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Anger Management: Cognitive Therapy Interventions7 CEUs Anger Management: Cognitive Therapy Interventions

Section 11
Responding to a Violent Incident
Part Two: Case Study and Discussion

Question 11 | Answer Booklet | Table of Contents | Anger Management

Case study
The following case study gives a detailed insight into the treatment and management of Jim’s anger with the use of anger management as a therapeutic intervention.  Jim is a 30-year-old-male and was referred to an anger management group. He had a long history of aggressive behavior with other people and with social institutions.

He had frequently appeared in court and had been admitted to penal and psychiatric facilities on a number of occasions. The offending behavior leading to court appearances was mainly acquisitive (minor theft) and violent in nature. Jim’s violent offenses were the main reason for admission to psychiatric clinics and prison. He had been in a number of fights since his childhood. For the vast majority of these, the outcome was non-serious, suffering minor bruises and lacerations. Occasionally, however, he had lost control entirely in a confrontation and caused serious damage to the other person.

Jim admitted to being frequently very angry and violent, the two normally being interrelated. In an assessment interview, he reported a history of confrontations with his family, teachers, the police, prison officers and hospital nurses.

He admitted being particularly sensitive to criticism and that this was often the start of a violent episode. He described himself as being easily carried away by his anger, provocation making him physically tense and sweaty. He expressed considerable dissatisfaction with his tendency to ‘blow his top’. He felt he did not understand how or why this occurred and he wished he had more control over his temper. He clearly identified his temper as a major reason for his general difficulties.

Jim’s family and social background is viewed by professionals as ‘disturbed’. In childhood he was admitted to a series of children’s homes because of family disturbance. He hated, and still hates, his father, who frequently beat him. He has a strong sense of always having been ‘picked on’ and criticized by his father. When beaten he was frightened, but later in childhood had fought back successfully.

Treatment
A number of methods were used to identify the triggers for Jim’s episodes of angry violence. For example, information from case records, interviews, diaries and staff observations, which suggested with some consistency that particular triggers of anger existed for Jim.

Analysis of the cognitive component of Jim’s anger was based, in part, on his self-reported thoughts, which were often followed by angry incidents, as revealed by his diary. Jim reported between three and five angry experiences on most days.

In addition to the above mentioned measures, observational, self-reported, role play and case record data suggested that Jim had a limited repertoire of behavioral reactions to provocation. Some angry incidents resulted in Jim becoming violent. The violent act itself rarely occurred immediately, but followed an escalation sequence of angry social exchanges. This may not have always been identified by staff and could be perceived as a solo act of violence – resulting in the intervention response of control and restraint.

The assessment task, then, was to identify the verbal and non-verbal features of Jim’s social behavior that produced the escalation effect. In essence, the objective was to define the difference between Jim’s aggressive social style and appropriate or inappropriate response to situations.

In accordance with Novaco (1975, 1978, 1994, 1998) an essential feature of anger management therapy in conjunction with violent people is the attempt to explain an understandable model of anger to the client and its relationship to triggering events, thoughts and violent behavior itself. Such identification of triggering events can suggest that therapeutic strategies and change are required.

In Jim’s case, the fact that his anger occurred only in response to particular forms of criticisms raises the possibility of removing triggering events themselves as a strategy for violence reduction.

Producing effective behavioral change by improving cognition processes is the central task of ‘cognitive therapy’. Jim’s hostile cognitiveappraisals may benefit from such therapeutic interventions.

In dealing with provoking situations successfully, Novaco’s (1975, 1978) cognitive methods focus mainly upon the modification of anger-inducing triggers. This was identified as an appropriate method of control for Jim’s anger. Thus, Jim underwent a cognitive-orientated group anger management-training programme, with particular attention paid towards the ‘habitual automatic’ nature of his thought process of other people as being malevolent and intent on doing him deliberate harm.

Evidently, Jim’s therapy increased his appreciation that his automatic thought process played a role in producing and maintaining his anger, and that he had an element of choice in deciding which thoughts were helpful and changing those which were harmful. These proved to be major steps in changing his violent behavior.

In addition, the physiological arousal component of Jim’s anger suggested that relaxation training might be of benefit in Jim’s anger management programme.

Finally, social skills training methods were used in an attempt to produce change in Jim’s overt behavior in angry situations, particularly in response to provocation. This was achieved by reducing the frequency of escalating verbal and non-verbal behavior.

The social skills methods used included: instruction, modelling, video feedback and role-play rehearsal, as part of a problem-solving orientation.

In practice, mental health clinicians maintained low voice volume and eliminated verbal threats, which proved to have the most obvious impact on actual encounters in terms of reducing the probability of a violent outcome.

Discussion
Ethical dilemmas surrounding the management of aggression are becoming increasingly important for mental health clinicians as carers of aggressive clients. Whilst the literature suggests that methods of coping with violence and aggression within mental health settings have improved, there is still a need to address certain areas ofconcern which have arisen within this paper.

According to Dale et al. (1999), control and restraint interventions have started to respond to the needs of the patient. This has been compounded by the need for physical interventions to be taught within a framework of analysis, trigger awareness, philosophical models and victimology. Therefore, there are methods available that allow interventions to be adopted on a wider scale. This gives the opportunity for violent offenders to be assessed taking into account interactive factors. This in turn gives the opportunity for an individually structured, reliable interactive treatment programme encompassing change, as highlighted within the case study.

However, the majority of literature discussing the use of control and restraint stress the need for its reduction, due to its highconnection with harm.

Although control and restraint may be perceived as the primary intervention within the hospital and prison environment for violent offenders, it is only a short-term intervention, which can no longer be defined as safe as it often results in harm; for example, deconditioning, strangulation, combativeness, humiliation, anger and fear, and especially the deaths of Joy Gardnerand Michael Martin which were the result of restraint use.

Additionally, Molasiotis (1995) claims that the challenge in improving the quality of care is in the development and testing of alternative measures to physical restraint. He goes on to state that it is important that practitioners’ attitudes, as well as knowledge, are taken into account when changes or improvements in nursing practice are considered, as attitudes influence practice.

It is clear that much is needed to be done before methods of control and restraint (such as physical restraint, seclusion, and chemical restraint), can be considered to be safe, therapeutic, measurable interventions that are compatible with the role of the carers.

A philosophy of care must influence how and when control and restraint teaching and its application takes place. The teaching of physical restraint techniques should be built on a knowledge and value base. In addition it should be incorporated within an overall framework aimed at offering skills in aggression management for both the client and the mental health practitioner.

The case study identified the need to both develop and restore non-touch interventions. Therapeutic interventions were less directed towards the simple prevention of aggression and violent behavior and more directed towards helping the client to find ways of articulating his feelings and engaging in non-violent forms of residence. It is evident that attempts in introducing non-threatening/non-violent interventions can be successful in reducing the probability of violent outcomes.

Thus, by having an extended number of interventions, mental health practitioners as carers can indulge in systematic risk-taking or negotiating techniques like physical restraint.

As highlighted within the case study, mental health clinicians were orientated towards exploring the clients’ experiences of oppression, invasion, privacy and criticism both within and outside the mental health services. Thus, aiding and enabling the client to use anger, resentment and frustration more productively. Nevertheless, the present move towards anger management will not eliminate the need for control and restraint in every situation. In the first instance, this is partly because whatever structures and therapeutic interventions are put in place, some individuals will always be unable to cope with their anger and frustration, which may present as aggressive and/or self-injurious outbursts.

Second, this is partly because there will always be individuals using mental health services for whom a normal way of living involves the use of violence to dominate and intimidate others.

However, the importance lies in reorienting mental health services away from ideologies that suggest disturbing behavior is maladaptive, and moving towards models of mental health that encourage the productive use of anger and anger management training. This would reduce the number of occasions where the use of physical restraint techniques becomes necessary. Thus, helping to dispel myths about the presumed danger of mentally distressed persons. In addition, this can hopefully challenge the myth that those considered most suitable for coping with aggressive patients need to be of a machismo disposition.
-Lewis, D. M. Journal of Psychiatric and Mental Health Nursing. December 2001

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Personal Reflection Exercise #2
The preceding section contained information about responding to a violent incident. Write three case study examples regarding how you might use the content of this section in your practice.

QUESTION 11
Although control and restraint may be perceived as the primary intervention within the hospital and prison environment for violent offenders, why can it no longer be defined as safe, according to Lewis? Record the letter of the correct answer the Answer Booklet.

 
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