a majority of Japanese Americans spoke English exclusively.

An interesting observation can be made from the Japanese immigration experience.  It appears that their willingness to work and their taking advantage of educational opportunities resulted in rapid improvement in their economic condition and an increase in their social acceptance into the mainstream of society. 


Chinese immigrated to the US during the 18th century.  The Chinese populations in the US dropped to approximately 60,000 in 1920, due to the Chinese Exclusion Act and other factors.  However, the Chinese are the largest Asian population in the US today.

Merchants and skilled laborers were generally accepted into society.  However, subsequent groups of unskilled workers encountered negative and hostile attitudes toward them.  These Chinese tended to live in large cities and formed ethnic enclaves called Chinatowns.  The general trends in these enclaves were to restore the social norms of their homeland and to somewhat resist integration into the mainstream culture.

As time passed, the cultural division between the Chinese and the Americans diminished.  “Chinatowns” become a quiet, colorful tourist attraction and China was an ally of the US during WWII.   This and other factors led to the repeal of the Chinese Exclusion Act.  Consequently, immigration from China resumed.


Approximately 1.5 million immigrated to the US during the mid-1800s to escape a serious potato famine.   Most settled in the Northeast and have made a successful transition into the US culture.


Approximately 4 million immigrated to the US during the mid-1800s in order to escape economic depression and political unrest.  German immigrates have demonstrated a high degree of acculturation into the American way of life.

Danes, Norwegians, and Swedes

Approximately 1.5 million immigrated to the US during the late 1800s to escape poverty.  The acculturation experiences have been similar to the Germans.


Approximately 1 million immigrated to the US during the late 1800s and early 1900s to escape poverty, disease, and political repression in their homeland.


Approximately 2.5 million immigrated to the US in the late 1800s and early 1900s to escape religious persecution.   The Jewish people encountered religious persecution in the US but were able to survive their difficulties and become accepted into the mainstream of American society.  Jewish immigration has continued throughout the last 200 years, with a corresponding increase in their acceptance throughout society.

Austrians (Czechs, Hungarians, and Slovaks)

Approximately 4 million immigrated to the US during the late 1800s and early 1900s to escape poverty and overpopulation. 


Approximately 4.5 million immigrated to the US in the late 1800s and early 1900s to escape poverty and overpopulation.  They have been very successful in adapting to the American way of life.


Approximately 700,000 immigrated to the US in the early 1900s to escape the Mexican Revolution of 1910, as well as the difficult social and economic conditions in Mexico at that time.   Also, approximately 2 million Mexicans immigrated to the US in the mid-1990s to escape unemployment and poverty.


Approximately 700,000 immigrated to the US in the late 1900s to escape the communist takeover.

Dominicans, Haitians, Jamaicans

Approximately 1 million immigrated to the US in the late 1900s to escape poverty and unemployment. 


Approximately million immigrated to the US in the late 1900s to escape the Vietnam War.  They have proven to be very adept at conforming to the new experience of living and working in the US. 


Africans were brought to this country against their will during the early history of America.  Given these circumstances, they have done an excellent job coping with the socio-economic issues they have faced.   They have transformed the difficulties and accepted (and have been accepted by) the American way of life.

Although only some of the major immigrations have been addressed, the reader can get a sense of the rich cultural and social diversity that went into building the American melting pot.  It is important to recognize that every culture has strengths and weaknesses, and generally, the composite is made stronger by the interaction of all of the individuals. 

 We tend to fall into the mindset that cultural diversity means respecting the differences of other people from different nations or of different colors of skin.  Differences can also present just from upbringing, belief systems such as moral, religious, political beliefs, and so forth.  Watch the following clip from the popular movie Legally Blonde as an example of very different stereotypes and how they don’t understand each other all right here in our country.



Race/Ethnicity And Other Social/Health Problems 

In the US, there are four major minority racial-ethnic groups:images-3

  • African Americans
  • Hispanic Americans
  • Asian Americans/Pacific Islanders
  • American Indians/Alaska Natives

These four groups make up approximately one-quarter of the total US population.  They also constitute the fastest-growing segment of the population. Consequently, the need to understand the socio-cultural factors affecting these racial and ethnic groups is crucial for the provision of adequate social services. 

The US Bureau of Census revealed that African Americans constitute approximately 13.2% of the population, followed by Hispanic Americans (17.4%), Mixed (2.5%), Asian Americans, and Pacific Islanders (5.4%).  There is considerable variation within racial and ethnic groups, as well as between groups, and there is often a complex relationship between racial/ethnic group membership and socioeconomic status.  A good example of this is if an individual has a high degree of acculturation (language, value systems, career, housing, etc.), then that individual could be rejected by his or her race or ethnic group.

Some minority groups have limited access to social services and are often at higher risk of anti-social behaviors.  This is a consequence of several factors, such as the migration experience, poverty, unemployment, and cultural differences between the minority groups and the mainstream society. Some low socioeconomic status individuals may engage in high-risk behavior for economic reasons.  For example, some may turn to prostitution and/or drug dealing to support their families due to lack of education or vocational training and the resulting limited access to employment.


General Barriers to Social Services 

Racial and ethnic populations may face a number of problems (language, transportation, etc.) that may impede their access to social services.  Individuals from racial/ethnic groups tend to under-utilize healthcare, prenatal care, mental healthcare, and substance abuse treatment, or they seek them as a last resort.  Treatment may be sought only when the resources of the traditional family support network have been exhausted.  At this point, problems may be so chronic and severe that treatment outcomes may be poor.

The individual’s economic status may be a deterrent to the purchase of imgresservices.  Racial/ethnic populations are not only more likely to have lower incomes than those of the mainstream population but to be less insured.   

Those needing social services may live in areas where access to providers is limited because of distance or transportation problems.  Also, those with access may often find services that are inadequate or inconveniently scheduled.  Others may not realize they are eligible or may not be aware of what services a local program offers.   Many social services providers are not able to address the specific needs of individuals from cultural backgrounds different from their own, even when they speak the client’s language of origin.  This is further compounded when trying to develop written material for linguistic and culturally diverse populations.   Issues such as literacy levels and regional differences (different dialects) need to be taken into account when developing written program material.

Beliefs and attitudes regarding health and illness may act as obstacles keeping racial and ethnic populations from seeking treatment for social problems.   The literature on health and mental health has identified a number of factors that contribute to the under-utilization of services.  For example, reliance on folk remedies may cause some under-utilization of medical services.  Cultural stigmas attached to psychiatric care, psychotherapy, counseling may invoke fear of losing status and of being judged a failure by the family and the community, and, thereby, contribute to under-utilization.   Cultures differ in their characterization and acceptance of abnormal behaviors.  For example, what is considered abnormal behavior in one culture may be accepted or encouraged in another.   For example, the practice of voodoo may be accepted in one group and scorned in other groups. Abnormal behaviors may be attributed to physical or psychological causes, or they may be viewed as the direct result of supernatural or spiritual factors.

Emergency rooms often serve as primary care providers for members of racial and ethnic minority groups in urban areas.  Individuals with long-standing social problems are more susceptible to serious medical problems and are more likely to use emergency rooms.  However, emergency rooms often are unable to provide appropriate referrals to social services or to provide the follow-up to assure appropriate care is provided.


Regardless of the services required, racism on an institutional or individual level can be a significant barrier to effective treatment.  Institutional racism within a service ocd4rganization is evident when the program design is oblivious to the racial, cultural, or ethnic backgrounds, values, and mores of its client population.    Latent prejudices on the part of the staff, as well as language and cultural differences,  undermine efforts to help patients achieve recovery.

A community in social and economic turmoil may reject social service providers who are outsiders.  Negative experiences with providers who may have lacked respect, awareness, or concern for cultural differences often reinforce unfavorable attitudes and distrust.  For example, some treatment programs may be rendered ineffective if the community has not been involved in their planning and implementation.


Cultural Competence

images-1The importance of culture increases in individuals living in a socio-cultural setting other than the one they came from.  Also, for those who have not experienced socio-cultural change, cultural issues may come to the forefront in interactions with individuals who do not share the same culture of origin. Such encounters prompt the realization that different cultures view the world in different ways.  A way to help bridge those differences is through the acquisition of knowledge about other cultures.  Cultural knowledge enhances the understanding of different views and also helps to develop more effective problem-solving strategies. 

A cultural competency program is one that demonstrates sensitivity and understanding of cultural differences.  It is a fundamental ingredient that helps to develop trust, as well as an understanding of the way members of different cultural groups,  define health, illness, and health care. Consequently, culture is a set of academic and interpersonal skills that allow individuals to increase their understanding and an appreciation of cultural differences and similarities within, among, and between cultural/ethnic groups.

A culturally competent social service provider recognizes and utilizes the client’s strengths, values, and experiences while encouraging behavioral and attitudinal change.  Culturally responsive services generally focus on the following: 

  •  Knowledge of the client’s native language
  •  Sensitivity to the cultural mores of the client population
  •  Staff background similar to clients
  •  Treatment/services modalities that include values of the client population
  •  Representation of the client population in decision-making and policy implementation.

It has been recommended that cultural competency programs need to implement cultural competence at all levels:  Policy, structure, attitude, staff, and policy.  Stated slightly differently, culturally competent systems include professional behavioral norms that are built into the organization’s mission, structure, personnel, and program design and treatment modalities.

Cultural competence also infers the willingness of professionals and the programs they operate to conduct self-appraisals to develop an understanding of how they may differ from the clients they serve.  Cultural competence also entails the acknowledgment of existing inherent cultural biases on one’s attitude and behavior.  A provider’s discomfort in relating to individuals who are different can be communicated in many non-verbal ways.  Common factors that influence comfort include ethnic and racial characteristics, socioeconomic background, religion, and physical and mental handicaps.  However, cultural competence requires communication that goes beyond language proficiency to focus on meanings and interpretations.  Consequently, within a culturally competent framework, knowledge of cultural beliefs and expectations are necessary for effective communication.

The conceptualization of a continuum of cultural competence was developed by Georgetown University in 1989.  It can be used to assess the level of cultural competence.  It includes:   

 Cultural Destructiveness:    Attitudes, policies, and practices that are destructive to other cultures.

Cultural Incapacity: Lacks the capacity to help, but is not intentionally destructive.

Cultural Blindness:  Attempts to treat all people as though they are alike.  It infers that one’s color or culture does not matter.  Services are so culturally neutral; they are not relevant to anyone.

Cultural Pre-Competence:  Individuals or agencies realize they have weaknesses in their cultural competence and attempts to improve.  The risk at this stage is that token change may be accepted as sufficient.

Cultural Competence:  Others are accepted and respected for their differences, and cultural knowledge is continually expanded.  In program settings, staff who are committed to their particular culture are hired; staff is encouraged to become comfortable working in cross-cultural situations.

CulturalProficiency:  Different cultures are held in high esteem.  Agencies and staff advocate and work to improve relationships among cultures throughout society.

The melting pot continues to blend people from all cultures into one person.  I think the great American experiment has proven successful, as we have adopted the strengths of each culture into the mainstream culture.  Again, we have made a lot of progress, but there remains a lot of work to be done.


Language Considerations 

imagesOne of the greatest barriers to the acculturation of racial/ethnic groups into the American way of life is language.  Most early immigrants that came to the US did not speak, read, write, or understand spoken English.  Fortunately, some of the more recent immigrants have a better command of the English language, but problems still exist, especially with low socioeconomic individuals who migrate to the US to avoid poverty and unemployment in their native country.  The following paragraphs will introduce the reader to the general language problem:

19.2 million Americans are classified as Limited English Proficient.  An increase of approximately 48% from the 1990 Census. 

Due to these factors and other considerations, OSHA requires that employers establish effective communication with non-English speaking workers. Again, some progress is being made, but there is a long way to go.  One way an employer can bridge the gap is to recognize the need for language interpreting and translation services.  Employers may also hire and train bi-lingual staff and translate safety-sensitive documents into native languages. The employer may also provide cultural diversity training for all staff.



Domestic Violence is an inclusive term gathering into itself several other related terms such as domestic abuse, spousal abuse, battering, family violence, dating abuse, and Intimate Partner Abuse (IPA). The definition of domestic violence is a pattern of abusive behaviors including a wide range of physical, sexual, and psychological maltreatment used by one person in an intimate relationship against another to establish power unfairly or maintain that person’s misuse of power, control, and authority. It is typically  viewed as a pattern of antisocial behaviors that can take many forms, including physical aggression or assault (hitting, kicking, biting, shoving, restraining, slapping, throwing objects, battery), or threats thereof; sexual abuse; emotional abuse; controlling or domineering; intimidation; stalking; passive/covert abuse (e.g., neglect); and economic deprivation. Domestic violence and abuse are not limited to obvious physical violence. It can also mean endangerment, criminal coercion, kidnapping, unlawful imprisonment, trespassing, harassment, and stalking.


The awareness, perception, definition, documentation, and treatment of domestic violence differ (slightly) from region-to-region in the United States. For example, studies indicate that it is tolerated more in the South than in other regions. Also, the laws pertaining to domestic violence vary by country. While it is generally outlawed in the Western World, this is not the case in some Middle East countries. For instance, some Arab countries allow a man to physically discipline his wife and children. The social acceptability of domestic violence also differs by country. While in most developed countries domestic violence is considered unacceptable by most people, in many areas of the world the views are different: according to recent studies, the percentage of adult women think that a husband is justified in hitting or beating his wife under certain circumstances is over 70% in Afghanistan, Jordan, and in the Central African Republic. Refusing to submit to a husband’s wishes is a common reason given for justification of violence.              

Domestic violence is largely thought to be male against female; however, the term includes any intimate relationship husband against wife, wife against husband, brother against brother, uncle against nephew, grandchild against grandparent, and roommate against a roommate. Wikipedia, The Free Encyclopedia states that domestic violence occurs when a family member, partner, or ex-partner attempts to physically or psychologically dominate another. The encyclopedia goes on to say that domestic violence often refers to violence between spouses or spousal abuse but can also include cohabitants and non-married intimate partners. Domestic violence occurs in all cultures; people of all races, ethnicities, religions, sexes, and classes can be perpetrators of domestic violence. Domestic violence is perpetrated by both men and women.

Domestic violence is a criminal act and includes physical assault (hitting, pushing, shoving, etc.), sexual abuse (unwanted or forced sexual activity), and stalking. Although emotional, psychological, and financial abuse is not always a criminal behavior in some legal systems, they are forms of abuse and can lead to criminal violence. There are a number of dimensions, including:

  • Mode: physical, psychological, sexual, and/or social.     
  • Frequency: on/off, occasional and chronic.
  • Severity: in terms of both psychological or physical harm and the need for treatment. Injuries may vary from mild to moderate to severe up to homicide.
  • Transitory or permanent

An important component of domestic violence, often ignored, is the realm of passive abuse, leading to violence. Passive abuse is covert, subtle, and veiled. This includes victimization, ambiguity, and neglect, spiritual, and intellectual abuse.

Recent attention to domestic violence began in the women’s movement, particularly feminism and women’s rights, in the 1970s, as concern about wives being beaten by their husbands gained attention. Estimates are that only about a third of cases of domestic violence are actually reported in the United States. According to the Centers for Disease Control, domestic violence is a serious, preventable public health problem affecting more than 30 million Americans. Popular emphasis has tended to be on women as victims of domestic violence. However, with the rise of the men’s movement, and particularly men’s rights, there is now advocacy for men victimized by women. In a special report on violence-related injuries by the US Department of justice, hospital, emergency room visits pertaining to domestic violence indicated that physically abused men represent just under one-sixth of the total patients admitted to the hospital reporting domestic violence as the cause of their injuries. The report highlights that significantly more men than women did not disclose the identity of their attacker. In significant numbers, males are the batterers, and females are the sufferers of domestic violence. However, that is not always the case. Fewer men report incidents.

Domestic violence has been an increasing health concern in America for the past 25 years; consequently, communities are developing strategies to slow the violence and provide more protective mechanisms for women, men, and children who are battered. Researchers estimate that approximately 90 percent of the violence is against females and that over 3 million experience some form of violence each year. Also, most have been attacked by a family member or a person they are acquainted with. However, domestic violence is a family problem that devastates every sector of society, overwhelming our courts and hospitals, spilling over into our streets, and filling our morgues. We must all be a part of the solution if we are to address the deadly toll this epidemic is taking. Every community is touched, yet the pervasive problem of domestic violence continues to be a problem that most individuals struggle with at the time of witnessing an event that seems as though it is pushing the envelope of just an argument. When do you call the police? When do you get involved? Do you look away?

Domestic violence was one of the leading causes of injury to women at the start of the 21st century and continues to the present time. It results in more injuries than muggings, stranger rapes, and auto accidents combined. Researchers estimate that some form of domestic violence occurs in approximately one-third of marriages in the United States and has a significant impact on the health care cost as the victims spend nearly 125,000 days in hospitals, make 40,000 emergency room visits, and 70,000 trips to the doctor every year.   Also, about one-half of homeless women and their children are fleeing from domestic violence situations. Also, over 4 million children witness or are involved in acts of domestic violence every year. The risk of psychological and behavioral problems increases dramatically for these children, and they are more likely to attempt suicide and/or abuse alcohol, tobacco, and other drugs. They start their early life with a significant handicap (due to no fault of their own) and frequently never completely overcome it. In essence, it’s a heavy load on children who either witness domestic violence or are victims themselves.


Recent Statistics And A Growing Problem 

 Researchers predict that over five million Americans will be victims of domestic violence this year. Almost one in three women will be assaulted by their partner, at least once. Even with those daunting figures, experts agree that the actual numbers are higher because many feel too ashamed or fearful of their perpetrator to report the incident. According to the American Psychological Association Task Force on Violence and the Family, this type of violence is the leading cause of injury to women age 15 to 44 in the US and represents a national epidemic of violence in the home. 

Although much can be predicted about the pattern after the abuse has begun, little can predetermine with validity who will abuse. Race and or socio-economic levels are not significant risk factors meaning that domestic violence occurs across all racial and socio-economic levels. African-American women experience more domestic violence than White women in the age group of 20-24. However, Black and White women experience the same level of victimization in all other age categories. Hispanic women are less likely to be victimized than non-Hispanic women in every age group.

Research suggests a high correlation between aggression and the use of alcohol and other drugs. Not necessarily in that, there is a correlation that suggests alcohol and other drugs cause abuse, but rather their presence can exacerbate the level of violence. Alcohol and other drug use lower inhibitions, affect judgment, and often increase emotions.



Researchers have found that over 40% of battering men came from male-dominated homes where the male was either violent or controlling or both. Typically, family members were afraid of the dominant male because of threats, or frequent violence acts generally directed at his mate or the children. Although men are more likely to be victims of violent crime overall, a recent study by the U.S. Department of Justice reports that “intimate partner violence is primarily a crime against women. Of those victimized by an intimate partner, approximately 90% are women, and 10% are men. In other words, women are considerably more likely than men to be victimized by an intimate partner. Even when men are victimized, 10% are assaulted by another man. In contrast, only 2% of women who are victimized are assaulted by another woman. With these statistics, it is important to note that women are more likely to report violent incidents. Only about half of domestic violence incidents are reported to the police. There is growing skepticism regarding the quality of police response, which is grounded in reality. For example, a recent study by D.C. Metropolitan Police Department concluded that only 17% of the victims were asked about a restraining order, and 83% were provided no printed information with contact information or resources, which is a department standard. This may or may not be indicative of service across the country, but it is an alarming discovery. As noted previously, Domestic abuse occurs when one person in a relationship or marriage tries to dominate and/or control the other person. The abuser may use fear, guilt, shame, or intimidation to gain an advantage over the victim. He or she may threaten the victim or their family (including their children). When abuse turns violent (physical attacks), it is called domestic violence. Victims of domestic abuse/violence may be men or women, although women are more commonly victimized. Domestic abuse/violence occurs among heterosexual couples as well as in same-sex relationships. Domestic abuse/violence does not discriminate except for gender (women are predominately the victims). Also, it occurs across all ages, ethnic backgrounds, and social/economic levels.

Heterosexual males (in relationships) are the most frequent domestic violence offenders. However, researchers have found that women are equally likely to hit or physically harm a partner. Also, an average man is larger and more capable of defending himself against physical assaults; consequently, they do not have the same reaction to violence directed at them. It is equally wrong regardless of who does the abusing, as no one should have to tolerate being abused by another person. In any case, the female is more likely to sustain a serious injury than the male counterpart. Also, a man’s reaction to a woman’s violence is usually less emotionally than a woman’s reaction to a man’s violent acts. The man’s reaction is usually categorized in the annoyance, anger, and self-righteousness categories, whereas the reaction for women is more traumatic, often involving varying amounts of fear or terror. When a 200-lb man hits a 120-lb woman, the impact is going to be greater for her than if the roles were reversed due to physical size, training, and mindset. If either the man or woman hits a young child, the results can be devastating.



Despite a common myth, domestic violence is not due to the abuser’s loss of control over his emotions and behavior. Researchers have concluded that their violence is a deliberate choice made by the abuser in order to control the victim. Some of the more obvious observations to support this conclusion are:


  • The perpetrator does not batter other individuals-the supervisor who treats him unfairly or the restaurant server who spills food.  He waits until there are no witnesses and abuses the person he says he loves.
  • In most cases, the perpetrator can stop when the police arrive at the scene.  It’s amazing how quickly he can regain his composure and look calm, cool, and collected, and she is the one who may look hysterical.  If he were truly “out of control,” he would not be able to stop himself when it is to his advantage to do so.
  • The incident generally escalates from pushing and shoving to hitting in places where the bruises and marks don’t show. An out of control perpetrator would not be able to direct or limit where he kicks or punches the victim.


Legal Considerations 

In most states, only the physical acts of domestic violence are actionable under law. This is generally interpreted as the use of physical force or threats to control or intimidate a victim. Certainly, there are many relationships between people that are dysfunctional in which one or both people are emotionally abusive to the other. But if there’s no battering (threat of violence or overwhelming control of that person’s life), then we’re simply talking about a bad relationship in which either party can choose to remove themselves, and not one in which a person feels threatened of serious harm if they leave. Another legal issue to consider is the mandatory arrest policies in which police are required to make an arrest if there is probable cause that a person has committed domestic violence. Passage of these laws was advocated by domestic violence experts to address the inadequate response to domestic violence victims by law enforcement. When officers arrive at the scene of domestic violence crime, they often cite evidence that both partners have engaged in some aggressive behavior and arrest both. This “dual arrest” strategy fails to take into account which of two people is primarily responsible for the aggression and which one is responding out of self-defense, and can have devastating effects, particularly if there are children involved in the relationship. To counteract this problem, some departmental or statewide policies now provide guidelines for an officer to determine who the primary aggressor is in a violent incident. For example, the California Commission on Peace Officer Standards and Training publish a guidebook for officers responding to domestic violence, discouraging “dual arrests” and outlining several factors to consider when determining who is the primary aggressor in a domestic violence situation. The primary aggressor is defined as “the person determined to be the most significant, rather than the first, aggressor.” Factors to consider include the history of domestic violence between the people involved, the threats and fear level of each person, and whether either person acted in self-defense. These are appropriate considerations when determining who the primary aggressor is, and therefore which of the two parties should be arrested.


Types Of Domestic Violence 

 Acts of domestic violence generally fall into one or more of the following categories:        

  • Physical battering includes bodily attacks or aggressive behavior. This type of behavior is what most people think of when they hear the term domestic violence. Physical violence ranges from pushing or shoving to bruising (while restraining) to punching, kicking, biting to serious injury up to and including death. Most experts agree that without some type of intervention physical violence escalates with time. It starts with a relatively minor incident, which is excused as trivial such as pushing someone or throwing keys, and then escalates over time into more frequent and serious attacks.
  • Psychological or emotional abuse is the deliberate undermining of someone’s sense of safety and well-being. This type of abuse includes repeated criticisms, humiliation, name-calling, extreme jealousy, harassment, threats of suicide, and isolation from friends and family. Isolation occurs to undermine the support system and reduce the negative feedback about the relationship someone might receive from family and friends.
  • Sexual violence is unwanted or coerced sexual contact of any kind. Married or not, a person has the right to say no.
  • Intimidation is defined in this context as the act of deterring or making someone fearful by threats of violence to manipulate or control behavior. The abuser inhibits the victim’s behavior by threatening to hurt or kill them or their friends and family, including blackmail and threats to abduct children. This category often includes physical violence against property such as breaking into an individual’s home and wrecking it or displaying weapons in such a way that a threat is implied.
  •  Parallel violence is when an abuser acts against another person the intended victim cares about or a pet in order to control the partner.
  • Economic abuse is often used to control a victim’s ability to leave a relationship. It involves restricting access to money or to other financial resources. Keeping a partner’s income or preventing them from earning an income is included in this type of abuse.


Psychological Profile Of An Abuser 

Some of the psychological/personality characteristics common in abusers (in addition to their propensity to use physical violence) are:

  • Dominance or type A personality: Most perpetrators have a domineering personality with a strong need to be in charge of those around them. They like to tell people what to do and when to do it and for their orders to be followed. They have a tendency to direct most family activities.
  • Humiliation tendencies: A perpetrator will do almost anything to embarrass a victim. His objective is to make the victim feel bad or feel defective in some manner. The abuser’s objective is to make the victim believe they are worthless and of no value to anyone else. Also, the victim’s self-esteem is eroded through insults, name-calling, shaming, and put-downs.
  • Isolationism: This trait is used to increase the victim’s dependence on the perpetrator. The perpetrator will limit transportation, money and other items to isolate a victim from family and friends. In severe cases, this may extend to work and school activities.
  • Threats: Threats are used to keep a victim from leaving or to scare them into dropping charges. The threats are generally related to the physical realm and may include a threat to harm children, other family members or pets. He may also threaten to harm himself.
  • Intimidation: A perpetrator may use threatening looks or gestures, damage personal property, drive-bys, injure your pets or display guns to scare a victim into submission. The message is that if you don’t obey, there will be violent consequences.
  • Denial and blame: Perpetrators blame their violent behavior on a bad childhood, trouble at work, bad neighborhood, a bad day, family or anything else that will shift the responsibility for the abuse to someone or something else. The perpetrator will also minimize his role or deny that it occurred. He will commonly shift the responsibility for his violence onto you as if somehow it’s your fault.


Symptoms of Abuse/Violence 

Emotional Abuse

  • Put-downs (erodes victims self-esteem)
  • Name Calling/personal insults
  • Playing the psycho game (make someone think they are going crazy)
  • Humiliation (public reprimand; exploit/exaggerate any mistake in public)
  • Causing guilt (false accusations)

Economic Abuse

  • Limit job opportunities (outside the home)
  • Denying a person money or access to money
  • Limit how much a person can spend (allowance)
  • Taking the other person’s money

Coercion and Threats

  • Making or carrying out threats to do something to hurt the other person.
  • Threatening to leave the other person, to commit suicide, report the other person to law enforcement
  • Making the other person do illegal things


  • Making the other person afraid by using looks, gestures, or actions
  • Smashing things
  • Abusing pets
  • Displaying weapons

Using Children

  • Making the other person feel guilty about the children
  • Using visitation to harass the other person
  • Threatening to take the children away

Abusing Privileges

  • Treating the other person like a slave
  • Making all the decisions  


Dynamics of Domestic Violence Relationships 

Many theories have been developed to explain ongoing violence in intimate relationships. Some have named family dysfunction, inadequate communication skills, stress, chemical dependency, and financial distress as theories. These problems may be associated with domestic violence but they are not the cause. Removing the factors that perpetuate anger will not end violence. Domestic violence is about power and control. Power and control over one or a select few. Power and control is the primary factor in this kind of conduct. The violence begins and continues because it is an effective method for gaining and keeping control over another person, frequently with few negative consequences.

Much can be predicted about the pattern that exists within the abusive relationship. Batterers typically externalize blame, explaining their violence is due to stress, the partner’s behavior, alcohol, etc. Poor self-esteem, feeling inadequate and feeling powerless in the world are frequent attributes of those that abuse. They take these feelings of inadequacy and lack of power over the outside world out on those that are on the inside and intimate. Often, their chief source of identity and ego gratification depends on their being able to exert control over their partner.

Often blame is placed on those who stay in abusive relationships. On the surface, the situation seems obvious. However, the barriers to leaving an abusive relationship are plentiful. Survivors of abuse typically experience shame, guilt, embarrassment, and isolation. How many men want to admit they are being physically abused? How many would make jokes about a man explaining he was forced to have unwanted sex? Homelessness in women is a leading outcome of leaving violent marriages. The threat of losing children is a terrifying nightmare. At the very least, leaving means a loss of income, the difficulties associated with single parenting, frequently harassment at work. Friends and family will not always believe the victim.

There is also the very real emotional pull that comes from the fact that most violent relationships are not violent at all times. The human spirit is full of hope. Abusers can be every bit as loving as they can be cruel. One of the most important points to remember is that leaving is dangerous.

Violent relationships frequently develop into cycles of violence. The cycle can be described as:

The cycle begins with Phase One: Escalating or Tension Building. In this phase, the batterer is in a low stage of anger. They degrade, humiliate, and verbally harass the victim. They are easily irritated and agitated. Often a husband will have a growing fear that his wife will leave and he has an increased degree of surveillance of her behavior and a higher degree of jealousy. There is a definite increase in stress and anxiety. The victim does everything they can to keep the peace. They often place blame on outside stressors. Characteristics/interactions of this phase include:

  •   Abuser begins to get irritable and begins verbal attacks; generally is in continuous hostile/anger mood
  •   Abuse may begin; may initially be minor; may include threats to the victim, other family members, friends, and others; may include a threat to commit harm self)
  •   There is generally a breakdown of effective communication; loss of trust; may become protective of joint property and joint financial resources
  •   The abuser may attempt to limit victims outside contacts with family and friends
  •   The victim feels the need to keep the abuser calm
  •   The victim feels they are walking on eggshells
  •   Tension increases to the critical/explosive stage


The second is Phase Two: Acute battering. In this phase, there is a violent discharge of tension or rage. The batterer appears to have impaired awareness and lacks control. Often batterers in treatment say, “she knew just what to do to push my buttons; she did it on purpose”. This can be explained by the victim in this phase as they often feel a passive acceptance and a belief that it’s futile to try to escape. In some instances they know if they get through the incident the next phase will come. The victim is isolated, depressed and often suffers from an emotional collapse after the violence.   The characteristics/interactions of this phase include:

  •   Abuser physically and emotionally attacks victims; may attack other family members or friends; may inflict physical and/or emotional harm to the victim.
  •    The abuser may appear to lose awareness of his surroundings and loss of control of his actions (researchers have concluded that most abusers know what they are doing at all times).
  •    Alcohol and or other drugs may increase the risk of severe injury
  •    The abuser will generally isolate the victim and limit their communication
  •    The abuser may restrain the victim
  •    The abuser may leave the scene with children (victim is emotionally stressed by the absence of children and fear that they may be harmed)
  •    Police are generally involved; parties are generally separated until they regain their composure and request reconciliation
  •    Restraining/protective court orders may be required

The third is Phase Three: The Honeymoon Phase. The batterer loves and asks for forgiveness. They promise never again. They are dependent on the victim’s acceptance and validation. The victim experiences guilt and responsibility for the batterer. They have hope that this is the last time until the behaviors begin again in phase one. The characteristics/interactions of this phase include:

  •   Abuser acts as if the incident never happened
  •  The abuser may apologize and be very remorseful (generally temporary); promises that it will never happen again; attempts to explain away the incident
  •   The abuser may shower the victim with gifts and affection
  •   The victim may hope that abuse is over

The cycle can happen to sever times in an abusive relationship. Each stage lasts a different amount of time in each relationship. The cycle can take anywhere from a few hours to a year or more to complete. It is important to remember that not all domestic violence relationships fit the cycle.


Characteristics of Abusers 

Most authorities on the subject of domestic violence agree that it is an issue of power and control rather than simply anger. Batterers can be characterized as using violence as a strategy to gain power and control over others. The following list defines qualities that are many experts have compiled that are frequently, but not always, present in batterers:

  •        Male
  •        Dependent, inadequate personalities
  •        Violent family of origin
  •        History of violence
  •        Abusive of alcohol or other drugs
  •        Easily frustrated
  •        Poor control of impulses
  •        Rigid beliefs
  •        Mood swings


Risk Factors For Abuse 

Abuse occurs in all socioeconomic groups, all genders, all religions, all races, all educational backgrounds, all ages, and all sexual orientations. In a national survey of over 6,000 American families, 50% of the men who frequently assaulted their wives also frequently abused their children. The following factors are areas of increased risk for abuse:

  •  Female between the ages of 19 to 29
  •  Pregnancy
  •  Individuals who come from abusive homes or have had previously abusive relationships
  •  Women who are single and under 35 are more likely to report the abuse


Barriers To Leaving An Abusive Relationship 

The most crucial reason to stay is leaving is dangerous. The most dangerous time in a violent relationship is when the victim is attempting to end the relationship. Men and women alike are frequently embarrassed to admit they have been physically abused. Often leaving means continued and escalated harassment. In an attempt to control the individual leaving, threats are frequently made concerning finances and child custody.

There is also a mixed emotion for love and hope along with the manipulation, intimidation, and fear. Often the abusers will threaten to hurt themselves or other loved ones if the victim does not stay.

Support systems often become weaker once the threat is increased and pointed at them, as well. A friend who offers a friend a safe place to stay can become threatened and scared. Clergy and secular counselors are often trained to see only the goal of saving the marriage. Financial institutes do not want to get involved in family issues.


Preparing Health Care Professionals To Screen for Domestic Violence 

Less than 10% of primary care physicians screen for domestic violence on a routine basis during regular office visits. In emergency rooms, less than 3% of female patients disclosed or were screened for domestic violence by a nurse or physician, yet an estimated 17% to 27% of the injuries that bring women to the emergency room were caused by their partner. Using protocols to identify and treat those in the population that is at increased risk of domestic violence and any others who meet certain criteria increases the identification rate to 30%. The National Institute of Justice and the Centers for Disease Control indicated that women make almost 700,000 health care visits due to injuries resulting from physical assault and that most of these are inflicted by intimate partners. All women and men who present with injure and implausible explanations should be evaluated with abuse in mind.

Injuries are not the only symptom of domestic violence. Many chronic health care problems, such as alcoholism and other substance abuse issues, depression, and other mental health problems are also caused by this type of violence.

According to The Family Violence Prevention Fund, all females over the age of 14 should be asked questions concerning the topic of domestic violence. Their publication has a set of clinical guidelines for routine screening for domestic violence in health care settings. They recommend these guidelines be utilized in all primary care, urgent care, obstetrics/gynecology, family planning, mental health, and residential settings. Screening should be a part of all initial intake forms, including prenatal visits. The number one most prevalent time in a woman’s life to be battered is during pregnancy.

The following is a checklist that could be utilized as a tool for health care providers:

Does your partner:

___Put you down, embarrass or make fun of you in front of others?

___Make fun of your goals or discourage you?

___ Intimidate or attempt to control you?

___ Tell you that you are nothing without them?

___Attempt to make all of the decisions?

___Treat you rough-grab, push, pinch, shove or hit you?

___Make you feel bad about yourself?

___Call you several times a night or show up to make sure you are where you said you would be?

___Blame you for how they feel or act?

___Blame alcohol or other drugs for how they act?

___Pressure you sexually?

___Are you ever afraid of them?

___Are you afraid they will hurt themselves or someone else if you leave the relationship?

___Do you find yourself attempting not to make them angry at all costs?

To ensure the effectiveness of the screening, health care providers should be educated about the dynamics of domestic violence, the safety, and autonomy of abused patients, and the cultural aspects of this type of violence. These screeners should be trained in asking about abuse and in intervening with abuse victims. This screening should be conducted in a private setting and under the best of circumstances should be done in person. A nonjudgmental approach is essential.

As a medical professional it is important for you to know how to build rapport and ask the appropriate questions.

Questions can be in the form of general framing questions such as:

  • Violence against women is becoming such a prevalent problem in our society that I have begun to include it in all of my assessments. Can you tell me about your experiences?
  • I’m concerned about how your injuries were caused.  Are you comfortable telling me how they occurred?

Questions can be direct such as:

  • Does your partner threaten you, attempt to control you, push or hit you?
  • Are you or have you ever been concerned for your safety?

If, as a medical professional, you are concerned for a patient who is not currently admitting to abuse or is not ready to leave the relationship you can refer them to counseling and or give them telephone numbers to shelters and protective agencies. Sometimes discussing the safety of children and pets motivates them to get the help they need.


Battering In Special Populations

Teen relationships follow the same pattern and have the same undercurrent, as do the relationships of adults. Young individuals are often struggling with self-esteem, gender roles, sexual activities they are comfortable with and those they are not. Even in the best of relationships, this is a time when individuals do not have assurance in who they are and what they want or need. Self-esteem can often easily be manipulated, isolation from family is often already occurring as the teen develops independence. Many times when a boyfriend displays extreme possessiveness it is taken as he must really love and care about me.

The elderly represent a population that often does not have a voice to defend themselves with. Special consideration should be given to screening for abuse in this population.

Understanding cultural issues are paramount in investigating domestic violence. Understanding how and why domestic violence occurs is impossible without taking into account the varying religious and cultural beliefs and practices. In many countries, society is permissive of violence. Popular songs, movies, even the nightly news and literature all normalize violence as a common, almost every day experience.

The patriarchal structure of the family is traditional in many countries with the husband’s authority unquestioned. Often in many cultures, there is a major emphasis on compliance and not speaking out. Laws in many cultures are designed to protect the male, head of the household’s right to make decisions about the family. A female who stands up to her husband or protests a beating causes the family, and herself, shame and embarrassment.

A few fundamental religions and cults promote keeping women and children in line with advice from the pulpit to beat unruly wives and children.

Because America is a melting pot of cultures it is necessary to keep these statistics and cultural aspects in mind. It is important to recognize that these situations are, by families of these cultures standards, not considered wrong. If you question a female from that culture if someone has done something out of line the answer will be no. They will often not report violence, as they do not see it as a reportable concern.

To intervene successfully in all these cultures, it will be necessary to change both men’s and women’s socialization patterns and establish a new definition of authority.


Impact Of Domestic Violence 

Every American suffers from the effects of domestic violence. Although women are who you predominately think of when discussing domestic violence, men are also frequent victims. Conservative estimates are that between 3.3 and 4.3 million children every year witness domestic violence, with devastating results. Pets are also frequently abused as part of the pattern.

An estimated three to five billion dollars every year are lost due to this problem. Lost wages, lower productivity, sick day usage, medical expenses, and legal expenses combine to drain the national economy.

When discussing domestic violence the issue of homelessness is brought to the surface. Statistic figures indicate that domestic violence is a factor in approximately 50% of homeless women and children. For women alone, estimates range from 17 to 24%.


Legal and Social Resources 

There are many options to give those in need. As a health care provider, it is essential you are prepared with the resources and suggestions.

If a person is not prepared to immediately leave an abusive relationship, it is critical that they develop safety plans. While in a violent relationship, a victim needs to be prepared to leave if physically threatened. If it is safe to do so, they should be prepared to call for help, by phone or by yelling. If a confrontation is occurring, advice is given to stay close to an exit, avoid being in the bathroom, kitchen, or near any weapons. The potential target of violence should consider in advance what the safe ways to quickly exit the house are. They need to determine which doors, windows, stairways, etc. are quickest and safest to use, and where they will be when they have exited. In some cases, it is a good idea to get spare keys to their vehicles made and placed in an accessible place. Keys are often taken from them in an argument.

Belongings are not a factor in the face of violence. Getting to a safe place is far more important. In the event of ongoing abuse, if safe, advice can be given to keep a bag of clothing and essentials at the residence of a friend. Neighbors need to be identified who are aware of the violence, and they should be encouraged to call the police if they hear a disturbance. The development of a code to be used with children, friends, and a neighbor when help is needed is advised.

If a person is already preparing to leave a violent relationship, additional elements of a safety plan can be considered. A separate savings account with a safe address is sometimes recommended when safe. Money, spare keys, important documents, and extra clothing can be left with a friend so that leaving can occur quickly. Arrangements for where a victim will stay can be made in advance. Arrangements for pets in danger can also be made. A calling card and the number of the closest emergency shelter should be kept on hand at all times. The most dangerous period of time is when someone is leaving a violent relationship.

Upon leaving a dangerous relationship, additional locks, different routes to and from work, sometimes informing employers is necessary, and an unlisted phone number should be obtained. A safety plan for the children when the parent is not with them needs to be developed. Daycare centers and schools need to be clearly informed about who can and cannot pick up the children. If the person has obtained a restraining order, they should keep a copy on their person at all times. All threatening phone messages should be documented, tapes of threats should be retained, and all instances of violating a protective order should be reported.

There are many domestic violence programs that can offer assistance and help in obtaining a civil protection order and for a referral to a lawyer who can be helpful in pursuing criminal prosecution. Laws vary widely in different cities, counties, and states. In most jurisdictions, judges can issue protective orders, order abusers to leave home, award temporary custody and order temporary child support. Unfortunately, a court order offers little protection against a determined abuser.

In the past, police have traditionally regarded domestic violence as a family dispute in which they did not get involved beyond stopping the immediate incident. The system is changing and frequently both parties are arrested and left to the court system to untangle. In many areas, the arrest of the alleged batterer is mandatory. Even if victims withdraw charges due to fear or emotional confusion, the perpetrator of the violence will still be prosecuted. Victims are not able to drop charges.

Many communities generally offer some sort of shelter and services for battered women and their children. The addresses and telephone numbers of shelters are kept as secret as possible. Under most circumstances, the police have these numbers and can make a referral.

Most court systems recommend domestic violence counseling. Individual therapy for victims generally focuses on assisting them to look at and correct distorted thinking and to deal with the terror of long-term abuse, anger, and anxiety that they experience. Many victims love their abusers. This is a time of confusion and loneliness. Building rapport, establishing a support system for the survivor, helping them to recognize and correct the distorted belief systems are critical components of treatment. Many will fall into similar types of relationships without personal growth. Violence, feelings of guilt, the inability to make decisions for them are normal, what is strange and different is a healthy relationship. Helping them explore their history of relationship patterns can enable them to seek out positive relationships the next time. Individuals need to deal with any family of origin issues and any reasons they stayed in an abusive relationship so that they do not repeat the same decisions in future relationships.

Group therapy can be very effective in this issue. This therapeutic mode of treatment allows individuals to build a support network and hear the stories of others in similar situations. As they offer support to others, as well, they become more confident in their abilities. They begin to recognize that they were not responsible for their partners’ behavior. Well, if she wasn’t pretty enough, together enough, a good enough mother, a good enough cook; then no one could be for him Group therapy is also helpful to show the effects of domestic violence on children.

As a professional, it is important for you to have your resources handy. Each local area has hotline numbers and resources specific to that location.

The following are national resource numbers:

  • National Domestic Violence Hotline: 1-800-799-SAFE
  • National Resource Center on Domestic Violence: 1-800-537-2238
  • Battered Women’s Justice Project: 1-800-903-0111
  • Resource Center on Domestic Violence/Child Protection and Custody: 800-527-3223
  • Health Resource Center on Domestic Violence: 1-888-792-2873
  • Family Violence Prevention Fund: 415-252-8089



When someone is affected by mental illness or addiction, it can affect the entire family. When that person enters treatment, the family’s pain and confusion don’t just go away. How does any family member move past the damage that has occurred?  Family therapy is one answer. It works together with individual therapy for the benefit of all family members.

Family therapy is based on the idea that a family is a system of different parts. This means that when one member of a family is affected by a behavioral health disorder such as mental illness or addiction, everyone is affected. As a result, family dynamics can change in unhealthy ways.  Lies and secrets can build up in the family. Some family members may take on too much responsibility, other family members may act out, and some may just shut down.  Sometimes conditions at home are already unhappy before a family member’s mental illness or addiction emerges. That person’s changing behaviors can throw the family into even greater turmoil. 

Often a family remains stuck in unhealthy patterns even after the family member with the behavioral health disorder moves into recovery.  Even in the best circumstances, families can find it hard to adjust to the person in their midst who is recovering, who is behaving differently than before, and who needs support.  Family therapy can help the family as a whole recover and heal. It can help all members of the family make specific, positive changes as the person in recovery changes. These changes can help all family members heal from the trauma of mental illness or addiction.

“Family” means a group of two or more people with close and enduring emotional ties. Using this definition, each person in treatment for a behavioral health disorder has a unique set of family members.  Therapists don’t decide who should be in family therapy. Instead, they ask,  “Who is most important to you?” Sometimes members of a family live together, but sometimes they live apart. Either way, if they are considered family by the person in treatment, they can be included in family therapy.
 parents
 spouses or partners
 in-laws
 siblings
 children
 elected, chosen, or honorary family members
 other relatives
 stepparents
 stepchildren
 foster parents
 foster children
 godparents
 godchildren
 blended family members
 extended family members
 friends
 fellow veterans
 colleagues who care
 mentors
 mutual-help group members
 sponsors

Family therapy is typically introduced after the individual in treatment for mental illness or addiction has made progress in recovery. This could be a few months after treatment starts, or a year or later.  Timing is important because people new to recovery have a lot to do. They are working to remain stable in their new patterns of behavior and ways of thinking. They are just beginning to face the many changes they must make to stay mentally healthy or to remain sober.  They are learning such things as how to deal with urges to fall into old patterns, how to resist triggers and cravings, how to adhere to medication regimens, and how to avoid temptations to rationalize and make excuses. For them to explore family issues at the same time can be too much. It can potentially contribute to relapse into mental illness or substance using behaviors.  Family therapy tends to be most helpful once the person in treatment is fully committed to the recovery process and is ready to make more changes. The person’s counselor can advise on the best time to start
family therapy.


There are two main goals in family therapy. One goal is to help everyone give the right kind of support to the family member in behavioral health treatment so that recovery sticks and relapse are avoided. The other goal is to strengthen the whole family’s emotional health so that everyone can thrive.  Specific objectives for family therapy are unique to each family, and these objectives may change over time. The family decides for itself what to focus on, and when.

Sometimes family members are unwilling to join family therapy. There are many possible reasons for this:

Fear. They may prefer to have the family unit stay as it is, even if that is painful, rather than take chances with the unknown.

Fatigue. They may be tired of dealing with the issues.

Concerns about power. They may feel that they have an advantage the way things are—or that they don’t, but family therapy won’t fix it.

Distrust. They may be unwilling to risk speaking frankly with other family members or in front of a therapist.

Skepticism. They may not be convinced that family therapy will be useful, or they may have tried it before
and not liked it.

It may help to have the family therapist talk one-on-one with unwilling family members. Together they can identify the reasons for resistance, figure out how to resolve concerns, and discuss the benefits of family therapy.

Sometimes what’s needed is simply time. Willing members of the family can choose to get started. Unwilling members can join when they are ready.



Research shows that group therapy is as effective as individual therapy for many conditions. 

Group therapy has its own techniques, its own processes, and its own strategies. But without training facilitators don’t know how to intervene when problems arise among members of the group, and they may not have adequate supervision to fully understand what they are supposed to do to lead an effective group.  Learning how to handle conflict and how to address it in groups, as well as how to foster group cohesion, identify and repair ruptures, and deal with diversity in groups are all necessary skills to develop. 

Not every client is an appropriate candidate for every group. That’s why it’s important for the facilitator to conduct a high-quality screening and preparation interview with each potential group member before the group begins. Using tools such as the 19-item Group Readiness Questionnaire (GRQ), which is designed to identify risk factors for potential dropout or poor outcomes can help inform the facilitator’s clinical judgment so they can decide whether they need to spend more time preparing members or redirecting them to a treatment where they are more likely to be successful. If their assessment and individual interview suggest they may not be a good fit for the current group, perhaps their needs would be better served in individual therapy, or in a different group setting.

It’s also important to educate your referral sources about inclusion or exclusion criteria for group therapy.

During the initial individual intake, ask clients what they expect group therapy to look like and how quickly they expect change to occur, to ensure their hopes are in line with reality. 

It’s also important to prepare members for possible challenges this type of therapy can present.  For example, patients who avoid conflict or disengage when relationships become difficult need to know that group discussions can become difficult. “Discuss how they might react if they experience a desire to flee and help them commit to attending a minimum number of sessions.

Some groups more naturally lend themselves to being cohesive from the get-go.  In grief groups, for example, you don’t have to work as hard to get people to feel connected once they start talking about why they’re there. However, groups without an easily identifiable common bond—those geared toward cognitive-behavior therapy, for example—might take a bit more work to help members feel connected. One strategy group leaders can use is to break the group into smaller groups and have them take time during the first session to get to know each other. Icebreakers that encourage members to delve deeper or have fun together can also promote group bonding when appropriate.

Disagreements are almost inevitable in group therapy, but it’s important that group leaders spot and work through concerns as soon as they arise among members. Sometimes ruptures in group cohesion are obvious and confrontational, such as when a group member comments that they don’t understand how something being discussed is relevant, or if they challenge the intervention. Other times, ruptures can be more passive, with a member who begins to come late, doesn’t show for sessions, stops making eye contact or doesn’t contribute to discussions.  You can also look for nonverbal cues, such as eye-rolling, fidgeting or just looking frustrated when other people in the group are talking.

To address these issues, the facilitator can gently bring it up directly with the member or with the entire group by asking if others are feeling frustrated as well.  Giving clients the sense that they are an active part of the therapeutic process is one of the best ways to address discord.

Four Important Notes For Running An Effective Therapy Group:

A Strict Policy of Non-Violence

It is important to avoid overly assertive or controlling behavior in a group therapy session, but there are other important factors that must absolutely be kept out of the setting. One of these is violent, threatening, or otherwise intimidating behavior. Many people, particularly those with social or self-esteem issues, will shut down when confronted with antagonizing behavior, rendering the group useless.  This kind of behavior needs to be avoided tactfully, if possible, but if necessary, it must be very calmly and directly shut down.

Respect a Participant’s Privacy

No personal, private information is owed to the group. People who are participating in a group therapy session should never be required to divulge any particular piece of information, at any time. This sense of vulnerability and obligation is directly counter to what is needed to help resolve a wide range of common psychological challenges, which people with a wide range of disorders find themselves facing. It is up to a group leader to actively protect participants from this kind of infringement, not simply avoid requiring anything of them themselves.  At the same time, all members must understand in advance the inherent risks of privacy within a group setting.  

Encourage, but Don’t Force Participation

By choosing to attend group therapy sessions, a person has already taken the first step in trying to help themselves face their challenges head-on. More often than not, such an individual has already sought individual counseling elsewhere, meaning that they have in fact taken several steps along the path to a healthier lifestyle. Attendees should be encouraged to participate as gently as possible, but it’s just as critical that they are never forced to do so before they are ready.

Be Straightforward and Direct, but Unassertive

Anyone running a group therapy session should be open and straightforward about the group’s purpose: what it intends to do, for whom, and how, and what challenges they hope to help others in attendance overcome. At the same time, this shouldn’t come across in a way that makes those present at the session feel as though they are being singled out, or in any way targeted. One of the crucial aspects of group therapy is that the people who come together feel like they are part of a sympathetic social circle. If they instead feel as though they’re facing a united front of resistance or accusation, the group can be turned on its head, even becoming counterproductive.

INFECTIOUS DISEASES                                                                 


Hepatitis is an inflammation of the liver. The condition can be self-limiting or can progress to fibrosis (scarring), cirrhosis or liver cancer. Hepatitis viruses are the most common cause of hepatitis in the world but other infections, toxic substances (e.g. alcohol, certain drugs), and autoimmune diseases can also cause hepatitis.

There are 5 main hepatitis viruses, referred to as types A, B, C, D and E. These 5 types are of greatest concern because of the burden of illness and death they cause and the potential for outbreaks and epidemic spread. In particular, types B and C lead to chronic disease in hundreds of millions of people and, together, are the most common cause of liver cirrhosis and cancer.

Hepatitis A and E are typically caused by the ingestion of contaminated food or water. Hepatitis B, C, and D usually occur as a result of parenteral contact with infected body fluids. Common modes of transmission for these viruses include receipt of contaminated blood or blood products, invasive medical procedures using contaminated equipment and for hepatitis B transmission from mother to baby at birth, from family member to child, and also by sexual contact.

Acute infection may occur with limited or no symptoms or may include symptoms such as jaundice (yellowing of the skin and eyes), dark urine, extreme fatigue, nausea, vomiting, and abdominal pain.

Hepatitis A virus (HAV) is present in the feces of infected persons and is most often transmitted through the consumption of contaminated water or food. Certain sex practices can also spread HAV. Infections are in many cases mild, with most people making a full recovery and remaining immune from further HAV infections. However, HAV infections can also be severe and life-threatening. Most people in areas of the world with poor sanitation have been infected with this virus. Safe and effective vaccines are available to prevent HAV.

  • Hepatitis A is a viral liver disease that can cause mild to severe illness.
  • The hepatitis A virus (HAV) is transmitted through the ingestion of contaminated food and water or through direct contact with an infectious person.
  • Almost everyone recovers fully from hepatitis A with lifelong immunity. However, a very small proportion of people infected with hepatitis A could die from fulminant hepatitis.
  • WHO estimates that hepatitis A caused approximately 7 134 deaths in 2016 (accounting for 0.5% of the mortality due to viral hepatitis).
  • The risk of hepatitis A infection is associated with a lack of safe water, and poor sanitation and hygiene (such as dirty hands).
  • In countries where the risk of infection from food or water is low, there are outbreaks among men who have sex with men (MSM) and persons who inject drugs (PWIDs).
  • Epidemics can be prolonged and cause substantial economic loss.
  • A safe and effective vaccine is available to prevent hepatitis A.
  • Safe water supply, food safety, improved sanitation, hand washing, and the hepatitis A vaccine are the most effective ways to combat the disease. Persons at high risk, such as travelers to countries with high levels of infection, MSM and PWIDs can get vaccinated.

Hepatitis B virus (HBV) is transmitted through exposure to infective blood, semen, and other body fluids. HBV can be transmitted from infected mothers to infants at the time of birth or from family members to infants in early childhood. Transmission may also occur through transfusions of HBV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. HBV also poses a risk to healthcare workers who sustain accidental needle stick injuries while caring for infected-HBV patients. Safe and effective vaccines are available to prevent HBV.

  • Hepatitis B is a viral infection that attacks the liver and can cause both acute and chronic diseases.
  • The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids.
  • WHO estimates that in 2015, 257 million people were living with chronic hepatitis B infection (defined as hepatitis B surface antigen-positive).
  • In 2015, hepatitis B resulted in an estimated 887 000 deaths, mostly from cirrhosis and hepatocellular carcinoma (i.e., primary liver cancer).
  • As of 2016, 27 million people (10.5% of all people estimated to be living with hepatitis B) were aware of their infection, while 4.5 million (16.7%) of the people diagnosed were on treatment.
  • Hepatitis B can be prevented by vaccines that are safe, available and effective.

Hepatitis C virus (HCV) is mostly transmitted through exposure to infective blood. This may happen through transfusions of HCV-contaminated blood and blood products, contaminated injections during medical procedures, and through injection drug use. Sexual transmission is also possible but is much less common. There is no vaccine for HCV.

  • Hepatitis C is a liver disease caused by the hepatitis C virus (HCV): the virus can cause both acute and chronic hepatitis, ranging in severity from a mild illness lasting a few weeks to a serious, lifelong illness.
  • Hepatitis C is a major cause of liver cancer.
  • The hepatitis C virus is a bloodborne virus: the most common modes of infection are through exposure to small quantities of blood. This may happen through injection drug use, unsafe injection practices, unsafe health care, transfusion of unscreened blood and blood products, and sexual practices that lead to exposure to blood.
  • Globally, an estimated 71 million people have chronic hepatitis C virus infection.
  • A significant number of those who are chronically infected will develop cirrhosis or liver cancer.
  • WHO estimated that in 2016, approximately 399 000 people died from hepatitis C, mostly from cirrhosis and hepatocellular carcinoma (primary liver cancer).
  • Antiviral medicines can cure more than 95% of persons with hepatitis C infection, thereby reducing the risk of death from cirrhosis and liver cancer, but access to diagnosis and treatment is low.
  • There is currently no effective vaccine against hepatitis C; however, research in this area is ongoing.

Hepatitis D virus (HDV) infections occur only in those who are infected with HBV. The dual infection of HDV and HBV can result in more serious disease and worse outcome. Hepatitis B vaccines provide protection from HDV infection.

  • Hepatitis D virus (HDV) is a virus that requires hepatitis B virus (HBV) for its replication. HDV infection occurs only simultaneously or as super-infection with HBV.
  • The virus is most commonly transmitted from mother to child during birth and delivery, as well as through contact with blood or other body fluids.
  • Vertical transmission from mother to child is rare.
  • At least 5% of people with chronic HBV infection are co-infected with HDV, resulting in a total of 15 – 20 million persons infected with HDV worldwide. However, this is a broad global estimation since many countries do not report the prevalence of HDV.
  • Worldwide, the overall number of HDV infection has decreased since the 1980s. This trend is mainly due to a successful global HBV vaccination program.
  • HDV-HBV co-infection is considered the most severe form of chronic viral hepatitis due to more rapid progression towards liver-related death and hepatocellular carcinoma.
  • Currently, treatment success rates are generally low.
  • Hepatitis D infection can be prevented by hepatitis B immunization.

Hepatitis E virus (HEV) is mostly transmitted through the consumption of contaminated water or food. HEV is a common cause of hepatitis outbreaks in developing parts of the world and is increasingly recognized as an important cause of disease in developed countries. Safe and effective vaccines to prevent HEV infection have been developed but are not widely available.

  • Hepatitis E is a liver disease caused by infection with a virus known as hepatitis E virus (HEV).
  • Every year, there are an estimated 20 million HEV infections worldwide, leading to an estimated 3.3 million symptomatic cases of hepatitis E.
  • WHO estimates that hepatitis E caused approximately 44 000 deaths in 2015 (accounting for 3.3% of the mortality due to viral hepatitis).
  • The virus is transmitted via the fecal-oral route, principally via contaminated water.
  • Hepatitis E is found worldwide, but the disease is most common in East and South Asia.
  • A vaccine to prevent hepatitis E virus infection has been developed and is licensed in China, but is not yet available elsewhere.


Tuberculosis (TB) is a potentially serious infectious disease that mainly affects the lungs. The bacteria that cause tuberculosis are spread from one person to another through tiny droplets released into the air via coughs and sneezes.

Once rare in developed countries, tuberculosis infections began increasing in 1985, partly because of the emergence of HIV, the virus that causes AIDS. HIV weakens a person’s immune system so it can’t fight the TB germs. In the United States, because of stronger control programs, tuberculosis began to decrease again in 1993 but remains a concern.

Many strains of tuberculosis resist the drugs most used to treat the disease. People with active tuberculosis must take several types of medications for many months to eradicate the infection and prevent the development of antibiotic resistance.

Although the body may harbor the bacteria that cause tuberculosis (TB), the immune system usually can prevent an individual from becoming sick. For this reason, doctors make a distinction between:

  • Latent TB. In this condition, there is a TB infection, but the bacteria remain in the body in an inactive state and cause no symptoms. Latent TB, also called inactive TB or TB infection, isn’t contagious. It can turn into active TB, so treatment is important for the person with latent TB and to help control the spread of TB. An estimated 2 billion people have latent TB.
  • Active TB. This condition makes someone sick and in most cases can spread to others. It can occur in the first few weeks after infection with the TB bacteria, or it might occur years later.

Signs and symptoms of active TB include:

  • Coughing that lasts three or more weeks
  • Coughing up blood
  • Chest pain, or pain with breathing or coughing
  • Unintentional weight loss
  • Fatigue
  • Fever
  • Night sweats
  • Chills
  • Loss of appetite

Tuberculosis can also affect other parts of the body, including the kidneys, spine or brain. When TB occurs outside of the lungs, signs and symptoms vary according to the organs involved. For example, tuberculosis of the spine may present with back pain, and tuberculosis in the kidneys might cause blood in the urine.

Tuberculosis is caused by bacteria that spread from person to person through microscopic droplets released into the air. This can happen when someone with the untreated, active form of tuberculosis coughs, speaks, sneezes, spits, laughs or sings.

Although tuberculosis is contagious, it’s not easy to catch. Someone much more likely to get tuberculosis from someone they live with or work with than from a stranger. Most people with active TB who’ve had appropriate drug treatment for at least two weeks are no longer contagious.

Human Immunodeficiency Virus (HIV)

HIV stands for human immunodeficiency virus. It weakens a person’s immune system by destroying important cells that fight disease and infection. No effective cure exists for HIV. But with proper medical care, HIV can be controlled. 

HIV is a virus spread through certain body fluids that attacks the body’s immune system, specifically the CD4 cells, often called T cells. Over time, HIV can destroy so many of these cells that the body can’t fight off infections and disease. These special cells help the immune system fight off infections. Untreated, HIV reduces the number of CD4 cells (T cells) in the body. This damage to the immune system makes it harder and harder for the body to fight off infections and some other diseases. Opportunistic infections or cancers take advantage of a very weak immune system and signal that the person has AIDS. 

When people get HIV and don’t receive treatment, they will typically progress through three stages of the disease. Medicine to treat HIV, known as antiretroviral therapy (ART), helps people at all stages of the disease if taken as prescribed. Treatment can slow or prevent progression from one stage to the next. Also, people with HIV who take HIV medicine as prescribed and get and keep an undetectable viral load have effectively no risk of transmitting HIV to an HIV-negative partner through sex.

Stage 1: Acute HIV infection

Within 2 to 4 weeks after infection with HIV, people may experience a flu-like illness, which may last for a few weeks. This is the body’s natural response to infection. When people have acute HIV infection, they have a large amount of virus in their blood and are very contagious. But people with acute infection are often unaware that they’re infected because they may not feel sick right away or at all.

Stage 2: Clinical latency (HIV inactivity or dormancy)

This period is sometimes called asymptomatic HIV infection or chronic HIV infection. During this phase, HIV is still active but reproduces at very low levels. People may not have any symptoms or get sick during this time. For people who aren’t taking medicine to treat HIV, this period can last a decade or longer, but some may progress through this phase faster. People who are taking medicine to treat HIV (ART) as prescribed may be in this stage for several decades. It’s important to remember that people can still transmit HIV to others during this phase. 

Stage 3: Acquired immunodeficiency syndrome (AIDS)

AIDS is the most severe phase of HIV infection. People with AIDS have such badly damaged immune systems that they get an increasing number of severe illnesses, called opportunistic illnesses.

Without treatment, people with AIDS typically survive for about 3 years. Common symptoms of AIDS include chills, fever, sweats, swollen lymph glands, weakness, and weight loss. People are diagnosed with AIDS when their CD4 cell count drops below 200 cells/mm or if they develop certain opportunistic illnesses. People with AIDS can have a high viral load and be very infectious.

Only certain body fluids—blood, semen, pre-seminal fluid, rectal fluids, vaginal fluids, and breast milk—from a person who has HIV can transmit HIV. These fluids must come in contact with a mucous membrane or damaged tissue or be directly injected into the bloodstream (from a needle or syringe) for transmission to occur. Mucous membranes are found inside the rectum, vagina, penis, and mouth.

 In the United States, HIV is spread mainly by

  • Having anal or vaginal sex with someone who has HIV without using a condom or taking medicines to prevent or treat HIV.
  • Sharing needles or syringes, rinse water, or other equipment (works) used to prepare drugs for injection with someone who has HIV. HIV can live in a used needle up to 42 days depending on temperature and other factors.

Less commonly, HIV may be spread

In extremely rare cases, HIV has the possibility to be transmitted by

HIV does not survive long outside the human body (such as on surfaces), and it cannot reproduce outside a human host.



Life skills training can be an effective supplement to a comprehensive treatment program. Life skills encompass the concept of emotional healing that can be used to help a person in the recovery process. These skills aren’t just an important component of a mental health program or addiction treatment process; they also contribute to decreasing the addict’s chances of relapsing in the future. Any skill that is useful in life can be considered a life skill. The term ‘life skills’ is usually used for any of the skills needed to deal well and effectively with the challenges of life.

It should, therefore, be clear that everyone will potentially have a different list of the skills they consider most essential in life and those that they consider unnecessary. Someone living in a remote rural community might put driving a car high on their list of essential skills. A Londoner or New Yorker, however, would probably rank that pretty low.

There is no definitive list of life skills.  Certain skills may be more or less relevant depending on life circumstances, culture, beliefs, age, geographic location, etc. However the World Health Organization identified six key areas of life skills:

  • Communication and interpersonal skills. This broadly describes the skills needed to get on and work with other people, and particularly to transfer and receive messages either in writing or verbally.

  • Decision-making and problem-solving. This describes the skills required to understand problems, find solutions to them, alone or with others, and then take action to address them.

  • Creative thinking and critical thinking. This describes the ability to think in different and unusual ways about problems, and find new solutions, or generate new ideas, coupled with the ability to assess information carefully and understand its relevance.

  • Self-awareness and empathy, which are two key parts of emotional intelligence. They describe understanding yourself and being able to feel for other people as if their experiences were happening to you.

  • Assertiveness and equanimity, or self-control. These describe the skills needed to stand up for yourself and other people and remain calm even in the face of considerable provocation.

  • Resilience and ability to cope with problems, which describes the ability to recover from setbacks, and treat them as opportunities to learn, or simply experiences.

When working with those who are managing a mental health issue and or in recovery from alcohol and drug abuse life skills are an important area.  To the above, we might also need to address other areas including:

  • Self-care and hygiene
  • Stress management
  • Prioritizing
  • Organization skills
  • Anger management
  • Personal development
  • Medication management
  • Financial planning
  • Leadership skills
  • Concentration and focusing
  • Social skills
  • Time management
  • Conflict resolution

Adopting Healthy Habits —Proper nutrition and hygiene are essential skills for life that can improve an individual’s physical and mental health. Since addicts tend to make their substances their first priority in life, they neglect their healthy habits, resulting in the need for rebuilding healthy minds and bodies. Life skills training should teach clients how to take proper care of their bodies, practice good hygiene, and becoming healthier people physically and mentally.

Developing Routines — Coming up with a daily routine for the morning, afternoon, evening, and bedtime can help clients fall into a cycle of healthy living. Support groups, counseling, exercise classes, and other parts of their comprehensive treatment program should be scheduled into their daily routines as well. Routines help clients maintain their healthy habits and get back to a better lifestyle.

Social Skills — Since clients usually begin to have relationship problems with their families and friends because of their addiction, life skills training can teach them many social skills that they’ll need to mend their broken relationships. Learning how to control emotions, practice effective communication, and understand others can help addicts enhance their social skills.

Becoming Financially Stable — Being responsible with finances, budgeting, and learning how to live within their means are usually not thought of when going through addiction as well as many mental health issues. It is important for clients to learn how to become financially stable and responsible for their money.

Organized Living Space — The spaces that we surround ourselves with can have a significant effect on how productive we are, how clear our minds are, and how responsible we are for our items. Learning how to clean, organize, and de-clutter our living spaces can significantly reduce stress.

Managing Medications — Learning how to manage one’s medications is a highly important life skill to learn. Becoming educated on how to appropriately manage medications can be beneficial for a person’s mental and physical health.


Moral Development

In the past, society viewed drug addiction as a moral flaw. The aim of “demoralizing” addiction retains a strong appeal for many addiction professionals.  They wish to stamp out entirely people’s continuing tendency to regard addiction as a reflection of the addict’s moral qualities and to hold people responsible for addictive behavior. At the same time, appetitive behavior of all types is crucially influenced by people’s pre-existing values, and that the best way to combat addiction both for the individual and the society is to instill values that are incompatible with addiction and with drug- and alcohol-induced misbehavior.  Even the most ardent supporters of the disease theory of alcoholism have agreed that cultural patterns are the major determinants of drinking behavior. Alcoholism has both a cultural and genetic source.

Morals represent what someone understands or has been taught about deciding what is good or bad, right or wrong.   Morals often translate to the standards of behavior a person wants to demonstrate—to him- or herself, as well as to others.  Our morals influence our priorities, our thinking, our choices, our decision-making, and our actions.  

Active addiction and the behaviors that coincide with addiction usually takes people away from their morals. In their quest to get what they want, be accepted by others, or just feel good or feel better, practicing addicts often go against their own values in ways that start out as subtle but become more blatant over time. 

  • Someone may value the moral character of honesty, but in order to continue to use alcohol and other drugs and avoid the consequences, they have to be dishonest with their family, partner, employer, etc.
  • Someone may value the moral character of responsibility, but the progression of active addiction renders them increasingly less capable of acting responsibly.

In recovery, what people consider important shifts. As a result, when people move from active addiction to recovery they always experience some changes in their morals and values. Longstanding values that people have ignored or let slide during their addiction again become a priority, while some newer values may also begin to assume importance. Recovery provides the opportunity to identify and establish new healthy priorities, and revive the personal qualities that have always been important to but were buried by alcohol and other drug use.

Helping clients identify what their moral compass is and how to use this as a standard for decision making and living a congruent life can be a very powerful tool in their recovery.



Toxicology is a scientific discipline, overlapping with biology, chemistry, pharmacology, and medicine, that involves the study of the adverse effects of chemical substances on living organisms and the practice of diagnosing and treating exposures to toxins and toxicants. The relationship between dose and its effects on the exposed organism is of high significance in toxicology. Factors that influence chemical toxicity include the dosage, duration of exposure (whether it is acute or chronic), route of exposure, species, age, sex, and environment. 

Toxicology testing in addiction medicine varies across the spectrum, yet remains a powerful tool in monitoring addictive patients. 

Initial (immunoassay) and confirmatory (gas chromatography-mass spectrometry [GC-MS] test) are the methods most commonly utilized to test for drugs.  Using a combination of both tests allows a high level of sensitivity and specificity, meaning there is an extremely low chance for false positives or false negatives.

Urine drug testing

A urinalysis will show the presence of a drug in the system after the drug effects have worn off; however, the length of time varies by drug. Urine screening may detect amphetamines or methamphetamines, barbiturates, benzodiazepines, cocaine, marijuana, MDA-analogues (MDA or MDMA), opiates (codeine, morphine, 6-acetylmorphine [indicative of heroin use], hydromorphone, hydrocodone, oxymorphone, oxycodone), nicotine, or alcohol.

Saliva drug testing

After urine drug screening, oral fluid (saliva) testing is the most common method to test for drug use. It may be referred to as a mouth swab test. Most saliva drug tests can detect usage within a few hours up to 2 days. 

Saliva is an easy lab test to gather samples, is less susceptible to adulteration or substitution, and can be tested for alcohol, barbiturates, benzodiazepines, cocaine, ecstasy, marijuana (THC), opiates, amphetamines, phencyclidine (PCP), and methamphetamines. It is suitable for all testing reasons, including pre-employment testing, random and post-accident testing.

Blood drug testing

A blood drug test may be used to determine amounts of drug in an individual’s system at that very moment, usually from minutes to hours. A variety of drugs can be tested for in blood: examples include alcohol, amphetamines, cocaine, fentanyl, marijuana, methamphetamines, opiates, phencyclidine, nicotine, and tramadol.

Blood testing is invasive, requiring a needle stick, but there is little chance for adulteration. Blood testing may be performed in the emergency room for toxicology testing, as well. However, blood analysis often has a short period of detection, as many illicit drugs are metabolized quickly and eliminated from the body. Drugs in urine can usually be detected in a one to three day time period. 

Hair drug testing

Hair testing may be used to determine drug use over the longer term, usually over a 90-day period of time. Hair can be tested for cocaine, marijuana and THC, cocaine, opiates, amphetamine and methamphetamine, ecstasy, phencyclidine, and alcohol. In general, hair testing allows the longest time frame to detect drugs of abuse.

These are the most common forms of tests.  There are others, as well.


Counseling Theories for Addiction

Addiction treatment centers use behavioral therapies more than any other therapeutic technique. Behavioral therapies help clients understand the causes of high-risk behavior and develop tools for avoiding or coping with high-risk situations.

Cognitive Behavioral Therapy

Cognitive behavioral therapy focuses on learning to reduce problematic behavior associated with substance abuse. A key theme in CBT is anticipating risky situations and applying coping strategies, such as avoidance or self-control, to prevent relapse.

CBT is one of the most popular therapies in addiction medicine, and counselors use it to treat a variety of addictions.

During CBT, patients learn to recognize and modify risky behavior by using a variety of skills. They learn the underlying causes of problematic behavior so they can fix the problems at their source. They’re able to recognize cravings or triggers and develop strategies for handling those situations. Research shows that patients who learn skills during CBT are able to apply them during real situations later in life.

Dialectical Behavior Therapy

Dialectical behavior therapy is effective for patients who struggle to regulate emotions and have thoughts of self-harm or suicide. The therapy emphasizes an acceptance of uncomfortable thoughts, feelings or behaviors to allow patients to overcome them.

DBT involves relaxation techniques, such as yoga, that help the patient become more aware of thoughts and emotions. They learn skills such as controlled breathing and muscle relaxation to tolerate self-destructive thoughts or urges. The goal is to decrease the frequency and severity of self-harming behavior and encourage healthy change.

Family Behavior Therapy

Family behavior therapy addresses problems that affect the entire family. The goal is to reduce risk factors for addiction, such as unemployment, family conflict, abuse and conduct issues. It uses techniques such as contingency management and behavioral contracting, in which a patient agrees to a written contract with a therapist.

Therapy sessions involve multiple family members, such as spouses or parents and their children. Therapists teach strategies and skills for improving communication and the living environment. Each patient sets behavioral goals that are reviewed during each session by other family members.