Maladaptive Anger

Please note due to patient privacy laws all names in this paper have been changed to keep the identity private.

Case Study

Mr. H, a 37-year-old man on disability, is engaged to Rebecca. They have two children, aged 12 and 1. Having experienced severe childhood physical and sexual abuse by his stepfather and having a history of drug abuse as a young adult, Mr. H has a history of anger and aggression problems. He is reluctant to reveal most of his family history, but states that he has not used drugs since age 27. Mr. H is the oldest of seven, having one brother and five sisters. Mr. H reports that he has severe symptoms of PTSD and extremely high levels of distrust. He also served in the army for approximately one year before his discharge due to verbally aggressive altercations with his commander and others. He has since then held many jobs resulting in him quitting or getting fired due to angry outburst when he felt he was being overly criticized or having “too many people in my space”. After seeking some help, he was diagnosed with Bipolar, PTSD, Dissociative Disorder, Panic Disorder with Agoraphobia, and Drug Abuse, which resulted in him being put on disability. Mr. H still tries to find work, but it never last longer than a month.

Mr. H describes his personal life as pleasant but stressful at times. There is no physical violence in the relationship and few arguments between him and Rebecca. He states that Rebecca tries her best to be understanding to his needs, helps him to remember to take his medicine and encourages him to seek therapy. Sometimes Mr. H feels overwhelmed by the children, especially since he is home all day with the 1 year old and Rebecca is gone day and night due to her schooling and work.

Mr. H reports needing eight or more hours of sleep per night in order to function in a “good mood” the next morning. He actively avoids public places or surrounding unfamiliar to him and large crowds, resulting in him staying in his home most of the time. He often feels irritable, can be easily frustrated and he has a negative outlook on society. He has come to notice that at times when he tries to control his anger, his vocal tones still exhibit aggression. When in uncomfortable situations he is quick tempered and often does not remember what he has said or has done. Mr. H was evicted from an apartment complex after having an outburst over the water being turned off for maintenance reasons, the apartment management felt threatened by his words and actions that they called the police. He recalls several other occasions where he has had public altercations with friends and sometimes strangers as well. Another example of an angered outburst was when a friend of his was to watch his son until Rebecca got home from school or until he got home from work. That friend rushed Mr. H, constantly calling him asking when he would be home. When Mr. H finally arrived to pick up his son, he and the friend ended up in a face-to-face altercation in the courtyard in front of his son and neighbors. He recalls his actions from this episode but has no regrets.

Mr. H is motivated to change, acknowledging that he does not want his children or future wife to fear him. In the past, he has tried counseling and Cognitive Behavioral Therapy. When going to doctor appointments, his demeanor is often guarded and when anxiety sets in, he begins to stutter, thus leading him to feel as though it was a negative experience. Even though the sessions were short lived, he reports that he now knows some of his triggers and listens to music when he feels angry. At the same time, he still experiences days or “episodes” of angry outbursts. He reports that usually these outbursts occur when his stress levels are high and there is too much “noise”. For example, when family and friends that he is comfortable with are visiting him, if there are too many people talking or making noise, Mr. H becomes agitated and irritable. He is currently taking Paxil for his anxiety. He reports that as long as he does not miss a dose, Paxil works for him.

Treatment Plan

The proposed psychotherapy for Mr. H would be Cognitive Behavioral Affective Therapy (CBAT) combined with the proper medications. Since Paxil is working for Mr. H, there is no reason to take him off that medication. A recommendation to see a psychiatrist to evaluate the necessity for other types of medications is advised. CBAT combines cognitive strategies, behavior modification techniques, and affective therapy (Potegal et al. 2003). There are three phases to CBAT; Prevention, Intervention, and Postvention.

In the Prevention phase, behavioral techniques are primarily used in attempt to prevent the onset of anger (Potegal et al. 2003). This begins with a signing of a contract committing the client to participation of the prevention phase. Of course, this contract holds no legal grounds; it is strictly for the client’s reward system. The client will have goals to which he /she will obtain and upon doing so he/she will get rewarded with points. With the points the client may redeem an appropriate reward or privilege, ultimately receiving a certificate of completion once all phases of CBAT have been completed successfully.

Self-monitoring is a large part of the prevention phase. Willingness of the client to self-observe and self-record instances where he/she has an angry outburst is key to this phase. A booklet or note pad is used to document the activities or events that trigger anger and the intensity of anger. The items written down are then used to determine if fulfilment or non-fulfilment of the contract (Potegal et al. 2003).

Another component of the prevention phase is behavior rehearsal. Behavioral rehearsal consists of anticipation and response to anger-provoking events. Role-play is often used to help teach the client the proper or desired response to what triggers anger. This is also tied to the next part of the prevention phase, Response prevention. This is for situations that may escalate to extreme altercations. This includes practicing control of vocal tones and demeanor in attempts to maintain composure (Potegal et al. 2003).

Stimulus control is the final part to the prevention phase (Potegal et al. 2003). The client may limit the people or places that trigger anger. Such as terminating an unhealthy friendship or in some cases, finding new employment. This is not meant to socially disengage the client, but to limit the amount of anger-provoking situations.

The intervention phase consists of cognitive strategies (Potegal et al. 2003). In this phase, should the client still struggle with their anger, the strategy is based on reappraisal. Identifying the angered person’s attributes, critically evaluating, then replacing them with more rational alternatives (Potegal et al. 2003). Other techniques such as distraction and relaxation can be used in the intervention phase. Distractions can be passive (e.g. watching TV) or active (e.g. going for a walk). These activities can divert the attention from the anger-provoking situation but cannot change the person’s mind about something. It is merely a way of taking one’s mind off what troubles them (Potegal et al. 2003). Distractions may go hand-in-hand with relaxation; meditating or listening to music can both be relaxing and a diversion.

The postvention phase is where affective therapies are applied dealing with what is felt by the individual (Potegal et al. 2003). Here, a clinician may attempt the empty chair technique. The client will sit facing an empty chair and imagine the reason for their anger is sitting there. The client may then voice his/her opinions, thoughts, and feelings without interruption or distractions. The result is release. The client is able to release the emotions that he/she feels without turning to anger, all the while being in a safe place. For those who are not as comfortable with vocalizing their emotions, they may write a letter about the unresolved anger. The letter does not have to be given to anyone (including the therapist) if the client so chooses. Disposal of the letter is solely up to the client.

When language is limited, art is a suitable medium for the expression of anger (Potegal et al. 2003). Art may include painting, sculpting, sketching, and musical performance, all of which can help one to express his/her anger. Although, assessable outcome data for this is lacking, many in the clinical practice support the value of art being used as a medium for the expression of emotions (Potegal et al. 2003).

Finally, the client is awarded a certificate given to him/her during a ceremony to honor his/her completion of the CBAT (Potegal et al. 2003). Even though one may have completed CBAT, he/she is still encouraged to keep practicing the skills obtained during CBAT and extra sessions are welcomed should the client need a little more training. (refresher sessions).

The course of action for Mr. H is as follows:

Phase one of CBAT will consist of Mr. H gaining trust or an alliance with the therapist. This helps him to see that he is not alone and helps him to view the world in a more positive light. Mr. H will also sign a contract stating his commitment to participating in CBAT. Mr. H will take down notes of his actions during events and situations where he feels angered. By taking notes, Mr. H can self-evaluate his surrounding and his actions. Acknowledging what is anger-provoking can help him to control his response, thus, controlling the outcome of a situation that normally may end up in an altercation. Mr. H may also learn how to anticipate when an altercation may occur because he has learned what upsets him. Then, if applicable, eliminate the object, place, or subject that is anger-provoking. For example, associates that push or rush Mr. H, leading to large amounts of stress, which eventually lead to anger and outbursts, can be removed from his daily activities or social interactions. Mr. H already avoids certain public places that he has learned to be triggers for his anger.

For the intervention phase, should Mr. H’s anger persist, a word or phrase that is soothing to him should be repeated. This is something he can do in his head or speak softly to himself. He may use words or phrases such as “calm down” or “breath”. If the anger still persists, a more elaborate strategy can be used called reappraisal (Potegal et al. 2003). Other options include distractions and relaxation. Mr. H has already has a hobby that he finds relaxing such as gardening to ease him when he feels like he is going to get angry. It was suggested that Mr. H acquire at least a few more alternatives for relaxation and distractions in case he is unable to be in his garden, such as taking walks or playing video games.

It is very plausible that some angry feelings may still persist, even after the intervention phase. This is when the postvention phase begins. Mr. H will begin to learn how to control the feelings of anger using techniques like the empty chair. In the safety of the clinicians office or even at home, Mr. H can sit across from an empty chair and imagine that the person or thing he is angry with is there. For example, if he is upset with Rebecca, he can imagine her in the chair and he can begin to tell her how he feels about her time away from home or how stressed and angry he feels when he is constantly left home alone with the kids. He is able verbally express himself without interruption, releasing the emotions he has locked up inside. When he finds himself at a loss for words, he is encouraged to write down his feelings of anger (or any other emotion). He may or may not want to share this with his therapist; it is his choice. There is also the option to express himself by way of music or art. Mr. H has expressed an interest in making music with a program that he has recently installed on his computer. He reported having done such activities when angry, feeling a little release once he has completed a song.

Once Mr. H has completed CBAT, there will be a ceremony held on his behalf to reward him a certificate of completion and to acknowledge his achievements. Mr. H will be encouraged to maintain contact with his therapist should he feel his anger getting out of control again. Throughout his therapy plan and after completion, Mr. H should continue to take Paxil as prescribed by his doctor.

References

Fernandez, E. (2013). Treatments for anger in specific populations theory, application, and outcome. Oxford: Oxford University Press.

Potegal, M., Stemmler, G., & Spielberger, C. D. (2010). Toward an integrative psychotherapy for maladaptive anger. International handbook of anger constituent and concomitant biological, psychological, and social processes (pp. 499-512). New York: Springer.