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As part of my mental health clinical rotation to Karwan-e -Hayaat, I came across with a patient who was migrated from Afghanistan, diagnosed with schizophrenia and bipolar affective disorder since 28 years and had multiple relapses in these years. The major reason for his current admission at the hospital was his uncontrolled anger. He had fought with everyone around his neighborhood. While reviewing the patient’s file, I was shocked to observe that his file was labeled as ‘black listed’. On inquiry with the hospital staff, I was informed that patient has an aggressive behavior and had beaten their family members and other persons during his relapsed time. During an interview with the patient, initially he denied having any problem except for high blood pressure and his admission at the hospital was for hypertension treatment. However, after having developed some rapport with him, he described that since his teenage, he is in a habit of getting anger on small issues or when someone is disagreement or do unfair to him and he fights with everyone on petty matters. His habit of getting anger has lead to his aggressive and violent behavior over the years. As patient has also verbalized that he has difficulty in controlling anger and because of this he has poor relationships with others. During the various interviewing sessions with the patient and studying his history, I realized that poor anger management is a leading cause of aggressive and violent behaviors including many physiological and psychological problems. In my scholarly paper I relate the concept of anger in light of current literature and integrated with my client.
Anger is a mature and natural human emotion expressed by all individual at any point of their lives and also plays a significant role in human development. According to Novae° “anger is understood as a subjective emotional state, involving both physiological and cognitive activity, but which is clearly related to environmental circumstances”. Anger can be experienced and expressed in a healthy / adaptive way as well as in an unhealthy/ maladaptive manner. In an
adaptive way, anger helps an individual to communicate his or her feelings directly and assertively, in socially expectable manner and measure to resolve conflicts. Anger becomes maladaptive when it is experienced and expressed in a way that is detrimental to them and to society. Anger that expressed in an offensive manner is an early warning sign for aggressive and violent behavior.
In developing countries like Pakistan, anger plays a significant role in emerging many mental health problems. According to WHO in Pakistan, 65% women and 25% men in the community are suffering from psychiatric illness. Anger is root cause of domestic violence, widespread in Pakistan and the victims of domestic violence are prone to develop further anger and mental illness. According to Lalani 2008, researches show that 48% adolescence who witness their parental violence suffer from depression. Another study conducted at Psychology Department of the Punjab University, highlighted causes of domestic violence by male partner, as male chauvinism, gender biases, aggressive behavior and decision-making. In Pakistani culture people (especially women) are not encouraged to express their emotions openly and freely and their introvert attitude and passive aggression leads to many psychological problems including depression, self harm and suicide. A study conduct at Department of Psychiatry, Aga Khan University, Karachi, Pakistan in 2008, 69 patients admitted with deliberate self-harm (DSH) from them 63.8% were female, family conflicts was the main stressor reported by 66.7% and most frequent diagnosis made was major depressive disorder in 18%. Pakistan is a low socioeconomic country where poverty is an important cause in development of anger and hostile feeling in individuals. The people live in poverty are deprived of their basic needs and at high risk for developing many physical and mental health problems along with other behavioral problems. Adverse economic condition leads to many conflicts, aggression and depression.
Furthermore, the political instability and increasing rate of street crimes and bomb blasts are playing a major role in developing anger in the in the citizens. Many of them are maladaptive with these situations and demonstrate their anger by indulging in further crimes with unhealthy ways to cope with anger. As a result, many of young people indulge them in substance abuse or end up with self harm and suicide. Furthermore, they transfer anger and aggressive behaviors to their family members in one way or another by promote mental illness within their family.
Anger is a significant mental health problem, but persistent anger is still not represented by the diagnostic category in the official psychiatric diagnoses DSMIV. Anger is not always a primary emotion it can generate in response to hurt, frustration or fear to one’s self harm. Anger may exist alone without any psychiatric problems, as behavioral or social problems like school or workplace problems, financial problems, low self-esteem on other hand it may be part many psychotic disorders like anxiety disorders or mood disorders. Gorenstein, Gorenstein, Tager, Shapiro, Monk and Sloan.(2007)
The anger development process in an individual can explained by Novaco’s (1979) cognitive behavioral theory. According to this theory most anger event involves four components: a trigging event they can be internal events (person thinking) or external circumstances. The anger arousal as result to provocation will, however, depend on cognitive processing, including appraisals of current and past situations, attributions, cognitive expectations of situations, and private speech and self statements. Individuals who are prone to experience high trait anger are thought to have distortions in these cognitive processes, including the tendency to attribute hostile intent, ruminate about upsetting events, and make attributions of unfairness, blameworthiness and intentionality. Physiological arousal is the third component of Novacois
model of anger, given that heightened physiological activation in response to provocation is common among individuals with high trait anger. At the fourth level, a number of behavioral reactions may follow the subjective experience of anger, including violent and aggressive behavior, as well as more constructive responses, successful assertion.
If I integrate this theory on my patient scenario, the anger provoking events in patient life are as he is from Afghanistan were he see wars through out of his life, and also participate in the war. As patient verbalized throughout his life we saw fighting and crime and observed every one reacting in same way. In short he learned to express his emotion through anger. Secondly anger provoking events as disagreement with parents and brother on married issue, as he was older son and his brother marry before him. This event continuous impose negative thoughts in patient thinking and patient interprete this event as unfairness. According to Gorenstein, Tager, Shapiro, Monk and Sloan.(2007) “Fairness is the main cognitive sticking point with anger patients. Much of their anger derives from the idea that they are not being treated fairly, or that other people are behaving improperly, or that some other form of injustices being perpetrated”. While interview patient I released that patient thought stuck on that event and he related all current event with that, which bring continues negative thoughts in patient mind. In physiological response to this event patient develops high blood pressure and fainting. In behavioral response patient stated express his anger verbally which shortly leads to hitting, bitting and destroying other properties. More over the cognation deterioration and copping with anger is related to patient mental illness or disease process. According to Daniel, Goldston , Erkan, Franklin and Mayfield (2009). “Trait anger and both the inward and outward expression of anger moderated the risk for suicide attempts associated with major depression.”
Anger is a considerable problem that required effective and efficient treatment. A nurse/therapist applies multiple strategies at individual, groups and institutional level dealing with clients with anger disturbance. This will help client to manage and cope with anger and can live an acceptable life in the society. If I relate this practice to my scenario, I had applied steps of nursing process that is assessment, planning, implementation and evaluation. Since, I have already discussed my assessments throughout the paper, thus; now I would be focusing on next three steps. While planning an education session for patient, I tried to keep in mind all patients’ perceptions, and how he can control or manage their anger. The main objectives of session were; to create an understanding anger, discuss some useful coping strategies that could help him in reducing anger. Moreover, I planned the session as an interactive one so patient gets an opportunity to ventilate his feelings. Furthermore, I prepared a pictorial chart on coping strategies. At the day of implementation, during teaching session I discuss the concept of anger, its causes, some relaxation coping skill that will help the patient dealing his anger. These copping skills include muscles relaxation techniques in mild exercise form and walking, breathing techniques (deep breathing exercises) and asking patient to involve in religious practices. If I evaluate this session then the session was interactive and patient was able to express concerns and exchange his ideas and redemonestrate some of relaxation techniques. There are more anger management therapies available that can apply on individual level as cognitive behavior therapy (CBT). According to a metaanalysis of 50 studies concluded that patients have 75% better outcome receiving CBT for anger management then of control (.Howells .K et al 2009). The goal behind (CBT) is not only helps clients to manage their anger feeling but also help them to avoid these feelings. Gorenstein, Tager, Shapiro, Monk and Sloan. (2007). CBT it focused on these components: psychoeduction, self monitoring, cognitive
restructuring, behavior therapy relaxation and visualization exposure, and in vivo exposure (real life exposure). Through Psychoeducation patient provide the knowledge about the disease process and how to cope with it, Then client explain about self monitoring of their anger feeling and includes information about each anger event and reaction. Through cognitive restructuring therapist help client to change their negative thoughts to positive. Following this therapist focused on client behavioral modification by inhibition of over responding and reversal of under responding through acquisition of effective communication and problem solving techniques. Relaxation techniques and visualization of anger provoking situations help the client combined, help to evaluate therapy. Gorenstein, Tager, Shapiro, Monk and Sloan. (2007). On group level group therapies help the patient to interact the people have same problem, by sharing their experiences and feedback from other they can learn problem solving techniques for socially acceptable behaviors. As group, we conduct an art activity to encourage patient to verbalize his feeling through art and enhance the communication with others. Patient was also involved in music therapy organized in hospital setting where he went twice a week patient verbalized that it helps to ventilate his feelings. Music therapy helps patient to expresses their feeling Wright & Howells (2009). Illness management rehabilitation session is one example of group session held at hospital level. In institutional level, there is responsibly of institution to hire more psychologists which can help patient counseling at individual level and training of staff caring for the anger client. Seminars and session should organize for awareness of families.
Before reading about the anger, I used to think that anger is a bad emotion and expressing anger always generate conflicts and in fact the main cause of conflicts are anger. However, after doing some research, I realized that anger is a natural emotion and it can be good or constructive. It depends upon individuals how he or she expresses their emotions. Furthermore, it is not
necessary that collets stimulate anger. It could be some pain, hot weather or so. Moreover, I
always thought that all menially ill patients are aggressive but after communicating with them I
understood that it is not true and it may be part of their disease process.
To conclude anger is a natural emotion it can experience by all but the my in which it expressed
matters and make anger construction as to share their feelings or &tided leading to hair self
and other. More over the proving events leads to cognitive and behavioral arousal that leads
experiences of anger by one. There are multiple strategies can do at individual pup and
illstitutioi level to manage and avoid anger, as relaxation techniques, CBI and awareness
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Jackson.A.N.( 2010)Models of response to client anger in music therapy. The Arts in Psychotherapy. 37 ,46-55
Wright.S., Day.A.& Howells.K.(2009). Mindfulness and the treatment of anger
problems. Aggression and Violent Behavior. 14, 396-401.
Gorenstein.E.E.,Tager.A.F.,Shapiro.A.P., Monk.C.& Sloan.P.R.(2007). Cognitive-
behavior therapy for reduction of persistent anger. Cognitive and Behavioral Practice 41,168-184.
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Lalani.S.(2008,April). Child witnessing domestic violence.Chitral times
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Waciar Gillani.W.(December,2003). Domestic violence confuses victims, shatters their confidence: study,dady timesseterived April 22,2010,from httpp://Bangerl Daily Times – Leading News Resource of Pakistan – Domestic violence confuses victims, shatters their confidence study.mht
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