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Tuesday, July 7, 2009

Treatment Tuesday - Intermittant Explosive Disorder

Today's assesment comes courtesy once again from Chas. He's written in before about Evelyn, an angel turned human. From the same story premise comes Gretchen*, a human. Here's her character sketch.

* Names have been changed to protect the fictional.

Gretchen has always been the obedient older sister growing up. She was shy and geeky and boys teased and shunned her. She coped with this in high school by playing basketball. Once in college though, she rebelled and slept around because she could. The one significant relationship she had in school was a heartbreaker and she's struggled with men ever since. When she met her husband, she still hadn't resolved using flirtationto seek attention. As her relationship progressed with her husband (before and after her marriage at 27), anger resurfaces from those formidable years growing up, resulting in outbursts she can't control. In once such outburst directed at her husband, Gretchen partakes in an affair.

The first thing to consider is just how angry you want to make her. On the continuum of anger, you can range widely from mild irritation to full out assault or someone else or your self. Gretchen's anger seems outwardly to be directed at others (due to how she was treated), but I would assert it is an anger directed mainly at herself. Maybe she feels insecure because she didn't measure up to others (in her estimation). Maybe each and every time she had sex with a different guy, she was filled with self-loathing. Depending on her relationship with her father and whether or not she felt protected and supported, it's quite easy for her to translate her feelings about him to her husband. These are all questions I would find out the answers to in an initial therapy session with a client coming in for anger management.

Anyone coming in for anger issues will likely expect some sort of miracle fix for their symptoms. Almost 100% do NOT expect the therapist to delve into the reason BEHIND the anger. (I'm not may think this would be a given, but it's not. Especially with court-appointed clients. In and out is what they want.)

So, Chas, have your angelic therapist ascertain the bulk reason behind the anger. As I mentioned, Gretchen might be able to identify it was her treatment by others that still makes her mad today, but WHY is getting to the therapy behind it. Hope this makes sense. Counseling really isn't that hard...very instinctual.

But you will want to address her symptoms as well as the underlying reasons. The easiest way to do this would be with systematic desensitization. This is the same technique used with clients who have a fear or paranoia. It's easier than it sounds. In a nutshell, you have Gretchen come up with a hierarchy of, say, ten things that she gets the angriest over. Have her list them out. Then out teach her progressive relaxation skills (where you go through areas of the body from toe to head clenching and relaxing muscle groups) and then have her visualize the least angering event on her list and monitor her reactions (pulse, breathing). If she is able to remain calm through the visualization, you move onto number 9. Stop immediately when her anger can no longer be controlled in session when she thinks about these things. Treatment is considered complete when she can successfully visualize the number one thing on her list and remain calm.

Some therapists are even more directive then this and want to create the situation that angers or produces fear. If the client is ever asked to recreate an argument with their spouse or something like that (like making a person scared of the subway take a ride), then the technique is called in vivo desensitization.

As to a diagnosis that could fit, Intermittent Explosive Disorder could work, especially if her anger results in aggressive impulses that cause harm to someone else or destroy property (throwing a vase at someone's head would cover both). The key to this disorder is that the aggressiveness is grossly out of proportion to the precipitating psychosocial stressors. This is what we call "flying off at the handle for no reason."

Since Gretchen is at least 27, none of the disorders usually diagnosed is childhood and infancy would fit (like Conduct Disorder) unless she did these things before she was 18. The therapist would need to check her drug history and medical background to make sure nothing could have triggered such outbursts. During this assessment, a psychosocial history would also be gathered, including a developmental timeline. Then the red flags should be abundant. I don't feel she remotely meets the characteristics of Borderline or Antisocial Personality Disorders, but those would have to be ruled out, as would adult ADHD.

Now I haven't forgotten about the affair, just had to cover a lot before then while it was on my mind. The key to how the therapist should approach the affair is in what order it falls in the line of importance with the client. What brought Gretchen in in the first place? If it was the affair and she and her husband want marital counseling to get through the breach of trust, then the anger issues for her might be better explored in individual counseling with her, to keep the focus of the session on the couple instead of singling her out with her issues. I'm assuming that she feels horrible about the affair because she is a Christian, but what led the the breakdown in the marriage in the first place? Most affairs have already occurred long before the actual act of intercourse. The emotional attachment begins with someone else for several reasons, chief among them being the other partner being unavailable emotionally. As takes two to make or break a marriage. It often gets pinned on just the one who committee the overt sin. But it is also a sin to deny your partner yourself except by way of mutual agreement. So what I'm really trying to do here is make sure the husband owns up to his responsibility. Sure, no one forces Gretchen to sleep with someone else, but therapist should never take sides.

I guess this is as good as I can do from an iPhone! So no pictures or links...I might add those later when I get back from the sticks. I hope there isn't any typos, as I'm not at all sure how to go back! As always, more specific questions are welcome in the comment section, Chas. Thanks for writing in!

This service is for fictional characters only, so any resemblance to real life examples is entirely coincidental. Any other fictional assessment questions can be directed to

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