Managing Anger and Agitation at Home

Brain Injury Blog by Janet Cromer

May 12, 2011

Managing Anger and Agitation at Home

Part Two – Changing Behavior Safely and Effectively

angery manLast week we talked about how to figure out what causes or triggers an angry response. Now let’s get into how to set up and use a behavior plan. I’ve also included important points to keep the survivor and family safe.

After you’ve collected your A-B-C data, pick out one problem behavior to work on at a time.

Step 2: Try out a new approach

Set a goal that’s measurable and realistic. For example, “Alan will say “I need to talk” three times this week instead of yelling. The reward (consequence) was that he could pick a restaurant for lunch, which he enjoyed.

Decide on one new change or approach to try at a time. Be patient and consistent.. After a week or two, evaluate the effect. Have there been fewer outbursts? Does a particular reward work best? If it worked, great! If not, pick another approach to try, or consult a professional for more suggestions.

When a behavior is potentially dangerous or doesn’t respond to rewards, you may need to take a privilege away. When Alan yelled and tried to hit his home health aide, we agreed the penalty would be that he forfeited their trip to the swimming pool. Alan loved to swim, so this sometimes worked. At the same time, I reported the increased agitation to his psychiatrist so we could look at the cause and perhaps adjust his medication.

Over time, we came up with a repertoire of skills and strategies to help Alan manage his outbursts, and to keep us safe. We worked on improving his ability to SAY he was getting angry, anxious, or frustrated when the feeling was still manageable rather than demonstrating with a yell. I drew a speedometer gauge and taught  him how to recognize he was getting angry when he was in the 20 mph zone. He could take a deep breath, go for a walk, or tell me he was annoyed, instead of letting the anger zoom to the 60 mph zone where yelling began.

We attacked the sources of the problem by limiting his choices or preparing him for an event.. We boosted his esteem to counter the humiliation of lost skills. We identified jobs where he could be the boss and show off the skills. For example, he taught me how to paint craft kits or empty the dish washer his way.

Getting a few friends involved helped too. When Alan was angry at how much I “ran his life,” he called his nephew Tom who could empathize about Alan’s losses for a few minutes before changing the subject with a good joke that got Alan laughing.

Alan had memory impairment that complicated learning new strategies. So, we wrote each new plan in his notebook so we could review and evaluate its value. He carried an index card to remind him of the strategy he was practicing.

Sometimes Alan needed to destimulate by going into his office alone to read a book quietly for 15 minutes. He often forgot why he was angry, but the physical sensation persisted longer than the memory. Then I’d suggest taking a walk or doing yoga together to decrease his tension.

Another strategy was to redirect him from ruminating over something he couldn’t do to an activity he liked such as raking the yard or sorting out that junk drawer every kitchen has.

It tried to model good communication skills, and apologized when Alan said I wasn’t polite enough.

We wrote out contracts or agreements for important issues that became major problems. Alan was not able to drive, and this loss troubled him greatly. We negotiated an arrangement to allow his nephew Tom to use Alan’s car (and remove it from our driveway where its presence fueled Alan’s rage.) This is very important: Whenever I had to take something away from Alan, I made sure to give him something to control in return. In this contract, Tom agreed to be Alan’s chauffer one day a week and drive him anywhere he wanted to go.

Key points to remember:

1. Safety is your first concern. As a caregiver, you must insure your safety as well as the survivor’s. Do not hesitate to call the police or another emergency contact. I had to call the police a few times when Alan’s rage reached threatening levels. Their presence and skill helped him regain control.

2. Tell a professional about the problem. They can evaluate for a medical, psychiatric, neurologic, or other cause and recommend better ways to manage. Sometimes caregivers are afraid to tell the truth because we fear being blamed or having the survivor placed in a facility. It often takes a team approach to figure out the best solution.

3. You can never win an argument with a person who can’t think reasonably. Don’t get trapped into unproductive arguing. Disengage and figure out how to defuse the situation.

4. Ask for help learning communication skills for your particular situation.

5. Take anger seriously. As a psych nurse I knew that when a person yells, turns red, makes fists, tenses his muscles, or gets very quiet he is capable of striking out. Stand at least a leg length away, speak clearly in short sentences, and have an emergency plan as back-up.

2 responses to “Managing Anger and Agitation at Home”

  1. Janet Cromer says:

    Hi Marie,
    I enjoy your stories about Tucker’s valuable lessons very much. Have you seen the poster that says “I’m trying to become the person my dog thinks I already am.” That’s my visual for being a nicer person!

  2. Marie G. Cooney says:

    Dear Janet,

    I like the speedometer image for anger or any emotion. Sometimes when words fail me, a simple picture is what I need. My emotional speedometer and the car speedometer will help me keep this picture in mind. Hopefully, I can ask myself when am I cruising along at a steady speed, when am I approaching road rage, when do I need to slow down and when do I need to resume speed. The goal is to hit cruise control with greater immerging awareness when approaching dangerous intersections with others or myself. Sometimes it is particularly emotionally dangerous for me when others just don’t understand why I’m not the old me. Thanks for this image and the other good ideas too.

    Marie G. Cooney
    TBI Survivor, Writer

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