Anger Provocation as a Crisis Intervention Technique LEWIS
BRODSKY,
MD.
Chief, Crisis Intervention Sinai Hospital of Detroit Detroit, Michigan
Center
The author describes the use of anger provocation, a technique that encourages patients to express their repressed anger to a therapist who makes himself the target for their anger. He presents five case examples to Illustrate the positive effects of the technique in crisis and emergency situations. Three of the patients were depressed and withdrawn, one was suffering from conversion hysteria, and one was a paranoid schizophrenic. The author cautions that the technique must be used with discretion only in those cases where the repression of anger is producing major incapacitating symptomatology, but where the anger is not the major source of disorganization. UThe overt display of emotions seems to vary from one culture to another. For instance, Latins are more typically expressive, and Anglo-Saxons characteristically maintain a stiff upper lip. However, the expression of anger has generally met with social repression and ultimately intrapsychic repression. It may represent a need to maintain order as opposed to anarchy, but we must recognize that in many instances the satisfactory expression of anger, even in modified form, is not permitted. From our knowledge of psychodynamic theory, we understand to some extent the problems that ensue as a result. In our society we pay homage to a stoic ethic, which prefers that if people are to suffer at all, that they suffer in silence. We all are aware of situations in which the degree of withdrawal in an individual is so marked, and the quantitative introjected rage so intense, that it actually poses a threat to the continued survival of the individual. That kind of situation would certainly constitute an emergency as well as a crisis, adhering to the strict
Dr.
Brodsky
Wayne
clinical
State
also
is an
University
instructor
in the department
School of Medicine in
Detroit
of psychiatry and
of
assistant
professor at the Michigan State University College of Human in East Lansing. His mailing address is Sinai Hospital of Detroit, 6767 West Outer Drive, Detroit, Michigan 48235. Medicine
definitions of the terms.’3 In an attempt to deal with such grave situations, I have used some methods in which I act as a provocateur and the immediate target for the patient’s anger. Several crisis-oriented workers have acknowledged that it is good to encourage individuals to express their anger. Korner said that “Anger is a tonic. It instills motivation to move toward the offending object, it creates action. It sets emotions into motion toward the environment, thus working in the direction of crisis reduction. The individual needs to be stirred up, his passivity must be combated.”4 The approach I am talking about is not new. Periodically, rather vague references to the use of the angerprovocation technique have appeared in the literature. I hope to establish a clearer conceptualization of the use of such a technique, which, when appropriately and judiciously used, can be effective in dealing with certam crises and which may even be life-saving. I have used anger provocation with depressed withdrawn individuals who are at high risk for suicide. I also have used the approach in some cases of conversion hysteria and with a few more generally negative and covertly hostile patients, including some borderline and possibly psychotic patients with whom communicating in any other way is impossible and opening some channel of communication may be vital. The approach is not universal and should not be used indiscriminately. An anger-provocation technique, in which a therapist uses an aggressive-abrasive attitude, is an emergency tool to be used with considerable care and discretion in carefully selected situations and, if successful, it should be replaced immediately by an attitude of understanding and empathy. I will begin with the case that demonstrated to me the therapeutic value of mobilization of affect by anger provocation. .
.
.
and L. Small, Emergency Psychotherapy and Brief Grune & Stratton, New York City, 1965. 2 T. N. Rusk, “Opportunity and Technique in Crisis Psychiatry,” Comprehensive Psychiatry, Vol. 12, May 1971, pp. 249-263. C. H. Wolkon, “Crisis Theory, the Application for Treatment, and Dependency,” Comprehensive Psychiatry, Vol. 13, SeptemberOctober 1972, pp. 459-464. N. Korner, Crisis Reduction and the PsychologIcal Consultants In 1
L. Bellak
Psychotherapy,
Crisis
VOLUME
Intervention,
28
Behavioral
NUMBER
Publications,
7 JULY
1977
New
York
City,
1973.
533
CASE
ILLUSTRATION
The patient was a 43-year-old white man who had a long history of psychiatric treatment and hospitalization because of severe depression and suicidal risk. He was an obsessive-compulsive man who had much difficulty recognizing and expressing his feelings. Although the patient’s depression could be traced back to his childhood, it was intensified after his mother’s suicide, when he was 20 years old. The patient had seen several therapists, but other than some superficial intellectualizations he had gained no understanding of his conflict. Shortly after I started to treat the patient, I had to hospitalize him because he was profoundly depressed and potentially suicidal. I made many attempts to reach the patient emotionally after his hospitalization, all unsuccessful. Then an incident occurred that made me aware of the more active role I could have been playing. I had three appointments a week with him in the hospital. The third week I had to miss an appointment. When I arrived on the unit several hours later, he was obviously upset. He asked, Why weren’t you here earlier when we were supposed to meet?” I asked him how he felt about it, saying that he seemed to be upset. He said that he was, but that he thought I must have a good reason for not being there. I assured him that I did have a good reason, that an emergency had required my presence. Thus despite the fact that I had allowed him to express his feelings before explaining why I hadn’t been there, I had, in effect, further fed into his difficulty in giving voice to his anger. I had told him that he had no reason to be angry with me. I was also aware of his increasing feelings of dependency toward me. I decided that if a similar situation arose, I would not explain or excuse my behavior but would cooperate with him in the belief that I was being derelict in my duties. (I am sure that my decision was also based on the frustration I was feeling.) A week later I again had to miss our appointment, and I wasn’t able to see him until the next day. When I did see him, he appeared to be much more shaken emotionally than on the first occasion. He spoke carefully, obviously attempting to control his feelings; his fists were clenched, and his voice was tremulous. He asked what had happened this time. Once again I asked him about his feelings, and again he said there must be a good reason for my not being there. Then when he asked what the reason was, I shrugged my shoulders and said that it had slipped my mind. The result was an emotional explosion. He pounded the table so hard that it cracked. He began sobbing and speaking in a voice like that of a little boy. He said that it wasn’t fair, that I had no right to treat him that way, and that his mother should pay more attention to him and shouldn’t put all those responsibilities on his shoulders because he was just a little boy. He brought up a lot of material specifically related to his mother. It was as if the situation with his mother were being re‘ ‘
534
HOSPITAL
I had further fed into his difficulty in giving voice to his anger. I decided that if a similar situation arose, I would cooperate with him in the belief that I was being derelict in my duties.
ONE
& COMMUNITY
PSYCHIATRY
enacted in the therapy session. From then on the therapy began to progress. Telling him that I had forgotten the appointment justified his anger with me, and this justification allowed him to express the angry feelings that he had been unable to acknowledge. For the first time he became aware that he had such feelings. In a relatively short time we were gaining much access to the anger, guilt, and ambivalence in his relationship with his mother. At follow-up two years later he was symptom-free. He was enjoying relationships with others and was able to express feelings more easily than in the past. Although the case was not the typical crisis or emergency, it was the case from which I learned the value of affect mobilization and anger provocation in crisis and emergency situations. The following cases are other examples of my use of the anger-provocation technique. CASE
ILLUSTRATION
TWO
The patient was a 36-year-old white woman who had been in an automobile accident with her husband, who was driving. She and her husband were critically injured, and one of their three children was killed. Her husband quickly recovered, but she had to be hospitalized for weeks after he was released. She developed many complications, including intercurrent infections. The patient’s major problem was severe depression; she would not eat or participate in any kind of physiotherapy. The nursing staff interpreted her negative behavior as obstructionistic, and they developed a dislike for her and had as little to do with her as possible. When I first spoke to the patient, she was extremely thin and appeared to be in pain. She was very depressed. My attempts to communicate with her were to no avail. She said that she didn’t feel like talking and that there was nothing to talk about. When I said that she must be depressed and unhappy and in a lot of pain, there was essentially no response. I tried various approaches using a gentle, solicitous manner, but there was no response. The next day I decided to try another approach. I introduced myself again, and again there was little response. Then I asked the patient how long she had been trying to commit suicide and why she hatml her
husband and children so much that she wanted to leave her husband a widower and her children motherless. Her immediate response was to sit bolt upright and shout, How dare you talk to me like that! You don’t know what you’re talking about. Get out of here.” I replied that there was no reason to listen to her since she obviously was just collecting bedsores and preparing to die. (It should be noted that the comments I made about suicide were all the more inflammatory because her religion prohibited suicide. ) The patient was livid by the time I left, having maintained her angry responses for more than half an hour. The next day when I arrived, she was sitting up and eating. Angrily, and between mouthfuls, she told me that she would show me that I didn’t know what I was talking about. The patient was well enough to be discharged within two and a half weeks after my first visit. On the day of her discharge, she came up to me and said, “Well, doctor, will you admit that you were wrong?’ I answered, You’re right, I was wrong. Many issues had to be avoided because of the limited ego resources of this patient; however, we could work with some of her feelings about her dead child, her anger toward her husband, and her guilt. It is certainly clear that there was value in allowing myself to become the target for this woman’s anger. In this case the results were highly dramatic. “
‘
“
CASE
ILLUSTRATION
‘ ‘
THREE
The patient was a 40-year-old white married woman who had been hospitalized medically because of difficulties adjusting to a gastrostomy, which was necessary because of damage to her esophagus suffered as a result of radiation therapy for a thyroid disorder. When I first saw her, she was emaciated and withdrawn. She lay in a private room in semidarkness with the shades drawn and the door closed. She was very reluctant to speak and said only that she felt I couldn’t help her since her problem was physical and not emotional. From her history, the patient was a dependent, narcissistic woman who had succeeded in alienating her family by constantly demanding attention and behaving in a childlike manner when her demands were not met. An illness during childhood apparently was the only time that she had received a lot of attention from her mother, who she felt had otherwise neglected her. The second time I saw the patient, she was almost mute and had lost even more weight. As in the previous case I suggested that she was trying to kill herself because she was angry with her husband and children. She denied this vehemently. I refused to accept her denials and asked how long she had wanted to punish her husband and her children. The reaction was an intense angry outburst. She asked me to leave and said that I had no right to talk to her that way. I replied that I had no reason to respond to her demands because she was so helpless and ineffective in any case. During this session I was able to establish meaningful communica-
tion with the patient that eventually led to more cognitive and affective insight. The effects were quickly apparent, and the patient became active in her physical and psychiatric therapy. Thus far the case examples have been of patients who were profoundly depressed and whose introjected rage was mobilized as a result of the therapist’s provocation. The following case illustrates the use of this technique with a patient suffering from conversion hysteria. CASE
ILLUSTRATION
FOUR
The patient was a 38-year-old black married man who was hospitalized medically because of a paralysis of his left side that developed the night before admission. He was a large athletic-looking man who had a history of difficulty relating to men in a position of authority. At the time of his hospitalization, the patient had been involved in a conflict with an older partner about an invention that the patient had developed and that they were trying to market. The patient was extremely angry because his partner had arranged to market the invention without consulting him and was applying independently for a patent. Although the patient tended to be somewhat paranoid, he was not delusional. He never knew his father, who had died when the patient was still an infant. He had a succession of stepfathers, one of whom was quite brutal with him. The patient remembers trying to defend himself against a threatened beating, with the result that he got a harsh one. He recalled his last fight as an adolescent with his older brother, who gave him the worst beating he had ever received. The patient said that he was opposed to fighting because he had everything to lose and nothing to gain. Almost from the start the patient considered me an authority figure. On my third visit following his transfer to a psychiatric unit, after a totally negative physical and neurological work-up, I found him quite angry with me. He talked about how obvious it was that I thought I was the big boss man who could see him whenever I chose, and he called me one of those fat cats. He said that he was thinking of discharging himself because he didn’t believe his problem was emotional. I decided that I could use the patient’s anger at me to help him. I pointed out to him that since he was crippled and totally helpless, the only way he could leave the hospital was with my approval. I said that he was right, I was the boss man, and I certainly wasn’t prepared to wheel him off the unit. He became infuriated. His left fist clenched as he raised his arm as if to strike me. At that moment I pointed to his arm to draw his attention to what he was doing. Within a day of the confrontation, the patient was improved symptomatically. After that episode, we were able to begin assimilating the past situations with the present one. (It is important to mention that the paralysis began while the patient was fantasizing planning a fight with his partner.) ‘ ‘
VOLUME
28
NUMBER
7 JULY
1977
‘ ‘
535
Successful resolution of crises requires a flexible approach and knowledge of a variety of therapeutic techniques. At times it is of primary importance to be resourceful and innovative, particularly when time is cruciaL The final case example provocation I used with little less direct. CASE
ILLUSTRATION
is somewhat a rather brittle
atypical. patient
The was a
FIVE
The patient was a 34-year-old white woman who had been treated in the clinic before and had been diagnosed as a chronic paranoid schizophrenic. She told me that she was extremely depressed and had no reason for living, but that she wasn’t prepared to talk about it. From then on she was hostile and negative. Despite my attempts to deal with the anger that she must have been feeling, she remained silent. Although obviously not in a catatonic state, she refused to answer my questions. After many attempts I simply turned my chair toward my desk, picked up a medical journal, and started to read. After several minutes, the patient flew into a tirade at me for wasting her time and money. She shouted, How dare you treat me this way!” My actions had catalyzed interaction, which was quite successful therapeutically and was beneficial to the patient. It is clear that this aggressive-abrasive technique aimed at mobilizing passive and ineffective patients must be reserved for those patients whose major ego functions are intact. (Case number five is an exception.) A clear example of a contraindication was highlighted when I used the technique with a patient who was extremely withdrawn and depressed, but who demonstrated many borderline features. In that instance the patient withdrew into an almost catatonic-like state. With very gentle support she emerged from that state many minutes later. Anger, for this patient, was a major source of disorganization. Successful resolution of crises requires a flexible approach with the knowledge of, and a willingness to employ, a variety of therapeutic techniques.3 At times it is of primary importance to be resourceful and innovative, particularly in situations where time is crucial. Unfortunately some of our more traditional techniques have been wholly inadequate in meeting the needs of crisis and emergency situations. “
$ A. E. Slaby, J. Leib, and L. R. Tancredi, Handbook Emergencies: A Guide for Emergencies In Psychiatry, ination Publishing, New York City, 1975.
536
HOSPITAL
& COMMUNITY
of Psychiatric Medical
Exam-
PSYCHIATRY
It is clear that the anger-provocation technique must be used with much discretion and in a limited number of situations. I have found it useful in situations where, on the one hand, the repression of anger was producing major incapacitating symptomatology and, on the other hand, where the anger was not the source of major disorganization, such as that seen in some prepsychotic, psychotic, and severe panic states. The approach favored by customary psychotherapeutic practice emphasizes warmth, compassion, empathy, concern, and kindness. That approach may be unwise in certain crisis situations. In fact, it may encourage the individual to remain in the passive comfort of inactivity. The anger-provocation approach takes advantage of several factors that may bring about catharsis in a patient. The therapist makes himself the target for the patient’s hostility. There is no heavily invested, guiltridden, ambivalent relationship to interfere with the expression of anger. The therapist has, in fact, provided a justification for the anger, the absence of which sometimes interferes with such expression. Also, the therapist’s aggressive-abrasive attitude gives the patient the opportunity to identify with the aggressive therapist, and thus a learning experience or model is provided for the patient. It must be acknowledged that a contaminant has been introduced into the therapeutic setting. It may even be impossible for the therapist who has used such a technique to remain involved in a long-term therapeutic relationship with the patient. At those times, the patient should be referred to another therapist. However, a certain amount of unresolved hostility in therapists, who nonetheless are comfortable with the hostility, may be a useful factor. Thus the success of the technique may depend on the personal style of the therapist. Social pressure creates the need to repress anger and is sometimes responsible for the development of symptom formation, which at times even poses a threat to the continuation of life. The aggressive-abrasive approach described encourages the expression of anger in a patient and establishes the therapist as the target for that anger. As long as the technique is used judiciously, the benefits of anger provocation are clear. I #{149} R. Liberman,
“A
Behavioral
Reinforcing and Prompting apy,” Behavior Therapy,
Approach
to
Group
Hostility to the Therapist Vol. 1, August 1970, pp.
Dynamics:
in Group 312-327.
II.
Ther-
BRODSKY,
MD.
Chief, Crisis Intervention Sinai Hospital of Detroit Detroit, Michigan
Center
The author describes the use of anger provocation, a technique that encourages patients to express their repressed anger to a therapist who makes himself the target for their anger. He presents five case examples to Illustrate the positive effects of the technique in crisis and emergency situations. Three of the patients were depressed and withdrawn, one was suffering from conversion hysteria, and one was a paranoid schizophrenic. The author cautions that the technique must be used with discretion only in those cases where the repression of anger is producing major incapacitating symptomatology, but where the anger is not the major source of disorganization. UThe overt display of emotions seems to vary from one culture to another. For instance, Latins are more typically expressive, and Anglo-Saxons characteristically maintain a stiff upper lip. However, the expression of anger has generally met with social repression and ultimately intrapsychic repression. It may represent a need to maintain order as opposed to anarchy, but we must recognize that in many instances the satisfactory expression of anger, even in modified form, is not permitted. From our knowledge of psychodynamic theory, we understand to some extent the problems that ensue as a result. In our society we pay homage to a stoic ethic, which prefers that if people are to suffer at all, that they suffer in silence. We all are aware of situations in which the degree of withdrawal in an individual is so marked, and the quantitative introjected rage so intense, that it actually poses a threat to the continued survival of the individual. That kind of situation would certainly constitute an emergency as well as a crisis, adhering to the strict
Dr.
Brodsky
Wayne
clinical
State
also
is an
University
instructor
in the department
School of Medicine in
Detroit
of psychiatry and
of
assistant
professor at the Michigan State University College of Human in East Lansing. His mailing address is Sinai Hospital of Detroit, 6767 West Outer Drive, Detroit, Michigan 48235. Medicine
definitions of the terms.’3 In an attempt to deal with such grave situations, I have used some methods in which I act as a provocateur and the immediate target for the patient’s anger. Several crisis-oriented workers have acknowledged that it is good to encourage individuals to express their anger. Korner said that “Anger is a tonic. It instills motivation to move toward the offending object, it creates action. It sets emotions into motion toward the environment, thus working in the direction of crisis reduction. The individual needs to be stirred up, his passivity must be combated.”4 The approach I am talking about is not new. Periodically, rather vague references to the use of the angerprovocation technique have appeared in the literature. I hope to establish a clearer conceptualization of the use of such a technique, which, when appropriately and judiciously used, can be effective in dealing with certam crises and which may even be life-saving. I have used anger provocation with depressed withdrawn individuals who are at high risk for suicide. I also have used the approach in some cases of conversion hysteria and with a few more generally negative and covertly hostile patients, including some borderline and possibly psychotic patients with whom communicating in any other way is impossible and opening some channel of communication may be vital. The approach is not universal and should not be used indiscriminately. An anger-provocation technique, in which a therapist uses an aggressive-abrasive attitude, is an emergency tool to be used with considerable care and discretion in carefully selected situations and, if successful, it should be replaced immediately by an attitude of understanding and empathy. I will begin with the case that demonstrated to me the therapeutic value of mobilization of affect by anger provocation. .
.
.
and L. Small, Emergency Psychotherapy and Brief Grune & Stratton, New York City, 1965. 2 T. N. Rusk, “Opportunity and Technique in Crisis Psychiatry,” Comprehensive Psychiatry, Vol. 12, May 1971, pp. 249-263. C. H. Wolkon, “Crisis Theory, the Application for Treatment, and Dependency,” Comprehensive Psychiatry, Vol. 13, SeptemberOctober 1972, pp. 459-464. N. Korner, Crisis Reduction and the PsychologIcal Consultants In 1
L. Bellak
Psychotherapy,
Crisis
VOLUME
Intervention,
28
Behavioral
NUMBER
Publications,
7 JULY
1977
New
York
City,
1973.
533
CASE
ILLUSTRATION
The patient was a 43-year-old white man who had a long history of psychiatric treatment and hospitalization because of severe depression and suicidal risk. He was an obsessive-compulsive man who had much difficulty recognizing and expressing his feelings. Although the patient’s depression could be traced back to his childhood, it was intensified after his mother’s suicide, when he was 20 years old. The patient had seen several therapists, but other than some superficial intellectualizations he had gained no understanding of his conflict. Shortly after I started to treat the patient, I had to hospitalize him because he was profoundly depressed and potentially suicidal. I made many attempts to reach the patient emotionally after his hospitalization, all unsuccessful. Then an incident occurred that made me aware of the more active role I could have been playing. I had three appointments a week with him in the hospital. The third week I had to miss an appointment. When I arrived on the unit several hours later, he was obviously upset. He asked, Why weren’t you here earlier when we were supposed to meet?” I asked him how he felt about it, saying that he seemed to be upset. He said that he was, but that he thought I must have a good reason for not being there. I assured him that I did have a good reason, that an emergency had required my presence. Thus despite the fact that I had allowed him to express his feelings before explaining why I hadn’t been there, I had, in effect, further fed into his difficulty in giving voice to his anger. I had told him that he had no reason to be angry with me. I was also aware of his increasing feelings of dependency toward me. I decided that if a similar situation arose, I would not explain or excuse my behavior but would cooperate with him in the belief that I was being derelict in my duties. (I am sure that my decision was also based on the frustration I was feeling.) A week later I again had to miss our appointment, and I wasn’t able to see him until the next day. When I did see him, he appeared to be much more shaken emotionally than on the first occasion. He spoke carefully, obviously attempting to control his feelings; his fists were clenched, and his voice was tremulous. He asked what had happened this time. Once again I asked him about his feelings, and again he said there must be a good reason for my not being there. Then when he asked what the reason was, I shrugged my shoulders and said that it had slipped my mind. The result was an emotional explosion. He pounded the table so hard that it cracked. He began sobbing and speaking in a voice like that of a little boy. He said that it wasn’t fair, that I had no right to treat him that way, and that his mother should pay more attention to him and shouldn’t put all those responsibilities on his shoulders because he was just a little boy. He brought up a lot of material specifically related to his mother. It was as if the situation with his mother were being re‘ ‘
534
HOSPITAL
I had further fed into his difficulty in giving voice to his anger. I decided that if a similar situation arose, I would cooperate with him in the belief that I was being derelict in my duties.
ONE
& COMMUNITY
PSYCHIATRY
enacted in the therapy session. From then on the therapy began to progress. Telling him that I had forgotten the appointment justified his anger with me, and this justification allowed him to express the angry feelings that he had been unable to acknowledge. For the first time he became aware that he had such feelings. In a relatively short time we were gaining much access to the anger, guilt, and ambivalence in his relationship with his mother. At follow-up two years later he was symptom-free. He was enjoying relationships with others and was able to express feelings more easily than in the past. Although the case was not the typical crisis or emergency, it was the case from which I learned the value of affect mobilization and anger provocation in crisis and emergency situations. The following cases are other examples of my use of the anger-provocation technique. CASE
ILLUSTRATION
TWO
The patient was a 36-year-old white woman who had been in an automobile accident with her husband, who was driving. She and her husband were critically injured, and one of their three children was killed. Her husband quickly recovered, but she had to be hospitalized for weeks after he was released. She developed many complications, including intercurrent infections. The patient’s major problem was severe depression; she would not eat or participate in any kind of physiotherapy. The nursing staff interpreted her negative behavior as obstructionistic, and they developed a dislike for her and had as little to do with her as possible. When I first spoke to the patient, she was extremely thin and appeared to be in pain. She was very depressed. My attempts to communicate with her were to no avail. She said that she didn’t feel like talking and that there was nothing to talk about. When I said that she must be depressed and unhappy and in a lot of pain, there was essentially no response. I tried various approaches using a gentle, solicitous manner, but there was no response. The next day I decided to try another approach. I introduced myself again, and again there was little response. Then I asked the patient how long she had been trying to commit suicide and why she hatml her
husband and children so much that she wanted to leave her husband a widower and her children motherless. Her immediate response was to sit bolt upright and shout, How dare you talk to me like that! You don’t know what you’re talking about. Get out of here.” I replied that there was no reason to listen to her since she obviously was just collecting bedsores and preparing to die. (It should be noted that the comments I made about suicide were all the more inflammatory because her religion prohibited suicide. ) The patient was livid by the time I left, having maintained her angry responses for more than half an hour. The next day when I arrived, she was sitting up and eating. Angrily, and between mouthfuls, she told me that she would show me that I didn’t know what I was talking about. The patient was well enough to be discharged within two and a half weeks after my first visit. On the day of her discharge, she came up to me and said, “Well, doctor, will you admit that you were wrong?’ I answered, You’re right, I was wrong. Many issues had to be avoided because of the limited ego resources of this patient; however, we could work with some of her feelings about her dead child, her anger toward her husband, and her guilt. It is certainly clear that there was value in allowing myself to become the target for this woman’s anger. In this case the results were highly dramatic. “
‘
“
CASE
ILLUSTRATION
‘ ‘
THREE
The patient was a 40-year-old white married woman who had been hospitalized medically because of difficulties adjusting to a gastrostomy, which was necessary because of damage to her esophagus suffered as a result of radiation therapy for a thyroid disorder. When I first saw her, she was emaciated and withdrawn. She lay in a private room in semidarkness with the shades drawn and the door closed. She was very reluctant to speak and said only that she felt I couldn’t help her since her problem was physical and not emotional. From her history, the patient was a dependent, narcissistic woman who had succeeded in alienating her family by constantly demanding attention and behaving in a childlike manner when her demands were not met. An illness during childhood apparently was the only time that she had received a lot of attention from her mother, who she felt had otherwise neglected her. The second time I saw the patient, she was almost mute and had lost even more weight. As in the previous case I suggested that she was trying to kill herself because she was angry with her husband and children. She denied this vehemently. I refused to accept her denials and asked how long she had wanted to punish her husband and her children. The reaction was an intense angry outburst. She asked me to leave and said that I had no right to talk to her that way. I replied that I had no reason to respond to her demands because she was so helpless and ineffective in any case. During this session I was able to establish meaningful communica-
tion with the patient that eventually led to more cognitive and affective insight. The effects were quickly apparent, and the patient became active in her physical and psychiatric therapy. Thus far the case examples have been of patients who were profoundly depressed and whose introjected rage was mobilized as a result of the therapist’s provocation. The following case illustrates the use of this technique with a patient suffering from conversion hysteria. CASE
ILLUSTRATION
FOUR
The patient was a 38-year-old black married man who was hospitalized medically because of a paralysis of his left side that developed the night before admission. He was a large athletic-looking man who had a history of difficulty relating to men in a position of authority. At the time of his hospitalization, the patient had been involved in a conflict with an older partner about an invention that the patient had developed and that they were trying to market. The patient was extremely angry because his partner had arranged to market the invention without consulting him and was applying independently for a patent. Although the patient tended to be somewhat paranoid, he was not delusional. He never knew his father, who had died when the patient was still an infant. He had a succession of stepfathers, one of whom was quite brutal with him. The patient remembers trying to defend himself against a threatened beating, with the result that he got a harsh one. He recalled his last fight as an adolescent with his older brother, who gave him the worst beating he had ever received. The patient said that he was opposed to fighting because he had everything to lose and nothing to gain. Almost from the start the patient considered me an authority figure. On my third visit following his transfer to a psychiatric unit, after a totally negative physical and neurological work-up, I found him quite angry with me. He talked about how obvious it was that I thought I was the big boss man who could see him whenever I chose, and he called me one of those fat cats. He said that he was thinking of discharging himself because he didn’t believe his problem was emotional. I decided that I could use the patient’s anger at me to help him. I pointed out to him that since he was crippled and totally helpless, the only way he could leave the hospital was with my approval. I said that he was right, I was the boss man, and I certainly wasn’t prepared to wheel him off the unit. He became infuriated. His left fist clenched as he raised his arm as if to strike me. At that moment I pointed to his arm to draw his attention to what he was doing. Within a day of the confrontation, the patient was improved symptomatically. After that episode, we were able to begin assimilating the past situations with the present one. (It is important to mention that the paralysis began while the patient was fantasizing planning a fight with his partner.) ‘ ‘
VOLUME
28
NUMBER
7 JULY
1977
‘ ‘
535
Successful resolution of crises requires a flexible approach and knowledge of a variety of therapeutic techniques. At times it is of primary importance to be resourceful and innovative, particularly when time is cruciaL The final case example provocation I used with little less direct. CASE
ILLUSTRATION
is somewhat a rather brittle
atypical. patient
The was a
FIVE
The patient was a 34-year-old white woman who had been treated in the clinic before and had been diagnosed as a chronic paranoid schizophrenic. She told me that she was extremely depressed and had no reason for living, but that she wasn’t prepared to talk about it. From then on she was hostile and negative. Despite my attempts to deal with the anger that she must have been feeling, she remained silent. Although obviously not in a catatonic state, she refused to answer my questions. After many attempts I simply turned my chair toward my desk, picked up a medical journal, and started to read. After several minutes, the patient flew into a tirade at me for wasting her time and money. She shouted, How dare you treat me this way!” My actions had catalyzed interaction, which was quite successful therapeutically and was beneficial to the patient. It is clear that this aggressive-abrasive technique aimed at mobilizing passive and ineffective patients must be reserved for those patients whose major ego functions are intact. (Case number five is an exception.) A clear example of a contraindication was highlighted when I used the technique with a patient who was extremely withdrawn and depressed, but who demonstrated many borderline features. In that instance the patient withdrew into an almost catatonic-like state. With very gentle support she emerged from that state many minutes later. Anger, for this patient, was a major source of disorganization. Successful resolution of crises requires a flexible approach with the knowledge of, and a willingness to employ, a variety of therapeutic techniques.3 At times it is of primary importance to be resourceful and innovative, particularly in situations where time is crucial. Unfortunately some of our more traditional techniques have been wholly inadequate in meeting the needs of crisis and emergency situations. “
$ A. E. Slaby, J. Leib, and L. R. Tancredi, Handbook Emergencies: A Guide for Emergencies In Psychiatry, ination Publishing, New York City, 1975.
536
HOSPITAL
& COMMUNITY
of Psychiatric Medical
Exam-
PSYCHIATRY
It is clear that the anger-provocation technique must be used with much discretion and in a limited number of situations. I have found it useful in situations where, on the one hand, the repression of anger was producing major incapacitating symptomatology and, on the other hand, where the anger was not the source of major disorganization, such as that seen in some prepsychotic, psychotic, and severe panic states. The approach favored by customary psychotherapeutic practice emphasizes warmth, compassion, empathy, concern, and kindness. That approach may be unwise in certain crisis situations. In fact, it may encourage the individual to remain in the passive comfort of inactivity. The anger-provocation approach takes advantage of several factors that may bring about catharsis in a patient. The therapist makes himself the target for the patient’s hostility. There is no heavily invested, guiltridden, ambivalent relationship to interfere with the expression of anger. The therapist has, in fact, provided a justification for the anger, the absence of which sometimes interferes with such expression. Also, the therapist’s aggressive-abrasive attitude gives the patient the opportunity to identify with the aggressive therapist, and thus a learning experience or model is provided for the patient. It must be acknowledged that a contaminant has been introduced into the therapeutic setting. It may even be impossible for the therapist who has used such a technique to remain involved in a long-term therapeutic relationship with the patient. At those times, the patient should be referred to another therapist. However, a certain amount of unresolved hostility in therapists, who nonetheless are comfortable with the hostility, may be a useful factor. Thus the success of the technique may depend on the personal style of the therapist. Social pressure creates the need to repress anger and is sometimes responsible for the development of symptom formation, which at times even poses a threat to the continuation of life. The aggressive-abrasive approach described encourages the expression of anger in a patient and establishes the therapist as the target for that anger. As long as the technique is used judiciously, the benefits of anger provocation are clear. I #{149} R. Liberman,
“A
Behavioral
Reinforcing and Prompting apy,” Behavior Therapy,
Approach
to
Group
Hostility to the Therapist Vol. 1, August 1970, pp.
Dynamics:
in Group 312-327.
II.
Ther-
