Friday, July 13, 2007

Angry, did you say?

Like I've said in other posts,

Just about all of my interventions weave in some form of cognitive behavioral therapy somehow.

I like CBT for anger management especially. And I personally use it all of the time to control my emotions. But people who see red can't slow themselves down long enough to work the therapy. And they make friends and family very uncomfortable.

So something has to be done.

The rule is that if it's hard for a person to control an outburst then a med eval (medication evaluation) is a good idea. Once chilled a bit, Cognitive Behavioral Therapy (CBT) is pretty useful. Plus there's no harm in getting a med eval. Nobody can make a person take drugs.

I'm forever telling people, We have better drugs!

We do have some really good ones now, meds that take the edge off, and they're not all addicting, either. But you can develop quite a tolerance to some of them, so if that's a concern, check it out with your doc.

Anger's a totally different animal you know, than anxiety or depression. It's sometimes hard for a person to tell exactly what it is that's causing the bad feelings in anxiety and depression, but we know very well who or what is making us angry.

Like this morning. I had almost finished this post when FD asked me calmly, “Where are the car keys? They're not on the hook.” His stress was palpable.

Little One is home from yeshiva and he had the keys last night. FD was leaving. It was 6:30 a.m. He was late. “I’ll find them,” I said. "I'll wake him up."

The keys were in Little's pocket. I said thanks, never yelled. FD didn’t yell. We remained polite and calm throughout the whole drama. But it was tense.

Me empathizing with FD's frustration motivated me to jump and hurry up, wake up the kid. The kid jumped to find the keys.

Negative emotion motivates people like nothing else, for better of for worse.

But what if we'd lost it? What if FD had had a tantrum, then it could have become ugly! I would have been angry and defensive with FD for his tantrum and somehow my anger and defensiveness would have trickled down to Little and we'd all have had a nasty morning. And it was a beautiful morning.

So to me anger's the symptom that best exemplifies how emotions affect family systems. Anger isn't at all fuzzy. You know why you’re angry, you know who you're angry at. Or do you?

If we hold that irrational core beliefs about ourselves drive our emotions, and we have to rationally counter them to feel better, then we have to figure out the core belief. There has to be a little psychotherapy going on for CBT to work.

The emphasis in CBT is on rationality, which is not nearly as sexy as emotionality, like I've said before, which is why people resist being rational. Depression and anxiety make us look vulnerable. Angry people don't give off vulnerable vibes. So anger is not sexy.

Nobody wants to take an angry person in their arms and say, There, there, it'll all be fine, don't worry (although that's exactly what we need sometimes). Most of us wish that angry people would just go away.

I for one am allergic to them unless they're paying me to help them.

But even though I’ll deal with angry people all day long, if you're in my family you know that I won’t listen to you if you’re screaming and that I need about twenty degrees of separation. I can handle anger better on the telephone than in person, or in writing. Violent books are sometimes okay for me. But violent movies? Never.

Nobody’s perfect.

Now. Most therapy docs will agree that a rational argument, meaning measured verbal expression without drama and screaming, slammed doors, fists and silverware flying is a good thing. The way to solve problems is to discuss, debate, present feelings, thoughts, new solutions—with relative calm.

Notice I didn't say dump your anger all over the house to get it out of your system. You can get it out of your system in some other way. If you were in the army you’d have to do a hundred push-ups. So you can do that rather than rant and rave. Push-ups. Or clean out the basement.

Or rearrange the furniture. Weed. You'll lose your rage.

But let's take a quick peak at the psychological/social system and CBT before the weekend begins and people start drinking and throwing things.

We'll use a new fake, fictional totally imaginary couple, Reg and Ranata (choose different genders if you like, gay or straight makes no difference).

Ranata is the identified patient, the one who chose to come to therapy for her issues. But I brought in Reg to get his point of view, of course, to rat out Ranata. After a couple of months of depression Ranata is just now getting in touch with some flammable anger that she says she’s always had.

"It's never bothered me," she says. "I don't hit anyone, I just . . . go off. It's Reg who's uncomfortable with it." He hates it.

This going off thing tends not to work in most relationships. In some cultures the exaggerated expression of emotion is totally expected and even encouraged. This is why sometimes it's best to date within your own tribe so your behavioral mores don't clash.

But I think that even within a cultural context that values the free expression of emotion, it's dangerous to express anger violently.

Your partner, even if he or she grew up in an emotionally expressive family still might not have developed a "tough skin." Sometimes having grown up in a very emotionally expressive family can make us even more sensitive.

"I have to stop for Reg,” she says. “I need to stop for him."

Actually, not only does Reg find anger a real drag, but he's very embarrassed and turned off when he sees Ranata behave angrily at people. She doesn’t get angry at him. She gets angry at others in front of him.

But she wants to change. This is true love, friends. If it's a problem for your partner, it's a problem for you. If it's a problem for you, it's a problem for your partner.

Quick history: Ranata's father, a very old fashioned, critical man, criticized the way she dressed, the way she put on make-up, her friends. He did not let her date (she had to lie to go out) and her occasional back talk brought out emotional, verbal, even physical abuse.

Despite this she has a survivor in your face personality and very successful in the business world. Aggressive successful.

But her core belief is that she's not good enough and that she’s powerless when it comes to changing people who are important to her, like her father. And she likes letting off steam, displacing her frustration on her office team, sales clerks, telephone solicitors, credit card company reps, etc.

When faced with a problem Ranata starts out rational, even intellectual. But as soon as she gets to the point of frustration she loses all civility, bangs on counters, says mean things. That's when her guy wants out of the relationship.

(It's supposed to be one big table, not three little ones, so use your imagination a little. Thanks)

Let's look at the A-B-C in the table, AFFECT, BEHAVIOR, COGNITION. Remember that you can intervene ANYWHERE. You can change the affect. You can change the behavior. You can change the cognition.

Ranata would say, “If I could change my anger (the affect), I wouldn’t be seeing you.”

So change the behavior or the cognition. Start by identifying the feeling.

Ranata, like most people, can tell when she’s getting angry. Because she went to therapy she knows that she learned to be angry from her father, as opposed to say, being sad. I mean, why do some people (like me) get sad whereas other people get angry?

One reason is that some families prescribe a preferred emotion. They give the kids permission to feel and act in certain ways. Like in my family there was permission to be sad, whereas in a lot of families crying is considered a weakness. But my mom said, Go ahead, cry. It feels really good to get it all out. (thanks Mom!)

So of course, people like me learned that it's okay to cry and that crying will generally evoke sympathetic loving responses in people.

You know about reinforcement from the other behavioral posts, I think.

Long story long in Ranata’s case we know that her anger is really about being frustrated and shut down, powerless with her father who gave permission to be angry. She’s aware that being frustrated in her relationships is dangerous and tends to culminate in verbal violence.

Since anger's an aversive stimulus, she loses friends. Her anger spells doom. It's like Voldemorth’s strength in the Harry Potter books, gains power with the host, the object.

So her job is to catch it when it's on the rise. The cognitive piece is recognizing the anger rising, sensing it, noticing the feeling as it becomes more and more uncomfortable. Then she has to ask herself:

What is this horrible feeling? Oh, it's anger. I know it well. Anger puts the "A" in AFFECT.

She recognizes the feeling, then THINKS. Thinking is the next step (COGNITION). She has to slow down the action to mentally evaluate what's going on, what is happening.

Then she has to challenge her knee jerk thinking on the subject and her automatic behavior (exploding) and think of an alternative response, a new BEHAVIOR.

Wow. All of this is so much work. So much easier to throw the dishes, no?

Have a nice weekend.

Copyright 2007, therapydoc


Bud Weiser, WTIT said...

With all due respect to your cabinet of drugs and your Harry Potter analogies, perhaps an approach be simpler. Example: I used to get road rage and yell like most drivers I know. About ten years ago it occured to me. "Only get angry at drivers who do something I have NEVER done." We all pull out at the wrong time or misjudge someones speed. I have not had a bad of driving since. I'd say twice in ten years I've seen smething I have never done, but, now I just laugh and think, "That's a new one".

Just a thought. I could be wrong, and I do have references.

therapydoc said...

Bud, if you had read more carefully (and I did font in red) you would have noticed that I said, IF YOU'RE A PERSON WHO SEES RED AND CAN'T STOP YOURSELF. . .then maybe you should get a med eval.

Your intervention IS a rational cognitive intervention.

You talk to yourself and rationalize. . .Only if that person does something I've never done. . .Then I have the right to get angry.

That's a rational cognitive therapy, definitive.

Well done.

Bud Weiser, WTIT said...

Thanks for the clarification. I understand your point. And I am not anti-med. My 22 year old daughter has just re-entered a treatment center for eating disorders for the third time. We wish she would take her meds.

Anyway, thanks!

Bud Weiser, WTIT said...

Oh. And if you'd like to read about my daughter, your input would be appreciated.

therapydoc said...

I hope she gets well soon.

Anonymous said...

Long story long in Ranata’s case we know that her anger is really about being frustrated and shut down, powerless with her father who gave permission to be angry. She’s aware that being frustrated in her relationships is dangerous and tends to culminate in verbal violence.

Wow, did I really tell you about my past (it wasn't my dad though) and BTW my name is not Renata...

Eh, I mostly threw the kids' toys. They never landed anywhere near DH. I don't do that anymore, but he never understood (and I told him a few times) that if I MEANT to bean him with one, I would have!

Interestingly, I went cold turkey off Wellbutrin last week (300 mg, due to sucidal ideation, bad, very bad) and I've had some dizziness and double vision, otherwise nothing. OTOH, I've tried to go from 375 to 300 of Effexor before, and the brain shocks and agitation are brutal. When Effexor works it's a lifesaver, and it's a good thing. (I think I'm answering another post in this parag)

therapydoc said...

Great synopsis of the case. I have absolutely no idea who you are and DH, G-d bless him, knows this by now if you've ever seen me, right?

Cases like Reg and Renata, as all you've all figured out by now, are textbook.

Thanks for writing. I've always worried about people on Effexor for that reason, it's hard to quit. But sure, when these meds work, there's nothing like them if you really need to make a change in how you feel quickly.

But everyone's different. Always take drugs/go off drugs under the supervision of a medical doctor.

have popcorn will lurk said...
This comment has been removed by the author.
therapydoc said...
This comment has been removed by the author.
Anonymous said...

This is anon (cough, anon) at 11:02pm again...

Yes, I will definitely echo what you said: "Always take drugs/go off drugs under the supervision of a medical doctor." Esp. when dealing with Effexor! Scary. It's all relative. For example, a traumatic c-section cured me of my fear of the dentist. (!)

Don't worry, I am under the care of an excellent psychiatrist at a major teaching hospital, and a therapist with a doctorate too (not yourself, too bad for me!) who takes on long term bpd cases everyone else runs from...!

BTW the reason why you thought that was a great synopsis, is because I copied and pasted yours! ;)

therapydoc said...

It did sound a little familiar.

It's great to have comments like yours because you provide anecdotal data that supports the things I've learned in practice and/or sifting through the research.

Glad to hear you're with a great doc, ANON.

Anonymous said...

Excellent article and thank you for such an informative blog!

Lisa said...

I don't know if comments are still posting here, but I'm not sure where to put this. I'm writing this as a mom, a therapist, and the daughter of a police officer. (He's been dead for years). Comments are appreciated as I'm struggling with this, big time.
Reader's Digest version:
We live in a college town. Good school system, all of that. Recently, an all state football player who had graduated from high school two weeks prior had a big party at his house. By big, I mean 100 kids showed up. Mine was one of them. I've never liked this kid. I've always known he's had rage issues. He's fine if he likes you, but get on his wrong side, and he's animalistic in his anger outbursts. He's also been a bully (peeing in kids lockers in middle school.) He also has never had any respect for authority...surprise, surprise...
Anyway, the police get called at this party. Two officers show up, and I guess in the officer's naievity, sticks his foot in the door. Apparently, this is not allowed as there was no warrant and the cop was not invited in. This football player kid, slams the door on the cop's foot, which causes problems. The cops then force their way in. The kid who is HUGE, takes the cop's radio, takes the taser, and taser's the cop. He then takes the cop down to the ground. Then the kid attempts to run. At this point, the gun is pulled and they body slam the kid to the ground. His shoulder is hurt, and he is bleeding from the mouth. Still, he is mouthing off. He has been in jail for 5 days, and is now of course, in big trouble. My son, and many others in this community, are OUTRAGED at the policemen, who they say belittled this young man, and laughed that he almost got killed. I am appalled and worried that my son's thinking is not in the realm of respecting authority, but is protecting his friend's (and yes he calls him a friend's RAGE.) He does not support the rage,and agrees the kid was in the wrong. but he thinks the cops reacted poorly to the rage. I say, as soon as the cops knocked on the door, everyone needed to be saying "how can I help you sir?" This kid's rage is obviously deep seated, and there are TONS of family issues. But they have a good "lawyer" who will probably get him off on the technicality that the police were in the wrong. Anger, you say? Why, yes. I'm overflowing with anger, confusion, wondering if I should really worry about my own kid's thought processes, or if this other kid's rage, though, out of line, caused a chain reaction in the policeman. I walk around with a lump in my throat due to this rage. This just happened a few days ago, and it's the big talk. It's causing a huge wedge between me and my 18 year old son. Is my own anger that I can't seem to squelch just as bad????? And the policeman's? I fear someone is going to scream "rodney King" or something!

therapydoc said...

Well ya' know, anger's the enemy.

I can only speak hypothetically, of course, but with teenagers I never let them know what I'm thinking, not unless it's absolutely necessary. I'm always ferreting out why they feel the way they feel, listening hard, trying to get at what is really underneath the emotion. Often the anger is at a parent, but sometimes it's just free-floating, too much energy, no place for it to go, displaced upon the closest available, ready and willing object.

So fight about something like this because there's a principle that needs to be taught? Well, you lose it in the fight, is for sure. Teens and young adults are dying to be valued, to be right, and even if they aren't, need to be heard. Let them decide that what they're supporting isn't worth it. They're not stupid.

But they won't get there over night. Welcome to parenting young adults, is what they'll tell you.

Lisa said...

Ahh, thank you for that. I can breathe again.

Therapy Websites said...

Anger is a strong expression if our inner self, and can be highly dangerous. I agree that it motivates to nothing more than positively. That's why I really treasure advises that says like when I get angry, i'ts better to just walk away and breathe deeply.

What's Going to Be with Our Kids?