John is a 36 year-old, married military veteran. He has two children, ages 4 and 6 and has been married for eight years. He came into treatment to work on his PTSD, resulting from a combat trauma in Iraq. In Session 1 of trauma-focused treatment, you notice that he frequently appears irritable and responds to your questions angrily, saying things like “I don’t know, isn’t that your job?” “How am I supposed to do homework, I have enough on my plate” and “You tell me what my goals are.” You are concerned that his anger is interfering with his treatment and recovery from PTSD and begin to question whether he is ready to begin trauma processing treatment.
Before starting that conversation, however, you decide to ask him more about his anger and provide psychoeducation on specific aspects of PTSD, mainly hyperarousal symptoms. He describes a long-standing pattern of problematic anger, adding that “it comes out of nowhere” and often lasts several hours at a time. John states he feels “irrational” during these angry episodes and “out of control.” He continues, stating this anger has greatly increased since his time in Iraq and his wife has talked with him about it on many occasions.
At your suggestion, John agrees to begin treatment by working specifically on his anger which he agreed was “a problem for other people who just don’t get where I’m coming from.”
John’s treatment approach warrants directly targeting his anger. Let’s take a look at a specific model of CBT to treat anger. The premise of this treatment model is that anger develops from unmet expectations. Norman Cotterell, Ph.D., Clinical Coordinator, Beck Institute, puts it this way: “We expect people to treat us fairly and they don’t. We expect children to respect the wishes of their elders and they don’t. We expect the government to have our needs at heart and it doesn’t. Each time there is a gap between expectation and reality, anger is more than willing to fill in that gap. We may decline. We may accept. But it’s important to know that it’s a choice we are making” *. Perceived loss of control for getting important values met causes anger. More specifically, when we don’t recognize our reactions to unmet expectations as a choice, when we perceive a loss of control, we may experience thoughts of helplessness and hopelessness that lead to anger. This perception of loss of control can also be a contributing factor to thoughts and feelings about a trauma event, believing we are helpless to prevent symptoms, and it is hopeless to expect we can overcome PTSD.
The CBT treatment model developed by Dr. Cotterell contains eight steps toward achieving command and control over urges to react angrily in any given situation. Educating the patient and taking these steps in order provide needed tools and skills.
Recognize Choice: One of the first things you can work on with a patient is to acknowledge that anger is present. When it rises to a fever-pitch, we often get strong urges to act (think honking your horn). The more intense the anger, the shorter the time between the angry urge and our action. So, we act without thinking. To slow this process down a bit, and allow time for a little more choice and rational thought, mindfulness can be helpful. Ask your patient to notice physical manifestations of anger, such as a flushed face, then describe the feelings silently in their mind: “I notice my face feels hot and flushed.” As angry thoughts arise, do the same: “I’m noticing thoughts about how I should be treated,” or “I’m noticing urges to react.” Putting words to experience rather than being hooked by them can be a helpful tool in reacting differently to angry impulses, and reducing the intensity and duration of anger.
Cost/Benefit Analysis: Weigh the pros and cons about acting out of anger. Ask your patient to list the benefits of reacting in anger “feeling of relief, feeling of control, people listen, etc.” Then list the cons “say hurtful things to others, stress relationships, regret…” It is likely that the pros are more short-term, and the cons are more long-term. Human beings are more likely to be influenced by short-term consequences rather than long-term consequences. By reminding your client of some of the long-term cons when the anger arises, it forces the negative consequences into the short-term, and makes them more compelling to consider before reacting.
Control: Suggest the patient remove themselves from the situation: It’s likely that the longer they are in a triggering situation, the more triggered they will be. Use a simple practice assignment, asking them to take a 5-minute break from whatever they are doing to allow the emotion to return to baseline. Take a bathroom break - - most people won’t argue for needing to go to the bathroom. That way your patient will be able to handle things more effectively on their return, with judgment unclouded by anger.
Personal Value System: Discuss the patient’s own value system. Does it include an ability to accept differing viewpoints? Consider alternate perspectives: Ask them to notice the way they are thinking about what is making them angry. Suggest that it is likely that the angrier they get, the more rigid their thinking is becoming. To loosen up thought patterns and consequently reduce the level of anger, ask that the patient think of the triggering situation from a few different viewpoints. In the grand scheme of things, is this really that important? What would be the worst-case scenario, and is it really that bad? What are some reasons your opponent’s position makes perfect sense? Why might it be a good idea to reconsider your point of view? Rather than focusing on the problem, consider focusing on the solution. Considering these questions may help to soften intense emotions.
Helping Patients Act in the Direction of their Values: Develop love and compassion:.We can’t have two primary emotions at the same time. Finding humor in situations can dissipate anxiety. Love is incompatible with anger. The two can’t exist in the same person at the same time. Practice learning to love and appreciate people and situations that frustrate you. One exercise you can try with a client is to think of a time when they’ve had to deal with a problem with a service they’re paying for, such as a cable company. By the time they get through to a real person, they may be frustrated, gritting their teeth and ready for battle. Have them consider the person on the other end of the phone. Have them visualize that person and describe what it may be like for them to be answering calls all day from frustrated customers. Maybe they have personal problems they’re dealing with too. Ask your patient to describe how this new awareness changes their emotions and how they might continue the conversation with that person without anger. Have them put themselves in that person’s place, practicing empathy.
Dealing with Moral Disengagement: There is significant new research to suggest that inducing thoughts of love and compassion can have numerous benefits, including improved mood, better immune response, and increased psychological flexibility not to mention fewer instances of uncontrolled anger. Forgiving is not forgetting, it is remembering and letting go.**
When Anger Turns to Aggression: When an emotion, like anger, turns to aggression, it’s important to remind our patients that this is also a choice they are making – first, they are, possibly unconsciously, choosing to ignore the rights of others and second, its vital that they take a moment to consider the possible negative consequences, including feelings of guilt and remorse. One question to ask may be “is that moment of acting on my anger worth all the potential outcomes?” We can assist patients by breaking anger into steps to recognize they have choices about what to do with that energy and helping them through mindfulness, breathing, and a reminder of their moral beliefs, to think through a decision before acting on it.
Anger Redefined: Finally, anger can be useful, if redefined. By incorporating mindfulness, the patient can identify cues and use what was an anger response to provide energy to work through the thoughts that most likely are triggering the anger, look for better and generally more accurate ways to think about the situation and find open, creative and far fewer damaging solutions.
Using these steps can help patients control their anger in a more workable way. The more they practice them, the better they will get at them, putting them back in the driver’s seat with the awareness that they get to decide how they choose to respond with specific tools to enable that choice .
After practicing these steps for a few weeks, John began to feel more in control of anger outbursts, both in and out of session. He described that instead of feeling out of control of his anger responses, he now felt he had new ways to consider how he wanted to respond, thus taking back autonomy that had been absent for a long time.
For more on anger and PTSD, join us on 26 June for a webinar on "Understanding and Managing Anger and Aggression in PTSD."
The opinions in CDP Staff Perspective blogs are solely those of the author and do not necessarily reflect the opinion of the Uniformed Services University of the Health Science or the Department of Defense.
Laura Copland, MA, LCMHC, Senior Military Behavioral Health Clinician and a National Cognitive Processing Therapy Trainer at the Center for Deployment Psychology at Uniformed Services University of the Health Sciences in Bethesda, MD.
*Norman Cotterell, Ph.D.
**Weng, H. Y., Fox, A. S., Shackman, A. J., Stodola, D. E., Caldwell, J. Z. K., Olson, M. C., Rogers, G. M., & Davidson, R. J. (2013). Compassion training alters altruism and neural responses to suffering. Psychological Science.
Beck, A.T. (1999). Prisoners of Hate. New York: HarperCollins Publishers.
Beck, A.T., Wright, F.D., Newman, C.F., & Liese, B.S. (1993). Cognitive therapy of substance abuse. New York: Guilford Press.