Other Emotional Issues

Anger Management

EFT and severe mental illness--a murderous impulse

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Hi Everyone,

There is much we don't know about EFT, including its use with severe mental illness. Even though we are frequently delighted with the speed and efficiency with which EFT appears to work with the vast majority of "normal" people, we must still consider EFT to be in the experimental stages and proceed with normal caution and common sense.

With this in mind, Dr. Patricia Carrington outlines for us in great detail a case of hers regarding a man who was previously diagnosed as having paranoid schizophrenia. While EFT appeared to readily resolve an anger issue regarding his daughter, it also appeared to "open the door" for a decision to murder a co-worker.

While no one was actually harmed and it is difficult to say just how, if at all, EFT actually opened the door, this case merits our attention. It is particularly appropriate for professionals who deal with this very small percentage of our society.

Hugs, Gary


By Dr. Patricia Carrington

Dear List,

In today's letter I'd like to build on the theme introduced by Lori Lorenz in her report to this list on her use of EFT with a client who suffered from "explosions" of anger. The way Lori handled this client's problem was what I consider to be the approach of choice for such cases and it is the way I have recommended that we use EFT for a problem of this sort. I come to this conclusion because of a hair raising incident (described below) that occurred in my practice several years ago and which taught me an unforgettable lesson about how best to use EFT to deal with uncontrollable impulses - AND how not to use it.

"Roland" had called me because my name was on his Managed Care Referral list. I knew nothing about him except what he told me on the phone. He was in technical maintenance in a major company in our neighborhood and he wanted to see someone as soon as possible because he had a problem with anger.

When he arrived at my office I saw a very neatly dressed man with a tightened jaw. His eyes had a steely look to them, and I sensed enormous tension beneath his somewhat smooth exterior.

Roland started right in, with a somewhat disarming lack of emotion, to relate to me his "case history", using almost exactly the wording a psychiatrist might use to report it - all the correct medical terms. He had experienced more than one incident when he had been restrained by the Military Police and even placed in confinement, when he was in the service, because of his violent outbursts. He had been a former officer in the armed forces and told me early on in the session, very coolly but very pointedly, that his branch of the service had diagnosed him as a "paranoid schizophrenic" and dismissed him from the service as not fit to serve any longer.

Hearing this I was immediately alerted. The armed services do not make this kind of diagnosis or decision lightly and it was obvious there had been a major incident to cause it, but it was one which he said he didn't want to reveal right away. I inquired only indirectly about this at that point, respecting his limits, and he changed the subject.

He told me why he was seeking treatment. He was upset by the fact that two days previously he had experienced an intense rage at his 13 year old daughter for answering him in a way that he considered "fresh" at the time, although now he thought it was probably just an innocuous teen remark. He had had a powerful urge to pick her up and throw her through the plate glass window in their living room. He clearly took this impulse very seriously, although he related it calmly and matter-of-factly. He told me that he was afraid that one of these days he was going to do just that. He also commented that he found himself getting very angry at some of the "stupid people" who worked with him - "VERY angry! There's one guy there I hate" he said.

At this point I felt somewhat uneasy. I didn't know this client. He was self referred. There was no-one else present in the building where I was working (my home office). Roland kept on reporting about himself in a detached, clinical fashion, but would stop every so often to ask me, "What can you do to help me?" He was pressing for immediate assistance.

Because of his urgency for help right away, I decided to use EFT with him as I frequently do in crisis intervention. I wanted to help him bring down his immediate inner pressure so that he could feel more comfortable and handle his difficult emotional issues more easily. It had been my experience that EFT can be extremely effective in controlling anger, so we commenced with the issue he was talking about - his impulse to throw his daughter through the plate glass window.

He reported that he was an 8 to start with on the SUDS scale (0 to 10 intensity) when he thought about the incident, but his body was taut as he spoke about it and he appeared almost desperate. I estimated that the actual SUDS level was probably higher - a 10. He went through all the steps of EFT, following me as I tapped on myself, my usual practice in order to role-model the procedure for him.

"Even though I wanted to smash my daughter through that glass, I deeply and completely accept myself..." Over and over again he repeated the set-up and reminder phrases for a number of rounds. His SUDS level began to come down - to a 7, to a 4, to a 3, and then he finally breathed a sigh of relief, but I suggested he keep going until it came down to a zero. So he kept going - 2, 1, and then he straightened up, looking steadily and intently at me, and said:

"I feel ok about it now. That helped" Then he added (in effect, I wasn't taking notes of every word) "I feel different now. I'm clear." (pause) "I know what I'm going to do."

I expected that he would tell me that he now had an idea of how he would deal differently with his daughter, after doing the EFT. But instead, staring intently at me, he said slowly:

"I know what I'm going to do. There's this guy in my office who's been bugging me like I told you. I hate that guy and now I know what I'm going to do. I keep a revolver in my desk drawer for safety purposes and I know I should take it out and kill him. It just came clear to me while I was doing the tapping. That's what I'm going to do. I feel ok about it now. I accept myself."

Fortunately I had been tapping along with him, round after round, for the whole time. I was deeply grateful for this fact because it allowed me to now have a surprising calm when dealing with this. I could not have done as well had I not been tapping on myself, I am convinced of that.

I had no doubt that Roland meant what he said and that he was clearly, at that moment at least, intending to shoot his co-worker. He had given me his own diagnosis - that of paranoid schizophrenia - one which certainly made such behavior possible. I realized as he talked that after he had done the tapping, the anxiety which had been preventing him from acting on his feelings of being "bugged" by this man up until now, had been removed through the use of EFT, and that he was now in danger of yielding to his impulse to kill. In effect, this appeared to be an untreated aspect that Roland did not want to address because his delusional system was still in place.

Inadvertently, I had applied EFT incorrectly in this situation in a manner which I came to understand afterwards, but not then. All I knew at the time was that there was imminent danger - he had told me that the man in his office was away but was returning next week. This didn't give us much time and I considered the man's life to be genuinely in danger, but intuitively I felt that it would not be wise to try to argue Roland out of his conviction that shooting the man was the right thing to do, at THIS point. There was a steel-like determination in his eyes and he simply was not willing to work on that impulse at this moment.

Given his unwillingness, I needed to take another tact. Instead of responding with surprise or alarm at what he had told me, which I believe he expected me to do, I instead started to discuss with him the usefulness of his getting a handle on the anger he was feeling toward his daughter. This was, after all, the reason he had come to therapy and I felt that here we had a genuine wish to prevent him from harming someone, a positive intention which we could build on in the treatment. I make a decision to address only the positive in order to help him motivate himself to seek the more extensive help that I knew he was going to need

In as relaxed a way as I could, I began to discuss the usefulness of some of the modern medications for the type of anger he had felt toward his daughter. Roland seemed almost relieved to talk about this and he didn't veto my suggestion for some tranquilizing medication in the interim, either. I think he appreciated my having not responded with alarm to his announcement about the gun but, instead, with understanding for the side of him that wanted to institute controls. I think this because he clearly wasn't actively resisting my suggestions about other interventions.

I knew I did not want to continue working with Roland because I could not feel safe doing so outside of a clinic or institutional setting where there were other people present in the same building and a measure of ritualized protection. Were I to feel unsafe treating him, but do so anyway, my fear would obviously transmit to him and destroy my effectiveness as a therapist.

The plan I began to formulate in my mind was to transfer Roland to a psychiatrist who would prescribe the necessary emergency medication and who would continue to see him in a controlled clinic setting. We ended the interview by my arranging with Roland that I would phone him and discuss with him "some helpful suggestions I have in mind" and arrange for scheduling the next session. I didn't want to dismiss him too abruptly from work with me. Rather I wanted to prepare the ground first by finding really good help for him and have the referral phone number in hand before I spoke with him about this.

After he left I went frantically to work to track down an appropriate psychiatrist in his managed care plan. I wanted someone who would be sympathetic and understanding--someone who would not be overly alarmed by this case but sufficiently alert to the real danger involved to be able to handle it rapidly and well. I also sought someone who would have enough strength and authority to help Roland institute the necessary controls that were presently missing in his own personality. I felt probably this should be a man since the absence of a father figure had been a major factor in Roland's early life.

After a seemingly interminable number of calls, I finally did locate a psychiatrist who met these criteria. He was prepared to prescribe the needed stabilizing medication immediately, to work with Roland on the emotional issues after that, and to see him right away. I phoned Roland and explained to him that it would be more satisfactory for him to work in therapy with the person who would be prescribing his medication and that I had told the psychiatrist all that Roland had told me (he had signed a disclosure form when he came into my office), and that this doctor thought he could be of real help. I thought it would comfort Roland to know that the psychiatrist would be seeing him with "eyes open", so to speak, with respect to the seriousness of his condition and the imminent situation. He might not have gone to him otherwise.

Fortunately the referral worked out. Roland did not harm anybody. He continued to see the psychiatrist for quite a while. He really got along with him and my assessment of his underlying positive motivation was correct - Roland cooperated both with the medication regime and with the treatment.

But the aftermath of this incident for me was a lot of self-questioning and thinking through. What did my mistake in using EFT in the manner I did with Roland have to teach me and others about this wonderful technique? I discussed the case extensively with colleagues who highly value EFT as I do, and eventually arrived at some conclusions and instituted some guidelines with respect to the use of EFT with clients who have serious problems with impulse control. I will put these out here for all of you to react to, and I would be interested in receiving any feedback you may have with respect to your own cases where you have used EFT with clients who were suffering from poor impulse control. What has been your experience with this?

My experience has been that EFT can be highly effective for dealing with bouts of unreasonable anger and that it can and should be used for this purpose. However, I feel that certain precautions should be followed when applying EFT to angry or murderous impulses. When we use it for clients who have a tendency to "act out" their aggression in real life in a violent manner rather than suffering from it internally or expressing it verbally, we need to be careful not to make the mistake I did with Roland and which some of my supervisees have reported making as well.

I find that with such impulse-laden clients, often the only thing that lies between them and acting out their rage is their fear of never being able to live with themselves were they to act out their aggression and hurt or kill someone. In this instance "guilt" has a great practical usefulness, destructive as it usually is and one of our great trouble makers under so many other circumstances, it can literally be a life-saver here.

GC COMMENT: I have had several conversations over the years regarding whether or not guilt is really a deterrent to inappropriate or criminal behavior. One could argue, for example, that guilt is the CAUSE of violent behavior--not its protector. Why? Because someone who has been taught by their parents, church, etc. that they are sinful and guilty can build intense anger about themselves that cries for expression in violent behavior. Is it possible in Roland's case that a guilt ridden psyche had causal effect on his paranoid schizophrenia? Who knows? It would be speculation at this point. This is not to detract from Pat's comment, however. This man appears to be seriously ill and thus debate over labels may not mean much.

The problem arises when someone like Roland, who had a delusional system which made him feel "bugged" by a man he hated in his office (persecuted by him) has been controlling their wish to kill that person by some form of self-confrontation and self-condemnation for their murderous impulse. To attempt to remove the self-condemnation FIRST (as I mistakenly did with Roland) might be to invite the irrational delusional system to take over and convince the person that their explosive impulses are fine, justified and acceptable. Obviously this is distorted reasoning on the client's part and a misinterpretation of the Reminder Phrase, but psychosis is a form of distorted thinking to start with. The point is that we don't want to inadvertently aid the irrational process.

What was inappropriate in my application of EFT to Roland is not that I used EFT with him, but how I did so. I made the mistake of having him say set-up and reminder phrases which encouraged him to accept his RAGE toward his daughter, rather than accepting the daughter herself or any pain he himself may have suffered in the past around these issues. I reasoned that acceptance of an emotion such as anger would make it more manageable for this is often the case with people who have good control over their own impulses -- I have seen EFT work many times to clear anger for such people by helping them to accept it. In a person with a serious disturbance of impulse control, however, an altogether different situation occurs and I recommend using EFT in one of the following ways.

You can use it to defuse the original events in the person's life which created their present uncontrollable impulses in the first place. In other words, work to heal the problem at its core rather than treating the SYMPTOM of rage, for example. This approach is illustrated perfectly for us by Lori Lorenz's case in which she did just this and it worked. Notice that Lori didn't treat the symptom, she didn't ask her client to accept himself even though he might explode. Instead she went straight to the core issue of his relationship with his explosive mother and helped him work on that. While it is tempting to treat the symptom as I did with Roland, and it might even work if the client had sufficient inner controls in place, my recommendation is that we as therapists not take this risk and instead follow the path that Lori did. If you move straight to the core issue and treat that, the rage will usually take care of itself.

In Roland's case, since he was so removed from immediate contact with his emotions, it might have taken quite a while for us to get at his core issues using EFT. Probably we wouldn't have made much if any inroads on this in the first session, although in retrospect it might have been worth trying.

To sum up, when dealing with problems which involve a severe disturbance of impulse control, I consider it best to apply EFT in such a way that it heals the distress that lies deep within the client him/herself first.

Another useful tactic can be to treat the rage without using any set-up or reminder phrases at all, just strategic tapping on acupoints. Roland's irrational conclusions stemmed from his use of a reminder phrase that involved acceptance of his anger, not from the tapping procedure itself. However, in Roland's case, since he was so detached from his emotions, I could not easily have asked him to tap for distress because he was apparently calm about the whole thing, actually one of the ominous signs he displayed. Possibly though, I could have located some tensions in his body and had him tap for these and that might have been of help. Ann Adams' use of EFT as a simple relaxation/impulse control method with emotionally disturbed boys in an institutional setting is a perfect example of this use of EFT to control a temper tantrum.

Ann's report brings up another an important question and that is whether there is a difference between the use of EFT for reducing violent impulses in a structured setting such as a rehabilitative institution or prison -- where the client is protected to some extent at least from acting out destructive impulses -- versus its use for out-patients where the only controls in place are the client's internal ones.

As we know, many behavioral interventions can be highly effective as long as a person remains in an institutional environment because the institution itself acts as a restraining force, while the same treatment may no longer be effective when that person leaves the protected environment and has to rely once again on his/her own often fragile internal controls.

It may be that using EFT to help a person "accept" such symptoms as explosive acting out tendencies might conceivably work if the person were confined in a protected environment, but I personally would not want to take the risk. I have heard reports from staff in some institutions, though, where tapping therapy has been used for acceptance of violent impulses with apparent success. Unfortunately, however, the staff workers involved could not adequately follow up with the youngsters they had treated after they had left the institution, so they actually didn't know whether these boys were able to control their rage when they were released. Until we learn more about this, I would advise any therapist using EFT for impulse control to apply it in one of the ways I have suggested above, or use some other failsafe method.

In closing I want to say that I have regrets when I think about the mistake I made when using EFT with Roland in the manner I did, but I console myself with the fact that my alternate treatment plan for him did work out, and I hope that my experience with this can help all of us learn a little bit more about how to apply this remarkable method in the most clinically effective manner.

 

 

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