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|Case Study - Page 2|
As for substances, Adam told me he drank lots of caffeinated diet colas at work and had begun consuming two or three glasses of wine each evening as a way of "winding down." I told him that while we all vary somewhat, even small amounts of alcohol and caffeine tend to be disinhibiting and could fuel anger arousal. We agreed it was best to avoid drinking alcohol during the work week and to limit other drinks to decaf versions and water. Sarah's Five S's included drinking wine with Adam in the evenings, as well as frequent headaches, which fueled irritability and negative self-talk. I encouraged her to limit her alcohol consumption and to seek medical guidance for her headaches.
From their anger logs, we identified the first physical sensations of anger arousal. Adam reported that his chest felt tight and his breathing would get heavy. In contrast, Sarah found that her first anger tell was when her jaw felt tight. Both reported that the next phase of anger arousal they noticed was heat in the neck and face. I encouraged them to learn to identify these feelings as signals to begin arousal management.
At this point, I taught both Adam and Sarah to employ an easily remembered protocol for dampening arousal, which I call the Stop method—Stop, Think, Objectify, Plan. The first step to controlling anger is to reduce initial arousal by internally stating the self-instruction to "Stop!" while mentally picturing an image and/or hearing a sound associated with cessation. For example, Adam would imagine a bright, red stop sign and his father's voice saying "Stop immediately!"
Next, to derail anger escalation, it's helpful to ask clients to sit down (assuming a physical position the brain associates with safety) and engage in deep, diaphragmatic breathing. Adam and Sarah learned to sit in a fully relaxed position while practicing a version of diaphragmatic breathing and exhaling to a slow, internal count from 10 to 1. The acts of sitting and consciously breathing interrupt angry thoughts, because they focus attention on these tasks. Each was instructed to continue taking relaxing breaths as needed until his or her anger signal diminished.
I then encourage each partner to focus on his or her most upsetting, angry thoughts, which usually sprang from common cognitive distortions. Some examples include: mindreading—"Sarah just loves to get me mad, so she can accuse me of being irrational"; personalizing—"Adam's fury isn't about his stress: it's to put me down!"; overgeneralizing—"Adam can never cool it: he's always just on the edge of losing it"; and thresholding—"If Sarah corrects me in front of the kids one more time, I know I'm going to lose it." These distortions trigger fight-or-flight instincts and associated arousal, making it critical to develop the ability to step back and look at the situation through a more objective and calming lens.
After quickly identifying one or two distortions prominent in their thinking, each learned to rebut and replace anger-arousing thoughts with affirming facts. This is called objectifying. I typically teach clients a strategy I call "camera checking" to focus them on the observable facts of the anger-inducing situation. By emphasizing the facts, rather than perceptions colored by resentments, experiences, or faulty beliefs, partners learn to avoid demonizing and personalizing the other's words and actions. This process diminishes the perceived threat and, typically, leads to an immediate decline in arousal. For example, instead of thinking "She loves to make me mad"—an irrational mindreading of Sarah, Adam was asked to focus on observable statements and actions devoid of interpretation: "The fact is that Sarah is telling me her opinion of how I handled our son Jake. She disagrees with me." This thought—an objective statement, rather than an attack on the other's character—sets the stage for a discussion of differences of opinion.
Each partner is encouraged to think of an immediate plan, focusing on the facts of the situation. Having a plan reduces perceived threat by increasing one's sense of control. Adam's plan was, "I'll suggest we table this until I feel less exhausted," or "I'll look at her and listen until she expresses her ideas—seeing them as information and not criticisms or put-downs."
Therapy often involves entirely too much talking about new skills the client should put into place, but not enough rehearsing. Clients often understand well enough what to do when life challenges arise, but often can't recall and enact new skills in the heat of the moment. Accordingly, new coping behaviors need to be rehearsed enough to be automatic. I spend a full session with each partner, role-playing how to implement the Stop in mock situations of provocation. I model how to use the Stop, and then we reverse roles and have the client use it in the heat of role-plays that enact the most difficult and volatile situations each client can imagine.