Conflict

Rehab with members who have difficulty managing disagreements with other people, or tolerating their behavior. They often have trouble controlling their temper and regulating emotional responses, leading to angry outbursts and other maladaptive behaviors.

 

These are examples of G & I sections only, not the entire note.

G: Jean is a 41 y/o single Caucasian female.  Due to irritability, paranoia, and disorganized thinking, Jean frequently gets into verbal altercations with others, including her mother, yelling and raising her tone of voice. I met with Jean today to work with her on her current #2 objective, “Jean will be able to describe 2 instances per week in which she used a de-escalation technique to remain calm in a situation where she would normally have lost her temper, and sustain this change for 6 months.”

I: Worked to increase Jean’s awareness of the physical responses and sensations she experiences as her anger begins escalating, from the earliest signs (changes in her breathing, tightness in her stomach, feeling flushed, etc.) to those she experiences as her anger increases (e.g., interrupting people more often than usual, raising her voice, assuming an aggressive posture). Purpose is to help her recognize physical signs of escalating anger as early as possible so she can disengage or implement calming strategies that I plan to begin teaching her next week.

G: Jean is a 41 y/o single Caucasian female. I met with Jean today to continue working with her on her current #2 objective, “Jean will be able to describe 2 instances per week in which she used a de-escalation technique to remain calm in a situation where she would normally have lost her temper, and sustain this change for 6 months.”

I: Reviewed signs of escalating anger that we identified last week. These are sensations and behaviors Jean experiences, which may not be visible to others, as she begins to escalate and her risk of having an angry outburst increases. Then we worked to identify things Jean can do when she recognizes these signs, such as slowing things down, “buying time”, focusing on her breathing, inhaling slowly and deeply, and disengaging if tension continues to escalate.  Modeled breathing deeply and how to disengage in a tactful way (e.g., saying “I need time to think about this”).

G: Jean is a 41 y/o single Caucasian female who has difficulty managing her anger. I met with her today to continue working with her on her #2 objective of being able to describe at least 2 instances per week in which she has successfully used a de-escalation technique to remain calm.

I: Reviewed what we covered in our prior 2 sessions, early warning signs that Jean experiences when she is becoming increasingly angry, such as patterns of behavior or physical sensations, and things she can do when she becomes aware of these signs. Today I modeled the use “I” statements, such as “I feel disrespected when that happens” instead of “You’re disrespectful”. I then did role-reversal with Jean, expressing anger in an accusatory way (“You don’t care about me”) and challenging her to express the same feeling with an “I” statement (“I don’t feel cared about by you”).  I also modeled how several different situations she encounters could be handled without the use of insults or threats.

G: Kailey is a 33 y/o single Caucasian female who is diagnosed with borderline personality disorder. I met with Kailey today to work with her on her current #3 objective of learning to express anger without raising her voice, and without turning and walking away from the situation (cutting the other person off) before it can be resolved.

I: Engaged Kailey in a discussion about anger and whether displaying it was an effective way of getting others to do what she wanted. Identified consequences of using anger to control and punish people. Kailey was able to come up with several undesirable consequences such as people avoiding her and becoming emotionally distant; replacing her in their lives with people who were easier to get along with; being less willing to do favors for her; and kicking her out of places she has lived. Began a discussion of more effective techniques Kailey can use to get her needs met.

G: Kailey is a 33 y/o single Caucasian female. I met with Kailey today to continue working with her on her #3 objective of expressing anger without raising her voice or walking away in the middle of a discussion.

I: Resumed discussion of techniques Kailey can use to get what she wants and needs without cutting others off mid-conversation or raising her voice and becoming aggressive.  Asked her to think of situations where she had abruptly ended the conversation leaving a problem unresolved, in some cases not speaking to the other person again for weeks or months, and consider what the eventual outcome was. Purpose was to raise her awareness of the fact that regardless of what she feels in the moment, the long-term outcome is almost always negative -- the loss of companionship, emotional support, opportunities to participate, etc. I then brainstormed with her to generate ideas on how she could have handled those situations differently.  Reviewed our best ideas (asking for time to think, taking deep breaths) and encouraged her to try applying one or both of them to similar situations she encounters in the future.

G: Kailey is a 33 y/o single Caucasian female who has difficulty managing her emotional responses. I met with her today to continue working with her on her current objective of expressing anger without raising her voice or abruptly terminating the conversation.

I: Today we discussed techniques that Kailey could use to decrease or eliminate angry outbursts. I explained a number of different techniques to her, such as journaling about her feelings, writing an angry letter and then throwing it away instead of sending it, venting to a trusted friend or someone who isn’t connected to the person or persons she is angry with, getting more physical exercise, and accepting her share of responsibility for conflicts she has with others. I told Kailey she can continue composing an angry letter for several days or weeks if she wants, getting the feelings out of herself and onto paper, adding and changing things in preparation for the final draft, which she will throw away. I explained that buying time this way can help her see things more objectively, possibly from the other person's point of view, and avoid saying things she later regrets.

G: Joseph is a 52 y/o divorced Caucasian male. Due to anxiety, angry outbursts, and social-skill deficits, Joseph has difficulty initiating and maintaining relationships with other people. He expects to be rewarded for small favors and friendly gestures he extends to others, and if the favor is not returned his anger continues to escalate until he has an explosive outburst.

I: Joseph denies having a problem and expresses no interest in learning anger management techniques, so I engaged him in a discussion about the pros and cons of having angry outbursts, with the goal of increasing his insight and motivation to change. On the plus side Joseph identified the release of pent-up tension, like a catharsis, and standing up for himself. On the negative side, he was able to see that these outbursts were toxic to his relationships if they occurred repeatedly, and that they left him with few friends. He was unable to recall any situation where a calmer approach would not have resulted in a better long-term outcome.

G: Joseph is a 52 y/o divorced Caucasian male. Due to angry outbursts and limited social skills, Joseph has difficulty initiating and maintaining relationships with others. I met with him today to work on his #3 objective of increasing the size of his social support network from a baseline of zero to a goal of at least 3. 

I: Reviewed our discussion from last week about the pros and cons of having angry outbursts, focusing on the negatives Joseph identified and how they appeared to outweigh the positives. Then I explored with Joseph how he could recognize a situation in which he was escalating towards an angry outburst. By looking back at a number of recent situations Joseph was able to identify several things he felt or did that seemed to precede an angry outburst, such as his skin feeling hot, clenching his fists, raising his voice, interrupting more often, and getting “tunnel vision”. I praised Joseph for his willingness to examine his own behavior and talk with me about it.

G: Joseph is a 52 y/o divorced Caucasian male. Due to irritability, angry outbursts, and limited social skills, Joseph has difficulty making friends and sustaining friendships he already has. I met with him today to continue working on his #3 objective of increasing the size of his social support network.

I: Last week I noted that Joseph responded positively to praise, so I began this session by framing "willingness to change" as sign of strength and courage, then praised Joseph for having this willingness despite the fact that he has not actually demonstrated it yet. Reviewed our last two sessions in which we identified how he could benefit by controlling his temper, and how he would know when it was time to take action (i.e., to either disengage or start using a de-escalation technique). Today I modeled disengagement for him (e.g., saying I needed to use the restroom, or that I needed time to think, or time to check something out). Demonstrated how he could do this tactfully and give himself time to calm down and regroup without creating a scene or losing face, then resume the conversation when he felt ready.

G: Carl is a 37 y/o single Caucasian male. Due to irritability and low tolerance for frustration, Carl gets into heated arguments with his housemates over minor issues such as the volume of their music, often destroying property and making threats while doing so. Carl's R&B manager reports that Carl will have to move out if this continues.

I: I met with Carl at his R&B. Helped him search for patterns in his behavior and assisted him in identifying precursors to angry outbursts. Reviewed self-interventions Carl can use as soon as he recognizes one of these early warning signs that he is about to lose his temper, such as counting to 10 or temporarily disengaging and taking a walk to discharge excess energy. Modeled these techniques for Carl and encouraged him to practice using them.

G: Chris is a 54 y/o single Hispanic male. Chris has needed dental work for several years but due to irritability, anxiety, and low tolerance for frustration, he gets up and storms out of waiting rooms, insults treatment providers, shouts profanity, and refuses to follow directions. For this reason I accompanied Chris to a dental appointment today to teach and reinforce coping skills to reduce the risk of an angry outburst that prevents him from receiving the treatment he needs.

I: Met with Chris at his apartment and took him to the dentist's office. On the drive to the dentist's office, I reviewed with Chris the self-interventions he can use if he starts getting upset or frustrated, such as focusing all his attention on his breathing and breathing slowly and deeply, using calming mental imagery, and signaling if he needs a time-out to calm down or ask questions. At the dentists, I sat with Chris during his procedure and provided support. I explained what was happening and prompted Chris to use the skills we had practiced on the way here. I did this repeatedly towards the end of the procedure as the hygienist was inexperienced and began making mistakes. On the drive back to Chris's home, I worked to increase his ability to put himself in in other people's shoes, with the goal of reducing angry outbursts. Pointed out that the hygienist was new and probably very nervous, and asked Chris to think about how he might feel in that situation, and how it might affect his performance.

G: Larry is a 44 y/o single Hispanic male. Due to irritability and low tolerance for frustration, Larry gets into loud arguments with his neighbors over minor issues such as the volume of their music. He pounds on shared walls and yells profanity at them through their windows. His apartment manager has given him warnings and says he will be asked to leave if his behavior continues.

I: Brainstormed with Larry about alternative ways of handling issues with his neighbors. We came up with 4 ideas: 1) Establish a good relationship with his neighbors before problems come up. Offer a friendly greeting, smile, introduce himself, and make small talk if the opportunity presents itself. Neighbors who know Larry in this way are more likely to be responsive to his requests than neighbors who don't; 2) Ask neighbors to turn the volume down politely, by going to their door, saying excuse me, and making his request in a non-threatening manner; 3) When volume levels are high, use that time to run errands, visit friends, go jogging (which Larry likes doing), or do another activity that takes him away from the apartments; 4) Talk to his apartment manager about it. That's what the manager is there for.

G: Meredith is a 38 y/o divorced Caucasian female. Due to A/H, trouble concentrating, and low tolerance for frustration, Meredith has difficulty setting boundaries with her 20-year-old son, who continues to come and go from her home as he pleases despite her requests that he stay away. Meredith's son shares her diagnosis but is more symptomatic, and the stress created by their heated exchanges causes Meredith's own symptoms to get worse, especially her A/H and ability to make good decisions. For this reason I met with Meredith at TAO today and accompanied her to her home to observe her interactions with her son, if he is there, and provide suggestions on how she could do things differently to improve communication and reduce the amount of stress their interactions create going forward. 

I: On the drive to Meredith's home, I explained that some people with her diagnosis are highly vulnerable to stress, and that even small amounts of it can make their symptoms get worse. Meredith acknowledged that she thinks this may be happening with her. I also explained that when people have A/H, being in a loud environment with multiple people talking at once can make communication difficult and ineffective. Since Meredith's son also has A/H, their habit of shouting at each other and trying to talk over each other probably makes things harder for both of them. Meredith's son was not at home when we arrived, so I modeled how to interact with him when he returns, listening to him at first and waiting until he is finished to say anything. I suggested they take turns this way, and do everything they can to keep volume levels low. I role-played this kind of communication with Meredith so she could practice it.

 

All PHI has been de-identified per HIPAA Privacy Rule