Ruling Out the Organic

A recent text from a (recent) former Anger Management client prompted me to become aware of just how important it is to rule out anything organic (medical) when people come to us for help with anger issues.

A college student of Asian descent, very Westernized, was self-referred after becoming violent verbally and physically with his (now former) girlfriend. On two of the three occasions, he had consumed a substantial amount of alcohol, a common occurrence for him when he went out. Although he was not arrested by NYPD since she did not file charges, there were witnesses to one of the incidents that occurred during the day (without the influence of alcohol) and campus security became involved. He risked expulsion from school at the very least and realized that enrolling in treatment would help his case.

In addition to self-serving motives, he was seriously ashamed of his behavior. He stated he was not raised in a violent home nor had this happened before. This was his first serious relationship and its failure broke his heart. He genuinely desired to understand what had happened to him and to avoid any future repetition.

We did double sessions for about two months, following the Anger Management Curriculum and added some mindfulness activities and insight-oriented counseling. We spent time talking about cultural influences in his life, including the overuse of alcohol. He also disclosed he was in constant pain due to a nerve problem in his foot.

Concurrently, and once again for self-serving reasons, he decided to also see a counselor on campus for some intensive work (one week). Additionally, he elicited the sympathy and support of his advisor to help him through this period during which his schoolwork had suffered.

He terminated our sessions prior to completing the curriculum, giving as his reasons the discomfort he felt being in counseling at all and the shame that was triggered by remembering the incidents of violence. He also was anticipating being extremely busy as the term came to an end. Despite all of that, he felt our sessions were helpful and agreed to do his best to implement the techniques we had covered. We agreed to stay in touch through text.

I recently received a text from him from Taiwan that opened my eyes to something I had not explored fully.

In the text, he mentioned that he has thyroid problems that surfaced during a health checkup in New York. His doctor at home in Taiwan was trying to tell him that his thyroid problems led to his excessive anger. The client asked for my opinion about whether that was possible. He also stated that he had “a little episode of crazy rage with myself and I didn’t know how to stop it so I went to the ER to be safe.” Further, while in Taiwan and China for the summer he was having a “whole medical team evaluating my situation.”

The research I was able to do online suggested a strong correlation between thyroid anomalies (both hyper- and hypo-) and rage.

Although anger, rage and violence are multi-determined, as Anger Management specialists, I believe it is important when we take a history during our initial consultations, to screen for medical issues. If we discover that the client has not had a medical checkup, which might be one of the first things we suggest, explaining that we want to rule out any underlying organic (medical) issues.

With this particular client, I made some assumptions that resulted in my missing this important link to his behavior. He was young and well-off, intelligent and seemed to take his health seriously. I was surprised that these thyroid problems had not been discovered sooner.

From this point on, I will be acutely aware, particularly in clients for whom there is no history of violence, that underlying medical issues may be present and should be explored.