Dealing with Jarrad's Thoughts of Harming Self/Others

If we weren't faced with the issue of Jarrad's harming himself or others, my usual approach would be to continue to focus on improving means-ends thinking, problem-solving, and coping with problem situations. As we did so, we would soon encounter situations where his lack of empathy and his lack of regard for others feelings makes it hard for him to deal with the situation effectively. This would provide an opportunity to work on what I sometimes call "empathy induction" (more on this later). However, the question of dealing with his hostile thoughts and impulses clearly takes priority.

This is not a simple issue. Given Jarrad's report that, in the past, he has faked psychiatric symptoms in order to be transferred, we are faced with the possibility that he may be faking again. However, his saying that he's faked symptoms in the past doesn't prove that he's faking now (it doesn't even prove that he was faking in the past). I don't know an easy way to know for sure if he's faking. (If I was faced with this situation I'd consider using some psychologial tests that have good validity scales.) When in doubt, it is necessary to err on the side of caution in situations like this, so the decision to transfer him sounds good to me.

How could we deal with his thoughts of harming himself or others? First I would need more information so that I could develop an understanding of this problem. You say little about his thoughts of harming himself. This leaves me with a series of questions:

• When do they occur?
• Are there identifiable precipitants?
• What emotions accompany the thoughts?
• What are the specific Automatic Thoughts that occur at those times?

You summarize the pattern with his thoughts of harming others as "He says that when he is around people, he becomes agitated and angry. When he gets back to his room, at night, he gets his anger out by violent fantasies." This leaves me with several questions:

• What are examples of specific situations where be become agitated and angry? What Automatic Thoughts occur at those times? How does he normally handle his agitation and anger?
• What is the content of his violent fantasies? Do the fantasies indeed "get his anger out"? In other words, is his level of anger lower or higher after he engages in his violent fantasies?
• Does he have other options for coping with agitation and anger? How effective are they?

Do you have answers for any of these questions? If so, please post them and I'll be better able to spell out how I'd deal with these problems.

Finally, I have some doubts about using aversive imagery or covert sensitization in an attempt to extinguish his violent fantasies. If the violent fantasies are his primary method for coping with agitation and anger and you succeed in suppressing the fantasies without also eliminating his agitation and anger, then how will he cope with his agitation and anger? It could be important to help him develop adaptive ways of coping with agitation and anger before attempting to suppress his violent fantasies.

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