Treating Violence in The Latino Mentally Ill Client
Rosa A. Dominguez, MSW, LCSW
Nora Otero, MEd, LMHC

Through our current practice at the Massachusetts Mental Health Center, we have seen an increase in the number of clients who have put others at risk due to their violent behavior. Our Center is one of the five mental health clinics that the Department of Mental Health of Massachusetts operates in the Metro-Boston area. The vast majority of the population served suffers from severe and persistent major mental illness. Approximately 15 percent of the clients are of Latino origin. Most of them have their roots in the Caribbean, with significantly fewer from Central America and other Latin American countries. Over the years, our group of bi-lingual and bi-cultural clinicians, which is very committed to serve this population, has developed an extensive group psychotherapy program. These psychotherapy groups were designed as a response to both, the needs of the patients and the interests that we, as a group of clinicians, developed in our professional growth. Weekly supervision and consultation meetings led the development of the group psychotherapy program.

During the summer of 1998, we responded to the trend of increasing violent behavior, which we noticed in our patients and initiated a discussion about starting a psychotherapy group for Latino clients with histories of physically and/or emotionally abusive behavior. One of our main hesitations stemmed from the fact that in our previous clinical experience we had been closer to the emotionally wounded, to victims of psychological trauma, early deprivation and/or domestic violence. In this therapeutic context, we became closer to the victim than to the perpetrator. During our initial discussions, we didn’t know whether we could develop any connection with the perpetrator and be effective in treating these individuals using a group model. 

In spite of the fact that this psychotherapy group represented a challenge to us, our personal and professional interests motivated us to continue. In the fall of 1998, we began to design the psychotherapy group and the treatment modality. The process of designing the group lasted seven months, and it included frequent discussions during group supervision. Through this experience we learned that we had a strong commitment to developing a treatment approach that could deal with violent individuals and to understanding the complex rational that underlies the perpetrator.

As co-leaders of this emerging group, we walked two parallel paths, which over time became interwoven. One path was related to the creation of the group structure, its frame, and its goals. The other path had to do with our own resistance and countertransferential feelings related to listening to brutality, violence, intense rage, and hate. We struggled with feeling afraid to develop therapeutic relations with individuals who had built up such violent attachments in their lives. Was it possible to preserve our goodness while working with these men? We had fantasies that an anger attack could be triggered in one of the group sessions and that violence would be the most fearsome consequence. Could we contain the anger expressed in the group, or were we at risk being traumatized by the group members? How could we as group leaders deal with our own wishes for retaliation and revenge? Was it possible to preserve an alliance with these individuals and to maintain a helping approach? Working through our fear and anxiety was an enriching process that increased our self-awareness and strengthened our connection. We discovered that the intensity of the feelings could be diluted in the co-leadership relation.

We struggled with the above feelings and with establishing a psychotherapy model that could help these individuals. These two areas ultimately became so connected and interactive that the one supported and enriched the other. 

We started to recruit members for a 12-week, cognitive-behavior group for Spanish speaking men. Appropriate referrals were those clients who had a history of physically and/or emotionally abusive behavior, who wanted to modify their violent behavior, and who were not actively psychotic and/or abusing substances. Group members had many differences among them, such as diagnoses, educational level, family and work history, living arrangements, and legal problems associated to their violent behavior. Their history of violence included behaviors such as intentional infliction of physical pain or injury to others (pushing, grabbing, hitting, choking, etc.), exerting intentional psychological pain to others (insulting, mockery, threatening, etc.), harassment, and arson.

Mr. B is a Hispanic, divorced, unemployed man in his forties who presented to treatment eight years ago. He sought treatment after his wife unexpectedly escaped from the Boston area (after he tried to strangle her), taking their three children with her. His initial presentation included severe symptoms of anxiety and depression. He reported sweaty palms, excessive perspiration, hyperventilation, and heart palpitations. He appeared with a face towel that he would continuously move from one hand to the other, drying his sweat or his tears or just rubbing his face. He had both history of significant loses as well as of assaultiveness, fire-setting, and domestic violence. Mr. B had been admitted several times for suicidal ideation and for feeling unsafe. One of these acute admissions was followed by a long stay in a partial hospitalization program. He stayed for a prolonged time because his symptoms turned to be severe each time his discharge was approaching. After seven years of individual psychotherapy, the patient was referred to the anger management psychotherapy group to work specifically on his violent behavior and his difficulties with impulse control. Mr. B reported to have a history of assaulting and threatening authority figures, who included, but were not limited to his sports coach and his supervisor at one of his jobs. He attempted to throttle his wife in the presence of their children, and he threatened and attempted to strangle one of his girlfriends. At the time of the referral to the anger management group, his clinician knew that he had tried to set his workplace on fire when frustrated and angry at his boss.

Group Model
Each 60-minute session was divided in three phases. During the first phase, members were asked to talk about a recent incident in which they lost control and behaved with excessive anger. They were required to provide a narrative of an episode that they identified as a problem. The focus was to center their attention on the problem behavior, to foster their self-observation, to increase verbalization and, even more importantly, to raise questions about their judgment.

The second phase of each session required that each member worked with an exercise book provided by the leaders of the group. This material was developed and adapted from, Paul Kivel’s The Men’s Work Workbook published by Hazelden. This workbook is a collection of exercises, incomplete sentences, questions, and true/false statements. The co-leaders read the exercises in order to help those clients who were illiterate in Spanish. Clients who had a good level of written Spanish could write their answers. This phase offered the opportunity to focus on themes such as male identity, cultural beliefs in which maleness is rooted, male socialization, and patterns of learned violence. Special attention was put on self-control of physical and emotional violence, anger management, and accepting and owning vulnerability through exploring ways to ask for help. 

The first two phases of each session pursued the strengthening of the members’ ego functions. Areas such as self-observation, judgment, search for more successful coping mechanisms, development of cognitive tasks, and problem solving skills were targeted during the group work. Group psychotherapy became an effective modality to build distance between intense anger feelings and aggressive behavior, introducing thoughts, and verbalization in between. 

Group members were dealing with strong emotions that were rooted in the memories that they brought up to life in each session. Once they felt in touch with these emotions, it was difficult for them to let go and to re-establish their affective balance. 

The third and last phase was directed to building the lost balance. It included breathing, relaxation, and imagery exercises. Members were asked to concentrate on the physical experiences that accompanied their intense emotions and simultaneously to practice the guided exercise. The goal was to generate a relaxation response that could be learned through practice, which would ultimately become incompatible with the uncomfortable physical sensations associated to anger. Eventually, this incompatibility could decrease the distressing emotional experience that used to prompt the client to lose control.

Mr. B had a very good attendance, and was active in accomplishing the group tasks. Even though he had used individual psychotherapy well, he had not been able to report all his past aggressive behaviors until he started to participate in group psychotherapy. Clearly the group facilitated his verbalization process. He reported episodes during his childhood and adolescence in which the violent behavior was his way to deal with frustration and anger. Mr. B could identify childhood exposure to violent male figures, as well as intense shameful instances. It became clear that his history of violence was prior to the onset of his mental illness. It was relatively easy for him to focus on recent incidents that triggered his outbursts in social contacts. He could describe then in detail but expressed fair or poor remorse in many of them. Eventually, his regret appeared connected with experiences similar to the ones where he felt intense shame when growing up, showing archaic signs of empathy for the victims. Gradually he seemed to be including thoughts and reasoning in between his feelings and his behaviors. Mr. B reported to deeply enjoy the breathing, relaxation, and imagery exercises that were practiced at the end of each session.

In spite of the fact that we have run this group only a few times, we have evaluated it as effective because of the following reasons.

• Members reported they could avoid escalating behavior when their anger was triggered.
• No new arrests were reported in a two-year follow up period.
• Most of the members could perceive choice in their behavior, showing more flexibility in their responses.
• Some members expressed interest in repeating the group when it is offered again.

We believe that this group model for the treatment of the mentally ill perpetrator can be applied not only to Latino clients but to other populations that fall under the described clinical profile.

This article was published in the April/May 2001 issue of The Group Circle.