Managing Anger

The basic components of anger-management are:

Building and sustaining motivation to work on the problem
Initiating the use of a time-out procedure
Cognitive and somatic self-calming techniques
Responding assertively

Anger management treatment teaches patients self-control over their angry outbursts, and to express their anger in appropriate ways.

Case Example

Rianna is 27 years old. She is moody and emotionally intense. She has come to therapy at the insistence of her fiancee Jack, who is threatening to call off their marriage unless she does something about her anger.

Rianna: Jack made me promise to bring this up in therapy. He’s upset with me. He's upset because when I get mad I yell at him.

Rianna has a "bad temper." She has always had this problem: "I can't help it. It's just the way I am," she says, "I've been this way my whole life." As a child, Rianna yelled at her mother and sister in the same way that she yells at Jack today.

Although Rianna's angry outbursts only last a few minutes, Jack feels shaken and upset for hours afterwards, even days. Rianna has yelled at him in public and in front of friends and family. Once she yelled at him in front of a business associate and he nearly broke up with her.

Rianna: I don't know why Jack makes such a big deal out of it. I get mad, I yell, and then it's over. It's not like I stay mad. I never hold a grudge like he does.
Therapist: So do you think your anger is a problem?
Rianna: No, not really. Not for me! (Laughs.)

Rianna feels entitled to yell when she is angry. She has little empathy about how her outbursts affect others. If I ask her how it feels when she yells, and she tells me, "It feels like I'm right." I ask her what she wants when she yells, and she says, "I want to win."

Many patients come to therapy because they are having trouble managing their emotions. They feel overwhelmed by their feelings -- anxiety, grief, guilt, shame, jealousy, hopelessness -- and they cannot seem to get control on their own. However, when the issue is anger, often patients do not seek help for this problem. They do not come to therapy, or, if they come, they do not bring it up. Many more patients have anger problems than try to solve them in therapy. This is not because managing anger is easy. On the contrary, developing effective ways to express anger is one of the greatest challenges in life. Then why do patients rarely seek help for anger-management problems? The answer is simple. Patients are often unmotivated to learn to control their anger.

Anxiety, grief, guilt -- these emotions feel bad. They are inherently painful. When they are too intense they drive people into therapy. But anger does not feel bad. It feels good. While patients might regret later what they did while angry, at the time, in the moment they express the anger, it feels good. The problem is that it feels bad to the people around them. Moreover, anger is often an effective strategy -- at least in the short run. When Rianna yells at Jack in public he will do anything to quiet her down. He feels embarrassed and intimidated. Most of the time when she loses her temper, Rianna gets what she wants. She "wins." Rianna might win the battles and lose the war, however, especially if Jack leaves her. In the long run, her anger management problems are having a damaging impact on her life.

Rianna is typical of patients with anger problems. She is raising the issue in therapy because she is faced with some terrible consequence of her anger. Many anger-management patients are this way. They are in crisis: Their spouse is threatening to leave them; their boss is threatening to fire them; their children are threatening to cut off contact. Their anger is ruining something they value, something they do not want to lose. Such potential losses can contribute to depression.

Building and sustaining motivation is a core issue in teaching patients to control their anger.

I. Building and Sustaining Motivation

First patients must accept that managing anger is a problem for them and they must make a commitment to solve the problem. For the reasons discussed above, this is often the hardest step.

Patients confront the long-term consequences of their anger -- how it is alienating the ones they love, harming their career, damaging friendships, pushing people away. They make a list of the negative consequences of their anger.

Here's how I helped Rianna make her list.

Therapist: Let's make a list of the reasons you want
to learn to control your anger. I'll write them down. What
are your reasons?  If you don't learn to control your anger, what
will it do to your life?  What has it done to your life so far?
Rianna: It cost me a couple of roommates in college.
Therapist:  What happened in college?
Rianna:  I was sharing a suite with these two girls,
and after the first semester they asked me to move out.  This
happened right after I got really mad at one of them for eating
some of my food.  I needed the food for that meal or something, my boyfriend was coming over, I was really upset.  Maybe I shouldn't
have gotten so mad, but she shouldn't have taken my food!
Therapist:  What did you do?
Rianna: I yelled at her.
Therapist:  How did you feel when they asked you to move out?
Rianna:  Pretty bad, actually.  It was a drag, I had to look for a
place off-campus, and I had to move over my vacation.
Therapist:  Did you like those girls?
Rianna:  Yeah, I really did.  But I didn't see them much after
that.
Therapist:  So that would be one consequence. Losing your temper cost you some friends.  I'll write that down.
What are some other consequences of your anger?
Rianna:  Well, it sure plays hell with my sex life!  (Laughs.) Jack doesn't want to come near me after one of our fights!

Patients compile as complete and meaningful a list as possible. They read the list at least once per day. They carry the list around with them and read it whenever they feel at risk to lose control of their anger. Being immediately aware of the negative consequences of losing control of their anger motivates them to use their strategies to control it.

II. Initiating the Use of a Time-Out Procedure

Patients to commit to taking a time-out whenever they experience anger that is 50 or greater on a 0-100 anger scale

0 25 50 75 100

/ / / / /

__________________________________________________

No Anger Mild Anger Moderate Anger Extreme Anger As Much Anger as Possible

Whenever their anger reaches "50" or greater on the scale -- that is, "moderate" or greater, that is the cue to take a time-out. Patients acknowledge their anger to themselves, but give themselves a time-out before they express their anger.

Therapist: A time-out can mean removing yourself from the situation temporarily, or it can mean staying in the situation but refraining from acting or speaking. In a time-out, you can feel your anger, but you cannot act on your anger. Stay in the time-out until you are calm -- until your anger is"25" or less -- at most "mild" -- on the anger scale.
For example, Rianna used the time-out procedure when she and Jack disagreed about what band to hire for their wedding.
Rianna: I got really mad at Jack when we were deciding on the band. I felt like he didn't care what I wanted. I was about to start yelling, so I decided to take a time-out. I went outside for awhile. I knew if I stayed I wouldn't be able to stop myself from blowing up at him. So I went outside to cool down and think about it.

III. Cognitive and Somatic Self-Calming Techniques

The next step is for patients to use somatic and cognitive self-control techniques

Therapist: You can help yourself calm down in the time-out with somatic and cognitive techniques. Somatic techniques help you calm your body, and cognitive techniques help you calm the thoughts that are going through your mind.

Somatic techniques include relaxation exercises, meditation, mindfulness, breathing, and imagery. One simple technique is to count one's breaths, breathing slowly and deeply: "One (inhale), relax (exhale)...two (inhale), relax (exhale)... all the way up to ten.

A simple mindfulness technique is to come into the present moment by focusing on one's senses one-by-one: "What do I see... what do I hear... what do I feel in my body... what do I smell... what do I taste....?"

The most important cognitive technique is thinking through the consequences of losing control. This is a basic priniciple of impulse-control. Between the impulse and the action, the patient must learn to insert thought.

Therapist: There are a number of cognitive techniques you can use in the time-out to help yourself calm down. The most important one is this: You must force yourself to consider the consequences of losing control of your anger in the situation. Will it really be to your benefit? If someone you love is involved, will losing your temper strengthen your bond with them, or damage that bond? Do you want to damage this relationship, or do you want to preserve it?
If it is a work situation, will getting angry help you meet your work goals? Try to put the situation into perspective. Is what is at stake worth getting so upset about?
Ask yourself how getting angry will affect the other person.
How will it feel to them? Will it frighten or upset them? How would you feel if someone yelled at you in the same way? You can read the list we wrote together of your reasons for wanting to control your anger. This can help you regain control as well.

IV. Responding Assertively

Once patients are calm, they can design an assertive response to the situation (see the page on Building Assertiveness Skills)-- one balancing self-respect with respecting the other person that is best for the relationship as a whole.

Therapist: When you are too aggressive, you give too little importance to supporting the relationship with the other person. All you care about is your own self-esteem. When you are assertive, you keep these two considerations in balance. You support the relationship and you support your self-esteem.
There are guidelines for you to follow if you want to behave assertively. Most importantly, stay calm. If you cannot present yourself calmly, then do not present yourself at all. Take a time-out.
Behave in ways that respect both of you equally. Do not put yourself down, and do not put down the other person. Do not attack or label the other person. Simply state what the person has done that has upset you. Tell the person clearly how you feel about what they have done, and what you want from them instead.
Try to see the other person's point of view and validate it. Say you understand how the other person feels. Listen as you would want the other person to listen to you. Try to restate the other person's position to make sure you understand, and to let the other person know that you do.

Patients consider carefully their goal in the situation. Then, they try to behave strategically, not emotionally, to meet this goal, acting to strengthen and maintain the relationship.

Rianna: While I was outside I thought about how it wasn't really so important that I win the fight. Maybe it wasn't really such a big deal that Jack disagreed with me about the band. Maybe he wasn't trying to control me, maybe he was just saying what he wanted. Anyway, it's more important that I work on my relationship with Jack, on making it better. That's what I really want. I want to stay together, and I want our relationship to be good.

When Rianna came inside, she did not yell at Jack or insult him. Rather, she spoke calmly. The end result was that Rianna and Jack felt closer to one another, rather than more distant. This result rewarded Rianna's behavior, and helped build her motivation for the next time.

The answer to situations that cause us to lose control of anger is almost always assertiveness. Patients often feel frustrated or threatened by a situation, do nothing at first, then explode in anger. Assertiveness training encourages patients to deal directly with situations as they occur and express their needs, rather than waiting for things to build up to unmanagable levels. Patients will find that if they take this approach, both their self-esteem and their relationships with others will improve.