Introduction

We present a case of a male client who was sent to treatment because of anger and violent behavior as well as use of alcohol. Literature shows a high comorbidity of violent behavior and use of substances including alcohol [1-3]. A study by [4] found an association between alcohol dependence and violent offenses. Individuals with higher levels of anger expressions are at higher risk to relapse to violence and substance use [5]. Individuals are socially conditioned how to deal with emotions and behavioral response. Being male and obtaining an alcohol use disorder is associated with an increased risk of being exposed to violence [6,7]. Dominant behavior is also linked to masculine norms as males are often expected to be strong, independent, and do not show emotions [8]. Research found that individuals recovered from an anger instigation easier when they used their common way of anger expression such as communication or inhibit it [9]. For example, Native American males were found to recover from anger more quickly when they inhibited it and recovered slower when instructed to express their anger [10]. Males from marginalized populations are more likely to perceive racial discrimination as threatening and experience anger but use inhibition of anger to avoid aggressive behavior [11] which can impact levels of blood pressure [12]. Hence, this shows that cultural norms impact the socially accepted mode of response to anger. Suppressed feelings of anger have been implicated to pathophysiology of health problems [13], blood pressure [14] including cardiovascular disease [15,16]. When individuals suppress their anger, they may cumulate their emotional responses within their body and respond delayed and more intense [17]. found that inhibiting emotional information is linked with prospective changes in an increased cortisol awakening response six months later and shows how it influences the Hypothalamic-Pituitary-Adrenal axis (HPA) functioning. Anger is reflected across physical components including stress reactivity with connected autonomic arousal, hypervigilance, and hostile attributions [18]. The emotional response of anger is often expressed in violent behavior toward others and the most serious violent offenders also represent the most severe drug issues [2]. When considering clients who struggle with violent behaviors and alcohol use disorders, the clinical mental health counselor should also assess the client’s trauma history. Childhood adversities are associated with early use of alcohol, which indicates high risk for alcohol use disorder in adulthood [19]. Individuals who experienced multiple adverse childhood trauma are more likely to be heavy alcohol users and males are showing a significant higher risk of violence [20]. A study by [21] investigated the correlation between drinking and trauma symptoms and found that drinking is mediating to cope with it. The results suggested the importance of assessing trauma in clients who struggle with alcohol use disorders as experienced trauma can be the etiology that leads to suppressed anger and emotional distress. The client may try to self-medicate the emotional distress with alcohol consumption which increases the risk for violent behavior. This case report provides the treatment plan based on treating re-processing trauma with EMDR including emotional catharsis, psychoeducation about emotions and coping to channel behavioral responses. The clinician considered the client’s cultural background related to historical trauma that impact indigenous populations until today. In addition, the clinical mental health counselor guided the client toward implementing healthy activities toward holistic wellness.

Case Report

Client History

A 33-year-old male was seeking mental health counseling services after having completed detoxification and crisis management in the clinic. The client was tall, raw boned, and represented some hesitance in our first session but answered questions and appeared feeling more comfortable after the first intake counseling session. On a mental examination, the client reported symptoms of anger since he started school at age 8 years old when his peers started bullying him because of his Native American background. He shared that he was never feeling a happy child as his family members were struggling with alcoholism, poverty, and conflicts that mostly resulted in domestic violence. The client described that he has not only witnessed violence from his father against his mother and siblings but was also exposed to physical and emotional abuse himself since he can remember. He reported that he started being physically abusive towards his peers and younger siblings at age 13 years as it made him feel being strong like his father. The client shared that he was also physically abusive toward his first girlfriend when he was 18 years old, and his romantic relationships did not last for long throughout his life.

The client shared not being in a romantic relationship and having no family support. He reported that he often felt unable to concentrate or cope and dropped out of high school and started construction work when he was 21 years that he continued at different workplaces over eight years. The client reported that he did not feel comfortable with his co-workers in general. He reported having been let go at his job because he was angry and threatening towards one of his team members. This was the time when the client increased his consumption of alcohol and got into legal issues due to driving under the influence of alcohol. The clinical mental health counselor completed a comprehensive diagnostical assessment and according to identified criteria, the client was diagnosed with Intermittent Explosive Disorder 312.34 (F63.81) and severe Alcohol Use Disorder 303.90 (F10.20) in early remission (DSM-5, 2013). The client did not meet all criteria for diagnosing Posttraumatic Stress Disorder (PTDS) but expressed that his childhood was painful. The clinical mental health counselor explored with the client the most traumatic childhood experiences and identified related belief systems of himself, others, and the world.

Treatment Process

The treatment process was based on theory and research as clinical mental health counselors engage in scientifically based interventions. Professional counseling is both science, clinical expertise, and an art that integrates theory and practice for the benefit of the client. The client’s major areas to treat were childhood trauma, emotional and behavioral responses, and alcohol use disorder. The clinical mental health counselor developed a positive working alliance with the client through empathy, authenticity, and unconditional regards and explored how his family and culture has influenced his upbringing and shaped his belief systems. A competent clinical mental health counselor conceptualizes the client through the lens of a counseling theory and integrates the best Evidence-Based Practices (EBP) to assist the client in improving mental health and overall wellness. The clinician based the case conceptualization on Rational Emotive Behavioral Therapy (REBT) that concentrates on the client’s irrational beliefs and considered the context of the client’s characteristics and cultural background. Related to the client’s experienced childhood traumas, the implementation of EMDR was recommended for a successful long-term treatment outcome. EMDR was originally developed by Francine Shapiro for trauma treatment in the late 1980s (Shapiro, 1989). This psychotherapeutic approach has grown as more clinicians underwent comprehensive training to learn about the origins and the theoretical underpinnings and utilizing protocols and techniques effectively. It is important to screen if this method is suitable for the client as individuals who are actively suicidal or are actively dissociating are not appropriate for immediate trauma processing failure (Shapiro, 1991). Because the client was found to be benefitting from EMDR therapy, the content for the next 6 sessions was the application of Reprocessing (EMDR) therapy for re-processing some of his recalled physical and emotional abuses by his father. The clinician prepared the client with resources including gained appropriate self-regulation skills and selfmanagement skills such as breathing techniques and progressive muscle relaxation before focusing on trauma re-processing. The identified irrational core beliefs related to the earliest and the most intense traumatic events at age 5 were the core of the EMDR treatment.

The process was based on a three-pronged protocol that utilized past, present, and future for organizing the targets of the application. The client preferred tactile stimulation for processing the traumatic event. It was also important to consider the cognitive associations of unresolved trauma that include responsibility, safety, and choice. Once these old traumas were processed, the clinical mental health counselor targeted present life situations that were triggering guilt and urging the client to act out violently. Additional techniques such as writing and culturally appropriate rituals such as sweats were implemented to strengthen the client’s recovery process and the clinician provided psychoeducation about historical trauma and how epigenetics influenced generations of indigenous populations. Providing psychoeducation about emotions and how the client can channel them into healthy behavioral responses as well as discussing characteristics of masculine norms that are constructed by society helped the client to discover more about his behavioral outbursts and violence against others. The clinician also enhanced the client’s visual representation of life without addiction by using bilateral stimulation. The client identified his triggers for relapse and the clinician helped him desensitized those triggers step by step to support his recovery. Healthy coping strategies such as mindfulness techniques helped the client to promote calmness and being centered and grounded. In addition, the clinician guided the client using the traditional tribal medicine wheel for working on all four areas to gain holistic well-being. REBT assisted well to work on the client’s irrational beliefs about himself, his family members, and the world. Treatment was effective in assisting the client to reprocess his past traumas, resolving his anger associated with the history of physical and emotional abuse, and preventing violent behavior and relapse to use alcohol. To conclude, the treatment helped the client to recover and rebuild his life.

Discussion

Addiction is a worldwide concern and governments are recognizing that more care is needed to help individuals to recover and rebuild their lives. According to the United Nations of Drug and Crime 2019 report, the worldwide number of individuals who were diagnosed with substance use disorders raised from 30.5 million in 2017 to 35 million in 2019, while only one in seven receives treatment. In 2017, an estimated 271 million individuals (5.5%) of the worldwide population aged 15-64 had used drugs in the previous year [22]. Substance use problems are one of the primary issues that are linked to social and health problems in indigenous people [23]. Nevertheless, there is also a high prevalence of relapse when clients seek treatment for addiction. According to the American Addiction Centers [24] the percentage of people who will relapse after a period recovery ranges from 50% to 90%. Researchers understand alcohol-related behavior change as a process over time by identifying relapse patterns and remission factors for longterm clinical outcomes [25]. Although medication helps to detoxify individuals from drugs it cannot replace treatment [26] provided by a clinical mental health counseling is necessary to assist the client for a long-term recovery. A comprehensive examination of published articles about relapse characteristics related to alcohol use disorders identified that comorbidity, severity, craving, using other substances, and social factors are crucial for risk of relapse after remission [27]. To treat addiction effectively, the underlying issues as well as the whole person must be considered. Trauma is manifested on emotional, behavioral, and physical levels and traumatized clients are acting out past events and experiencing loss of self-worth as the individual’s relationship with existence itself is shattered.

Childhood trauma was associated to significant increased health risk for alcoholism [28] and trauma that is not integrated increases sensitization and stress in the individual [29]. EMDR is a method developed to treat trauma and can be well integrated into various theoretical approaches to mental health counseling and psychotherapy. Clinicians who work with clients in the addiction field need to be trained well to deal with trauma and addiction treatment, as most clients presenting addiction have a trauma history [30]. In addition, the client’s cultural background is related to historical trauma as his ancestors experienced genocide and historical oppression over generations. Providing psychoeducation about the impact of historical trauma and how the collective experience of his community has resulted in higher risk for dysfunctional families, violence, and the use of alcohol helps the individuals to understand his internalized negative beliefs about himself. Acknowledging historical trauma in an honest and direct way enhances any relationship and is essential in the healing circle for Native Americans [31]. The memory of this collective injury and emotional and behavioral responses might be conserved at the molecular level inbuilt in epigenetic inheritance [32]. The clinical mental health counselor’s overall treatment framework was based on the self-medication model that believes that individuals develop addiction to mask other underlying issues. Therefore, one of the effective ways to heal addiction is to treat the underlying problem [33]. In this case report, the client has experienced multiple traumas throughout his childhood and his emotional response of anger manifested in his violence against others. Alcohol has been part of the problem to numb the pain that was the driving force behind his anger. The treatment of these underlying issues helped to build a steady foundation for the client to recover and prevent relapse. Working with the client on emotional and behavioral responses as well as his cultural background [34] was an effective approach. The clinical mental health counselor worked with the client on his irrational beliefs about himself to enhance his selfworth with REBT therapy. In addition, the integration of physical, mental, spiritual, and relational care including walking in nature, wood gathering, sweats, and other traditional healing practices improved the client’s holistic wellness and sustained sobriety.

Conclusion

The provision of trauma treatment for a client who was meeting the DSM-5 criteria for Intermittent Explosive Disorder 312.34 (F63.81) and severe Alcohol Use Disorder 303.90 (F10.20) in early remission (DSM-5, 2013) but not for PTSD was effective in this case report and led to achieve long-term recovery. This case report highlights the importance of involving clinical mental health counselors in treating clients with both addiction and underlying issues such as traumatic events. Clinicians must consider how trauma contributes to the progress of symptoms including anger and addiction as they are often connected.

Introduction

A case study is presented involving a male client who received treatment for anger, violent behavior, and alcohol use. Research indicates a frequent co-occurrence of violent behavior and substance use, including alcohol. Studies also show a link between alcohol dependence and violent offenses. Individuals with high levels of anger expression face a greater risk of returning to violence and substance use.

Social conditioning shapes how individuals manage emotions and behavioral responses. For males, having an alcohol use disorder is associated with a higher risk of violence exposure. Dominant behavior is also connected to masculine norms, which often expect males to be strong, independent, and unemotional. Research suggests individuals recover from anger more easily when they use their typical methods of expression, such as communication, or when they suppress it. For example, some studies indicate that certain male populations recover from anger faster when they suppress it and slower when asked to express it. Males from marginalized groups may perceive discrimination as threatening and feel anger but suppress it to avoid aggression, which can affect blood pressure. This highlights how cultural norms influence socially accepted responses to anger.

Suppressed feelings of anger have been linked to various health problems, including high blood pressure and cardiovascular disease. When individuals suppress anger, emotional responses may accumulate and be expressed later with greater intensity. Research suggests that suppressing emotional information can lead to changes in physiological stress responses over time. Anger manifests through physical components like stress reactivity, increased alertness, and a tendency to interpret situations as hostile.

Anger often results in violent behavior towards others, and individuals with the most severe violent offenses frequently also have the most serious drug issues. When addressing clients with violent behaviors and alcohol use disorders, mental health counselors should assess their trauma history. Childhood adversities are linked to early alcohol use, indicating a high risk for alcohol use disorder in adulthood. Individuals who experienced multiple childhood traumas are more likely to be heavy alcohol users, and males show a significantly higher risk of violence. Studies have explored the connection between drinking and trauma symptoms, suggesting that drinking may be used as a coping mechanism. These findings underscore the importance of assessing trauma in clients with alcohol use disorders, as past trauma can lead to suppressed anger and emotional distress.

The client may attempt to self-medicate emotional distress with alcohol, increasing the risk of violent behavior. This case report details a treatment plan focusing on trauma reprocessing using EMDR (Eye Movement Desensitization and Reprocessing), emotional release, and education about emotions and healthy coping strategies. The clinician considered the client's cultural background, including historical trauma affecting indigenous populations. Additionally, the mental health counselor guided the client toward healthy activities for overall well-being.

Case Report

Client History

A 33-year-old male sought mental health counseling services after completing detoxification and crisis management. The client appeared hesitant initially but became more comfortable after the first intake session. During a mental examination, the client reported experiencing anger since age 8, when peers began bullying him due to his Native American background. He described a difficult childhood, with family members struggling with alcoholism, poverty, and conflicts often leading to domestic violence. The client witnessed violence from his father towards his mother and siblings and was exposed to physical and emotional abuse himself from a young age.

At age 13, the client started physically abusing peers and younger siblings, stating it made him feel strong like his father. He shared that he was also physically abusive towards his first girlfriend at 18, and his romantic relationships throughout his life were short-lived. The client reported no current romantic relationship and no family support. He often felt unable to concentrate or cope, leading him to drop out of high school. At 21, he began construction work, continuing at various workplaces for eight years, but reported feeling uncomfortable with co-workers.

The client was dismissed from a job due to angry and threatening behavior towards a team member. This event led to increased alcohol consumption and legal problems related to driving under the influence. A comprehensive diagnostic assessment was completed. Based on identified criteria, the client was diagnosed with Intermittent Explosive Disorder and severe Alcohol Use Disorder in early remission. Although the client did not meet all criteria for Posttraumatic Stress Disorder, he described his childhood as painful. The counselor explored the most traumatic childhood experiences and related belief systems about himself, others, and the world.

Treatment Process

The treatment process was grounded in established theory and research, aligning with the practice of clinical mental health counselors utilizing evidence-based interventions. Professional counseling integrates scientific knowledge, clinical expertise, and art to benefit the client. The client's primary treatment areas included childhood trauma, emotional and behavioral responses, and alcohol use disorder. The counselor fostered a strong working relationship with the client through empathy, authenticity, and unconditional regard, exploring the influence of his family and culture on his upbringing and beliefs. A competent counselor conceptualizes the client through a theoretical lens and integrates evidence-based practices to improve mental health and overall well-being.

The clinician's case conceptualization was based on Rational Emotive Behavioral Therapy (REBT), focusing on the client's irrational beliefs while considering his characteristics and cultural background. Given the client's childhood traumas, EMDR (Eye Movement Desensitization and Reprocessing) was recommended for successful long-term outcomes. This psychotherapeutic approach has gained recognition among clinicians. It is crucial to screen clients for suitability for EMDR, as individuals who are actively suicidal or dissociating may not be appropriate for immediate trauma processing. Because the client was deemed suitable, the next six sessions focused on EMDR for reprocessing recalled physical and emotional abuses by his father.

The clinician prepared the client by providing resources, including self-regulation and self-management skills like breathing techniques and progressive muscle relaxation, before focusing on trauma reprocessing. The core of the EMDR treatment targeted identified irrational core beliefs related to the earliest and most intense traumatic events, which occurred at age 5.

The process followed a three-pronged protocol, addressing past, present, and future targets. The client preferred tactile stimulation for processing the traumatic event. It was also important to consider the cognitive associations of unresolved trauma, such as issues of responsibility, safety, and choice. Once old traumas were processed, the counselor focused on present-day situations that triggered guilt and urged the client to act violently. Additional techniques, such as writing and culturally appropriate rituals, were used to support the client's recovery. The clinician provided education about historical trauma and how epigenetics can influence generations of indigenous populations. Education about emotions and how to channel them into healthy behavioral responses, along with discussions about societal masculine norms, helped the client understand his behavioral outbursts and violence.

The clinician also enhanced the client's vision of a life without addiction using bilateral stimulation. The client identified relapse triggers, and the clinician helped desensitize these triggers step-by-step to support recovery. Healthy coping strategies, such as mindfulness techniques, promoted calmness and groundedness. Additionally, the clinician guided the client in using the traditional tribal medicine wheel to work on all four areas of holistic well-being. REBT effectively addressed the client's irrational beliefs about himself, his family members, and the world. Ultimately, the treatment helped the client reprocess past traumas, resolve anger associated with physical and emotional abuse, and prevent violent behavior and alcohol relapse. The treatment facilitated the client's recovery and rebuilding of his life.

Discussion

Addiction is a global concern, with a rising number of substance use disorders worldwide, yet many individuals do not receive treatment. Substance use problems are a primary issue linked to social and health problems in indigenous communities. High rates of relapse are common among clients seeking addiction treatment, with various factors contributing to this risk, including co-occurring disorders, severity of addiction, cravings, use of other substances, and social factors. While medication can assist with detoxification, comprehensive mental health counseling is essential for long-term recovery.

Effective addiction treatment requires addressing the underlying issues and considering the whole person. Trauma manifests emotionally, behaviorally, and physically, often leading to a loss of self-worth and re-enactment of past events. Childhood trauma is significantly associated with an increased risk for alcoholism, and unintegrated trauma can heighten an individual's stress and sensitivity. EMDR is a recognized method for treating trauma and can be integrated into various mental health counseling approaches. Clinicians in the addiction field require training in both trauma and addiction treatment, as a majority of clients presenting with addiction also have a trauma history.

The client's cultural background, marked by historical trauma experienced by his ancestors, also played a role. Providing education about the impact of historical trauma and how the collective experiences of his community have contributed to higher risks for family dysfunction, violence, and alcohol use can help individuals understand their internalized negative beliefs. Acknowledging historical trauma honestly is crucial for healing within certain cultural contexts. The memory of collective injury and emotional responses may even be preserved through epigenetic inheritance.

The overall treatment framework was based on the self-medication model, which posits that addiction often develops as a way to mask underlying problems. Therefore, effectively treating addiction involves addressing these foundational issues. In this case, the client's multiple childhood traumas fueled his anger, which manifested as violence. Alcohol was used to numb this pain. Treating these underlying issues provided a stable foundation for the client's recovery and prevention of relapse. Working with the client on his emotional and behavioral responses, alongside his cultural background, proved to be an effective approach. The counselor utilized REBT to address the client's irrational beliefs and enhance his self-worth. Additionally, the integration of physical, mental, spiritual, and relational care, including activities like walking in nature, wood gathering, sweats, and other traditional healing practices, improved the client's holistic wellness and sustained sobriety.

Conclusion

The provision of trauma treatment was effective for a client meeting diagnostic criteria for Intermittent Explosive Disorder and severe Alcohol Use Disorder in early remission, despite not fully meeting criteria for Posttraumatic Stress Disorder. This case report highlights the importance of clinical mental health counselors in treating clients with both addiction and underlying issues like traumatic events. Clinicians must recognize how trauma contributes to the development of symptoms, including anger and addiction, as these are often interconnected.

Introduction

This document describes the case of a male client referred for treatment due to anger, violent behavior, and alcohol use. Research indicates a strong connection between violent behavior and substance use, including alcohol. Studies have shown a link between alcohol dependence and violent crimes, and individuals who express more anger face a higher risk of returning to violence and substance use.

People learn how to manage emotions and respond behaviorally through social conditioning. For males, having an alcohol use disorder is linked to a greater chance of experiencing violence. Assertive behavior is also tied to masculine norms, which often expect men to be strong, self-reliant, and to suppress their emotions. Studies suggest that individuals recover more easily from anger when they express it in their usual way, such as through communication or by holding it back. For instance, Native American males have shown faster recovery from anger when they inhibited it, and slower recovery when encouraged to express it. Men from marginalized groups may view racial discrimination as more threatening and experience anger, but they often suppress this anger to avoid aggressive actions, which can affect blood pressure. This highlights how cultural norms influence socially acceptable ways of responding to anger.

Suppressed anger is connected to various health problems, including high blood pressure and cardiovascular disease. When individuals suppress anger, emotional responses may build up internally, leading to a delayed and more intense reaction later. Research indicates that holding back emotional information can lead to changes in stress hormones over time, affecting the body's stress response system. Anger manifests physically through stress reactivity, heightened alertness, and attributing hostility to others. This emotional response often leads to violent behavior, and the most severe violent offenders frequently have the most serious drug problems.

When working with clients struggling with violent behaviors and alcohol use disorders, mental health counselors should also evaluate their history of trauma. Difficult childhood experiences are linked to early alcohol use, indicating a high risk for alcohol use disorder in adulthood. Individuals who experienced multiple childhood traumas are more likely to be heavy alcohol users, with males showing a significantly higher risk of violence. Studies have explored the connection between drinking and trauma symptoms, finding that drinking often serves as a coping mechanism. These findings suggest the importance of assessing trauma in clients with alcohol use disorders, as past trauma can cause suppressed anger and emotional distress. Clients may attempt to cope with this distress by drinking alcohol, which further increases the risk of violent behavior.

This case report details a treatment plan focused on reprocessing trauma using Eye Movement Desensititization and Reprocessing (EMDR) therapy, which includes emotional release and education about emotions and healthy coping strategies. The counselor also considered the client's cultural background, acknowledging the ongoing impact of historical trauma on Indigenous populations. Additionally, the mental health counselor helped the client incorporate healthy activities to promote overall well-being.

Case Report

Client History

A 33-year-old male began mental health counseling after completing detoxification and crisis management at the clinic. The client, who was tall and lean, appeared hesitant during the initial session but answered questions and seemed more at ease after the first intake. During a mental health assessment, the client reported experiencing anger since age 8, when peers began bullying him due to his Native American background. The client shared that a sense of happiness was largely absent from his childhood, as his family experienced ongoing struggles with alcoholism, poverty, and conflicts, often leading to domestic violence.

The client reported that at age 13, he began acting physically abusive towards his peers and younger siblings, stating that this behavior made him feel strong, similar to his father. The client also shared that he was physically abusive towards his first girlfriend at age 18, and his romantic relationships generally did not last long throughout his life.

The client shared that he was not in a romantic relationship and lacked family support. He reported often feeling unable to concentrate or cope, leading him to drop out of high school. At age 21, he began construction work, which he continued at various job sites for eight years. The client stated that he generally felt uncomfortable with his co-workers. He was eventually fired from a job for acting angrily and threateningly towards a team member. Following this, the client increased his alcohol consumption and encountered legal problems related to driving under the influence.

A comprehensive diagnostic assessment was completed by the mental health counselor. Based on established criteria, the client received diagnoses of Intermittent Explosive Disorder and severe Alcohol Use Disorder, noted as being in early remission. While the client did not meet all criteria for Posttraumatic Stress Disorder (PTSD), he described his childhood as painful. The counselor explored the client's most traumatic childhood experiences and identified associated belief systems about himself, others, and the world.

Treatment Process

The treatment process was grounded in both theory and research, aligning with the practice of mental health counselors who utilize evidence-based interventions. Professional counseling combines scientific principles, clinical expertise, and a humanistic approach to integrate theory and practice for the client's benefit. The primary focus areas for treatment included childhood trauma, emotional and behavioral responses, and alcohol use disorder. The mental health counselor established a strong working relationship with the client through empathy, authenticity, and unconditional positive regard. This allowed for exploration of how the client's family and cultural background influenced his upbringing and shaped his belief systems.

A skilled mental health counselor views a client through the framework of a counseling theory and incorporates the most effective evidence-based practices to help improve mental health and overall well-being. The counselor in this case conceptualized the client's situation using Rational Emotive Behavioral Therapy (REBT), which focuses on identifying and challenging irrational beliefs, while also considering the client's unique characteristics and cultural background. Given the client's history of childhood traumas, Eye Movement Desensitization and Reprocessing (EMDR) therapy was recommended for a successful long-term outcome. EMDR was developed in the late 1980s specifically for trauma treatment and has become widely used. Before starting EMDR, it is crucial to screen clients for suitability, as those who are actively suicidal or experiencing severe dissociation are not appropriate candidates for immediate trauma processing.

Because the client was determined to benefit from EMDR therapy, the next six sessions focused on reprocessing recalled physical and emotional abuses inflicted by his father. Before starting trauma reprocessing, the counselor helped the client develop self-regulation and self-management skills, such as breathing techniques and progressive muscle relaxation. The core of the EMDR treatment involved addressing the irrational core beliefs linked to the earliest and most intense traumatic events, which occurred around age 5.

The EMDR process followed a three-pronged protocol, addressing past, present, and future aspects of the client's experiences. The client chose tactile stimulation during the processing of traumatic events. Consideration was also given to cognitive beliefs linked to unresolved trauma, such as feelings of responsibility, safety, and choice. After processing past traumas, the mental health counselor focused on current situations that triggered guilt and violent impulses. Other techniques, including writing and culturally appropriate rituals like sweats, were used to support recovery. The counselor educated the client about historical trauma and how generational experiences can affect Indigenous populations. Discussing emotions and healthy ways to channel them, along with exploring societal masculine norms, helped the client understand his behavioral outbursts and violence. Bilateral stimulation was used to help the client visualize a life free from addiction. The client identified relapse triggers, which the counselor then helped to desensitize. Healthy coping strategies, such as mindfulness, were taught to promote calmness and grounding. Furthermore, the counselor guided the client in using the traditional tribal medicine wheel to achieve holistic well-being across all aspects of his life. REBT effectively addressed the client's irrational beliefs about himself, his family, and the world. Overall, the treatment successfully helped the client reprocess past traumas, resolve anger from physical and emotional abuse, and prevent violent behavior and alcohol relapse, leading to a recovery that enabled him to rebuild his life.

Discussion

Addiction represents a global challenge, with governments increasingly acknowledging the need for greater support to help individuals recover. Reports indicate that the number of people diagnosed with substance use disorders worldwide has increased, yet only a small fraction receives treatment. Substance use issues are a significant contributor to social and health problems, particularly among Indigenous populations. Despite treatment efforts, a high rate of relapse is often observed among clients seeking help for addiction.

Relapse rates after a period of recovery from addiction are reported to be high, ranging from 50% to 90%. Researchers view changes in alcohol-related behavior as a long-term process, studying patterns of relapse and factors that contribute to sustained recovery. While medication can aid in detoxification, it does not replace the comprehensive treatment provided by mental health counseling, which is vital for long-term recovery. A review of studies on alcohol use disorder relapse indicates that co-occurring disorders, severity of addiction, cravings, use of other substances, and social factors are significant risks for relapse following a period of remission.

Effective addiction treatment requires addressing underlying issues and considering the client holistically. Trauma can manifest emotionally, behaviorally, and physically, leading clients to re-enact past events and experience a profound loss of self-worth. Childhood trauma is strongly linked to an increased risk of alcoholism, and unaddressed trauma can heighten an individual's sensitivity to stress. EMDR is a therapy designed to treat trauma and can be effectively combined with various counseling and psychotherapy approaches. Clinicians specializing in addiction treatment require thorough training in trauma-informed care, as many clients with addiction also have a history of trauma.

Furthermore, the client's cultural background involved historical trauma, given that his ancestors endured generations of genocide and oppression. Educating the client about the impact of historical trauma and how his community's collective experiences contributed to a higher risk of dysfunctional families, violence, and alcohol use helped him understand his own internalized negative beliefs. Openly acknowledging historical trauma strengthens relationships and is crucial for healing within Native American communities. The impact of such collective trauma, including emotional and behavioral responses, may even be passed down genetically through epigenetics. The mental health counselor's overall treatment approach was guided by the self-medication model, which suggests that individuals develop addiction as a way to mask deeper issues. Thus, effectively treating addiction often requires addressing these underlying problems.

In this case, the client experienced multiple traumas during childhood, with his anger manifesting as violence toward others. Alcohol served as a way to numb the pain that fueled his anger. Treating these underlying issues provided a stable foundation for the client's recovery and relapse prevention. Addressing the client's emotional and behavioral responses, along with his cultural background, proved to be an effective strategy. The mental health counselor utilized REBT to challenge the client's irrational beliefs, thereby improving his self-worth. Additionally, incorporating physical, mental, spiritual, and relational care, such as nature walks, wood gathering, sweats, and other traditional healing practices, enhanced the client's overall well-being and supported his sustained sobriety.

Conclusion

In this case report, providing trauma treatment to a client diagnosed with Intermittent Explosive Disorder and severe Alcohol Use Disorder in early remission, who did not meet full criteria for PTSD, proved effective in achieving long-term recovery. This case highlights the crucial role of mental health counselors in treating clients who present with both addiction and underlying issues like traumatic experiences. Clinicians must recognize how trauma contributes to symptoms such as anger and addiction, given their frequent interconnectedness.

Introduction

This report describes the case of a male client who sought treatment for anger, violent behavior, and alcohol use. Studies show a common link between violent behavior and substance use, including alcohol. Individuals who often express high levels of anger face a greater risk of returning to violent behavior and substance use.

People learn how to manage their emotions and reactions from their social environment. For males, especially, cultural norms often expect them to be strong, independent, and to hide their emotions. This can affect how they express anger. Research suggests that suppressing anger, particularly for men from marginalized groups, can lead to health problems like high blood pressure. When anger is suppressed, it can build up and lead to more intense or delayed reactions.

Furthermore, a history of trauma, especially during childhood, is strongly linked to early alcohol use and a higher risk of alcohol use disorder in adulthood. Individuals who have experienced multiple traumas as children are more likely to be heavy alcohol users, and males in this group show a significantly higher risk of violence. Alcohol may be used to cope with emotional pain or distress caused by past trauma, which can then increase the risk of violent behavior.

This case report details a treatment plan that focused on reprocessing trauma using EMDR (Eye Movement Desensitization and Reprocessing) therapy. It also included helping the client express emotions, learn about feelings and coping strategies, and understand how his cultural background and historical trauma affected him. The treatment also encouraged the client to adopt healthy activities for overall well-being.

Case Report

A 33-year-old man sought mental health counseling after completing detoxification and crisis management. During his first session, the client, though hesitant, became more comfortable and shared his experiences. He reported having anger issues since age eight, when he was bullied due to his Native American background. He described an unhappy childhood marked by family alcoholism, poverty, and domestic violence. The client witnessed violence from his father against his mother and siblings and experienced physical and emotional abuse himself. By age 13, he began being physically abusive toward peers and younger siblings, feeling it made him strong like his father. This pattern continued into his romantic relationships, which never lasted long.

The client was not in a romantic relationship and lacked family support. He often struggled to concentrate and cope, dropping out of high school. At age 21, he began construction work, which he continued for eight years at various sites, feeling uncomfortable with co-workers. He was eventually fired from a job for angry and threatening behavior. This event led to increased alcohol consumption and legal issues, including driving under the influence. After a full assessment, the client was diagnosed with Intermittent Explosive Disorder and severe Alcohol Use Disorder, now in early remission. While he did not meet all criteria for Posttraumatic Stress Disorder, he described his childhood as very painful. The counselor explored his most traumatic childhood experiences and the negative beliefs he held about himself, others, and the world.

Treatment focused on his childhood trauma, emotional and behavioral responses, and alcohol use disorder. The counselor built a strong, supportive relationship with the client and explored how his family and culture influenced his upbringing and beliefs. The treatment plan was based on Rational Emotive Behavioral Therapy (REBT), which helps address irrational beliefs, and integrated EMDR therapy for his childhood traumas. EMDR, developed for trauma treatment, was chosen after confirming its suitability for the client.

The EMDR therapy involved six sessions dedicated to reprocessing specific physical and emotional abuses experienced from his father, particularly focusing on core irrational beliefs formed during the most intense traumatic events around age five. Before beginning trauma reprocessing, the client learned self-regulation skills like breathing techniques and progressive muscle relaxation. The EMDR process used a three-part approach (past, present, future) and tactile stimulation to help the client process the traumatic memories. It also addressed how these unresolved traumas impacted his current feelings of responsibility, safety, and choice, and his triggers for violent outbursts.

Additional methods, such as writing and culturally appropriate rituals like sweats, supported the client's recovery. The counselor educated the client about historical trauma and its generational impact on indigenous populations, and about emotions and healthy ways to express them. Discussions about societal masculine norms helped him understand his own aggressive behaviors. The client also identified his triggers for relapse, and the counselor helped him gradually reduce their power. Mindfulness techniques were introduced to promote calmness. The client was also guided to use the traditional tribal medicine wheel to work on all four areas of holistic well-being. REBT effectively helped the client challenge his irrational beliefs about himself, his family, and the world. This comprehensive treatment helped the client process past traumas, resolve anger linked to abuse, and prevent violent behavior and alcohol relapse, ultimately aiding his recovery and ability to rebuild his life.

Discussion

Addiction is a global concern, with many individuals needing care to recover. Substance use issues are a major problem for indigenous communities, and relapse rates for addiction treatment are often high, ranging from 50% to 90%. While medication can help with detoxification, long-term recovery requires comprehensive counseling that addresses the underlying issues and the individual as a whole. Factors like co-occurring conditions, severity of addiction, cravings, use of other substances, and social factors are important risks for relapse.

Trauma impacts individuals emotionally, behaviorally, and physically. Clients with trauma may re-enact past events and lose their self-worth. Childhood trauma is linked to a significantly higher risk of alcoholism, and unprocessed trauma can increase stress and sensitivity. EMDR is an effective method for treating trauma and can be integrated into various counseling approaches. Mental health professionals working in addiction treatment need to be well-trained in both areas, as most clients with addiction have a history of trauma.

The client's cultural background, including historical trauma experienced by his ancestors, was crucial to his treatment. Educating him about how collective experiences like genocide and oppression have impacted his community, leading to issues like dysfunctional families, violence, and alcohol use, helped him understand his own negative beliefs. Acknowledging historical trauma is essential for healing within Native American communities. The treatment approach for this client was based on the "self-medication model," which suggests that people develop addictions to mask deeper, unresolved problems.

By addressing the client's childhood traumas, his anger, and the underlying reasons for his alcohol use, a strong foundation for recovery and relapse prevention was established. Focusing on his emotional and behavioral responses, combined with cultural understanding, proved effective. REBT helped the client improve his self-worth by challenging irrational beliefs. Additionally, integrating physical, mental, spiritual, and relational care—including activities like walking in nature, wood gathering, sweats, and other traditional healing practices—improved the client's overall well-being and supported his sobriety.

Conclusion

This case report demonstrates that trauma-focused treatment was effective for a client diagnosed with Intermittent Explosive Disorder and severe Alcohol Use Disorder, even without a formal Posttraumatic Stress Disorder diagnosis. This approach led to long-term recovery. The case highlights the critical role of clinical mental health counselors in treating clients with both addiction and underlying issues like traumatic experiences. Professionals must recognize how trauma contributes to symptoms such as anger and addiction, as these are often closely linked.

Introduction

This writing is about a man who received help for anger, violent actions, and drinking alcohol. It is common for violent behavior to happen along with using alcohol or other drugs. Studies have shown that people who drink a lot are more likely to act violently. Also, people who get very angry are more likely to act violently again or start using alcohol or drugs again.

People learn how to deal with their feelings and actions from society. Men who have problems with alcohol are at higher risk of being exposed to violence. Men are often expected to be strong and not show feelings. Research shows that people feel better from anger faster if they deal with it in their usual way, like talking or keeping it in. For example, some Native American men felt better from anger when they kept it inside, but felt worse when told to show it. Men from groups that face unfair treatment may feel anger because of unfair treatment but keep it in to avoid acting violently. Keeping anger inside can affect a person's health, including their blood pressure.

When people keep their anger inside, these feelings can build up and come out later in a stronger way. Anger affects the body, causing stress, being overly watchful, and thinking others are against them. Anger often leads to violent actions towards others, and the most violent people also often have the most serious drug problems. When helping people with violent behavior and alcohol problems, counselors should also check for past hurtful experiences, called trauma. Bad experiences in childhood are linked to using alcohol at a young age, which can lead to alcohol problems as an adult. People who had many bad childhood traumas are more likely to drink a lot, and men are at a higher risk for violence. Drinking can be a way to cope with trauma. This means it is important to check for trauma in people with alcohol problems, as past trauma can lead to kept-in anger and emotional pain. A person might try to use alcohol to make this pain go away, which then increases the risk of violent behavior.

This report shares a plan for treating trauma using a method called EMDR. It also includes letting out strong feelings, learning about emotions, and learning healthy ways to act. The counselor also thought about the man's cultural background, especially how past traumas affecting his people might still affect him today. The counselor also helped the man add healthy activities to improve his overall well-being.

Client History

A 33-year-old man came for mental health counseling after getting help for his alcohol use and bad behaviors at a clinic. The man was tall and thin. He seemed a little unsure at first but answered questions and felt more comfortable after the first meeting. When talking about his feelings, the man said he had been angry since he started school at age 8. This was because other kids picked on him for being Native American. He shared that he never felt like a happy child because his family had problems with alcohol, poverty, and fights that often led to violence at home. The man said that he not only saw his father hurt his mother and siblings, but he was also hurt physically and emotionally himself since he was very young. He said he started hurting his friends and younger siblings at age 13 because it made him feel strong like his father. The man shared that he also hurt his first girlfriend when he was 18, and his romantic partnerships did not last long throughout his life.

The man said he was not in a relationship and had no family support. He often felt he could not focus or handle things. He quit high school and started working in construction at age 21, which he did for eight years at different places. The man said he did not feel comfortable with his co-workers. He was fired from a job because he was angry and threatened one of his team members. This was when he started drinking more alcohol and got into legal trouble for driving after drinking. The counselor did a full check-up. Based on what was found, the man was diagnosed with a disorder that causes angry outbursts and a severe alcohol problem. He had recently stopped drinking. The man did not meet all the needs to be diagnosed with full Post-Traumatic Stress Disorder (PTSD), but he said his childhood was very painful. The counselor talked with the man about his worst childhood experiences and how they made him think about himself, others, and the world.

Treatment Process

The treatment followed methods based on science. Good counseling uses knowledge, skill, and understanding to help people. The main areas to help the man with were his childhood trauma, how he reacted emotionally and behaviorally, and his alcohol problem. The counselor built a good working relationship with the man by being understanding, real, and caring. They talked about how his family and culture affected his growing up and shaped his beliefs. A good counselor understands the client using proven methods to help them improve their mental health and overall well-being. The counselor used a type of therapy called REBT (Rational Emotive Behavioral Therapy) that helps change unhelpful thoughts. The counselor also thought about the man's personal traits and cultural background. Because of the man's childhood traumas, EMDR was suggested for good, lasting results. EMDR was first created for trauma treatment in the late 1980s. This way of helping with mental health has grown as more counselors have learned about its origins and how to use its rules and methods well. It is important to check if this method is right for the person, as it is not for those who are trying to harm themselves or losing touch with reality. Since the man was found to benefit from EMDR therapy, the next 6 sessions focused on using EMDR to help him deal with his memories of physical and emotional abuse from his father. The counselor helped the man learn ways to control himself, like breathing techniques and muscle relaxation, before focusing on processing trauma. The main part of the EMDR treatment was focusing on his deep, unhelpful beliefs linked to the earliest and strongest traumatic events he had at age 5.

The process used a three-part plan that looked at the past, present, and future. The man preferred feeling something like hand-held buzzers for processing the traumatic event. It was also important to consider the thoughts linked to unhealed trauma, which included feelings of responsibility, safety, and choice. Once these old traumas were processed, the counselor focused on current situations that made the man feel guilty and want to be violent. Other methods like writing and cultural practices like sweat lodges were used to help the man heal. The counselor also taught him about how bad things that happened in the past to his people can affect families over many years. Teaching him about emotions and how he could change them into healthy actions, as well as talking about ideas about how men are supposed to act in society, helped the man understand more about his angry outbursts and violence towards others. The counselor also helped the man imagine a life without addiction by using side-to-side stimulation. The man identified things that made him want to drink again, and the counselor helped him make those triggers less strong step by step to support his recovery. Healthy ways to cope, like mindfulness techniques, helped the man feel calm, centered, and grounded. The counselor also guided the man using the traditional tribal medicine wheel for working on all four areas to gain overall health. REBT helped a lot to work on the man’s unhelpful beliefs about himself, his family members, and the world. The treatment successfully helped the man deal with his past traumas, resolve his anger from the history of physical and emotional abuse, and stop violent behavior and drinking alcohol again. In summary, the treatment helped the man recover and rebuild his life.

Discussion

Addiction is a worldwide problem, and governments are realizing that more help is needed for people to recover and rebuild their lives. According to a 2019 report, the number of people worldwide with drug problems grew from 30.5 million in 2017 to 35 million in 2019. However, only one out of seven people receives treatment. In 2017, about 271 million people (5.5%) around the world aged 15-64 had used drugs in the past year. Drug use problems are a main issue linked to social and health problems in Indigenous people. Still, many people who get treatment for addiction start using again. One group reports that 50% to 90% of people will start using again after a period of recovery. Researchers understand that changes in alcohol-related behavior happen over time by looking at patterns of starting again and factors that help people stay in recovery for a long time. Even though medicine helps people stop using drugs, it cannot take the place of treatment provided by a counselor. This is needed to help the person for a long-term recovery. A full look at published writings about why people start drinking again found that other problems, how bad the addiction is, wanting the substance, using other drugs, and social issues all increase the risk of starting again after stopping. To treat addiction well, the hidden problems and the whole person must be considered. Trauma shows up in feelings, actions, and the body. People with trauma often act out past events and feel bad about themselves.

Childhood trauma was linked to a much higher risk for alcohol problems. Trauma that is not dealt with makes a person more sensitive and stressed. EMDR is a method made to treat trauma and can be used well with different kinds of mental health counseling. Counselors who work with people with addiction need to be well-trained to deal with both trauma and addiction, as most people with addiction have a history of trauma. Also, the man’s cultural background is linked to historical trauma, as his ancestors faced unfair treatment for many years. Teaching him about the effects of historical trauma and how the shared pain of his community has led to a higher risk for troubled families, violence, and alcohol use helps individuals understand their negative thoughts about themselves. Talking openly about historical trauma helps build trust and heal, especially for Native Americans. The effects of this shared pain and how people feel and act might even be passed down in families in how their bodies work. The counselor's overall treatment plan was based on the idea that people use drugs or alcohol to cover up deeper problems. So, one effective way to heal addiction is to treat the hidden problem. In this case, the man had many traumas throughout his childhood, and his anger turned into violence towards others. Alcohol was part of the problem because he used it to make the pain go away that was driving his anger. Treating these hidden problems helped build a strong base for the man to recover and stop starting again. Working with the man on his emotional and behavioral responses, as well as his cultural background, was an effective way to help. The counselor worked with the man on his unhelpful beliefs about himself to improve his self-worth using REBT therapy. Also, adding care for his body, mind, spirit, and relationships, including walking in nature, gathering wood, sweat lodges, and other traditional healing practices, improved the man's overall well-being and helped him stay sober.

Conclusion

Using trauma treatment for a man diagnosed with severe anger and alcohol problems (who had recently stopped drinking) but not full PTSD, worked well in this case and helped him stay sober for a long time. This case shows how important it is for counselors to help people with both addiction and hidden problems like traumatic events. Counselors must consider how trauma makes symptoms like anger and addiction worse, as they are often connected.