A Research Based Approach To The Treatment of Anger and Aggression

Cardwell C. Nuckols, PhD cnuckols@elitecorp1.com www.cnuckols.com

ROOT OF AGGRESSION

• The root of violence is the illusion of separation--from God, from Being itself, from being one with everyone and everything. When you don't know how to consciously live out of your union with Love, you resort to violence, fighting people who are not like you.

ROOT OF AGGRESSION • When you can become little enough, naked

enough, and honest enough, then you will ironically find that you are more than enough. At this place of poverty and freedom (humility) you have nothing to prove and nothing to protect. Here you can connect with everything and everyone. Everything belongs. This cuts violence at its very roots before there is even a basis for fear, anger, protection, vengeance, or self-promotion--the things that often cause violence.

SELF-IMAGE

• Violation of our image of ourselves (ego) leads to…….

• Defenses in the form of narcissistic character defects such as judgmentalism and anger fueled by…

• A fear of losing control

SELF-IMAGE • Heraclitus (5th Century BC)- “Know

Thyself” • People with faulty self-images tend to

have… – High levels of anxiety – High levels of defensiveness – High levels of self-doubt – High levels of narcissism

• IN OTHER WORDS…CHARACTER DEFECTS

REMOVING DEFECTS OF CHARACTER • THE EGO FUNCTIONS IN THE PAST AND

THE FUTURE AND IS FEAR BASED • CHARACTER DEFECTS CAN BE SEEN AS

SPIRITUAL DEFICITS • CHARACTER DEFECTS RESPOND BEST

TO SPIRITUAL METHODS SUCH AS… – THE STEPS OF AA – BEATITUDES – HINDUISM – BUDDHISM

ANGER AND FEAR

• NO OTHER PERSON CAN MAKE YOU FEEL ANYTHING- YOU DO IT TO YOURSELF

• THERE IS NO ANGER OR FEAR IN REALITY-IT ONLY RESIDES WITHIN YOU

• WHEN WE GET ANGRY AT ANOTHER IT IS BECAUSE THEY DIDN’T LIVE UP TO YOUR EXPECTATIONS

• FEAR OFTEN COMES FROM CONCERN ABOUT LOSING SOMETHING VALUABLE TO US

TREATMENT OF FEAR • MAY PRESENT AS ANXIETY OR ANGER Want energy but not feeling Disassemble

Physical symptoms Can you handle them?

Emotional symptoms Can you handle them?

Not experiencing fear just a bunch of symptoms

“Fear is not you, it is just a symptom

ANGER AND FEAR

• Letting go is a mechanism of the mind and causes a sense of relief and lightness – Example: I was with a friend and we were talking

about all of the problems we had to deal with on a work project. We both broke out in laughter. The problems still existed but they were no longer our problems (i.e. some deficit in us)

– Technique: Letting go consciously and frequently at will

• NO LONGER THE VICTIM

ANGER AND FEAR

• MECHANISM OF LETTING GO – Become aware of a feeling (sensation) without

labeling the sensation, venting, resisting, moralizing and judging

– Ignore all thoughts as they are just excuses and get us nowhere

– Let the sensation in and just stay with it – Let it run it’s course without trying to make it

different; just let the energy run out – If feeling returns or continues there is more to be

surrendered

ANGER AND FEAR • If stay with anger, hatred, resentments and

self-pity… – All have secondary gains (THE VICTIM) – It is our ego-mean, competitive, cheap,

mistrusting, vindictive, judgmental, guilty, ashamed, vain (little energy) and resentful

IS THIS WHO YOU WANT TO IDENTIFY WITH? IS THIS THE PART YOU WANT TO ENERGIZE? IS THIS HOW WE WANT TO SEE OURSELVES?

Violent Behavior Multi-determined

• Genetic Tendencies – Serotonin transporter gene 5-HTTLPR – MAO low activity allele

• Traumatic childhood experiences – Orbitofrontal Cortex – Reduction in serotonin levels – Disorganized Attachment

• Paranoid personality style – Organized or Disorganized

• Frontal cortex injury • Alcohol/Drugs-acute and chronic

Violent Behavior Multi-determined

• Girls and women are not necessarily less violent than boys and men – Female

• Indirect • Covert

– Men • Immediate outward physical aggression

• Various Psychiatric Disorders • Hormones-Testosterone

Anger, Aggression and Addiction • Alcohol

– Serotonin • Stimulants

– Fight or Flight – Increased Dopamine in Prefrontal Cortex

• Arylcyclohexylamines – PCP – Ketamine

Differential Diagnosis

• Neurological Dysfunction – ADHD – Autism – Dementia

• Brain Damage and Injury – Frontal lobe injury – Exposure to toxins – Maternal alcohol/ drug usage

Differential Diagnosis

• Personality traits and disorders – Antisocial traits or ASPD (Antisocial Personality

Disorder) – Paranoid traits or PPD (Paranoid Personality

Disorder) – Borderline traits or BPD (Borderline Personality

Disorder) • Neurotransmitters and hormones

– Serotonin • Many antiaggression meds work thru this

system – Testosterone

Differential Diagnosis

• Mental Illness – With paranoid symptoms

• Panic Disorder • Schizophrenia • Mania • Depressive Disorder • Drug Intoxication and withdrawal

– Mental Retardation – Oppositional Defiant Disorder – Conduct Disorder – Posttraumatic Stress Disorder

Differential Diagnosis

• Medical Diseases – Encephalitis – Alzheimer's Disease – Cerebrovascular Accident – Seizure disorders

Brief Assessment

• Information about past and current behavior – Client/Patient – Friends and family

• Review of past treatment – Successful – Unsuccessful

• Clinical evaluation over time – Medical – Psychosocial

RISK ASSESSMENT

• Documentation – Should be a separately labeled

narrative in the clinical notes – Should be based upon clinically

established risk and protective factors.

– Many of factors overlap with those of suicide so can be combined into a single assessment

RISK ASSESSMENT

• Documentation-Example of admission note “Patient delivered by police secondary to domestic dispute. Risk factors: history of domestic violence, owns several handguns, alcohol and cocaine intoxication, paranoid delusions regarding partner, threatening suicide in emergency room. Protective factors: currently detained in structured environment.”

RISK ASSESSMENT

• Documentation- Example of discharge note “Patient currently denies both suicidal and homicidal ideation, delusional symptoms resolved, intoxication and withdrawal managed, receiving appropriate medication, safety plan developed, agrees to follow-up chemical dependency and marital counseling, handguns removed from home. Claims he is hopeful about the future. Based on these factors, the patient no longer poses a high risk of violence.”

RISK ASSESSMENT

• Intuitive judgment based upon past experience and training

• Want to use both intuition and empirical knowledge

• Tools – Twenty Risk Factors for Violence (Simon and

Tardiff. Textbook of Violence Assessment and Management. Arlington, VA; American Psych. Press; 2008)

RISK ASSESSMENT

• Tools – Twenty Factors

• Non-dynamic – Male sex – Age between late teens and early twenties – Below-average IQ – Low socioeconomic status – Instability in housing and employment – HISTORY OF VIOLENCE – History of destruction of property – Mental Illness diagnosis – Personality Disorder (BPD or ASPD) – Substance Use Disorder

RISK ASSESSMENT

• Tools – Twenty Factors

• Dynamic – Intoxication – Acute Abstinence Syndrome – Positive psychotic symptoms in general – Command auditory hallucinations – Persecutory delusions – Paranoia – Physical agitation – Verbal aggression – Access to weapons – Anger

RISK ASSESSMENT • Tools

– Psychopathy Checklist-Revised (PCL-R) • Widely used to attempt to predict violent behavior • Interview may take up to 3 hours

– Psychopathy Checklist: Screening Version (PCL:SV)

• 12 item subset • Takes about 90 minutes • MacArthur violence risk assessment study found

stronger association with this tool than other variables evaluated (www.macarthur.virginia.edu/risk.html)

RISK ASSESSMENT • Tools

– Historical, Clinical, Risk Management-20 (HCR-20)

• 20 item instrument completed via interview, chart review, clinical presentation and collateral information

• Incorporates past actions, present conditions and future outlook

• Instrument of choice in many circles – Violence Risk Appraisal Guide (VRAG)

• 12 item actuarial tool to predict violence • Successfully predicts misconduct during

incarceration and recidivism (Harris, GT, et al. Law and Human Behavior. 2002; 26:377-395.)

RISK ASSESSMENT • Tools

– The Classification of Violent Risk (COVR) • Chart review and a 10 minute interview • Good in predicting risk for inpatients being

discharged into community • No special training required although might be cost

prohibitive to small practices (Monahan, J et al. Psychiatric Serv. 2005;56 (7):810-815)

– Psychopathy Checklist: Youth Version (PCL:YV)

• High scoring adolescents were 3 X more likely to commit a violent crime than those with low scores (Gretton, HM et al. J Consult Clin Psych. 2004;72:636-645.)

RISK ASSESSMENT • Past violence is most robust predictor of

future violence • Best source of historical data might be

from past treatment records and from collaborative sources such as caregivers and significant others

• Internet sources such as publically accessible court records, police blotters and social networking sites can often yield helpful and sometimes very surprising information.

POLICE BLOTTERS

POLICE BLOTTERS

RISK ASSESSMENT

• Research suggests narcissistic injury often involved in fueling strong anger and resentment (Knoll, JL. J Am Acad Psychiatry Law. 2010;38(1):87-94) (see Exhibit Two)

• HIPAA is no help when patient will not sign releases of information, especially when involuntary hold about to conclude

RISK ASSESSMENT

• Unlike children or adults, teenage boys show enhanced activity in the part of the brain that controls emotions when confronted with a threat. Magnetic resonance scanner readings in one study revealed that the level of activity in the limbic brain of adolescent males reacting to threat, even when they've been told not to respond to it, was strikingly different from that in adult men.

RISK ASSESSMENT

• Teenage boys were mostly immune to the threat of punishment but hypersensitive to the possibility of large gains from gambling. The results question the effectiveness of punishment as a deterrent for risky or deviant behavior in adolescent boys.

Florida State University. "Inside the teenage brain: New studies explain risky behavior." ScienceDaily. ScienceDaily, 27 August 2014. <www.sciencedaily.com/releases/2014/08/140827203544.htm>.

RISK ASSESSMENT

• Those with larger volume in a particular part of the parietal cortex were willing to take more risks than those with less volume in this part of the brain

• Researchers at Yale School of Medicine have found that the volume of the parietal cortex in the brain could predict where people fall on the risk-taking spectrum.

Yale University. "Brain structure could predict risky behavior." ScienceDaily. ScienceDaily, 9 September 2014. <www.sciencedaily.com/releases/2014/09/140909192132.htm>.

RISK ASSESSMENT

RISK ASSESSMENT

• People who behave more altruistically than others have more gray matter at the junction between the parietal and temporal lobe, thus showing for the first time that there is a connection between brain anatomy, brain activity and altruistic behavior.

RISK ASSESSMENT

• This area is linked to the ability to put oneself in someone else's shoes in order to understand their thoughts and feelings.

Yosuke Morishima, Daniel Schunk, Adrian Bruhin, Christian C. Ruff, Ernst Fehr.Linking Brain Structure and Activation in Temporoparietal Junction to Explain the Neurobiology of Human Altruism. Neuron, 12 July 2012 DOI:10.1016/j.neuron.2012.05.021

MANAGING RISK • Give yourself time to review your options • Consult a colleague • Develop a safety plan

– Developed with the patient to reduce violence risk and might include avoiding triggers, using mindfulness, how and whom to ask for help; include caregivers or significant others in the discussion

• Assess level of care – Increased intensity or increasing number of

outpatient contacts; telephone check-ins; for non-adherent patients outpatient commitment might be viable in some states

MANAGING RISK

• Reassess medications • Be informed about medication risks

– Some medications associated with increase in violent acts; utilize the website for the Institute for Safe Medication Practices (www.ismp.org); subscription required

– See Exhibit One • Refer when needed

– If patient requires treatment in areas where you are not well trained consider referral

MANAGING RISK

• Duties to warn and protect – Acute hospitalization temporarily removes the

threat with release predicated upon reduced threat

– Some states include threats to property and some require you to inform police, as well as, the potential victim

– If decide to warn might consider including the patient if believe it will minimize damage to relationship with the clinician and with person being warned

MANAGING RISK

• Guns – Understand what a gun means to the

individual (for example, a veteran who has been in combat)

– Document a firearm disposition plan – If will not relinquish guns they might

agree to place them with a friend or remove the ammunition

– Gun safes or trigger locks

MANAGING RISK

• Psychiatric Advanced Directive – In states where this is allowed, document

states what kinds of treatments they would prefer

– You can check each state’s law through the National Resource Center on Psychiatric Advance Directives at (www.nrc-pad.org)

– Can get sample forms from Bazelon Center (www.bazelon.org); the forms can be downloaded from (http://bit.ly/XQMRF5)

Case Study

29 yo male (Marcus) was physically abused by his father. When his father was drunk he would hit Marcus with a belt. At age 12 Marcus made a decision to never let anyone hurt him again. From that point on whenever he felt threatened by a male authority figure he would “get in their face”.

Case Study

27 yo female (Gina) would listen to her parents scream obscenities and hit each other. One day when she was 11 yo she decided that she would no longer put up with the situation. Every time her parents would fight and scream at each other, she would run away from home.

Learned Coping and Survival Skills • Fear or threat (real or perceived) of

being out of control leads to: – Withdrawal – Attack of others – Avoidance – Attack of self

• “Freeze, Flight or Fight”

Modulation Ratio

• IN ORDER TO USE THE COGNITIVE AND BEHAVIORAL RECOVERY STRAEGIES TAUGHT IN TREATMENT AND SELF-HELP WANT CLIENT TO HAVE:

INHIBITION EXCITATION

Clinical Example of Vertical Integration • Can be used with anger and many

Anxiety Disorders where lower brain overrides cortical areas

• “Checker System” – Amygdala – Basal Ganglia – Brain Stem

Clinical Example of Vertical Integration • “Checker System”

– Scans – Alerts – Motivates

• Helping the client have a different relationship with themselves – Psychoeducation – Promotes integration

Clinical Example of Vertical Integration

• Intervention – Personify the “Checker” – Observe what is going on

• Cortex • Discernment

– Teach meditation • Breathing

Clinical Example of Vertical Integration

– Promote Dialogue • Have Cortex communicate with subcortical

areas – “Thank you for trying to keep me safe” – “You are my friend” – “Here is the deal, we need to talk about

being safe” (contingent communication with self)

– Cortex and “Checker” as a team • Convince “Checker” that it does not have to be

hyperactive

INHIBITION OR EXCITATION

Pharmacotherapy

• Aggressive Episode – Oral

• Risperidone 2mg oral soln & Lorazepam 2mg • Benzodiazepines • Atypical Antipsychotics

– IM • Lorazepam 2mg

– Diazepam and chlordiazepoxide are absorbed slowly and erratically

– Pts abusing stimulants are more conducive to seizures and EPS

Pharmacotherapy

• Haloperidol 5mg & Lorazepam 2mg • IM Atypical Antipsychotics

– Olanzapine (Zyprexa) » Agitation associated with schizophrenia, bipolar

mania and dementia – Ziprasidone (Geodon)

» Agitation associated with schizophrenia and schizoaffective disorder

• FDA approved long-acting form of injected risperidone called Risperdal Consta

Pharmacotherapy

• History of Impulsivity – SSRIs – Lithium

• History of mood swings – Mood stabilizers

• Lithium • Tegretol • Depakote

Non-Pharmacological Management

• Don’t Personalize • Understand your personal reaction

to anger • Assess the environment for

potential danger • Know where the client is at all

times • Keep an appropriate distance

Non-Pharmacological Management • Validate the client • Shift from Emotional to Cognitive or

Behavioral Stance – What lead up to you feeling this way?

• Give the client a sense of being in control

• Clear the area of other clients or move client to safe place

Case Study

Larry was a 23 yo alcoholic and addict. His therapy group had a new therapist and before he even met the therapist he looked at him and said, “I’m going to break your_______ head.”

What would you do in this situation?

Dialogue between client and clinician • Larry: “I’m going to break

your___head.” • Therapist: “Whatever you do don’t stop

behaving the way you are now because you know and I know that it saved your life-didn’t it?

• Therapist: “I’d like to talk to that part of you that made a conscious decision to never let anyone hurt you again.”

Empirically Proven Approaches • Relaxation

– Reduce physiological and emotional arousal

• Cognitive – Reduce anger inducing information

processing – Increase problem-solving ability

• Behavioral – Teach adaptive behaviors

Why Change ?

• Responsibility and blame • Other condemnation • Self-righteousness • Cathartic expression • Short-term reinforcement

Therapeutic Relationship

THE ESSENCE OF A RELATIONSHIP OCCURS IN A MOMENT. THE DEPTH OF THE RELATIONSHIP TAKES TIME. WHY IS IT THAT ONE STAFF MEMBER CAN WALK INTO A ROOM AND THE CLIENTS IMMEDIATELY CALM DOWN WHILE ANOTHER STAFF MEMBER WALKS IN THE ROOM AND ALL HECK BREAKS LOOSE? THE ESTABLISHMENT OF THE RELATIONSHIP IS A PRELUDE TO CLINICAL EFFECTIVENESS.

Relaxation Therapy

• Start early • Techniques include:

–Control breathing –Voice tone and tempo –Progressive relaxation –Caution with mental imagery

Meditation Procedure

• Establish a routine – Times – Places

• Choose Technique – Repeat a prayer or special saying – Focus on a word or phrase

• “One” – Directed Breathing – Progressive Muscle Relaxation

Meditation Procedure

• Choose Technique (continued) – Warming of the hands – Warming of another part of body

• Chest • Feet

– Focus on a spot on the wall • As a part of the meditation close with

“What am I grateful for today?”

Smell the Flowers, Blow Out the Candle

MANAGING NEGATIVE FEELING STATES • TWO MINUTES OF SILENCE

– The auditory cortex has a separate network of neurons that fires when silence begins

– Two hours of silence per day prompted cell development in the hippocampus

– Silence helps newly generated cells to differentiate into neurons and integrate into the system

– Creates a state of “environmental enrichment” – Two minutes of silence allows the “default mode”-situated in

the prefrontal cortex- to activate

MANAGING NEGATIVE FEELING STATES • TWO MINUTES OF SILENCE (continued)

– The “default mode” gathers and evaluates information. Focused attention curtails this scanning activity

– It is observed most closely during the psychological task of reflecting on one’s personality and characteristics (self-reflection)

– It integrates external and internal information (Joseph Moran, Frontiers in Human Neuroscience, 2013)

Gross, DA. “This is Your Brain on Silence.” Brain in the News. September 2016, pgs. 5-6.

MANAGING NEGATIVE FEELING STATES • DANCE

– By yourself put on music that makes you feel like moving – Let your body lead – When you start to tire gradually slow down – Take two minutes in silence to appreciate the changes that have

occurred in your brain’s emotional system

• BREATHING FROM YOUR HEART (HEARTMATH) – Focus on the area of your chest that houses your heart – Breath in and out from the heart

MANAGING NEGATIVE FEELING STATES • BREATHING FROM YOUR HEART (HEARTMATH)

(continued) – The breathes should be a little deeper than usual

• 5-6 seconds on the in-breath and 5-6 seconds on the out-breath

– Appreciate the differences in your feeling state • APPRECIATION BREATHE

– 2-3 times per day – Bring into your mind something or someone you

appreciate

MANAGING NEGATIVE FEELING STATES • APPRECIATION BREATHE (continued)

– Might consider using a nice note or email from a friend that you carry with you

– Could be a prayer or Bible verse – Discern the changes you experience as you read or recall the

positive experience • BE OF SERVICE

– “I’VE LEARNED THAT PEOPLE WILL FORGET WHAT YOU SAID, PEOPLE WILL FORGET WHAT YOU DID, BUT PEOPLE WILL NOT FORGET HOW YOU MAKE THEM FEEL.” Maya Angelou

MANAGING NEGATIVE FEELING STATES • BE OF SERVICE (continued)

– Focus on you environment – Remember everything is God – Kindly act to be of service to people, places and things – Notice how you feelings change as you direct love

outward – The more you give of yourself the more we are filled

with Love (kenosis, theTrinity)

MANAGING NEGATIVE FEELING STATES

• LETTING GO – Letting go is a mechanism of the mind and causes a

sense of relief and lightness • Example: I was with a friend and we were talking

about all of the problems we had to deal with on a work project. We both broke out in laughter. The problems still existed but they were no longer our problems (i.e. some deficit in us)

– Technique: Letting go consciously and frequently at will

• NO LONGER THE VICTIM

MANAGING NEGATIVE FEELING STATES

• WELCOMING PRAYER – Become aware of a feeling (sensation) without labeling the

sensation, venting, resisting, moralizing and judging – Ignore all thoughts as they are just excuses and get us

nowhere – Let the sensation in and just stay with it – Let it run it’s course without trying to make it different;

just let the energy run out

MANAGING NEGATIVE FEELING STATES • WELCOMING PRAYER (continued)

– If stay with anger, hatred, resentments and self-pity…

– All have secondary gains (THE VICTIM) – It is our ego-mean, competitive, cheap,

mistrusting, vindictive, judgmental, guilty, ashamed, vain (little energy) and resentful

MANAGING NEGATIVE FEELING STATES • FORGIVENESS

– Giving up any thought of revenge or harm even when it might be justified

– Learning to make peace when you didn’t get something you want in life

– Other ways of dealing with life when you didn’t get something you wanted in life

Adapted from work of Dr. Fred Luskin

MANAGING NEGATIVE FEELING STATES • FORGIVENESS (continued)

– Forgiveness reduces anger, hurt, depression, and stress and leads to greater feelings of optimism, hope, compassion and self-confidence

– Forgiveness is not reconciliation. You do not have to rejoin the relationship. It is not the same as justice.

– We live in a world where people hold on to their grudges

– The brain has a negative bias – We are not taught how to forgive

MANAGING NEGATIVE FEELING STATES • FORGIVENESS (continued)

– When we do not forgive we give our power away – When people cannot forgive they become more

hopeless and feel less able to cope with life – When we discover there is some power within us that

can handle the situation – This empowers us emotionally and physically

FORGIVENESS

• FORGIVENESS (continued) – STEPS TO FORGIVENESS

1. Know exactly how you feel abut what happened and be able to articulate what about the situation is not OK. Then tell a trusted couple of people about your experience.

2. Make a commitment to yourself to do what you have to do to feel better. Forgiveness is for you and not for anyone else

MANAGING NEGATIVE FEELING STATES

3. Forgiveness does not necessarily mean reconciliation or condoning another's actions. What we want is peace. 4. Get the right perspective on what is happening. Recognize that your primary distress is coming from the hurt feelings, thoughts and physical upset you are suffering now, not what hurt or offended you in the past 5. At the moment you feel upset practice a simple stress management technique to soothe the fight or flight response 6.Give up expecting things from other people or your life that they do not choose to give you.

MANAGING NEGATIVE FEELING STATES 7. Put your energy into looking for other ways to get your positive goals met than through the experience that hurt you. Instead of replaying your hurt seek out new ways to get what you want. 8. Remember that a life well-lived is your best revenge. Look for the love, beauty and kindness surrounding you. Forgiveness is about personal power. 9. Amend your grievance story to remind

MANAGING NEGATIVE FEELING STATES • MEDITATION AND YOGA

– Review focused on three techniques: • Zen meditation, a Buddhist spiritual practice that involves the

practice of developing mindfulness by meditation, typically focusing on awareness of breathing patterns.

• Mindfulness-based stress reduction (MBSR), a secular method of using Buddhist mindfulness, combining meditation with elements of yoga and education about stress and coping strategies.

• Mindfulness-based cognitive therapy (MBCT), which combines MBSR with principles of cognitive therapy (for example, recognizing and disengaging from negative thoughts) to prevent relapse of depression.

MEDITATION AND YOGA • MBSR and MBCT have " broad-spectrum"

effects against depression and anxiety and can also decrease general psychological distress. Based on the evidence, MBCT can be "strongly recommended" as an addition to conventional treatments (adjunctive treatment) for unipolar depression. Both MBSR and MBCT were effective adjunctive treatments for anxiety.

Wolters Kluwer Health: Lippincott Williams & Wilkins (2012, July 11). Evidence supports health benefits of 'mindfulness-based practices'.ScienceDaily. Retrieved December 30, 2013, from http://www.sciencedaily.com

MANAGING NEGATIVE FEELING STATES

• An hour of meditation training can dramatically reduce both the experience of pain and pain-related brain activation

• About a 40 percent reduction in pain intensity and a 57 percent reduction in pain unpleasantness. Meditation produced a greater reduction in pain than even morphine or

MANAGING NEGATIVE FEELING STATES

• Meditation significantly reduced brain activity in the primary somatosensory cortex, an area that is crucially involved in creating the feeling of where and how intense a painful stimulus is

• Meditation increased brain activity in areas including the anterior cingulate cortex, anterior insula and the

MANAGING NEGATIVE FEELING STATES

• A single, 20-minute session of Hatha yoga significantly improved participants' speed and accuracy on tests of working memory and inhibitory control, two measures of brain function associated with the ability to maintain focus and take in, retain and use new information

• Yoga postures that included

MANAGING NEGATIVE FEELING STATES • Rehabilitation strategies coupling

meditation-like practices with drug and behavior therapies are more helpful than drug-plus-talk therapy alone when helping people overcome addiction

Yariv Z. Levy, Dino J. Levy, Andrew G. Barto, Jerrold S. Meyer. A Computational Hypothesis for Allostasis: Delineation of Substance Dependence, Conventional Therapies, and Alternative Treatments. Frontiers in Psychiatry, 2013;

MEDITATION AND YOGA

• Madhav Goyal, M.D., M.P.H., an assistant professor in the Division of General Internal Medicine at the Johns Hopkins University School of Medicine and leader of a study published online Jan. 6 in JAMA Internal Medicine. "But in our study, meditation appeared to provide as much relief from some anxiety and depression

MEDITATION AND YOGA • They found moderate evidence of

improvement in symptoms of anxiety, depression and pain after participants underwent what was typically an eight-week training program in mindfulness meditation. They discovered low evidence of improvement in stress and quality of life. There was not enough information to determine whether other areas could be improved by meditation. In the studies that followed participants for six months the

MINDFULNESS AND YOGA

• Mindfulness training, a meditation-based therapy, can improve attention skills in incarcerated youth, paving the way to greater self-control over emotions and actions. It is the first study to show that mindfulness training can be used in combination with cognitive behavioral therapy to protect

MINDFULNESS AND YOGALS

• 267 incarcerated males, ages 16 to 18, over a 4-month period. The researchers found that participation in an intervention that combined cognitive behavioral therapy with mindfulness training (or "CBT/MT"), called Power Source, had a protective effect on youths' attentional capacity.

• The CBT/MT approach responds

MINDFULNESS AND YOGA

• These experiences impair cognitive control processes, such as attention regulation, which is vital for the self-regulation of feelings and actions. The antisocial behavior prevalent among youthful offenders is the result of an ongoing interplay between this psychosocial adversity and deficits in cognitive

MANAGING NEGATIVE FEELING STATES

• BUDDHIST MEDITATION – What does neuroimaging enable scientists to

understand regarding the three major forms of Buddhist meditation?

– The three forms: • FOCUSED ATTENTION • MINDFULNESS • COMPASSION AND LOVING KINDNESS

Richard, et. al. “Mind of the Meditator.” Scientific American. November 2014, pgs.38-45.

MANAGING NEGATIVE FEELING STATES • Open monitoring meditation as participants

to take note of every sight or sound and track internal body sensations and inner self-talk

• Stay aware of what is happening without becoming preoccupied with any single, thought, sensation, etc. (nonreactive awareness)

• As one’s surroundings grows, normal daily irritants become less disruptive and a sense

MANAGING NEGATIVE FEELING STATES • MINDFULNESS

– Compared with novices, expert meditators were able to diminish anxiety-related areas such as the insular cortex and the amygdala preceding a painful stimulus

– Meditation training increases one’s ability to better control and buffer basic physiological responses-inflammation or levels of cortisol-to socially stressful tasks like public speaking

MANAGING NEGATIVE FEELING STATES • COMPASSION AND LOVING KINDNESS

– Being aware of someone else’s needs and experiencing a sincere, compassionate desire to help that person or alleviate the suffering of others

– Ability to experience the others feelings along with a desire to help someone without concern for personal benefit

MANAGING NEGATIVE FEELING STATES

• COMPASSION AND LOVING KINDNESS – The meditator focuses on an unconditional feeling

of benevolence and love for others accompanied by a silent repetition of a phrase conveying intent

– Causes increase in secondary somatosensory and insular cortices known to be involved in empathic responses without becoming overwhelmed emotionally

MANAGING NEGATIVE FEELING STATES • COMPASSION AND LOVING KINDNESS

– Activity also in the temporoparietal junction, the superior temporal sulcus and medial prefrontal cortex all of which are activated when we put ourselves into another's place

– May be helpful in reducing compassion fatigue – Compassion and altruistic love are associated with

positive emotions and “burnout” is an empathy “fatigue”

MANAGING NEGATIVE FEELING STATES

• MINDFULNESS – When an individual experiences stress, activity in the

prefrontal cortex -- responsible for conscious thinking and planning -- decreases, while activity in the amygdala, hypothalamus and anterior cingulate cortex -- regions that quickly activate the body's stress response -- increases. Studies have suggested that mindfulness reverses these patterns during stress; it increases prefrontal activity, which can regulate and turn down the biological stress response.

Carnegie Mellon University. "How mindfulness training affects health." ScienceDaily. ScienceDaily, 12 February 2015. <www.sciencedaily.com/releases/2015/02/150212183511.htm>.

MANAGING NEGATIVE FEELING STATES

• OTHER APPROACHES – Grounding – Taking a walk in nature – Playing with dogs, cats and small children – Taking a shower – Writing in a journal – Listening to certain music such as classical,

improvisational jazz, Tibetan Incantations, Gregorian Chant, etc.

– Physical exercise

Case Study

Samantha was a 17 yo female who smoked marijuana because it helped her to “mellow-out”. In early recovery she was having problems with anxiety and anger. Her therapist taught her several strategies that involved tensing and relaxing muscles along with cognitive and behavioral techniques.

Labeling Our Feelings

• Verbalizing our feelings and labeling emotions makes them less intense.

• Photograph of an angry or fearful face causes increased activity in the amygdala – Creates a cascade of events resulting in

“fight or flight” response • Labeling the angry face changes the

brain response

Labeling Our Feelings

• Labeling the response caused the amygdala to be less active and the right ventrolateral prefrontal cortex to activate.

• Using mindfulness and labeling the feelings one experiences allows the prefrontal cortex to override the amygdala. – Matthew Lieberman, UCLA, Psychological

Science, May 2007

David Creswell, UCLA

• “We found the more mindful you are, the more activation you have in the right ventrolateral prefrontal cortex and the less activation you have in the amygdala. We also saw activation in widespread centers of the prefrontal cortex for people who are high in mindfulness. This suggests people who are more mindful bring all sorts of prefrontal resources to turn down the amygdala.”

Cognitive Therapy

SITUATION AUTOMATIC THOUGHT BEHAVIORS, EMOTIONS,PHYSIOLOGY

Cognitive Therapy • Our thoughts, behaviors and emotions are

related • Patients are often oblivious to these

connections – Example-Client felt despondent but did not

realize this emotion was triggered by a friend’s failure to greet him. When asked, “Try to remember what you were thinking when your mood changed to sadness” the patient responded, “I assumed my friend was ignoring me because she does not like me anymore.”

Cognitive Therapy

– Example- Sometimes people infer their mood from their behavior. A speaker giving a presentation on the lower deck of a cruise ship assumed because his legs were shaking he was nervous until he realized the floor was vibrating because it was close to the propeller shafts.

• Controlled experiments show people infer their feelings from their behavior or what they think is their behavior

Cognitive Therapy – Example- Men looked at nude pictures of

women in a Playboy magazine as they listened to what they thought was their heart rate. The men were then asked to rate their attraction to the nudes. Experimenters found men gave the highest ratings when they thought their hearts were beating faster or slower than normal although this feedback had nothing to do with their actual heart rates.

Valins, S. J Pers Soc Psychol. 1966;4:400-408.

Cognitive Therapy

• Correcting Thinking Errors (distorted thinking can affect mood) – Clients overgeneralize from a single

failure and assume they are failures – Sometimes they extend this distorted

thinking with catastrophizing where one negative incident mushrooms into an imagined chain of events ending in disaster.

Cognitive Therapy

• Other common distortions include… – Black-and-white thinking, also known as

polarized or all-or-nothing thinking is imagining that events will lead to one extreme or another. For example, if I am not a complete success then I am a complete failure.

– Focusing on the negative involves filtering out the positives from an experience.

– Mind reading involves guessing what others are thinking and feeling without sufficient evidence.

Cognitive Therapy-Dysfunctional Thought Record

SITUATION AUTOMATIC THOUGHT

EMOTION ALTERNATE RESPONSES

OUTCOME

SAMANTHA MET A NEW FRIEND WHO SAID HE WOULD CALL HER AND DID NOT

“HE REALLY DOESN’T LIKE ME” “WHY DO PEOPLE ALWAYS LIE TO ME”

ANGRY HURT

“MAYBE HE IS BUSY” “MAYBE HE WILL CALL IN THE NEXT TWO DAYS IF HE DOESN’T I WILL CALL HIM

HER FRIEND DIDN’T CALL SO SAMANTHA CALLED HIM,HE WAS GLAD TO HEAR FROM HERE AND THEY ARE GOING OUT ON SATURDAY

Cognitive Therapy-Reframes CT: “My mother is always angry at me.” TH: “Let’s see you are 15 yo and have

been around you mom for 5475 days. In all of these days she has always been angry at you?”

CT: “Well no-not everyday” TH: “Tell me about one of the days that

you really had fun together.”

Cognitive Therapy-Reframes CT: “I get so mad when my husband says,' Are

you going out to another meeting’?” TH: “You have been clean and sober for over

90 days now and you average 4 meetings a week…so that’s 48 meetings. So your husband has said this to you approximately 48 times.

CT: “Yes” TH: “Why does this still surprise you.”

Cognitive Therapy-Changing the Channel • Cultivate a New Channel • Can be anything you love

– A beautiful nature channel – A person you love and admire – An experience of love and beauty

• When experiencing a negative emotion turn the channel

Cognitive Therapy-Changing the Channel SENSATION STAY WITH SENSATION

WORDS CHANGE THE CHANNEL

EMOTIONS

Behavior Therapy

STIMULUS RESPONSE SETTING LIMITS

Behavior Therapy-Changing Response 57 yo male (Lyle) came to treatment with

his wife. She said, “My husband gets mad at other drivers, starts to curse and gives them obscene gestures. He is going to get us killed.” Lyle said, “I cannot help it. Those idiots on the highway really make me nuts.” His wife stated, “We drive a VW and last week the driver of a large truck chased us off of an exit ramp.”

Behavior Therapy-Changing Response CT: “When I talk to my sister on the

phone, she keeps telling me that I am not an alcoholic.” She says, "With will power you can control your drinking.”

TH: “How does that make you feel.” CT: “Angry and Frustrated. She just

cannot admit that alcoholism runs in our family.”

TH: “For right now, why don’t you email your sister instead of speaking with her on the phone.”

Behavioral Exposure

CT: “I am afraid to go home for Christmas because everyone will be drinking.”

PLAN: • Use group role play to provide imaginal

exposure • Incorporate relaxation and cognitive

techniques • Limit “in vivo” exposure • Create a safety plan

Safety Plan

• On a 3x5 index card – If things get too heavy at home during

Christmas I will: • Call my sponsor • Find a meeting to attend • Practice my relaxation technique • Use the cognitive strategies I have

learned in treatment • If I need to, I can always leave

Use Of Humor

CT: “My supervisor is a “flaming asshole” and every time I am around him I get angry.”

TH: “I’ve never seen a flaming asshole, can you draw me a picture of one?”

CT DRAWS A PICTURE TH: “Every time you see your supervisor

think of this picture.”

THANK YOU FOR ATTENDING CHILDREN WANT

TO DO WELL AND PLEASE. ADOLESCENTS BELIEVE THEY ARE AS BAD AS THEY HAVE BEEN TOLD.

EXHIBIT ONE: MEDICATIONS WITH VIOLENCE POTENTAIL • 10. Desvenlafaxine (Pristiq) An antidepressant which affects both

serotonin and noradrenaline, this drug is 7.9 times more likely to be associated with violence than other drugs.

• 9. Venlafaxine (Effexor) A drug related to Pristiq in the same class of antidepressants, both are also used to treat anxiety disorders. Effexor is 8.3 times more likely than other drugs to be related to violent behavior.

• 8. Fluvoxamine (Luvox) An antidepressant that affects serotonin (SSRI), Luvox is 8.4 times more likely than other medications to be linked with violence

• 7. Triazolam (Halcion) A benzodiazepine which can be addictive, used to treat insomnia. Halcion is 8.7 times more likely to be linked with violence than other drugs, according to the study.

• 6) Atomoxetine (Strattera) Used to treat attention-deficit hyperactivity disorder (ADHD), Strattera affects the neurotransmitter noradrenaline and is 9 times more likely to be linked with violence compared to the average medication.

EXHIBIT ONE: MEDICATIONS WITH VIOLENCE POTENTAIL • 5) Mefoquine (Lariam) A treatment for malaria, Lariam has long been linked with reports

of bizarre behavior. It is 9.5 times more likely to be linked with violence than other drugs. • 4) Amphetamines: (Various) Amphetamines are used to treat ADHD and affect the

brain’s dopamine and noradrenaline systems. They are 9.6 times more likely to be linked to violence, compared to other drugs.

• 3) Paroxetine (Paxil) An SSRI antidepressant, Paxil is also linked with more severe withdrawal symptoms and a greater risk of birth defects compared to other medications in that class. It is 10.3 times more likely to be linked with violence compared to other drugs.

• 2) Fluoxetine (Prozac) The first well-known SSRI antidepressant, Prozac is 10.9 times more likely to be linked with violence in comparison with other medications.

• 1) Varenicline (Chantix) The anti-smoking medication Chantix affects the nicotinic acetylcholine receptor, which helps reduce craving for smoking. Unfortunately, it’s 18 times more likely to be linked with violence compared to other drugs — by comparison, that number for Xyban is 3.9 and just 1.9 for nicotine replacement. Because Chantix is slightly superior in terms of quit rates in comparison to other drugs, it shouldn’t necessarily be ruled out as an option for those trying to quit, however.

• Read more: http://healthland.time.com/2011/01/07/top-ten-legal-drugs-linked-to-violence/#ixzz2QwiOzgip

EXHIBIT TWO: FAMILY ANNIHILATORS • Slaying of family by parent • Increased by over 50% in first decade

of 21st century • Typically perceived as a spree killing

or serial murders • Mostly male (59%) • Very few had criminal justice or mental

health history

EXHIBIT TWO: FAMILY ANNIHILATORS • By age: 55% in 30’s; 10%-20’s; oldest was 59 yo • Over one-half on weekends especially Sunday • 81% attempted suicide after the event • No recorded case of stand-off with the police • 71% employed often successful • Stabbing and CO most common methods • Causation-66% family breakup (including

access to kids) and financial difficulties

EXHIBIT TWO: FAMILY ANNIHILATORS • FOUR TYPES: masculinity and

perception of power set the background with family role of the father being central to masculinity; may be last ditch attempt to perform masculine role – SELF-RIGHTEOUS

• Blames mother as responsible for family breakup

• Sees their bread winner status as key to their image of an ideal family

EXHIBIT TWO: FAMILY ANNIHILATORS

– DISSAPOINTED • Believes his family let him down or undermined his

vision of ideal family • Example-children not following the traditional

religious and cultural customs of father – ANOMIC

• Family has become firmly linked to the economy • See family as a result of his economic success

allowing him to display his achievements • If father becomes a failure the family no longer

serves the function

EXHIBIT TWO: FAMILY ANNIHILATORS

– PARANOID • Perceive an external threat to family (often

social service or legal system)which father fears will side against him and take away children

• Twisted desire to protect family

• Yardley E., Wilson D., Lynes A. “A Taxonomy of British Family Annihilators”, 1980-2013. The Howard Journal of Criminal justice, 2013.

Bibliography

• Perry, Bruce. Violence and Trauma: Understanding and Responding to the Effects of Violence on Young Children. Gund Foundation Publishers, Cleveland, pp 67-80, 1996.

• Clinical Management of Agitation. http://www.medscape.com/viewprogram/2311_pnt.

Bibliography

• Aggression. http://emedicine.com/med/topic3005.htm

• Pincus, J and Tucker, G. Behavioral Neurology Fourth Edition.Oxford University Press, New York,2003.

• Glover,Janikowski and Benshoff.”The Incidence of Incest Histories Among Clients Receiving Substance Abuse Treatment”.Journal of Counseling and Development.March/April 1995.

Bibliography

• Van der kolk, van der Hart, and Burbridge. “Approaches to the Treatment of PTSD”. Trauma Clinic, Harvard Medical School.

• Perry, Bruce.”Neurodevelopmental Factors In The ‘Cycle Of Violence’”.Child, Youth and Violence:The Search For Solutions (j osofsky, Ed.) Guilford Press, New York, pp124-148, 1997.

• Pincus, Jonathan. “Base Instincts”. W.W.Norton, New York, 2001.

• Kent, Sullivan and Rauch. “The Neurobiology of Fear”. Psychiatric Annals.Volume 310, No 12, 2000.

• Thimble. “Psychopathology of Frontal Lobe Syndromes”.Seminars In Neurology. Vol10, No3, 1990.