- Case Study Vignettes – Confidentiality and Consent
- Case Study vignettes – Confidentiality
- Anger Management
- Case Study vignettes – the duty and boundaries of care
- Case study vignettes – Nurse Holding Powers
- A Baby Vignette
- Case Study vignette – Blood tests
- Case Study vignette – Complicated Concordance
- Quick mini-scenario
- Case Study Vignettes: Cigarette Rationing
- Case Study Vignette – Just for Socrates
- Case Study Vignette – Anorexia and Veganism
Did you all miss me? I decided to wait a couple of days after returning from the Comrade Stalin Expects Productive Diligence Recreational Facility, Scarborough before making any fresh posts. A bit of time to properly unwind from my sunny holiday and to allow the radiation poisoning to fade.
Since Mr Ian is suggesting we do some case study vignettes, here’s one from me, on the subject of anger management. I notice from the previous vignette that there’s requests in the comments thread that technical jargon is kept to a minimum. I’ve attempted to do so, but where I’ve been unable to I’ve included a wikipedia link for those who aren’t familiar with some of the terms.
Anger management is something that the CMHTs seem keen to give a wide berth (at least round where I live), but with child and adolescent mental health services it’s offered quite commonly. The following vignette is a semi-fictional amalgam of several cases.
A 13 year old boy is referred to CAMHS on the basis of a rather scanty letter from the GP.
Thank you for seeing this 13 year old lad who is reporting significant emotional and behavioural difficulties. His parents went through an acrimonious divorce two years ago, and relations are still fraught between him and his parents and siblings. This often leads him to lose his temper and become verbally or physically aggressive. He has recently been temporarily excluded from school after swearing at a teacher. I would appreciate your assessment and input.
He’s initially assessed. No sign of ADHD (which would be more likely to have been picked up in primary school anyway), Autistic Spectrum Disorder or depression. He does, however, come across as an unhappy kid living in a family where there are frequent rows, where Mum has ongoing money worries and with a sporadic and sometimes difficult relationship with an estranged Dad who has a new girlfriend. A decision is taken to offer him 4-6 sessions of cognitive-behaviour therapy, focusing on anger management.
A few comments from me on the subject of CBT before offering some points to ponder and then opening debate over to you lot. CBT for anger management is generally seen as a good-quality, evidence-based intervention. On an anecdotal level, I’m rather less impressed with it – at least with kids, anyway. For more than one patient I’ve been tasked to do CBT with, the best that could be said for the CBT techniques is that they gave us something to do together while we worked out what the real issue was.
Something I’ve also noticed is that from consultants and senior managers, the most pressure to offer CBT interventions is for the highly troubled kids with ADHD co-morbid with oppositional defiant disorder. I’m guessing this is because they’re sensitive to the criticisms that they’re not offering any solutions other than shovelling methylphenidate down their throats. However, these are precisely the kind of kids for whom the evidence base suggests CBT is a complete waste of time. If you have a child with very poor impulse control, trying to get them to engage in cognitive approaches to restructure some of their thinking patterns is next to impossible. What can work, however, is training of parents, carers and teachers in behavioural interventions in order to help them to control the child. Though that’s rather a more complicated undertaking than simply asking the nurse to give them 4-6 sessions of CBT.
Anyway, my points for you lot to ponder are:
- Is “anger management” a legitimate concern of psychiatry?
- Could excessive, over-frequent anger be seen as a form of mood disorder, along the same lines as e.g. an anxiety disorder?
- Alternatively, is it just an attempt to use CBT as a sticking-plaster semi-solution to a range of social problems?
Discuss.
Just a quick question Z. What is getting done with the family during the time the young man is getting his CBT ?
I’m not sure if I’d call it a legitimate concern of *psychiatry*, but I certainly would consider it a legitimate concern of mental health, if that makes any sense. In lots of cases I wouldn’t think it appropriate to medicalise it, but left unmanaged, wayward anger causes a hell of a lot of problems both for the ‘angry person’ and the people around them, and so I think that in order to promote good mental health, it’s important to deal with anger. I think this is particularly the case in CAMHS, where I would imagine if you deal with signs of inappropriate/excessive/badly handled anger early on, it reduces the risk of more serious things happening, like an angry kid turning into a teenager that uses to drugs to try to calm down.
I don’t know about the CBT thing. I’m not the world’s biggest fan of just throwing CBT at problems, but it does seem like this might be a case where CBT or solution-focused brief therapy would be appropriate to deal with the problems in hand (along with, ideally, some family work, although that brings up whole new problems of its own!)
Depends on the kid, really. Depends on whether his anger concerns him, and whether he wants it to change. Anger management – particularly a CBT approach – with kids who don’t see anything wrong with how they’re acting and have no wish to make any changes is a waste of everyone’s time. My very angry little sister has proven this to the CPN attached to her Youth Offending Team!
I’m a little nervous of submitting my thoughts on this but here they are:
These are just my initial feelings I haven’t been away and researched so much of it could be nonsense.
I think anger management has a legitimate place in psychiatry in this respect, I don’t want to fall prey to the ‘slippery slope fallacy’ but it seems that waiting for this anger to develop into something else before a person is either treated or dealt with by the criminal justice system is to do them a disservice.
I don’t mean to say that it should be down to services like psychiatry to provide this forever, ideally anger management, stress management etc should be taught to kids before they get to the stage CAMHS is involved. As this doesn’t currently happen than yes those most qualified to help should step in and at the moment this is likely to be your service.
I’m not sure about anger being a type of mood disorder I’m not really sure about psych disorders in general but that is a whole other long topic. What attracts me to CAMHS (it’s the area I want to go into) is that kids don’t need to have a disorder attached to them, at the moment (and I guess unfortunately this will change) they can get help before having to do something drastic to ‘prove’ they need it.
With regards to CBT, I agree these don’t seem to be the sort of cases where CBT is indicated but sometimes maybe CBT is easier to sell than psychosocial interventions? It is most likely ‘easier’ than trying to solve the social issues and often easier than trying to engage parents in learning how to mange behaviour (this is not a judgement on the parents there are many reasons why this may be difficult).
Actually I second what ‘in the margins’ said its a concern of mental health not psychiatry. I was thinking of a coherentish way to say that and my mind gave up.
I’m not being facetious when I say, I think it’s the parents that need medicating and therapying. Or possibly just slapping.
Not just a slapping Socrates. You are such a shallow thinker. Possibly a slight kicking as well just to drive the message home.
Out of sight of the impressionable young man of course.
- Is “anger management” a legitimate concern of psychiatry?
I’m gonna pick up on this one just for fun.
Anger management is another one of those socially unacceptable behaviour anomalies that, if nothing were done, someone would eventually get told to do something about it. That someone would be ‘health’.
Much like suicide; alcoholism; gambling; illicit drugs; etc it has become the remit of mental health services to intervene and ‘treat’ these socially disgraced behaviours.
I’d reduce the question a step further –
- Is poor anger management a social problem or a health one?
- Is the person with anger issues the problem or the symptom?
- If they are the symptom – what’s being done about the problem? (ie govt policy)
Rather than question if anger management is psychiatric concern – I believe further questioning on the defined role of mental health services is required. (I might get the post together for that debate)
A quick answer to Dazedandconfused question, “What is getting done with the family during the time the young man is getting his CBT ?”
It depends. Some families will come in with the young man. Others will basically dump him with me and come back in an hour to collect him. I think of the latter response as saying, “He’s the problem, not us. Mental health services can fix him for us.”
I don’t think that’s a very fair or realistic way to think about it. When they do that, I usually do one session alone with the kid, and then make a point of dragging the parents into the next session so we can talk about the family as a whole rather than just him.
http://mentalhealthupdate.blog.....-with.html
Not everyone who commits a violent crime is angry and not everyone who gets angry commits a violent crime but on average prison inmates score more highly for anger than the rest of the population and violent offenders score more highly than non-violent ones. Anger management programmes have been shown to be effective in the general population and among offenders generally but little research has been done into its effectiveness on violent criminals. A study of 418 offenders in Australia found that, compared to a control group, the improvement produced by an anger management course was small and ‘not statistically significant’. The researchers hypothesized that while the violent offenders improved their knowledge of the causes of and thought processes behind their anger this wasn’t enough to cause them to change their thoughts and behaviour at a more fundamental level, particularly as those who were violent often had very complex problems. They called for a longer, more intensive programme of therapy more targeted on those at risk of re-offending
Howells, Kevin – Brief anger management programs with offenders : outcomes and predictors of change. The Journal of Forensic Psychiatry & Psychology June 2005, 16(2), 296-311
Is “anger management” a legitimate concern of psychiatry?
No. Psychiatry is concerned with the treatment of mental illness. Anger is not a mental illness.
However, it might come under the broader remit of “mental health”, that vast umbrella term which is coming to mean “anything societally unacceptable”, which appears to be where Z’s young man comes into the picture.
His parents are divorced, he’s 13 years old, he’s not getting on well with his family. His anger is entirely understandable, normal and non-pathological, and is likely to pass of its own accord. He needs CBT about as much as a fish needs a bike, it seems to me. By offering him this service, the parents can sit back and point to him as the source of his problems rather than examining how they as a family, albeit one in pieces at the moment, might help him.
There seems generally to be a low tolerance to the kinds of expressions of anger or indeed any emotion that may not have attracted such attention even five years ago. Everything needs to be labelled and pathologised now, every aspect of ordinary human misery has to be a condition that we can treat.
I demand the right for people to be bloody miserable and angry if they want to be without being sent to the feckin doctors about it!
I’m glad I didn’t jump in first.I have to agree with Beakie here that it is not a mental illness.To my knowledge though (very little on my part !) it can be part of a group of symptoms for consideration in diagnosis..Of course the kid is angry his parents are divorced, it’s obviously upsetting for him & unsettling.Infact surely it’s human nature to react this way & if he didn’t then maybe there’d be more cause for concern.Don’t forget also that this situation has come at a crucial time in his life when he’s own mind/body is going through a lot of stuff at the tender age of 13.Again I’m with Beakie on this it’s not right to throw CBT at him, when infact it’s his parents who’ve caused the problem & need to find ways of helping him through this.Maybe CAMHS could focus on an intervention for the whole family ?
I’m with the “psychiatry – no. Mental health – possibly, by default” answer.
But to debate the point of concern – the young man – we have a person in the making. It’s not his fault his parents are arses, yet he is suffering. It is possible 3 things happen:
1. It stays the same – he remaions angry at his parents and grows up a bit miffed
2. It gets better – and he outgrows it or the parents get their act together and ‘parent’ outside of their egos.
3. It gets worse and he turns to drugs or alcohol to escape and then gets schizoid and costs half a gazillion in Zyprexa over the rest of his life and possibly assaults a few people on the way.
Aside the absence of formal mental illness – is this not early intervention at it’s earliest? (until we start antenatal CBT of course) but meanwhile we have a troubled young man – should we just let him fester amidst his parents acrimony?
Do we not abide by an edict of prevention of harm to self or others?
If he is being directly insulted by this relationship is he not deserving of support?
CBT for anger management? No.
Perhaps Social Services should have compulsory ‘You’re a shit parent’ class under the Social Health Act 2009?
@Serotonin
“Maybe CAMHS could focus on an intervention for the whole family ?”
Indeed. We do have a team of qualified family therapists that we can access. Failing that, on a more informal level I can involve the rest of the family by the simple action of dragging them into the therapy room.
Actually, thinking back on cases I’ve worked with recently, in 90% of the times where I’ve been told “please do 4-6 sessions of CBT with this kid”, it’s wound up morphing into some sort of family work.
I wonder if it’s an area where social services could be more involved rather than mental health services in working with family support, co-ordinating therapeutic input etc. Instinctively, I am not sure I’d be comfortable about working with anger management in Mental Health services although of course, it affects general mental healthiness or not.
I think I’m coming round to Dr Ian’s ‘You’re a shit parent’ classes.. to be honest.
Of course, if anyone can be offered that can help, then it is better to do so than to do nothing, but perhaps a different source of these kinds of issues needs to exist. This is where I think there is a need for more cohesive links between health and social care.
(As a defence, I have no experience of any kinds of children/family services in general so there may be things out there that I don’t know about.. in fact, I’d be amazed if there aren’t!).
We don’t have a “you’re a shit parent” class, but we do have a “how to be a good parent” class. I thnk they decided the latter title would be more appealling.
Is the subtitle for the being a good parent class some thing like:
Dr Ian, cb? I hope that was a typo.
d&c: you beat me to the retort on the subtitle
Something I missed out earlier on why he shouldn’t have anger management:
He is angry – but he’s angry for discernible reasons.
Anger is the right response to being in the wrong situation.
I’ll go out on a limb and suggest:
To ‘treat’ him and take away his right to be angry is actually emotional abuse of a child.
Mr Ian –
He is angry – but he’s angry for discernible reasons.
Anger is the right response to being in the wrong situation
I think the main thing is not necessarily to try and get rid of the anger – as everyone says, it’s a natural response to being in a shit situation. But it might be that he needs help to deal with the anger appropriately, so that it doesn’t become the dominating factor in his life. Yes, he is ‘allowed’ to be angry, but that isn’t going to help him if he starts getting high and beating up his classmates. Personally I’d get him into some sort of martial arts training
Meanwhile, give the parents a good kicking.
Doctors, nurses.. all the same to me..
(now time to run and hide on the Guardian site.. )
If it’s not a mental health issue now, it will be when he starts to think the misery he’s undoubtedly feeling is some kind of character flaw, let alone the first time Mum tells him he’s just like his dad. A couple more years in that pressure-cooker of a home environment without some constructive -or at least [i]legal[/i]- coping strategies and he’ll be lucky if the worst he gets off with is clinical depression.
Of course, it’d also be wise to try convince his parents to behave like civilised human beings before the boy realises that [i]they[/i] are the problem, and furthermore a problem that can be solved quite effectively by cold-blooded murder!
PS: Did your source material for this include the case notes of someone whose initials are J.J.? The situation seems uncannily familiar…
cb: making Shrink an honorary Nurse is something we do to humour him and his delusional aspirations.
Making a Nurse an honorary doctor is like making Bill Gates an honorary tech-help.
c_d: Denying him the natural processes of his person is to modify him away from the way he was designed to function. Does anger management teach us to manage – or to misdirect ourselves from that which we ought pay attention to? Are we not teaching ourselves against the instincts of human survival when we teach people to employ unnatrual responses to unnatural situations?
We do it here in our local area – we teach the aborigine zero tolerance to violence. Then they return to their communities – which (as posted elsewhere) accepts certain levels of violence – yet we have stripped them vulnerable and naked to their own culture.
I admit it would be wrongful to allow him to struggle – but to suggest to him his anger is wrong in any sense is to invalidate his experiences and his life.
Before he gets help to better manage himself; he deserves the right to express his frustration; the right to be validated and – under our own social determined ethos of paternalism – to have his ‘anger’ duly represented for him against his protagonists.
sorry c_d – just for the record – I’m not picking at your responses. I’m just expanding my earlier point
@Jake
No, it doesn’t include a JJ, but to be honest this is a pretty common scenario.
I wonder if a lot of these cases are another body of supporting evidence for the need for a parent-ectomy.
While sitting on my tod in hospital years ago, I became friends with a lot of teens who had eating or substance disorders plus depression, mainly because their parents were abusive assholes.
They would dump Little Johnny or Little Janey in the hospital on the appropriate program (eg EDs) and basically say, ‘my kid is a problem, I want this problem to go away, here’s my insurance policy number, now go fix my problem’ without wanting to be told, ‘actually, beating the living daylights out of your kid isn’t going to help them recover from anorexia’ or more commonly, emotional abuse, denying that past sexual abuse or rape had occurred.
So, Little Johnny makes progress in his treatment during the week. He then goes home for the weekend. Monday morning, he’s visibly skinnier, or hung over, or whatever, and significantly reduced in terms of recovery.
However, since he is underage, he can’t move out of home. And since social services will intervene if there is significant physical or sexual abuse going on at that point in time, but not if, as in the case of one girl who was raped and severely injured, being taunted by her parents about it who refused to let her go to the police, there’s nothing anyone can do.
I’d imagine it sucked more if you worked there. I was just an observer.
Ben Goldacre 1/9/08:
http://www.guardian.co.uk/busi.....cals.drugs
In 2007 the British Medical Journal published a large, well-conducted, randomised controlled trial, performed at lots of different locations, run by publicly funded scientists, that delivered a strikingly positive result: it showed that one treatment could significantly improve children’s antisocial behaviour. The treatment was entirely safe, and the study was even accompanied by a very compelling cost-effectiveness analysis.
Did this story get reported as front-page news in the Daily Mail, natural home of miracle cures (and sinister hidden scares)? Was it followed up on the health pages, with an accompanying photo feature, describing one child’s miraculous recovery, and an interview with an attractive happy mother with whom we could all identify?
No. This story was unanimously ignored by the entire British news media, despite their preoccupation with antisocial behaviour, school performance and miracle cures, for one very simple reason: the research was not about a pill. It was about a cheap, practical parenting programme.
Z: Found this article of (some) relevance to the post – but perhaps more relevance to you – and other CAMHS staff:
http://findarticles.com/p/arti.....tBody;col1
Caring for the involuntarily hospitalized adolescent: The issue of power in the nurse-patient relationship
Journal of Child and Adolescent Psychiatric Nursing, Apr-Jun 2002 by Biering, Pall
[...] This pretty much mirrors my own rather cynical view of anger management. [...]