Anger management and antisocial behavior in at-risk adolescent males

Therapist Name:

Case Name/#:

Reason for Referral:

The client is a 15-year-old male who has issues with anger management. The client is also a gang member and given his age and background he is considered to be at risk for a number of antisocial behaviors.

Presenting Problems:

Clinical concerns: Anger management/acting out.

Clinical concerns: Interpersonal isolation/relationship issues.

Clinical concerns: Underage cigarette smoking.

Client is a high potential risk for substance abuse.

Clinical concerns: Client is at a high potential risk for depressive symptoms.

Contextual considerations:

The client has been in counseling with another counselor for four months before being transferred to this counselor's caseload. According to the reports from his previous counselor this client had made very little progress and was uncooperative.

He was uncooperative during the initial assessments and did not wish to discuss his feelings or acknowledge that he has difficulties with managing his anger. He tends to rationalize his outbreaks and does not see himself as responsible for them, but instead places the blame on other people for his outbursts of anger and aggressiveness. These outbursts can occur whenever someone disagrees with him or he does not get exactly what he wants. He uses anger and aggressiveness as a form of intimidation to coerce others to either give him what he wants or to leave him alone (which is often what he wants). Thus, his outbursts of anger are reinforced on a contingent basis because he can justify leaving or he can intimidate others into giving him what he wants or getting them to leave. In this manner it allows for him to feel superior to anyone that he can intimidate or he can remove himself from. This leads to him being quite self-centered and self absorbed and only concerned with his needs.

We can hypothesize that the client's anger actually represents a number of affective states including his frustration with his life and with personal relationships as well as anxiety and frustration that he attempts to gain mastery over by "acting out" via the use of sarcasm, aggressive behaviors, and cigarette smoking (McWilliams, 1994).

III. Relevant Background Information

The client is the oldest child in a sibship of two with one younger brother. The family lives in a four room flat in Bukit Batok. Both parents work collecting old newspapers, soft drink or aluminum cans, and other things that can be sold to companies that collect materials for recycling purposes. They both leave very early in the morning before the children go to school and come home very late, but the mother does cook dinner. The parents have very little interaction with both of the boys and their interactions primarily consists of punishing the boys for reported transgressions at school, behavioral issues at home, and poor grades. Outside of being punished by his parents the client appears to have very little parental supervision and does not appear to view his parents as positive role models that he would like to emulate, although he does state that he wants to help support them someday. The client looks up to higher-level gang members, musicians, and elite sport sports athletes as his role models.

The client has exhibited issues with anger management since upper Primary school, and is reportedly doing below-average level work in school. He joined a gang at the age of 13 years old for protection purposes as gangs are common in his environment. He was arrested in 2012 being apprehended at a gang settlement talk and sentenced to six months in a corrective boy's home. He has no other offenses.

The client denies the use of drugs as he is fearful he will be caught by the police and this will be a "death sentence" for him. He smokes regularly in an effort to relieve "boredom" but has resisted the attempts of his peers to get involved in alcohol or drugs.

IV. Contact Details:

Client was seen for eight sessions.

V. Formulation:

First and foremost, while there are obvious anger management issues currently there is not enough information to apply any other solid diagnoses in this case. We can get a sense of depressive symptoms, a need for acceptance, his frustration and acting out, and his potential for substance abuse. However, we need to keep in mind that there are features of depression and anxiety in nearly every psychiatric disorder and in all instances of dissatisfaction with one's circumstances (Hoch, 1972). It is tempting to diagnose a mood disorder when in fact the moodiness may represent part of a larger issue; therefore, just diagnosing the patient with "depression" will not reach the core issues here, aside from the fact that we do not have enough information to satisfy the diagnostic criteria for depression (American Psychiatric Association [APA], 2000).

The patient does display very early features of a potential characterological disorder, but again, there is not enough information to satisfy the diagnostic criteria for a personality disorder, he is too young for such a diagnosis, and there is no indication of an Oppositional Defiant Disorder at this time (APA, 2000). There also appear to be long-standing issues regarding this patient's personal relationships. These may reflect feelings of inferiority, concerns of self-worth, the need to gain acceptance, and may be rooted in an unconscious wish to be accepted and perhaps nurtured.

Individuals who experience difficulty controlling their anger often experience problems with perceived pressures from other people, their life situation, and difficulty understanding and predicting how people relate to them. Their everyday negative thoughts, negative beliefs, and difficulties with interpersonal relationships are all intertwined with these issues because tension related distressing creases the likelihood of an anger outburst or aggressiveness.

For most people there is a continuum between being irritable and anger that is fueled by beliefs that one's life is unfair or that other people have violated one's standards of behavior. Often difficulties with anger management in young people can surface when the person is repeatedly criticized or humiliated to the point where they do not feel worthwhile. Such wounds to the young person's self-esteem are triggered when they believe that they have to defend themselves against negative feelings by engaging in aggressive behaviors to protect their own self-esteem.

Of course there are times when someone really is threatened and responds with aggression or anger, but becomes problematic when one responds with anger to a broad range of circumstances or uses inappropriate anger to defend oneself. Anger of any type is composed of: (1) the method a person uses to interpret their experience; (2) the process a person uses to recognize, to express, and to control their anger; and (3) communications that occur in interpersonal relationships (either communication errors or genuine communications; Sukhodolsky & Schahill, 2012).

Sessions One and Two

During the first session of treatment the client was hesitant to discuss his feelings in session. It was clear that he did not believe that he needed any type of therapy or counseling for his anger issues. Most of his responses to questions were short and he did not want to discuss his involvement in the gang other than to explain that he joined the gang for protection as gang activity was rampant in the schools. Belonging to a gang afforded him some security against being bullied and attacked by other gangs.

In order to develop poor within it was important for this counselor to emphasize with his feelings. Since both client and counselor knew that he was in counseling for anger management issues it was easy to work in instances of when the client felt angry during conversation. Once he discussed his anger during the session we focused on his instances of getting angry at people outside the session. It was easier to get him to explain why people made him angry as opposed to how he felt. Initially, as long as the focus of the conversation was and that what others did to make him angry he became very cooperative. By the second session it was easy for the counselor to get the client to think about what he did to make others angry. This was a major step in the progress of the counseling sessions because it allowed the client to become introspective as opposed to reactive. Being able to look "within oneself" so to speak is an important component of any CBT intervention and this is often something very hard for adolescents to do.

Sessions Four through Five.

One of the important goals of this therapy was to reduce anger outburst in the client. Once he was able to reflect on his contribution to his outbursts of anger it became important to get him to acknowledge that his anger was not productive in his relationships. Unfortunately for a gang member anger sometimes is very important in avoiding conflict as it acts as a bluffing mechanism that can avoid physical confrontations. It was important then to discuss when his use of anger was functional and when it was not functional. Both counselor and client decided that in the context of gang interactions he would continue to react as normal, but in the context of reactions with teachers and non-gang members such as parents and others he would try to interact with them differently. We discussed how we could use a mental "stop" technique whenever he felt himself getting angry with an adult or non-gang member and how this would call his attention to the situation. Based on the stop technique we were able to define the predisposing situations of when he felt angry with others and this resulted in four broad categories that triggered anger in him: threats to his self-esteem, feeling like someone was trying to control him, feeling like someone was treating them as worthless, and in situations where he was intimidated by someone.

It was much more difficult to get this client to practice relaxation techniques and stress reduction techniques. We were able to practice them in -- session, but he freely admitted that he did not use them outside of the sessions. There was no point in trying to force him to practice regularly; instead the counselor decided to devote five minutes of relaxation and breathing at the beginning of each session. This allowed him to develop the skill and if he decided he ever wanted to use it for himself in the future he could do so.

Sessions six and seven.

These sessions focused on challenging many of his core beliefs such that the client would have to re-examine the way he viewed others and his predictions about future events. Most of these perceived threats were centered on a false image of masculinity that probably is not uncommon for an adolescent this age. When he would discuss his beliefs that others were trying to control him or thought of him as weak the counselor suggested that he attempt to look at the situation differently, as if there might be another reason for the teacher or parent's behavior. While this strategy was not successful all the time, it did jumpstart him into thinking about other possibilities for the actions of his parents and teachers. For example, when his mother once complained that the house was messy and he should help clean it he reported to the counselor that he initially perceived this to mean that she was accusing him of messing up the house. He thought about it, discussed it in the session, and told the counselor that he was taking his mother's comment personally and that is not what she meant. Instead his mother was asking for help. This was another breakthrough moment in the course of the counseling where the client was able to identify his own negative beliefs and consider that these beliefs were not always true.

Once the client was able to identify a situation with his mother where he was holding onto a negative belief it was easier for him to recognize other instances where he engaged in the same type behavior with his parents. However, it was much more difficult to get the client to consistently reevaluate his interactions with teachers. He held the belief that because he was in a gang all authority figures other than his parents were out to get him. We were able to identify several instances where this obviously was not the case, such as an instance when he was yelling at another student and a teacher confronted him about yelling and being aggressive. In this instance he was able to dissect the situation and admit that that type of behavior in the school was really not appropriate and that he could have easily walked away from the incident and nothing would have come of it.

It was more difficult to have him make the connection between his poor study habits and reluctance to do homework assignments and his grades which had fallen. The client continued to have the impression that his schoolwork was not that important to him and his gang activities and friendships were much more valuable. He was able to identify with his parents who worked extremely hard and work long hours and he wanted to be able to help them. During discussions concerning his parents he was able to admit that he would be a better position to help them if he did well in school and when graduated got an advanced degree that would lead to better employment opportunities as opposed to helping them collect materials for recycling. He was also able to make the connection that his attitude concerning his schoolwork would not allow him to reach that goal, but by the end of the seventh session he still had not significantly changed his studying habits or had committed to a particular area of interest outside of sports.

Session Eight.

The client was set to be discharge from therapy due to meeting his requirements as a result of his infraction and the last session was spent reviewing, discussing how to handle future instances, and working on obtaining resources for him that would allow him to investigate fields of study he may be interested in the future. He was quite interested in many areas of science and computers and he was given a list of resources to follow up after he was discharged. Due to time constraints we were unable to investigate many of his core beliefs and their origins as stated in the goal outline for this client. However, at the termination of therapy that client had been able to reflect back on his own behaviors and see some of the potential mistakes in his thinking about how others see him as well as to apply some cognitive and behavioral techniques to changing these mistakes.

VIII. Outcomes of Counseling and Future Recommendations

Several goals of the counseling sessions were achieved:

First, the client was able to recognize several of the conditions that led him to becoming angry and we were able to categorize them. While he was still more focused on what others did to make him angry he was able to conceptualize how at times he was a contributor to his feelings.

Second, the client was able to use the "stop" technique when he began to experience feelings of anger. However, the counselor had to compromise with the client and he also exclusively used this technique in his interactions with his parents. He did use it in some interactions with teachers but virtually no interactions with other students. Nonetheless, he did develop a helpful tool to help them recognize when he is getting angry and approach the situation in a more constructive manner.

Finally, he was able to challenge several of his negative beliefs and come to the conclusion that in some instances these beliefs were not functional. However, again there was quite a bit a compromise with this and he still could not apply this to many of his peer interactions.

While the client was able to learn stress reduction techniques he would not practice them on his own and this must be considered a partial failure at the least because even though he learned the skill it is doubtful that he found it useful. Moreover, while progress was made in getting the client to recognize anger and in certain situations realize that he was responsible for it he still did not fully apply his new skills to all areas of his difficulties. Another ten to fifteen sessions would have been recommended to assist this client to solidify these skills.

Summing up the client did develop some new skills and learn some new tools but it is questionable whether he will be able to apply them outside of his time in counseling.

IX. Evaluation

This case highlights the need to devote a considerable amount of time to developing rapport and a working alliance with an adolescent or child client. The client in this case had been in counseling for two months with another counselor and little progress was made due to either the inability or refusal of the counselor to spend time with the client and develop rapport. Initially this counselor found the client aloof and uncooperative; however, once the counselor was able to empathize with the client and explain things from the client viewpoint counseling began to progress. The working alliance between counselor and client is extremely important in all cases, but especially with adolescents who often cannot or will not explain their problems

It may have been helpful for this client to have completed some formal measures of personality, mood, and anger control before formal counseling sessions were initiated. This could provide a counselor with the guideline as to how to approach the client on a more individualized basis and also to point out to the client areas of discomfort at the client endorses.

Is also extremely important to remember that clients often make progress at their own pace and cannot be rushed into realizations before they are ready, especially those that do not voluntarily come into counseling. It may be more appropriate to focus on several very circumscribed goals as opposed to broader areas such as "anger management." For instance in this case it may have been more realistic to concentrate on anger outbursts only directed at parents and teachers and not at anger in general. Having the client become more involved in setting goals is also helpful, but in this case given the history of previous counseling and pending termination it was deemed more appropriate by the counselor to attempt to direct the focus of the counseling sessions.