Support And Family Education: Session Three - What can I do when my family member is angry or violent?

Session Three - What can I do when
my family member is angry or violent?

Materials Needed:
Handout F: "Anger Management -- Time Out Process"
Handout G: "Referrals for Domestic Violence"

Brochures on local treatment options for patients with anger management difficulties

Anger is a normal human emotion
1. Just like other feelings (e.g., sadness, joy), humans experience anger at different times and express the emotion in different ways.
2. Although many people think that being angry is wrong or bad, anger itself is not a problem. The behaviors that stem from this emotion can become problematic.
Important issues to consider about anger and violent behavior
1. Intense emotions may be a symptom of the mental illness. However, individuals can learn to control and be accountable for their behavior.
2. Anger may be related to delusional thinking.
3. Anger and its expression may be strongly affected by substance use.
4. You as the caregiver may not have done anything to upset the person. Further, you are never responsible for your family member's acting-out behavior (even if your behavior upsets him/her). Your family member may try very hard to blame you for his/her behavior.
5. Anger may be the emotion that is expressed directly, but the individual may be experiencing a great deal of fear underneath the anger.

Common causes of anger in all human beings (Note: These can be reality-based or not, such as with paranoia)
1. Feelings of injustice (feeling somehow wronged or treated unfairly).
2. Feeling of personal or physical attack (feeling threatened by another person).
3. Feelings of inferiority or lack of control (put-downs, excessive criticism, being told what to do, feeling like you don't have any choices).
4. Feelings of vulnerability (feeling exposed or afraid of being harmed, emotionally or physically).
  
  Discussion Questions:
  - What pushes your buttons? (e.g., your family member not taking medications, refusing to go to the doctor, refusing to participate in family activities, not taking care of hygiene, drinking too much alcohol)
  - What pushes your family member's buttons? (e.g., being told what to do, overwhelming situations, feeling out of control)
5. Although our science is not very good at predicting violent behavior, the best predictor of future violence is past violent behavior. Reflecting on the situations that surrounded previous acts of violence can provide clues as to potentially difficult situations in the future. This information may also guide efforts to prevent future violence.
Effects of chronic anger

Discussion Question:
- How can chronic anger and/or inappropriate expressions of anger affect the family?
1. Strains interpersonal relationships.
2. May lead to feelings of guilt, regret and shame.
3. Can have adverse effects on communication (may not feel safe to express one's feelings honestly for fear of consequences - so significant emotional distance may result).
4. Family members may feel like they are "walking on eggshells."
5. May be somatic / physical effects of chronic anger in family members (e.g., migraines, stomach problems, tension, jaw / TMJ pain).
6. Anger may lead to physical violence, which is never acceptable, regardless of the cause.

Cycle of Violence: Episodes of violence have a predictable beginning, middle, and end: (Write stages on board) (Woolis, 1992)

Phase One	Activation	Stress occurs
Phase Two	Escalation	Intervene now if possible
Phase Three	Crisis	Violence may occur
Phase Four	Recovery	Less agitation
Phase Five	Stabilization	Guilt and remorse

In what phase would intervention be most effective?

Family members often try to intervene in the most heated moments (in crisis or recovery phases). During these phases, patients are not ready or able to take in information and discuss issues calmly.
Intervening in the escalation stage has the highest likelihood of preventing an angry outburst.
Most effective communication can occur (and efforts made to prevent future violence) in phase five (stabilization). If you ever feel in danger, immediately remove yourself from the situation and/or call 911. You should never stay in a frightening situation.

Coping strategies for family members in dealing with another individual's anger
1. Be prepared.
  1. Decide in advance what the limits are regarding your relative's expression of anger. These limits need to be consistently enforced to be effective.
    
    Example: I will tolerate my family member raising his/her voice, but I will not put up with swearing or name-calling.
  2. Decide in advance the consequences of such a behavior.
    
    Example: I will walk away from the discussion if name-calling or swearing begins.
  3. Discuss these limits with your loved one during a calm time. Clearly and concisely explain the limit without getting into a debate or justifying your rationale.
  4. Follow through on the consequence every time. Otherwise, your family member will learn that he/she doesn't have to abide by this limit and will push you the next time.
2. Stay calm and nonjudgmental.
3. Attempt to understand and acknowledge the person's angry feelings. Oftentimes individuals escalate their expression of anger when feeling misunderstood. The intensity of the anger usually decreases when the person feels that the listener is genuinely trying to understand.
4. Choose your words wisely. Avoid generalizations ("you always…" or "you never…"), as these evoke retorts, counter-attacks, and further polarization.
5. Avoid asking too many questions (can spark defensiveness and further anger).
6. Use "I" statements to report your own feelings.
  
  Example: When you yell at me, I feel hurt.
Time-out process
1. Many parents use a time out process in disciplining their children. Although the discipline strategy and this anger management tool share the common goal of giving each party some time to cool down, the techniques are quite different.
2. This time out process is a mutually-agreed upon strategy between equals (rather than involving a power differential such as in a parent-child relationship). Further, this technique helps people disengage from conflict early in the argument (to avoid further escalation), rather than functioning as a form of punishment.
3. This is an excellent process to negotiate with your family member in advance (during a calm time).
4. Distribute Handout F: "Time Out Process."
5. Review process step by step.
6. Role play in session.
7. Brainstorm possible obstacles in applying it to your relationship(s). Problem-solve possible solutions.
Violence in relationships
1. Threats of physical violence and/or actual violence are very important issues to address in families. Abuse should never be tolerated, as it is damaging to you, to the patient, and to your relationship.
2. Domestic violence is eroding our families, as 25% of American couples experience at least one act of physical aggression in their marriages (Bogard, 1984). The FBI estimates that a woman is beaten every 15 seconds in the United States.
3. Most people with mental illness are not violent; rather, many are socially withdrawn and quiet. Most of the research has not found a higher incidence of violence among people with mental illness than the general population (Woolis, 1992). However, Vietnam veterans who have symptoms of PTSD (post-traumatic stress disorder) are at increased risk for perpetrating acts of domestic violence (Jordan et al., 1992; Riggs, 1997).
4. Distribute list of local referrals for domestic violence (example shown in Handout G: "Referrals for Domestic Violence").
  - This list includes 24-hour crisis hotlines and emergency shelters. Shelters provide a safe place to stay, without the guilt of imposing on friends or extended family. Contact numbers for low-cost legal aid and victim protective orders (VPOs) are also listed.
Provide local treatment options for individuals dealing with anger management issues

Example: Oklahoma City VA Medical Center
1. Anger Management Class
  - This 4-week class assists patients in identifying the triggers for their anger and learning effective ways of expressing this emotion.
2. Couples or Family Therapy
3. Psychiatric Medications

Special thanks to Ernestine Duncan, M.A. and Anita Bazile, M.S. who contributed to this session outline.