Anger: Fight, Flight or... Opportunity

Years ago, I worked with a client who came into therapy after his wife left him. He reported that their relationship was characterized by constant bickering and fighting—a pattern that appeared to have pre-dated their marriage. He insisted that there was no physical violence and stated that “I only become angry when I’m backed into a corner.” He acknowledged that his anger “could become” verbally abusive: name-calling, cursing, invective. For the first two months of treatment, he presented as calm, thoughtful, and motivated to reunite with his wife. He insisted that he was “not an angry person”. During one session, he spoke about a recent telephone conversation with his wife, and as he reported the conversation, I noticed that he was clenching his fist and hitting his other hand with it. I asked him how he felt about the conversation. He stated that he understood her position (although he “didn’t like” what she had to say) and that he “respected” her. I reflected back that he seemed to have other feelings and called attention to his non-verbal behavior. He looked at me, looked at his clenched fist, thought for a moment, and then said, “I guess I’m really angry.” It was the first time in session that he was able to recognize and be present to his anger. We could now begin to work. Psychotherapy isn’t always about warm, fuzzy feelings or affirmation. Often psychotherapy is a means for experiencing and working through very difficult feelings. Clients frequently come to sessions feeling angry and upset. I’ve had clients who’ve told me they have felt angry all their lives; they want to get to the root of the anger in hopes of feeling differently. Some clients come to therapy aware of their angry feelings and hope to learn specific techniques to better manage their anger. Conversely, others come to therapy because they feel unable to express their anger in healthy ways. Still others come to therapy unaware of their anger and discover that they have been acting it out in destructive or dysfunctional ways. And there are many clients who come to therapy because they feel confused about the patterns of anger that emerge in their relationships.

Feeling angry and being on the receiving end of another person’s anger are never easy experiences. Occasionally, therapy itself evokes feelings of anger and a client will become angry with the therapist. Those moments, though difficult, are valuable since they offer opportunities to learn about ourselves, how we see the world and respond to it, our beliefs about ourselves and others, and our deepest needs.

Indeed, I see those angry moments as opportunities for understanding and change.

Anger is a very challenging emotion—one that is often present during psychotherapy. Anger is often a response to a loss or a threat of loss. It can be an expression of an unmet need. Anger also covers underlying fear. Sadly, anger can compound loss, since anger can be used defensively to push people away. The angry person is often experienced as alien by witnesses and by those at whom anger is directed. While anger often reflects an unmet need, anger can also become a barrier to fulfilling the need. It’s hard to genuinely give when you’re being yelled at. The result: confusion, more anger, and fear for everyone involved.

Whenever anger boils up and over, it can be difficult for the listener to remain open, non-defensive, and to find clarity in what is being expressed. It’s hard to hear what the anger is really all about; the intended message gets lost, especially when the force of the anger is strong. Extraneous material gets attached to the emotion of the moment, and sometimes issues surface that have little obvious relation to the immediate trigger. Moreover, it’s difficult to hear the message when invectives are hurled at a pitched volume and physical gestures threaten violence.

Some lessons I’ve learned over the years about managing anger:

1. Always make yourself safe. If you feel unsafe, threatened, or abused, take action to make yourself safe. You are not a doormat. There can be no meaningful resolution in the absence of safety. 2. Whatever the source and cause, it is important—and very difficult—to remain verbally non-defensive in the face of anger. Defensiveness tends to provide fuel for more anger. 3. More often than not, all that anger does not belong to you—although some of it might. Therapy can help you discern what belongs to you and let go of what doesn’t. 4. There is always a cause for anger; reach for it. There is always a message in the anger; try to hear and understand it. Start by reaching for the facts: what triggered the anger? What does the angry person need? What does the anger mean? 5. Recognize when the force of the anger seems out of proportion to the trigger—a sure sign of misdirected and displaced anger. Keep in mind that the real root of the problem may not be immediately evident. Chances are that your spouse is not really angry at you because you squeeze the toothpaste tube from the middle. Psychotherapy is enormously helpful at getting to the real problem. 6. In the heat of the moment—when the invective is flying—do not attempt to justify, rationalize, or excuse your position. The angry person may not be able to hear you in these moments. Instead, reflect back what you are hearing. I’ve found it helpful to reflect back the triggers of anger and other facts that seem related to the situation—NOT the anger itself. 7. As the heat of the anger diminishes, try to reflect back the message you heard. Again, staying grounded with facts is key. This helps further de-escalate the situation. Asking what the other person needs is even more helpful. 8. Accept responsibility for your part in stimulating the anger, if indeed you have a part. If you cannot discern your part (and, indeed, you may not have a part), affirm that you are having trouble understanding what you’ve done; ask for detail. You may want to bring the situation to therapy to help you separate facts from feelings, untangle causes and find the sources of anger. 9. Reach for clarity. 10. Keep the door to communication and resolution open. It may not be possible to resolve the problem in an angry moment; negotiate a time to return to the issue to work it through. But make sure you come back to the issue to work it through. A time out is just that; it is not a resolution. 11. Once the anger is worked through, find ways of letting it go.

All this is easier said than done—which, again, is where therapy can be helpful. A psychotherapist may help illuminate the seeds of the anger. Psychotherapy can help you develop clarity, learn coping strategies, identify next steps toward resolution, and perhaps deepen your relationships. It can also help you rebalance, find and reclaim lost confidence and courage, and be prepared for the next time anger makes an appearance. And it will.

Assessing the Need for Medication

A reader recently wrote to ask about medications: when is medication indicated for a depression or anxiety? Do you need psychotherapy and medication? What differentiates depression and anxiety from “stress”? Depression is a widely used term to identify a particular set of mood states—the feeling of being “down” or “low”. Most of use experience depression at some point in our lives. Many of us may feel depressed in response to a particular situation: loss of a job, family stress, conflict in a marriage. Situational depressions are common and often get better when the situation changes or improves. However, depression becomes more serious when it starts to significantly impact a person’s ability to function in the world and persists over a period of time.

Many symptoms characterize depression, and they persist over a period of time:

• Persistent feelings of sadness or emptiness • Diminished interest or pleasure in most activities • Low self-esteem • Significant weight loss when not dieting, or • Significant weight gain • Insomnia, or hypersomnia (too much sleep) • Agitation and irritability • Daily fatigue or loss of energy • Feelings of worthlessness or inappropriate guilt • Diminished ability to think or concentrate • Indecisiveness • Feelings of hopelessness • Recurrent thoughts of death (suicidality) • Impairment in social functioning: withdrawal and/or isolation • Impairment in vocational functioning: inability to work --from the Diagnostic and Statistical Manual (4th edition, revised)

We know that depression has a chemistry and neurology. In depression, the brain’s chemistry is altered, resulting in changes in mood and thinking. Medications work because they restore “balance” among the neurotransmitters in the brain.

There are a number of different types of depression, and therapists and other clinicians are careful to assess symptoms, the length of time symptoms are present, circumstances surrounding the onset of symptoms, stressors and life situations that impact mood, family history of mood disorders, and medical conditions that might impact mood. In addition, there are several standardized assessment protocols (e.g., the Beck Depression Inventory; the Hamilton Rating Scale for Depression) that help clinicians evaluate the severity of the depression—which might also indicate that medication is needed.

As a therapist, evaluation of mood is something I routinely do every time I see a client. Further, I always explore changes in mood and note when they persist. I am alert to depressive patterns of thinking; these patterns and the thoughts themselves are focal points for discussion. Several factors typically indicate the need for a medication: persistent changes in appetite, sleep, and libido; persistent feelings of worthlessness and guilt; significant cognitive changes that bother the client –i.e., difficulty with concentration; and, most significantly, thoughts of suicide or death. (When these last symptoms occur, I immediately evaluate for safety and am not hesitant to recommend or arrange for a hospitalization.)

I’ve found that medication is a helpful adjunct to psychotherapy. Since I am not licensed to prescribe medication, I typically refer clients to a psychiatrist or psychopharmacologist for a medication evaluation. (I rarely recommend that clients ask for psychotropic medications from internists or general practitioners; physicians who do not specialize in psychiatry often do not conduct full evaluations and often are not well-informed about psychotropics; consequently, they do not properly medicate clients. However, it is important that you tell your doctor you are taking an anti-depressant or anti-anxiety medication!)

I also believe that psychotherapy is critical to the treatment of depression. There is no magic pill. A prescription may alleviate some of the symptoms but will not address the psychological factors—i.e., low self-esteem, distorted thoughts and beliefs—that are part and parcel of depression. Psychotherapy will address those issues. In addition, certain psychotherapies help build coping skills or strengthen the coping mechanisms that are already in place but may have become eroded by depression. Together, medication (when it is indicated) and psychotherapy have been shown to be effective means of helping people with depression.

I will address anxiety in another posting…