Although it’s a good reminder from Bessel van der Kolk, a leading expert on trauma, who affirms, “You know, one of the most bizarre treatments to me is anger management training. It is frontal lobe training, which shuts down when you get really angry. So anger management is great as long as you don’t get angry.”
Sue Johnson, ground-breaking researcher and founder of Emotionally Focused Therapy (EFT) for relationships, has a Youtube video in which she says:
“People say to me sometimes, ‘Well, do you fight with your husband?’
“Of course I do. Do you think I am an EFT therapist every minute?”
‘And do you use all your skills?’ they ask
“Of course I don’t. Which is why teaching people skills doesn’t work. You can only use them when you don’t need them.”
“Like when your in a fight with your husband I don’t want to use my EFT skills. I want to prove him wrong. I want to show him he can’t talk to me like that. I want to be right. I want to be in control. And the EFT therapist in my head says don’t say that and I say it. Yes, I do. Because I’m a human being with my toes over a thousand-foot drop. The difference is that then we can come back and this is what securily attached folks could do. They can come back and heal the fight.”
While the anatomy of anger, is apparent in the autonomic or “fight and flight” system of the body, and there are physiological, emotional and medical contributing factors. Looking at parts of the brain, a stimulus passes through the thalamus and hippocampus before creating a response in the amygdala and prefrontal cortex, the amygdala being the brain’s alarm system. While the purpose is to enhance survival, our body is “angry” before we realize we are angry making it even harder to control. The cingulate gyrus is also activated which makes it hard to put on the brakes and control behavior. Heart rate and blood pressure increase. Airways in the lungs expand. Thus blood flow to the brain and the digestive system. This is where gastrointestinal issues can be related to stress, especially when the ratio of stomach acid to blood in the digestive system is affected. It also affects memories which through the hippocampus become a guide for future action. Memories associated with anger and fear become dominant in one’s decisions making and may inaccurately assess the current situation as a threat. This is related to trauma. It also disrupts sleep as you can imagine as your brain at night has a less of an ability to refocus on balanced thinking. Instead, we tend to think about the negative side of life. The most problematic results include medical conditions, high frequency of anger display, withdrawing or overeating, aggression or sarcasm. getting even or substance use, and arguing and depression.
Contributing factors include hormone levels, the availability of neurotransmitters, epigenetics, family and cultural modeling, and brain injury. Disorders that are factors in chronic anger include, ADHD, depression, anxiety, behavioral disorders, obsessive compulsive disorders, fatigue, low blood sugar and hyperthyroidism.
Joan Borysenko who does research on the mind/body connection had an interesting perspective on anger. “It actually looks similar to happiness in the brain, especially in the left prefrontal and pre motor cortex. It activates the reward system. It gives you energy, power and justifies yourself to reduce guilt. There is a difference though between anger and uncontrolled aggression.”
Ron Siegal, Psy. D. from Harvard Medical School adds, “Interestingly, people who act angrily a lot are not so good at feeling anger.”
In fact, anxiety and fear are uncomfortable or alarming enough so that anger becomes preferred. It induces a state that I heard called “adrenaline drunk.”
Attending to the backdrop behind anger is stress management. The safer we feel the less stress we feel. To counter stress which may be out of our control we may need to augment what is in our control: our own sense of accomplishment, connection with others, enjoyment and self-care. Behavioral activation or behavioral restructuring include routines that give meaning to life that are appropriate in expectations. It includes executive functioning skills. Connection includes family, friends and faith, pets, a supportive community, humor, kindness, asking for help, grieving and forgiving. Enjoyment includes gratitude, hobbies, joy and excitement. Self-care includes sleep hygiene, eating right, exercise, taking breaks, and general self-care.
Mind-body interventions include mindfulness of all of what you feel, in the present in a non-judgmental way. Judgment add stress which may be unnecessary. Breathing, calming and grounding techniques are effective if practiced regularly and engage your sensory input, like music or relaxing sounds, visualization, different textures and sensations, even different tastes and scents. Healthy distraction techniques can help buy you time to feel better, or emotions can be channeled into healthy ways to express them.
A brief overview of evidence-based practices for anger include the following:
- Cognitive Behavioral Therapy
- Acceptance and Commitment Therapy
- Dialectical Behavioral Therapy
- Eye Movement Desensitization and Reprocessing
- Solution-Oriented Therapy
- Motivational Interviewing
- Trauma Informed
- Internal Family Systems
Cognitive Behavioral Therapy (CBT)
CBT identifies triggers that cause discomfort and pain and reveal underlying fears and sadness. Vulnerable and painful feelings like inadequacy, rejection, abandonment and helplessness may be avoided and replaced with problematic symptoms. It uses both cognitive and behavioral interventions.
An example of a cognitive intervention uses the acronym TRUTH to challenge problematic thoughts:
- T– True: Is this thought actually true, or is it an exaggeration or distortion?
- R– Reasonable: Does the evidence support this thought, or is it based on irrational assumptions?
- U– Useful: Does believing this thought help you in any way, or does it create unnecessary stress?
- T– Thoughtful: Does the thought reflect your values?
- H– Helpful: Does this thought contribute to your overall well-being?
Self-talk may include statements like the following to control behavior:
- Is it worth it?
- Don’t respond right now
- Keep your breathing even
- This too shall pass
- Anger will be an energy drain
Skill development involves practicing the following behaviors:
- Relaxation Techniques
- Stress Management
- Problem-solving Skills
- Communication Skills
- Assertiveness Training
- Conflict Resolution Skills
Dialectical Behavior Therapy (DBT)
DBT skill development include specified steps to build:
- Mindfulness Skills
- Distress Tolerance
- Emotion Regulation
- Interpersonal Effectiveness
Marsha Linehan, creator of DBT, suggests anger is an excess of emotion. If you tell an angry person that they have a problem with anger, they will get angry with you. She suggests instead telling them they have a problem with irritability and they’ll more likely agree. One example of an intervention is called Willing Hands. Open palms signify willingness and acceptance in a situation signaling to your brain that you are open to what’s happening. It means facing your fears and eliminating resistance. She claims the fastest way to reboot or regulate the autonomic nervous system is to put your face in a bowl of ice water for 30 seconds!
Acceptance and Commitment Therapy (ACT)
ACT works with the underlying emotions that the client can access, acceptance of anger as a natural emotion, using cognitive diffusion to detach from unhelpful thoughts and beliefs, along with mindfulness and value-based actions.
Eye Movement Desensitization and Reprocessing (EMDR)
EMDR uses bilateral stimulation of the brain through sound, sight and touch to process how a past event is linked to present-day anger. For example would be a past event that left you overwhelmed with helplessness. It is reprocessed in a healthier and more adaptive way based on positive experiences when you felt empowered, strong and capable, or nurturing figures that are kind and compassionate are used to help clients know that they matter. Bilateral stimulation helps clients process quicker.
Solution-oriented Therapy
Solution-oriented therapies explore and build on client strengthes, resources and any past success. The client’s best hopes for change is elicited. It is also creative. Bill O’Hanlon, a pioneer in solution-oriented therapy promoted creative solutions like singing instead of arguing, which incorporates the proper breath work, and a little fun, for autonomic regulation.
Motivational Interviewing (MI)
MI lists reasons to change and not to change. It rolls with client resistance, but develops discrepancy between a client’s desired outcome and actual outcomes. What changes in behavior or thought may lead to the desired outcomes? It works with triggers and develops coping strategies.
Trauma-Informed Therapies
Recognizing that a signficant source of anger occur in experiences of trauma. Pierre Chenais, a research analyst, said, “Traumatized patients keep repeating the actions that began when the trauma happened.” Bessel van der Kolk said most traumatized people are angry. “They’re angry because people have hurt them. And nobody did anything about it.” He believes anger is actually undeveloped in the traumatized.
Internal Family Systems (IFS)
In IFS, different parts of self are identified that play a role in anger. These positive parts have positive intentions, even when there is negative impact. For example, anger could be a part of you that protects you from getting humiliated or hurt or taken advantage of. More specifically, parts called “managers” could come across as edgy or hostile to keep people at arm’s length. IFS develops a sense of communicating with different parts that are involved in one’s behaviors, thoughts and feelings. Related to anger, you may ask anger why it gets aggressive, and it may be there to counter another part of the person that is passive. Anger may protect what they call exiled parts that are vulnerable and stuck in a past event that caused shame. Other parts may feel terrified of the anger. Developing a relationship with these parts, getting permission, not being afraid of them, even appreciating them and then interacting with them as the “Self” remain treatment goals. “Self-energy” is often found in acceptance, curiosity and compassion, and can go “back in time” to help parts that are stuck and bring them to safety in the present.
Quotes are from video from the National Institute for Clinical Application of Behavioral Science course on Practical Skills for Working with a Client’s Anger, or found in YouTube searches.
