Individual Planning: A Treatment Plan Overview for Individuals with Antisocial Problems

Transcription

1 COURSES ARTICLE - THERAPYTOOLS.US Individual Planning: A Treatment Plan Overview for Individuals with Antisocial Problems A Treatment Overview for Adults with Antisocial Problems Duration: 3 hours Learning Objectives: Obtain a basic understanding of how to identifying, causes, symptoms of children with lying problems or history, and learn different options to complete a treatment plan that includes: a. Behavioral Definitions b. Long Term Goals c. Short Term Goals d. Strategies to Achieve Goals e. DSM V diagnosis Recommendations ***Coming Soon - For a full list of 20 short term goals with dozens strategies listed next to each goal check the Child Treatment App for Windows or Apple PC and Android Devices, under our main menu Windows-Apple Apps. Download the Free Demo to Evaluate*** Course Syllabus:

2 Introduction Prevalence Symptoms Causes Diagnosis Treatment Steps to Develop a Treatment Plan that includes Behavioral Descriptors, Long Term Goals, Short Term Goals, Interventions/Strategies and DSM V CODE Paired with ICD_9 and 10-CM Codes for ODD Sample Treatment Plan Introduction: Antisocial personality disorder is a psychiatric condition characterized by chronic behavior that manipulates, exploits, or violates the rights of others. This behavior is often criminal. Antisocial personality disorder is a condition in which people show a pervasive disregard for the law and the rights of others. People with antisocial personality disorder may tend to lie or steal and often fail to fulfill job or parenting responsibilities. The terms "sociopath" and "psychopath" are sometimes used to describe a person with antisocial personality disorder. Some scholars, such as Robert Hare, still distinguish psychopathy from mere antisocial behavior. The National Comorbidity Survey, which used DSM-III-R criteria, found that 5.8% of males and 1.2% of females showed evidence of a lifetime risk for the disorder. Prevalence estimates within clinical settings have varied from 3% to 30%, depending on the predominant characteristics of the populations being sampled. Perhaps not surprisingly, the prevalence of the disorder is even higher in selected populations, such as people in prisons (who include many violent offenders) (Hare 1983). Similarly, the prevalence of Antisocial Personality Disorder is higher among patients in alcohol or other drug (AOD) abuse treatment programs than in the general population (Hare 1983), suggesting a link between Antisocial Personality Disorder and AOD abuse and dependence. People with antisocial personality disorder are at an increased risk of:

3 Dying from a physical trauma, such as an accident Drug and alcohol abuse Suicide Homicide Other mental disorders such as depression, bipolar disorder and anxiety Other personality disorders, particularly borderline and narcissistic personality disorders Committing serious crimes that may result in imprisonment Symptoms: Antisocial personality disorder, sometimes called sociopathy, is a mental condition in which a person consistently shows no regard for right and wrong and ignores the rights and feelings of others. People with antisocial personality disorder tend to antagonize, manipulate or treat others harshly or with callous indifference. They show no guilt or remorse for their behavior. Individuals with antisocial personality disorder often violate the law, becoming criminals. They may lie, behave violently or impulsively, and have problems with drug and alcohol use. Because of these characteristics, people with this disorder typically can't fulfill responsibilities related to family, work or school. Antisocial personality disorder signs and symptoms may include: Disregard for right and wrong Disregard for right and wrong Being callous, cynical and disrespectful of others Using charm or wit to manipulate others for personal gain or personal pleasure Arrogance, a sense of superiority and being extremely opinionated Recurring problems with the law, including criminal behavior Repeatedly violating the rights of others through intimidation and dishonesty

4 Impulsiveness or failure to plan ahead Hostility, significant irritability, agitation, aggression or violence Lack of empathy for others and lack of remorse about harming others Unnecessary risk-taking or dangerous behavior with no regard for the safety of self or others Poor or abusive relationships Failure to consider the negative consequences of behavior or learn from them Being consistently irresponsible and repeatedly failing to fulfill work or financial obligations Adults with antisocial personality disorder typically show symptoms of conduct disorder before the age of 15. Signs and symptoms of conduct disorder include serious, persistent behavior problems, such as: Aggression toward people and animals Destruction of property Deceitfulness Theft Serious violation of rules Although antisocial personality disorder is considered lifelong, in some people, certain symptoms - particularly destructive and criminal behavior - may decrease over time. But it's not clear whether this decrease is a result of aging or an increased awareness of the consequences of antisocial behavior. Other Symptoms to check for: A record of constant rule-breaking History of lying

5 History of violence Disregard for others and their property History of stealing History of substance abuse Projects blame upon others Non-compliance to follow rules Record of irresponsible behaviour Reckless and high-risk behaviors Constantly cheating on others Behavior of sexual promiscuity Lack of respect or confronts authority figures Non-apologetic for insensitive behavior Verbally abusive Physically abusive Non-compliant to social norms or laws Impulsive behavior Not responsible or concerned parent Exposure to explosive behaviors at home Causes: The specific cause or causes of Antisocial Personality are unknown. Like many mental health issues, evidence points to inherited traits. But dysfunctional family life also increases the likelihood of Antisocial Personality. So although Antisocial Personality may have a hereditary basis, environmental factors contribute to its development. Researchers have their own ideas about Antisocial Personality s cause. One theory suggests that abnormalities in development of the nervous system may cause Antisocial Personality. Abnormalities that suggest abnormal nervous system development include learning disorders, persistent bedwetting and hyperactivity.

6 A recent study showed that if mothers smoked during pregnancy, their offspring were at risk of developing antisocial behavior. This suggests that smoking brought about lowered oxygen levels with may have resulted in subtle brain injury to the fetus. Yet another theory suggests that people with Antisocial Personality require greater sensory input for normal brain function. Evidence that antisocials have low resting pulse rates and low skin conductance, and show decreased amplitude on certain brain measures supports this theory. Individuals with chronically low arousal may seek out potentially dangerous or risky situations to raise their arousal to more optimal levels to satisfy their craving for excitement. Brain imaging studies have also suggested that abnormal brain function is a cause of antisocial behavior. Likewise, the neurotransmitter serotonin has been linked with impulsive and aggressive behavior. Both the temporal lobes and the prefrontal cortex help regulate mood and behavior. It could be that impulsive or poorly controlled behavior stems from a functional abnormality in serotonin levels or in these brain regions. Social and home environments also contribute to the development of antisocial behavior. Parents of troubled children frequently show a high level of antisocial behavior themselves. In a study, the parents of delinquent boys were more often alcoholic or criminal, and their homes were frequently disrupted by divorce, separation, or the absence of a parent. In the case of foster care and adoption, depriving a young child of a significant emotional bond could damage his ability to form intimate and trusting relationships, which may explain why some adopted children are prone to develop Antisocial Personality. As young children, they may be more likely to move from one caregiver to another before a final adoption, thereby failing to develop appropriate or sustaining emotional attachments to adult figures. Inappropriate discipline and inadequate supervision have been linked to antisocial behavior in children. Good supervision is less likely in broken homes because parents may not be available, and antisocial parents often lack the motivation to keep an eye on their children. The importance of parental supervision is also underscored when antisocials grow up in large families where each child gets proportionately less attention. A child who grows up in a disturbed home may enter the adult world emotionally injured. Without having developed strong bonds, he is self-absorbed and indifferent to others. The lack of consistent discipline results in little regard for rules and delayed gratification. He lacks appropriate role models and learns to use aggression to solve disputes. He fails to develop empathy and concern for those around him.

7 Antisocial children tend to choose similar children as playmates. This pattern usually develops during the elementary school years, when peer group acceptance and the need to belong start to become important. Aggressive children are the most likely to be rejected by their peers, and this rejection drives them to form bonds with one another. These relationships can encourage and reward aggression and other antisocial behavior. These associations may later lead to gang membership. Child abuse also has been linked with antisocial behavior. People with Antisocial Personality are more likely than others to have been abused as children. This is not surprising since many of them grow up with neglectful and sometimes violent antisocial parents. In many cases, abuse becomes a learned behavior that formerly abused adults perpetuate with their own children. It has been argued that early abuse (such as vigorously shaking a child) is particularly harmful, because it can result in brain injury. Traumatic events can disrupt normal development of the central nervous system, a process that continues through the adolescent years. By triggering a release of hormones and other brain chemicals, stressful events could alter the pattern of normal development. Diagnosis: Antisocial personality disorder is the most reliably diagnosed condition among the personality disorders, yet treatment efforts are notoriously difficult. Therapeutic hope has not vanished, however, and one study indicated that almost two-thirds of psychiatrists think that "psychopathic disorder" is sometimes a treatable condition. A similar finding was reported nearly 40 years ago. Diagnostic refinement is critical before any treatment efforts are undertaken, especially the determination of the degree of psychopathy in the patient with antisocial personality disorder. According to the Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition (DSM IV) by the American Psychiatric Association (APA) (1994), Antisocial Personality Disorder is characterized by a pervasive disregard for, and violation of, other people's rights. The concept of such a personality type is not new. For example, Theophrastus, a student of the ancient Greek philosopher Aristotle, described a personality type that he termed the "unscrupulous man" and which included behaviors that are significant elements of the current concept of Antisocial Personality Disorder (Millon et al. 1998).

8 During the past century, researchers and clinicians have used numerous terms to describe Antisocial Personality, including "moral insanity," "psychopathy," and "sociopathy." Likewise, the symptoms considered to be the key elements of psychopathy or an antisocial personality have evolved from a focus on the lack of emotional attachment in relationships with others (Cleckley 1964) to a greater focus on external behaviors, especially aggressive and impulsive behaviors (APA 1994). The current criteria for Antisocial Personality Disorder, as described in DSM IV, include a behavioral pattern that begins before age 15 and comprises at least three of the following behaviors: Repeated criminal acts Deceitfulness Impulsiveness Repeated fights or assaults Disregard for the safety of others Irresponsibility Lack of remorse This pattern of behavior has occurred since age 15 (although only adults 18 years or older can be diagnosed with this disorder) and consists by the presence of the majority of these symptoms: failure to conform to social norms with respect to lawful behaviors as indicated by repeatedly performing acts that are grounds for arrest deceitfulness, as indicated by repeated lying, use of aliases, or conning others for personal profit or pleasure impulsivity or failure to plan ahead irritability and aggressiveness, as indicated by repeated physical fights or assaults reckless disregard for safety of self or others

9 consistent irresponsibility, as indicated by repeated failure to sustain consistent work behavior or honor financial obligations lack of remorse, as indicated by being indifferent to or rationalizing having hurt, mistreated, or stolen from another The manual lists the following additional necessary criteria: The individual is at least 18 years of age. There is evidence of conduct disorder with onset before age 15 years. The occurrence of antisocial behavior is not exclusively during the course of Schizophrenia or a Manic Episode. The classic person with an antisocial personality is indifferent to the needs of others and may manipulate through deceit or intimidation. He or she shows a blatant disregard for what is right and wrong, may have trouble holding down a job, and often fails to pay debts or fulfill parenting or work responsibilities. They are usually loners. The diagnostic criteria for antisocial personality disorder are set forth in table above. DSM-IV states that this disorder is characterized by "a pervasive pattern of disregard for and violation of the rights of others that begins in childhood or early adolescence and continues into adulthood." The antisocial features are reflected in poor job performance, academic failure, participation in a wide variety of illegal activities, recklessness, and impulsive behavior. The patient with antisocial personality disorder also experiences a feeling of subjective dysphoria, characterized by tension, depression, inability to tolerate boredom, and a feeling of being victimized. There is also a diminished capacity for intimacy. A substantial body of research has shown that only a minority of patients with antisocial personality disorder have severe psychopathy, and this latter group has a significantly poorer treatment prognosis than do patients with non psychopathic antisocial personality disorder. They appear to be incapable of any true emotions, from love to shame to guilt. They are quick to anger, but just as quick to let it go, without holding grudges. No matter what emotion they state they have, it has no bearing on their future actions or attitudes:

10 Disregard for the feelings of others Impulsive and irresponsible decision-making Lack of remorse for harm done to others Lying, stealing, other criminal behaviors Disregard for the safety of self and others Differential Diagnosis: The diagnosis of Antisocial Personality Disorder is not given to individuals under age 18 years and is given only if there is a history of some symptoms of Conduct Disorder before age 15 years. For individuals over age 18 years, a diagnosis of Conduct Disorder is given only if the criteria for Antisocial Personality Disorder are not met. When antisocial behavior in an adult is associated with a Substance-Related Disorder, the diagnosis of Antisocial Personality Disorder is not made unless the signs of Antisocial Personality Disorder were also present in childhood and have continued into adulthood. When substance use and antisocial behavior both began in childhood and continued into adulthood, both a Substance-Related Disorder and Antisocial Personality Disorder should be diagnosed if the criteria for both are met, even though some antisocial acts may be a consequence of the Substance-Related Disorder (e.g., illegal selling of drugs or thefts to obtain money for drugs). Antisocial behavior that occurs exclusively during the course of Schizophrenia or a Manic Episode should not be diagnosed as Antisocial Personality Disorder. Treatment: The most important goals of treating antisocial behavior are to measure and describe the individual child's or adolescent's actual problem behaviors and to effectively teach him or her the positive behaviors that should be adopted instead. In severe cases, medication will be administered to control behavior, but it should not be used as a substitute for therapy. In a review of the effectiveness of treatments for antisocial personality disorder Garrido et al (1995) concluded that treatment is more effective with those subjects who are not currently abusing drugs, who have less serious histories of criminality, and who are treated in an institutional setting such as an inpatient unit or a prison rather than in an outpatient setting. As an example Dolan (1998) describes a therapeutic community program for antisocial patients and those with other violent personality disorders that is successful in reducing not

11 only impulsive behaviors but also physical health problems, rates of incarceration for criminal offenses, and core features of personality disorder. Effective psychotherapy treatment for this disorder is limited. It is likely, though, that intensive, psychoanalytic approaches are inappropriate for this population. Approaches the reinforce appropriate behaviors and attempting to make connections between the person's actions and their feelings may be more beneficial. Emotions are usually a key aspect of treatment of this disorder. Patients often have had little or no significant emotionally-rewarding relationships in their lives. The therapeutic relationship, therefore, can be one of the first ones. This can be very scary for the client, initially, and it may become intolerable. A close therapeutic relationship can only occur when a good and solid rapport has been established with the client and he or she can trust the therapist implicitly. Prognosis is not very good because of two contributing factors. First, because the disorder is characterized by a failure to conform to society's norms, people with this disorder are often incarcerated because of criminal behavior. Secondly, a lack of insight into the disorder is very common. People with antisocial personality disorder typically see the world as having the problems, not him or herself, and therefore rarely seek treatment. If progress is made, it is typically over an extended period of time. Steps to Develop a Treatment Plan: The foundation of a good treatment plan is based on the gathering of the correct data. This involves following logical steps the built-in each other to help give a correct picture of the problem presented by the client or patient: The mental health clinician must be able to listen, to understand what are the struggles the client faces. this may include: issues with family of origin, current stressors, present and past emotional status, present and past social networks,

12 present and past coping skills, present and past physical health, self-esteem, interpersonal conflicts financial issues cultural issues There are different sources of data that may be obtained from a: clinical interview, Gathering of social history, physical exam, psychological testing, contact with client s or patient s significant others at home, school, or work The integration of all this data is very critical for the clinician s effect in treatment. It is important to understand the client s or patient s present awareness and the basis of the client's struggle, to assure that the treatment plan reflects the present status and needs of the client or patient. There 5 basic steps to follow that help assure the development of an effective treatment plan based on the collection of assessment data. Step 1, Problem Selection and Definition: Even though the client may present different issues during the assessment process is up to the clinician to discern the most significant problems on which to focus during treatment. The primary concern or problem will surface and secondary problems will be evident as the treatment process continues. The clinician may must be able to plan accordingly and set some secondary problems aside, as not urgent enough to require treatment at this time. It is

13 important to remember that an effective treatment plan can only deal with one or a few problems at a time. Focusing in too many problems can lead to the lost of direction and focus in the treatment. It is important to be clear with the client or patient and include the client s or patient s own prioritization of the problems presented. The client s or patient s cooperation and motivation to participate in the treatment process is critical. Not aligning the client to participate my exclude some of the client s or patient s needs needing immediate attention. Every individual is unique in how he or she presents behaviorally as to how the problem affects their daily functioning. Any problems selected for treatment will require a clear definition how the problem affects the client or patient. It is important to identify the symptom patterns as presented by the DSM-5 or Diagnostic and Statistical Manual or the International Classification of Diseases (ICD). Behavior Definitions for Adults with Antisocial Disorder: A. A record of constant rule-breaking, lying, violence, disregard for others and their property, stealing, and/or substance abuse leading to recurrent conflict with authority figures. B. Projects blame upon others for what happens to him or her. C. Non-compliance to follow rules with the mind-set that they apply to others, not him or her. D. Record of irresponsible behaviors that reveal a lack of consideration for self or others E. Recreational behavior consists of reckless and high-risk situations. F. Constantly lying and cheating others. G. Behavior of sexual promiscuity, inability to be completely monogamous in a relationship for at least a year, and incapable or unwilling to take responsibility for children. H. Lack of respect for authority figures treating them in an opposing, hostile, and confrontational manner. I. Non-apologetic for insensitive behavior. J. Verbally and physically abusive, usually self-initiated.

14 K. Non-compliant to social norms, no respect to social standards or laws. L. Impulsive behavior (e.g. moving without reason and / or quitting job without having another). M. Usually unemployed or jumping from job to job, does not possess behavior needed for constant employment. N. Cannot fill the role as a constantly responsible and or concerned parent. Step 2, Long Term Goal Development: This step requires that the treatment plan includes at least one broad goal that targets the problem and the resolution the problem. These long term goals must be stated in non-measurable terms but instead indicate a desired positive outcome at the end of treatment. Long Term Goals for Adults with Antisocial Disorder: A. Increase accountability of behavior, abide by and contain behavior within the acceptable norms and standards or society. B. Increase the regard and use of social norms. Demonstrate respect for others, acknowledge and practice the importance of honesty. C. Improve social awareness, become less self indulgent, and increase regard/respect for authority figures. D. Acknowledge and accept the importance of standards and boundaries of behavior. E. Take responsibility for own actions, express remorse, and do not project blame upon others. F. Demonstrate capability of consistent employment and show financial and emotional responsibility for children. Step 3, Objective or Short Term Goal Construction: Objectives or short term goals must be stated in measurable terms or language. They must clearly specify when the client or patient can achieve the established objectives. The use of subjective or vague objectives or short term goals is not acceptable. Most or all insurance

15 companies or mental health clinics require measurables objectives or short term goals. It is important to include the patient s or client s input to which objectives are most appropriate for the target problems. Short term goals or objectives must be defined as a number of steps that when completed will help achieve the long-term goal previously stated in non measurable terms. There should be at least two or three objectives or short-term goals for each target problem. This helps assure that the treatment plan remains dynamic and adaptable. It is important to include Target dates. A Target day must be listed for each objective or short-term goal. If needed, new objectives or short-term goals may be added or modified as treatment progresses. Any changes or modifications must include the client s or patient s input. When all the necessary steps required to accomplish the short-term goals or objectives are achieved the client or patient should be able to resolve the target problem or problems. If required all short term goals or objectives can be easily modify to show evidence based treatment objectives. The goal of evidence based treatment objectives (EBT) is to encourage the use of safe and effective treatments likely to achieve results and lessen the use of unproven, potentially unsafe treatments. To use EBT in treatment planning state restate short term goals in a way that steps to complete that goal and achieve results. For example, the short term goal 13. Increase positive self-descriptive statements. Can be restated as; By the end of the session the patient or client will list at least 5 positive self descriptions of himself or herself, and assess how they can help alleviate the presenting problem Remember, that it must be stated in a way one can measure effectiveness. It is important to note that traditional therapies usually rely more heavily on the relationship between therapist and patient and less on scientific evidence of proven practices. Examples of Short Term Goals for Adults with Antisocial Disorder: A. Acknowledge to the involvement of reckless behaviors that have been detrimental to others and society. B. Convey the understanding and appreciation of benefits for others and self of abiding within the standards and laws of society. C. Commit to abiding by the standards and laws of society.

16 D. Recognize the different relationships of the present and the past that have suffered and been lost due to dishonesty, disloyalty, aggressive behavior, and disregard. E. Express and accept the degree of self-indulgence and disregard for others in all relationships. Step 4, Strategies or Interventions: Strategies or interventions are the steps required to help complete the short-term goals and long-term goals. Every short term goal should have at least one strategy. In case, short term goals are not met, new short term goals should be implemented with new strategies or interventions. Interventions should be planned taking into account the client s needs and presenting problem. Examples of Strategies or Interventions for Adults with Antisocial Disorder: A. Investigate the client's pattern of illicit and reckless behavior and confront client's issues with denial and acceptance of responsibility. B. Evaluate the outcomes of antisocial behavior and the consequential effects to others and self. C. Explore the foundations for any relationship, being: trust, respect, and kindness. D. Express and educate about the meaning of fairness and lawfulness as the foundation of trust. E. Emphasize the importance of dedication to abiding by a pro-social lifestyle. Step 5, Diagnosis: The diagnosis is based on the evaluation of the clients present clinical presentation. When completing diagnosis the clinician must take into account and compare cognitive, behavioral, interpersonal, and emotional symptoms as described on the DSM-5 Diagnostic Manual. A diagnosis is required in order to get reimbursement from a third-party provider. Integrating the information presented by the DSM-5 diagnostic manual and the current client s assessment data will contribute to a more reliable diagnosis. it is important to

17 note that when completing a diagnosis the clinician must have a very clear picture all behavioral indicators as they relate to the DSM-5 diagnostic manual. DSM V Code Paired with ICD_9-CM Codes (Parenthesis Represents ICD-10-CM Codes Effective ): Possible Diagnostic Suggestions for Adults with Antisocial Issues: (F43.1 0) Posttraumatic Stress Disorder (includes Posttraumatic Stress Specify whether: With dissociative symptoms Specify if: With delayed expression (F6381) Intermittent Explosive Disorder Cluster A Personality Disorders (F60.0) Paranoid Personality Disorder (F60,1) Schizoid Personality Disorder (F21) Schizotypal Personality Disorder Cluster B Personality Disorders (F60.2) Antisocial Personality Disorder (F60.3) Borderline Personality Disorder (F60.4) Histrionic Personality Disorder (F60.81) Narcissistic Personality Disorder Cluster C Personality Disorders (F60.6) Avoidant Personality Disorder (F60.7) Dependent Personality Disorder (F60.5) Obsessive-Compulsive Personality Disorder

18 Other Personality Disorders (F07,0) Personality Change Due to Another Medical Condition Specify whether: Labile type, Disinhibited type, Aggressive type, Apathetic type, Paranoid type, Other type, Combined type, Unspecified type (F60.89) Other Specified Personality Disorder (684) (F60.9) Unspecified Personality Disorder (684) V71.01 (Z72.811) Adult Antisocial Behavior Alcohol Use Disorder (F10.10) Mild (F10.20) Moderate 303.(90) (F10.20) Severe ***Check for Other Substance Addictive Disorders*** Overall Integration of a Treatment Plan: Choose one presenting problem. This problem must be identified through the assessment process. Select at least 1 to 3 behavioral definitions for the presenting problem. if a behavior definition is not listed feel free to define your own behavioral definition. Select at least long-term goal for the presenting problem.

19 Select at least two short-term goals or objectives. Add a Target Date or the number of sessions required to meet this sure term goals. If none is listed feel free to include your own. Based on the short-term goals selected previously choose relevant strategies or interventions related to each short term goal. If no strategy or intervention is listed feel free to include your own. Review the recommended diagnosis listed. Remember, these are only suggestions. Complete the diagnosis based on the client's assessment data. Sample Treatment Plan Present Behavioral Descriptors of Problem: Record of irresponsible behaviors that reveal a lack of consideration for self or others. Non-compliance to follow rules with the mindset that they apply to others, not him or her. Long Term Goals: Increase the regard and use of social norms. Demonstrate respect for others, acknowledge and practice the importance of honesty. Improve social awareness, become less self indulgent, and increase regard/respect for authority figures.

20 Short Term Goals Objectives: Explore the past and present for major conflict causing anxiety. Construct a suitable relaxation technique to decrease levels of anxiety. Strategy or Intervention for Goal 1: Investigate reasons why client blames others for his or her own actions. Investigate client's childhood of any abuse or abandonment. Assist client in discovering and understanding that he or she engages in self-indulgent and emotionally detached behavior in relationships to avoid pain and rejection. Strategy or Intervention for Goal 2: Use relaxation techniques to construct an outline listing positive and productive traits that are associated with good parenting. Using visual imagery help patient acknowledge and tackle the lack of understanding and compassion towards others feelings and positions.

21 DSM V Diagnosis: (F60.2) Antisocial Personality Disorder Alcohol Use Disorder (F10.10) Mild Copyright 2011 THERAPYTOOLS.US All rights reserved