Coping Skills Therapy for Managing Chronic and Terminal Illness


I recently had an opportunity to read this excellent book written by Social Worker Kenneth Sharoff. It presents a model of therapy he calls “Cognitive Coping Theory” (CCT) and applies this model to working with individuals who have chronic (or life limiting) and terminal illnesses.

Below I present some of the content from the book I found particularly useful.

Executive, Policy and Operational Beliefs

The first concept in the book, after the discussion of how CCT fits in with CBT and other therapies and models is the idea of policy, executive and operational beliefs. Policy beliefs are the most high-level, and roughly match what is called schema in other therapies. Examples of executive beliefs given in the book include:

  • My body should not interfere with my ability to pursue my career
  • Doctors must find a cure for my disease. Doctors and modern medicine should be able to cure me

Executive beliefs are often “shoulds” or “musts” that frame an individual’s approach to a situation. They dictate rights and beliefs about what an individual will experience – even when those things are out of that individual’s control. These policy beliefs are then carried out by executive beliefs, which explore how the policy belief is carried out.

One example is someone who wishes to join the Police Service even though they have found themselves paralyzed after an accident. They may hold policy beliefs like “I should be able to do whatever I set my mind to” and “My body should not interfere with my ability to pursue my career”, the resulting executive beliefs might look like:

  • Get angry at those around me who do not recognize my struggle
  • Continue trying to join the Service even though I am not able to
  • Vent my jealousy at individuals who are not limited in this way

The policy beliefs influence the Belief part of the Cognitive Behavioural Therapy ABC scale, while the executive beliefs influence the Consequences part:

  • Activating Event – I am not able to pursue my chosen career
  • Belief – I am inferior if I can’t pursue my dreams
  • Consequences – I feel worthless, angry, jealous, etc.

The last type of beliefs are known as operational beliefs. These are the most concrete thoughts that an individual has related to their illness. Examples include:

  • I am worthless
  • My life is awful
  • It’s not fair that I am experiencing this

These might be compared to the unconscious thoughts typical of CBT. Changing the executive beliefs, which dictate coping strategies, or responses is a key part of CCT.

Phases of Coping with Disease or Disability

Sharoff dictates five phases of coping with disease or disability. They are:

  • Crisis
  • Postcrisis
  • Alienation
  • Consolidation
  • Synthesis

Like most models, this is presented linearly but an individual may move back and forth among the phases as they proceed through their illness or disease.

Crisis Phase

In the crisis phase, the individual is first experiencing symptoms. They may be experiencing feelings of threat or loss, and experiencing a loss of self-esteem, self-efficacy, and increases in physical discomfort or other direct impact by the illness.

Sharoff describes “dream crush” – the feelings experienced by someone who has discovered that their plan for themselves is no longer possible because of their illness. He identifies “self-placement” as a significant component of this. Self-placement is the task of comparing yourself to where you want to be in life at a particular point in time; realizing that you are not “living up” to this ideal causes significant distress.

Changes in identity are also common in the crisis stage.

Postcrisis Phase

In the postcrisis phase, an individual has become accustomed to their situation. They begin to stabilize in that things become routine. As they resume as much of their previous roles as possible, the feelings of “anomie” end. The postcrisis state may lead to alienation if they have not are still experiencing negative emotions as a result of their illness’s effect on the body.

Alienation Phase

The alienation phase involves a psychological disconnection from the body. An individual struggling with a chronic disability or disease may actually disscoiate themselves from their body and see it as distant or distinct from themselves. This provides short-term coping but will not allow the individual to progress past this state.

Hostility or indifference towards their body is common, as individuals seek to separate themselves from their disease. The major tasks of this phase are to neutralize bitterness and to work on beliefs of disfiguration. If individuals believe they are disfigured, the negative beliefs that lead tot his will need to be worked on in order to avoid a loss of self-esteem or feelings of inferiority.

Consolidation Phase

The consolidation phase may be entered into directly after the postcrisis phase if the individual is coping adequately, or may require significant work in the alienation phase if they are not. An individual in the consolidation phase feels more in control of their life, and may experience increased self-efficacy.

Although an individual may experience a loss of meaning, they can develop new goals and behaviours that work within the limitations of their body. If they are able to do this successfully they will begin to move to the Synthesis Phase.

Synthesis Phase

The final phase of coping is the Synthesis Phase. This phase is marked by a blending of the old and the new, and a recognition that although an individual is changed by their illness they can still find a quality of life and activities that bring them happiness.

Skills Training

Sharoff suggests a variety of coping skills and strategies for each phase that an individual that will pass through. For instance, for individuals who have magical thinking or wish that they could control things like what activities they can perform now that they are limited by their disability, focusing on “area thinking” is one strategy to work on this. In area thinking, an individual considers each goal and whether that is within their control. If it is not, it is consciously replaced by a different goal that is within their ability to control.

What is below is just a few of the many skills, subskills and microskills contained in each category. They are accompanied by detailed explanations and demonstrations of the skills and other tools to make them as useful as possible in therapy.

Assimilation and Rejection of Suffering

Assimilation of suffering means to cope with suffering and to accept that some degree of discomfort, pain or suffering is a necessary part of the process of coping. It is expressed by complaining and expressions of powerlessness, with an undercurrent of magical thinking that if one rejects or denies their reality or the future that it will go away.

This involves acceptance of the reality (without enjoyment of it), forbearance (accepting showing “patience, tolerance, and restraint” with themselves demonstrating endurance as a personal goal), and forgiveness of one’s body, self, their deity or others they may blame for the illness.

Other coping skills that may be used include guided imagery, therapeutic metaphors (such as David versus Goliath) deep breathing, self-encouragement and substituting automatic thoughts when they occur. Outcome enactment is borrowed from solution-focused therapy and asks clients to identify when they do not suffer, and then to note what thoughts or feelings underlie that lack of suffering.

Discomfort and Frustration Management

Sensory diversion training is used to cope with physical discomfort. It involves choosing a sense like sight, smell, or touch and mindfully focusing on an item involving that sense. For instance, if someone who is experiencing pain focuses on an object they can see, and follows it with their eye, tracing it and creating a mental map. Then, moving to the next object, continuing this process until they are no longer aware of their negative physical symptom.

“No Mind No Thing” is a technique borrowed from Buddhism to deal with frustration or other negative experiences by attempting to clear the mind of conscious thought. This is a meditative technique that involves staying in the present and taking in all sensory input. Use of a white noise machine may be helpful in this regard.

Self-instruction training involves using positive self-talk by examining the positive aspects of thinking well and maintaining mantras. Managing activities can help an individual avoid frustration but running up against the wall created by their illness.

Identity Management

An individual’s identity can be challenged by the onset of their illness. Identity is measured by one’s belief in their membership in a group, such as men, military veterans or construction workers. For instance, a woman who believes that in order to be a woman she must have breasts will experience distress when she loses a breast to a mastectomy as a part of breast cancer treatment.

Identity adulteration describes the process by which an individual’s identity has changed as a result of their condition. Identity alienation is indifference towards the individual’s changed body, while identity loss is the recognition that an individual has (rightly or wrongfully) lost their membership in a chosen group.

Reconciling identity involves realizing that we often adopt restrictive definitions of what it requires for membership in a category. Continuing the example of the woman missing her breast, reconstructive surgery may allow her to feel like she belongs to the group again, or seeing other elements of womanhood like nurturing behaviour.

This is especially important for men who often put high standards on themselves, believing a very narrow definition of manhood. Expanding that definition to include stability, being a provider, being confident and assertive, and other “soft skills” may help reduce the distress an individual feels when they cannot participate in their former vocation, if they are physically not as imposing as they were, or are experiencing other symptoms as a result of their illness.

Self-Support Training

Self-support training involves the reduction of self-criticism and building a strong internal support network so that individuals do not have to rely on others who may be inconsistent in their ability to provide support. Self-support training involves focusing on strengths (known as becoming a self-booster), holding self-compassion, self-advocacy and exoneration training.

Exoneration training is a skill that may be used when someone holds themselves responsible for their shortcomings. For instance, someone who cannot pursue a hobby of running because of their multiple sclerosis may blame themselves for that outcome – even though they have no control over it.

Sharoff recommends instead, staging a “mock trial” in an individual’s mind. Stack all the evidence for the belief, against all of the evidence against. Play prosecutor and defense, in order to stimulate a protective instinct in the client. If they steadfastly hold to their belief that they are responsible, he recommends taking it further and having them determine guilt or innocence, and even prescribe punishment! The reason for this seems paradoxical, but punishing themselves for their own maladaptive beliefs helps them to realize the futility of their thought processes and may enable them to begin moving towards a less blameful attitude.

Uncertainty Tolerance

Uncertainty is at the heart of chronic illness, disability and disease. Although an individual’s disease course may stabilize, in many cases there is an uncertainty about the future. Self-monitoring is suggested in order for clients to recognize when they are feeling uncertain.

Deep breathing and other relaxations exercises can be used to cope with high levels of anxiety, along with “worry management” where an individual decides to limit their thoughts about their illness to a certain time per day (such as 15 minutes in the morning and 15 minutes at night.) This management gives them permission to push those thoughts out of their mind at other points in time, and apply thought-stopping when necessary.

Bitterness Disposal Training

Bitterness is an extremely common part of coping with a chronic illness or disease. Bitterness can be experienced inwardly (such as bitterness with your illness or your body) and outwardly (such as challenges with friends or family.) Examining one’s identity as perceived by others is an element of this process, followed by comparing that image of others to one’s self-image in order to determine if others are making unrealistic demands on them.

Recognizing that the disease is the cause of their feelings may help them externalize those thoughts. Cognitive restructuring allows an individual to compare their thoughts and expectations about those around them with the reality, by examining the other person’s identity (the husband or wife, the brother or friend) and how that affects their behaviour.

Constructive mourning allows an individual to grieve the changes in their life, by allowing that person to ventilate those emotions.

Body Accommodation and Disfigurement Neutralization

Body accommodation is the process of recognizing that one’s body has changed and setting softer standards to accept the body as it is rather than rating it or comparing it with a previous body or someone else’s body. This can be a difficult process as it involves realistic expectations and changing negative attitudes.

Positive self-talk before engaging in activities can help mitigate automatic thoughts of weakness or worthlessness that may occur as a result of the disability.

Disfigurement neutralization involves evaluating the client’s beliefs about themselves, and the words that they use. Assigning meaning to those words as a severe negative evaluation, that can be changed. New beliefs about an individual should be proposed, that see the body objectively, the result of the illness and not the individual’s decisions.


Meaning-making is the process of making a new plan for one’s life after the onset of an illness. This can be because depression or physical/emotional limitations have caused an individual to be unable to pursue their dreams or because the onset of a terminal illness makes them feel like their existing plans are no longer powerful enough to satisfy their desire for meaning in their life.

This process involves deciding on new goals, starting from the very small (like waking up at a specified time or engaging in basic hygiene) to larger goals, like exploring new options. Instilling hope will help the client stay curious and continue to move towards their new goals.

This may also involve helping clients learn to be “alone” with themselves to stimulate creativity, and allow clients to explore new options.

Limitation Management

Finally, limitation management involves activities to help clients cope with their “new self.” Limitations caused by illness can create a feeling of helplessness and a lack of control that can cause depression, anger or other sensations. This involves skills previously discussed like deep breathing and relaxation, forbearance, and acceptance of things that one cannot change.

Focusing on elements that are within an individuals’control may help move individuals closer to the things that bring them happiness.  Self talk can also be helpful in this regard.

Cite this article as: MacDonald, D.K., (2017), "Coping Skills Therapy for Managing Chronic and Terminal Illness," retrieved on May 27, 2019 from
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Financial Social Work


Financial social work is an under-valued component of a counsellor or social worker’s activities, however with the average debt level in the US (including mortgages) above $130,000 and credit card debt above $16,000 (El Issa, 2016), financial issues are a significant component of many individual’s negative emotional health.

Money problems are a leading cause of divorce (Dew, Britt, & Huston, 2012), anxiety (Archuleta, Dale & Spann, 2013) and suicide (Coope, et. al., 2015; Hempstead, et. al., 2015). Poor financial skills can cause even an individual with a high income to experience stress, much less low-income individuals who may find themselves accessing counselling or community social work services.

What is Financial Social Work?

Financial social work or financial counselling is the process of working with clients to “provide practical, sustainable skills for controlling and managing finances…and create real behavioral change in your clients.” (Center for Financial Social Work, n.d.) This is a comprehensive process of assessing an individual’s financial situation and building lifeskills of budgeting, responsible use of credit and debt management.

Financial social work is often performed by non-profit credit counsellors, Marriage and Family Therapists (MFT) and may be performed by social workers in other capacities, such as those who work as case managers with individuals on a low-income or struggling with substance abuse issues.

Assessing Financial Anxiety

Archuleta, Dale & Spann (2013) discuss the Financial Anxiety Scale (FAS), a tool that can be used to assess the impact of financial counselling or financial social work’s on an individual well-being. As they proceed through their treatment, their anxiety reduces.

Financial Anxiety Scale (FAS)

Each item on the FAS can be rated either yes/no (with a cut-off score of 4 or higher) or on a Likert scale for clinical purposes.

  1. I feel anxious about my financial situation.
  2. I have difficulty sleeping because of my financial situation.
  3. I have difficulty concentrating on my school/or work because of my financial situation.
  4. I am irritable because of my financial situation.
  5. I have difficulty controlling worrying about my financial situation.
  6. My muscles feel tense because of worries about my financial situation.
  7. I feel fatigued because I worry about my financial situation.

Money Personalities

Money personalities (Mellan, 1995) describe an individual’s approach to working with money, and what makes an individual happiest or unhappiest as they work with money. Brief descriptions of the money personalities are below:

  • Amasser – an individual who prefers to have large amounts of money but may also struggle with significant anxiety as they try to do this
  • Avoider – an individual who avoids working with money because of the negative emotions involved, because of feelings of inadequacy or overwhelm
  • Hoarder – an individual who likes to save money. In extreme cases a hoarder may literally hoard money in their house or other areas instead of investing them
  • Money Monk – an individual who is afraid of money, considers it unclean or dirty, and tries to avoid having a relationship with it at all
  • Spender – an individual who likes to spend money and gets immediate satisfaction from spending

Financial Social Work Qualifications

In order to practice financial social work or credit counseling it is important to receive training in this area. Rappleyea, et. al. (2014) discuss a curriculum for financial social work training that was designed for Marriage and Family Therapist (MFT) students. Some of the many topics suggested in this paper that are valuable to learn include:

  • Money personalities (described above)
  • How to track expenses
  • How to live within your means
  • How to spend money in a way that leads to happiness rather than guilt or unhappiness
  • How to understand emotions created by money

Financial Social Work Certification

The Center for Financial Social Work provides the Certification in Financial Social Work. It provides 20 CE credits, workbooks and curriculum on financial planning, credit, debt, savings and spending plans and investing. The whole package costs $595. There is also information available from the Center on how to develop financial support groups to help individuals make better choices.

Financial Social Work Jobs

Financial social work job titles include Case Manager, Credit Counsellor, Financial Counselor, and Marriage and Family Therapist (MFT). All of these job roles may involve elements of financial counselling or financial social work either as a primary or secondary function of the role.

Financial Self-Care

It’s important that social workers recognize that financial health is a part of their own development and self-care. If you are worried about money, it’s difficult to be fully present for your clients. Developing a budget, reducing and eliminating debt, and investing are valuable skills for both your clients and yourself.

Taking care of these things will help reduce your burnout and make you a more effective social worker.


Archuleta, K. L., Dale, A., & Spann, S. M. (2013). College Students and Financial Distress: Exploring Debt, Financial Satisfaction, and Financial Anxiety. Journal Of Financial Counseling And Planning, 24(2), 50-62.

Center for Financial Social Work. (n.d.) “Become Certified in Financial Social Work”. Retrieved on March 8, 2017 from

Coope, C., Donovan, J., Wilson, C., Barnes, M., Metcalfe, C., Hollingworth, W., & Gunnell, D. (2015). Research report: Characteristics of people dying by suicide after job loss, financial difficulties and other economic stressors during a period of recession (2010–2011): A review of coroners׳ records. Journal Of Affective Disorders, 18398-105. doi:10.1016/j.jad.2015.04.045

Dew, J., Britt, S., & Huston, S. (2012). Examining the Relationship Between Financial Issues and Divorce. Family Relations, 61(4), 615-628. doi:10.1111/j.1741-3729.2012.00715.x

El Issa, E. (2016) 2016 American Household Credit Card Debt Study. NerdWallet. Retrieved on March 8, 2017 from

Mellan, O. (1995). Money Harmony: Resolving money conflicts in your life and relationships. New York, NY: Walker & Company.

Rappleyea, D. L., Jorgensen, B. L., Taylor, A. C., & Butler, J. L. (2014). Training Considerations for MFTs in Couple and Financial Counseling. American Journal Of Family Therapy, 42(4), 282-292. doi:10.1080/01926187.2013.847701

Hempstead, K. A., & Phillips, J. A. (2015). Research Article: Rising Suicide Among Adults Aged 40–64 Years. The Role of Job and Financial Circumstances. American Journal Of Preventive Medicine, 48491-500. doi:10.1016/j.amepre.2014.11.006

Cite this article as: MacDonald, D.K., (2017), "Financial Social Work," retrieved on May 27, 2019 from

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Using the Sex Offender Risk Appraisal Guide (SORAG)


Following up on my article about how to use the Violence Risk Appraisal Guide (VRAG), this article reviews how to use a tool that is bundled with that tool, the Sex Offender Risk Appraisal Guide (SORAG). Like the VRAG, this is an actuarial tool that can be used to predict the risk of re-offending among sex offenders.

Before reading about the SORAG, it is helpful to review the VRAG post as many of the elements that are covered in that post are required before proceeding to the SORAG items. It is recommended that any completion of the SORAG be preceded by a completion of the VRAG as this will save you a significant amount of time.

Completing the SORAG

Like the VRAG, the first step is to complete the Childhood & Adolescent Taxon Scale (CATS) worksheet and the list of Conduct Disorder Symptoms.

Cormier-Lang Criminal History Scores

In order to answer item 5 on the SORAG, Criminal History Score for Non-Violent Offenses Prior to the Index Offense, it’s necessary to complete the Cormier-Lang Criminal History worksheet also provided on the SORAG. This worksheet is completed by filling out the number of non-violent offenses and applying the weight to them noted on the sheet.

Sex Offender Risk Appraisal Guide (SORAG) Items

The SORAG itself has 14 items that are similar to those found on the VRAG.

  1. Lived with both biological parents to age 16 (except for death of parent)
  2. Elementary School Maladjustment
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense)
  5. Criminal history score for nonviolent offenses (from Cormier-Lang system)
  6. Criminal history score for violent offenses (from Cormier-Lang system)
  7. Number of previous convictions for sexual offenses (pertains to convictions known from all available documentation to be sexual offenses prior to the index offense)
  8. History of sex offenses only against girls under 14 (including index offenses; if offender was less than 5 years older than victim, always score +4)
  9. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release)
  10. Age at index
  11. 11. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  12. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  13. Phallometric test results
  14. 14. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
    14. b. CATS score (from the CATS worksheet)
    14. WEIGHT (Use the highest circled weight from 12 a. or 12 b.)

You’ll note that many of these items are available from the VRAG. The tool indicates where there are overlaps in order to save you time filling out the worksheets and tools.

Determining Risk Level of Sex Offenders

After completing the tool, you must take the total score of the SORAG and compare it to the below levels.

  • A score of -17 to +2 indicates an individual is at Low risk for re-offending
  • A score of +3 to +19 indicates an individual is at Medium risk for re-offending
  • A score of +20 to +34 indicates an individual is at High risk for re-offending

An individual who is on the border between these two levels should have that indicated. For instance, someone who scores at +1 or +2 should be noted as “Low-Medium Risk” to highlight that they are at the edge of the established risk level.

Recidivism Rates using the SORAG

Rather than grouping an individual into low, medium or high risk categories, it is often more illuminating to examine the recidivism rates. These come from Violent Offenders as well.

Probability of Recidivism
SORAG score 7 years 10 years
< − 9 0.07 0.09
−9 to -4 0.15 0.12
-3 to +2 0.23 0.39
+3 to +8 0.39 0.59
+9 to +14 0.45 0.59
+15 to +19 0.58 0.76
+20 to +24 0.58 0.80
+25 to +30 0.75 0.89
> +31 1.00 1.00


American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Cite this article as: MacDonald, D.K., (2017), "Using the Sex Offender Risk Appraisal Guide (SORAG)," retrieved on May 27, 2019 from
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Coping with Flashbacks and Dissociation


There are a variety of situations where a client or helpline caller may experience negative emotions and need to use coping strategies to help themselves cope. These can include flashbacks to abuse or trauma (such as in child sexual abuse or Post Traumatic Stress Disorder), dissociation, or simply intrusive thoughts or memories of a variety of painful experiences.

In these situations, there are a variety of techniques that can be taught to clients to help them stay grounded and cope. They are summarized below.

Physical Techniques for Coping with Flashbacks

Physical techniques focus on using your physical body or space to reduce your flashbacks or dissociation.

  • Plant your feet on the ground or grasp the arms of a chair
  • Repeat one’s name, age or location
  • Go to a safe space (e.g. home), a place where you feel calm and safe

Behavioural Techniques for Coping with Flashbacks

Behavioural techniques are actions that you can take when you feel stressed or overwhelmed. Ways of expressing yourself can give you a sense of control that will make it easier to cope.

  • Journal or writing
  • Verbalizing emotions
  • Calling a crisis line or mobile crisis team
  • Going to the hospital
  • Taking a walk

Cognitive Techniques for Coping with Flashbacks

Cognitive techniques are those things that involve your thoughts. These may be more challenging than the other techniques but with practice will become easier to use when you are feeling overwhelmed. Because these are hard to summarize they’ve been listed with more detail than the above techniques.

Identify Internal Cues

Internal cues are those things that prompt you to think that you are going to dissociate or experience flashbacks. Sometimes they come on randomly, but for other individuals there is a period of feeling flushed, having a racing heart, feeling anxious or restless, or other symptoms that precede the flashbacks or dissociation. When you recognize these occurring, using the other techniques on this list can help you cope.

Identify Associational Cues

Associational cues are those things that you associate with safety and security. These can be objects, sources of support like pets or other things that remind you that things will be okay. The association between the item and the positive thoughts it brings can help ground you.

Safe Space (Mind)

Going to a “safe space” mentally and remembering that what you are experiencing is temporary can be helpful. Guided imagery (described below) can help you find this safe space, which can also be a place in your own memory where you felt safe and protected.

Meditation and Guided Imagery

Meditation is a very common strategy for coping with flashbacks and dissociation. Meditation takes practice, but by using slow and steady breathing and trying to clear your thoughts when you are not in a state of dissociation or flashbacks, you will build this skill up to where you can implement it when you sense you are going to dissociate.

Guided imagery is similar, but rather than meditating or focusing on your own breathing, you focus on a guided story that will help keep you grounded.

Label Emotions

Labeling your emotions can be a very effective way of reducing immediate stress. This can be both to yourself (merely talking out loud), or to a support like a friend, a pet or a crisis line. Many people who experience trauma have difficulty labeling their emotions and this exercise (especially when practiced as part of comprehensive therapy) can help keep you grounded.

Cognitive Restructuring

Cognitive restructuring refers to techniques of identifying and challenging automatic or maladaptive thoughts. The simplest way to do this is with an ABC (Action, Behaviour, Cognition) worksheet. An ABC worksheet lists actions that made you feel bad, behaviours or results from that, and the cognitions that went along with that.

For instance,

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I felt bad
  • Cognition: I’m not attractive

This is an example of a common ABC scenario. The goal is to identify other possible cognitions so that you can “rewrite the script.” An example of a different script:

  • Action: A girl didn’t smile at me when I smiled at her
  • Behaviour: I realized she probably didn’t see me
  • Cognition: Nobody has judged my attractiveness yet

This process is best accomplished with a therapist, but can be done in a self-help format. The book Mind Over Mood utilizes many of these techniques.

General Self Care for Coping with Flashbacks

  • HALT – Hungry, Angry, Lonely, Tired. These are the 4 states that make it harder to regulate your emotions and increase your impulsiveness.
  • Eating Healthy
  • Exercising
  • Medical Evaluation

5-4-3-2-1 Coping with Flashbacks

This technique is a very popular technique for coping that focuses on what you identify as real and also serves as a form of meditation.

  1. In 5-4-3-2-1 coping, you begin by thinking about five things that you can see around you. Listing them off out loud can help you with this exercise. Study them and describe them to yourself. Performing deep breathing (a slow inhale over 5 seconds, holding for 5 seconds, and exhaling over 5 seconds) can help with this as well.
  2. Next, describe 4 things that you can feel, such as your heart beating, your feet on the floor or your back in your chair.
  3. Next, 3 things that you can hear, like a television in another room, traffic outside or birds singing.
  4. After that, 2 things that you can smell – or two smells that make you happy, like fresh baked cookies.
  5. Finally, end with one thing you can taste. Your saliva, gum, or food you ate recently? Some people also substitute “One thing you like about yourself” for this exercise as well.
Cite this article as: MacDonald, D.K., (2017), "Coping with Flashbacks and Dissociation," retrieved on May 27, 2019 from
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Using the Violence Risk Appraisal Guide (VRAG)


The Violence Risk Appraisal Guide (VRAG; Quinsey, Harris, Rice, & Cormier, 2006) is a tool that can be used to estimate statistically the risk of recidivism. It is comprised of 12 items that are associated with a risk of re-offending and is completed with all available information. You can download the full VRAG in PDF format. The Sexual Offender Risk Appraisal Guide (SORAG) is reviewed in another article.

The VRAG is an actuarial risk assessment, involving a mathematical technique applied to determines what factors were present in offenders who later went on to commit violent crimes. (Brown & Singh, 2014) This approach eliminates the bias found in unstructured judgement.

The VRAG has been examined in over 40 studies, and has been found effective even with individuals who have a lower IQ. (Camilleri & Quinsey, 2011)

Completing the VRAG

The first step to completing the VRAG is to complete the Childhood & Adolescent Taxon Scale. Below, where a request for information relates to an “index offense” that is the one that led to the individual entering the Criminal Justice system

Childhood & Adolescent Taxon Scale (CATS) Worksheet

This scale includes 8 items that are scored from 0 to 1, based on the coding guidelines provided. These items are:

  1. Elementary School Maladjustment
  2. Teenage Alcohol Problem
  3. Childhood Aggression Rating
  4. More Than 3 DSM Conduct Disorder Symptoms
  5. Ever suspended or expelled from school
  6. Arrested under the age of 16
  7. Lived with both biological parents to age 16 (except for death of parents)

Conduct Disorder Symptoms

Next, the assessor will complete the list of Conduct Disorder symptoms, circling those that occurred before age 16 except for items 13 and 15 which are before aged 16:

  • 1. Often bullied, threatened or intimidated others
  • 2. Often initiated physical fights
  • 3. Used a weapon that could cause serious physical harm to others (e.g., a bat, brick, broken bottle, knife, gun)
  • 4. Was physically cruel to people
  • 5. Was physically cruel to animals
  • 6. Stolen while confronting a victim (e.g., mugging, purse snatching, extortion, robbery)
  • 7. Forced someone into sexual activity
  • 8. Deliberately engaged in fire setting with the intention of causing serious damage
  • 9. Deliberately destroyed others’ property (other than by fire setting)
  • 10. Broken into someone else’s house, car, or building
  • 11. Often lied to obtain goods or favors or to avoid obligations (i.e., “cons” others)
  • 12. Stolen items of nontrivial value without confronting a victim (like shoplifting, theft, or forgery)
  • 13. Before [age] 13, stayed out late at night, despite parental prohibitions
  • 14. Ran away from home overnight (or longer) at least twice while living in parental or parental surrogate home (or once without returning for a lengthy period)
  • 15. Before [age] 13, was often truant from school

Cormier-Lang Criminal History Scores for Non-Violent Offenses

This scoring form allows you to answer item number 5 below, the Criminal History Score for Non-Violent Offenses Prior to the Index Offense. This score is developed by counting the number of non-violent offenses and applying a weight to them. For instance, bank robbery is counted x7 while Indecent Exposure is counted x2. So an individual who has two instances of Indecent Exposure and 1 instance of Bank Robbery would have (2×2 = 4) + (1×7 = 7) = 4+7 = 11.

Violence Risk Appraisal Guide (VRAG) Items

Next are the 12 VRAG items. The tool provides detailed coding instructions for each of these:

  1. Lived with both biological parents to age 16 (except for death of parent):
  2. Elementary School Maladjustment:
  3. History of alcohol problems
  4. Marital status (at the time of or prior to index offense):
  5. Criminal history score for nonviolent offenses prior to the index offense
  6. Failure on prior conditional release (includes parole or probation violation or revocation, failure to comply, bail violation, and any new arrest while on conditional release):
  7. Age at index offense
  8. Victim Injury (for index offense; the most serious is scored):
  9. Any female victim (for index offense)
  10. Meets DSM criteria for any personality disorder (must be made by appropriately licensed or certified professional)
  11. Meets DSM criteria for schizophrenia (must be made by appropriately licensed or certified professional)
  12. a. Psychopathy Checklist score (if available, otherwise use item 12.b. CATS score)
  13. (Technically 12b) bCATS score (from the CATS worksheet)

Scoring the VRAG

Determining Risk

Risk categories are provided in the VRAG manual. They are approximated here although more detail is available in the complete manual. For each score, if an individual is close to the next score you should list them as a combination of the two. For instance an individual whose score is -10, -9 or -8 would be listed as Low-Medium rather than just Low.

  • -24 to -8 is Low Risk
  • -7 to +13 is Medium Risk
  • +14 to +32 is High Risk

Determining Rate of Recidivism

The risk of recidivism is presented below, from the same manual (pages 283-286):

Probability of Recidivism
VRAG score 7 years 10 years
< −22 0.00 0.08
−21 to −15 0.08 0.10
−14 to −8 0.12 0.24
−7 to −1 0.17 0.31
0 to +6 0.35 0.48
+7 to +13 0.44 0.58
+14 to +20 0.55 0.64
+21 to +27 0.76 0.82
> +28 1.00 1.00

This is to be interpreted as a percentage. For instance a score of -10 is in the -14 to -8 category; therefore an individual would have a 7 year recidivism rate of 12% and a 10 year recidivism rate of 24%.


American Psychological Association. (2006) Quinsey, V.L., Harris, G.T., Rice, M.E. & Cormier, C.A. (2006) 2nd Ed. Violent Offenders: Appraising and Managing Risk. Washington D.C: American Psychological Association.

Brown, J. & Singh, J.P. (2014) Forensic Risk Assessment: A Beginner’s Guide. Archives of Forensic Psychology. 1(1). 49-59. Retrieved on January 20, 2017 from

Camilleri, J.A. & Quinsey, V.L. (2011) Appraising the risk of sexual and violent recidivism among intellectually disabled offenders. Psychology, Crime & Law. 17(1) 59-74

Cite this article as: MacDonald, D.K., (2017), "Using the Violence Risk Appraisal Guide (VRAG)," retrieved on May 27, 2019 from
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