Cause and Effect Tracing Worksheet 3 of 4

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed this adversarial and/or dysfunctional behavior? Select all that apply to this behavior.

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Try to complete this question. If not select this option.

3. Do you currently express and or experience this behavior with yourself or others on a daily, weekly, or monthly basis?

Daily
Weekly
Monthly
Specific days or times of the year (Example: memorable emotional experiences like birthdays, holidays, or when loved one's departed, or specific dramatic or traumatic events took place)
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to this adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media outlets
Social Media Outlets
Online Print and or Video Content Sources
Other

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think about or go to specific locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. What insightful thoughts and discoveries would you like to add? Please use the space below or write and date additional information on separate paper, or in journal or notebook.

This response will be reviewed and graded after submission.

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed some of this dysfunctional behavior? Select all that apply to this behavior.

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Make an attempt to complete this question. If not select this option.

3. Do you currently express and or experience this behavior from yourself or others on a daily, weekly, or monthly basis?

Daily
Weekly
Monthly
Specific days or times of the year (Example: memorable emotional experiences like birthdays, holidays, or when loved one's departed, or specific dramatic or traumatic events took place)
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to this adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media Outlets
Social Media Outlets
Online Print and or Video Content Sources
Other

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think specific about or go to locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. If you have any insightful thoughts you would like to add, please use the space below or write and date them in a separate journal or notebook.

This response will be reviewed and graded after submission.

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed some of this dysfunctional behavior?

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Make an attempt to complete this question. If not select this option.

3. Do you currently express and or experience this behavior from yourself or others on a daily, weekly, or monthly basis?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to this adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media Outlets
Social Media Outlets
Online Print and or Video Content Sources
Other

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think specific about or go to locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. If you have any insightful thoughts you would like to add, please use the space below or write and date them in a separate journal or notebook.

This response will be reviewed and graded after submission.

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed some of this dysfunctional behavior?

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Make an attempt to complete this question. If not select this option.

3. Do you currently express and or experience this behavior from yourself or others on a daily, weekly, or monthly basis?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to additional forms of this type of adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media Outlets
Social Media Outlets
Online Print and or Video Content Sources
Other

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think specific about or go to locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. If you have any insightful thoughts you would like to add, please use the space below or write and date them in a separate journal or notebook.

This response will be reviewed and graded after submission.

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed some of this dysfunctional behavior?

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Make an attempt to complete this question. If not select this option.

3. Do you currently express and or experience this behavior from yourself or others on a daily, weekly, or monthly basis?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to additional forms of this type of adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media Outlets
Social Media Outlets
Online Print and or Video Content Sources
Other

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think specific about or go to locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. If you have any insightful thoughts you would like to add, please use the space below or write and date them in a separate journal or notebook.

This response will be reviewed and graded after submission.

1. Identify one adversarial (abuse, aggression, antagonism, bullying, hostility, humiliation, imminent danger, name-calling, shaming, threatening, unfriendly, violence, etc… ) or other dysfunctional behavior that was frequently expressed in your home and elsewhere during the first 20 years of your life.

If you are feeling emotional about your answer, do the following to help regulate your emotions. Take 2-3 deep breaths Close your eyes and think about one person, place, or thing you are truly grateful for in your life. If you are still unable to continue with your answer, pause for a few minutes and choose another.

This response will be reviewed and graded after submission.

2. Who in your home or elsewhere expressed some of this dysfunctional behavior?

Father
Mother
Sibling
Other Relative
Friend
Teacher
Classmate
Public Authority Figure (meaning an individual working in municipal, political, religious, or social capacity)
Business owner, manager, co-worker if you were employed during this time period.
Other
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life. Make an attempt to complete this question. If not select this option.

3. Do you currently express and or experience this behavior from yourself or others on a daily, weekly, or monthly basis?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

4. Do you have children or live with others who express this behavior more than once a day?

Yes
No
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

5. Which forms of media and entertainment exposed you to additional forms of this type of adversarial dysfunctional behavior?

Books
TV Shows
Movies
News Media Outlets
Social Media Outlets
Online Print and or Video Content Sources
Others

6. When and where do you notice yourself expressing this behavior?

Only when a specific topic comes up in conversation
Only when I think about or am around certain people
Only when I think about or do specific things
While listening or watching a specific TV or Movie
Only when I think specific about or go to locations (example: a store, work, school, someone’s house, a specific place or room in the home).
Feeling emotional, rather not say at this time. Before checking this answer, take 2-3 deep breaths. Close your eyes and think about one personal, place, or thing you are grateful for in your life.

Emotional Level

7. Enter a value from 0 to 100 on how the previous 6 questions make you feel now: 0 = no emotions 100 = Very emotional

8. If your answer to the previous scaling question is above 30, please write the corresponding question numbers and the words in this section that triggered emotional responses. (Example: Question 2, in the home, father, Question 3, behavior, daily, etc…)

This response will be reviewed and graded after submission.

9. If you have any insightful thoughts you would like to add, please use the space below or write and date them in a separate journal or notebook.

This response will be reviewed and graded after submission.

Cause and Effect Tracing Worksheet 3 of 4

Step by Step We Progress

Worksheet Summary

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