Anger in our age of anxiety: what clinicians can do

B W K Lau 劉偉楷

HK Pract 2001;23:258-264

Summary

Anger manifests itself in different shapes and forms including aggressive violent behaviour and is becoming an increasingly prevalent social problem. It often arises from frustrations in needs, expectations or goals, and channels into overt socially undesirable expressions of feelings. The development of anger has hereditary and acquired elements, the latter encompassing mounting life stresses and progressive social isolation in modern society. Cognitive behavioural therapy is of value in managing anger by relaxation strategies (e.g. progressive muscular relaxation or slow deep breathing) and cognitive strategies (e.g. cognitive restructuring, mental distractions, rationalisation, sublimation, or use of humours). Clinicians are instrumental in helping patients to cope with their anger and unleash the pent-up emotions in a more regulated, appropriate and adaptive manner. Sometimes understanding one’s own anger goes a long way in mollifying one’s mental disquiet.

摘要

憤怒的表現方式有很多種，其中侵犯性的暴力行 為，正成為有相當比例的、日漸增加的社會問題。憤 怒常常因需要、期望或目標未能實現受到挫折而產 生，並且通過不受社會歡迎的形式公開表達。它的產 生有先天和後天的原因，後者包括不斷增加的生活壓 力和在現代社會中日益嚴重的孤獨感。認知行為療法 通過放鬆的策略（如漸進性肌肉放鬆或緩慢深呼吸） 以及認知的策略（如認知重組、精神轉移、合理化、 昇華或幽默使用等等），來處理憤怒，有一定的價 值。醫生應幫助病人以一種經過調整的、更適宜、更 具適應性的方式應對其憤怒和釋放被壓抑的情緒。有 時了解自己的憤怒情緒對舒解精神上的不安很有幫 助。

The size of the problem

Time and again we hear some say that it is a violent world. It appears that we are surrounded by aggression and many of us may indeed have had some personal experience of physical or emotional attacks.¹ Here and there we have gangs imbuing their hands with blood just for the sake of laying hands on a territory by taking the field; muggers marauding by callous and atrocious means; weaker gender or minors coming under spiteful family assault and poignant domestic violence; the very young and very old subjected to random or senseless sex attacks; young women stalked by obsessive, rejected suitors; ‘road rage’ victims chased along motorways, forced off the road or, on rare occasion, shot; and many others.

As an illustrative example known to many of us, it seems that some individuals on the road are angry all the time. They explode at the slightest provocation, particularly when their vulnerability is triggered. People with an anger that does not subside but only changes in intensity literally have a “fire-breathing dragon” inside. Aggressive drivers or perpetrators of road rage may ordinarily feel unable to stand up for themselves, but once they are behind the wheel, they feel powerful and invincible. They might not like to let a person close to them know how they are feeling, but they can be quite happy to release aggression on anonymous others. They seem to feel justified in uncorking their pent-up emotion on unknown individuals. Probably they want to discharge their aggression without assuming any real responsibility. There are some individuals driving fast, gesturing and yelling who want to take control of the fast lane and appear to live in it. They are simply addicted to the adrenaline rush of danger and anger. Unaware to the individuals concerned, living in the fast lane often camouflages a long-term, lowlevel depression in much the same way as do addictions to alcohol, drugs or food.²

Even flight attendants have been physically and emotionally attacked on board, sometimes in brutal fashion, by drunken passengers losing control. The alarming thing is: from official records, the number of attacks on flight attendants has steadily increased in various continents.³ It might suggest, according to news reports, that the number of raging passengers is increasing.

The list of rage incidents seems endless and is growing daily. Such incidents easily bring to mind the growing concern over rampant violence in our society, as evidenced by the fact that we today do have “sky rage”, “road rage”, “children killing children” and countless women and children being killed each year in cases of domestic violence all over the world. The impression is understandable in light of the sustained effect of the media, where such stories are often turned into newscasts. When people appear to be most interested in reports of anger outbursts or violence, violence does sell, lucratively. It would appear that the media are keen to ensure that we have vivid vicarious experience of the violence perpetuated against others everywhere, and we are bombarded mercilessly with awesome details of each and every incident.

At a less disturbing, albeit still disquieting level, social injustices or hardships have been a major cause of social unrest or upheavals for centuries. Discontent with unemployment, inequality in wealth, or indeed anything that has an impact on their livelihood or quality of life, people are now ready to take to the streets to voice out their grievances. More recently, in various continents, fuming at rising oil prices, drivers turned their vehicles into barricades on the highways. In the local scene, the issues on the right of abode, negative equity of properties, revamping of the civil service structure, and institution of language standard test are at the heart of many notable protests.

Negative aspects of anger

It is a truism that we all struggle at times as life is normally challenging but oftentimes difficult. While anger can help confront a life-threatening attacker or some other real emergency, it does not make any sense when we are just responding to some of the usual frustrations of everyday life. In fact, if we keep activating our anger-creating system, it can one day take a serious toll on our body. Although anger is a natural human emotion, it is hardly the most useful for solving problems.

Unknown to many, anger as a response to life situations does have a premium. While many of the costs are very dramatic and noticeable, others may be less obvious and some are only privately experienced. These include serious emotional and personal distress, such as depression, guilt, embarrassment, and lack of confidence in dealing with other people. Sometimes anger is accompanied by feelings of helplessness or an inability to cope.⁴

Intense and frequent anger can cost us jobs and important relationships. When our anger somehow engenders such losses, we can easily fall into a valley of depression. Not infrequently anger and depression can afflict us simultaneously. In the midst of intense emotion, be it depression or anger, we may lose confidence about dealing with others. We may blame other people and things for our “misfortunes”, which further makes ourselves angry. We may then beat up on ourselves and bring on more depression. During rage, we may feel so out of control that we may respond by constantly struggling to control our actions. As with depression, embarrassment may follow our frequent rages. This vicious cycle is due to the fact that once we react in certain hostile ways to frustrations and annoyances, we get reinforced and/or penalised by our reactions. Either hostility encourages us to remove the stimuli that we find obnoxious or our rage helps bring on counterattacks from those we hate and attack. This is conceivable because when a person is angry, there is a tendency towards attacking or retaliating against the perceived cause of the frustration.⁵

From a medical point of view, repeated arousal is responsible for some cases of chronic hypertension.⁶ In particular there is a consistent relationship between high levels of anger and increased rates of hypertension⁷ and between hostility and trait anger and platelet activity.⁸ It has been shown that mental stress, especially anger, may increase platelet aggregability, which can lead to thrombogenesis and coronary events.^9,10 A high degree of anger or hostility actually predicts the later development of atherosclerosis.¹¹

Even recall of angry events in patients with existing coronary heart disease can make atherosclerotic-narrowed arteries constrict,¹² and compromise the heart’s efficiency as a pump.¹³ In some patients who have coronary artery disease, an episode of intense anger can bring on a heart attack within 2 hours.¹⁴ More specifically, anger can cause a plaque in a narrowed artery to rupture and occlude the artery, producing a myocardial infarction.¹⁵

Therefore, ample evidence is available that high levels of anger do increase the risk of coronary heart disease.^16,17 While anger and hostility are so strongly associated with one another that they have been implicated as “toxic” components in the relationship between the Type A behaviour pattern and coronary heart disease, chronic anger and hostility remain as independent risk factors for the development of coronary heart disease and premature mortality.¹⁸ A dose-response relationship was found between level of anger and overall coronary heart disease risk, even after relative risks were adjusted for other major cardiovascular risk factors.¹⁹ Other studies confirmed that high levels of self-rated irritability and easily aroused anger were associated with increased coronary heart disease mortality.²⁰

As regards new growths, Temoshock²¹ proposed that chronically blocked expression of needs and negative emotions, especially anger (Type C personality), results in feelings of helplessness under stress, and that helplessness often affects the outcome of cancer. Another study also confirms a strong association between emotion inhibition and cancer mortality.²²

It can now be seen that anger may take a heavy toll on our lives, in social, psychological, as well as medical terms. The disadvantages, if not problems, incurred are real. It inevitably follows that anger must be managed, and to be managed, it must be understood first.²³

An explanation for anger responses?

Frustrations are inevitable in life, because we are frequently thwarted from getting what we want or get what we do not want. Frustrations only turn into anger when it is thought that the frustrating situations categorically should not have happened.⁵ However, anger and violence rarely stem from mere frustration alone but are often due to low tolerance levels of modern-life people.

The lowered threshold for frustration may involve an inherited as well as an acquired disposition. If parents have an inherited vulnerability, they may well pass it on to their offspring. If so, the parents may then react to a child’s anger with harsh discipline, which may in turn reinforce the child’s aggressive disposition. This may create a vicious cycle of violence leading to more violence. It is well recognised that past experience may have an effect on present behaviour. A significant proportion of children who are severely punished by their parents in their childhood will develop a tendency to feel more anger and act more violently towards others throughout their lives than will children who are less violently or severely treated.⁴

By the same token, adults who grew up with self-hate also find themselves deficient in self-soothing and self-caring skills, as well as being critical and judgmental of themselves. Their need for external love, support, comfort and affection is a double-edged sword. Because early needs for nurturing, affection and comfort were met with sarcasm, ridicule and shaming, self-hating individuals often despise even their most basic needs for support and affection. However, many selfhaters promise themselves early in life that they will never allow themselves to be vulnerable again, so they may appear to others to be aloof, cold and immune to feelings. In reality, self-hate and emotional dependence feed on each other. Eventually self-hate causes individuals to reject themselves and, as a result of self-rejection, to feel unable to depend upon themselves. They are forced into emotional dependence on other people and subsequently hate themselves for the dependency. Individuals may also experience anger for the one on whom they are dependent.²

Even in relationships with friends and loved ones, people have inadvertently come to learn to suppress anger, fearing that if they unleash their anger, they will be abandoned, go crazy or hurt someone. This is because our culture is inclined to encourage inhibition of emotional displays. In particular a majority of people in our society are taught from a very young age not to feel anger at all or express it without the blessing from others. An extreme example is found in passive-aggressive individuals who learn early in their life not to openly admit or exhibit resentment or anger. They begin to harbour or stomach resentment, in constant need of looking good and outwardly compliant in order to maintain acceptance and connection with those they depend upon for emotional and physical sustenance. They learn not to confront situations directly but rather to achieve some measure of control through active manipulation and/ or passive opposition. In a metaphorical sense, they learn instead to vent out their anger sideways: hurtful humour, clenched jaws, grinding teeth, procrastination, illness, memory loss, chronic lateness, pseudo-righteousness, gossip, twitching eyes or a constantly moving leg while “relaxing”, chronic irritability over relatively trivial things, depression, or violence. At this point a situation of double-bind in dealing with their behaviour sets in such that fulfilling their demands increases the self-loathing of the passive-aggressive, which then augments the behaviour. Rejecting the person will do the same. As another example, violent individuals were often taught when they were young that sadness, vulnerability and powerlessness were either too painful or not acceptable. They then come to learn to bypass vulnerable feelings and go directly into rage. It can hardly be overemphasised that rage is almost always a secondary reaction, resulting from denied feelings of helplessness, frustration, fear, threat, exhaustion or shame.

Though early traumas may have been important in contributing to trait anger, current beliefs, others’ ‘unfair’ and ‘unjust’ behaviours, and current adversities are even more important in dictating anger responses. In real-life, it is commonplace to find people tangled in work situations that generate anger and at the same time prohibit release. In particular, highly aggressive pursuits, such as dog-eat-dog business competition and prize-fighting, help make them more rather than less hostile in their feelings and behaviours.⁴ In this context, it is easy to misconstrue anxiety-provoking or embarrassing situations as instances where others are threatening, thereby responding with anger or aggression. They may also misconstrue feelings such as disappointment or anxiety as anger, and may accordingly act in an aggressive manner.²⁴ In this present age of anxiety,²⁵ when “Rush! Rush! Rush!” and keeping up with the high tech are the order of the day, the proliferation of frustration, helplessness, exhaustion and unhealthy expression of anger should come as no surprise.

As day-to-day frustrations increase, suppression of anger can lead to the aggressiveness and the random violence observed on the roads, in the workplace and at home. Unfortunately anger we hold towards people with whom we interact regularly may find its outlet in unwarranted outbursts of rage against total strangers. Aggression is the emotion many people usually go to in response to frustration. After all, violence is frequently glorified in the media. Rarely a day goes by without some form of violence as the lead story in newspapers, on local radio stations or on television, because “if it bleeds, it leads”.2

Anger management

Anger is not healthy unless it is expressed and released in ways that lead to appropriate action and resolution. Another reason to curb anger is that it can easily lead to aggression. It is certainly salutary to bring down the “boiling point” to a comfortable level.² However, it pays dividends to note that how we manage anger has powerful and potentially dangerous implications for our private lives and our social policies. It actually affects the entire web of our social relations.²³

Treatment for lack of anger control has been based on principles developed by Novaco.²⁶ This may involve relaxation strategies, cognitive strategies, or both. While different interventions theoretically focus on different aspects of anger elicitation and experience, arousal reduction, cognitive restructuring, and coping skills are employed as major elements throughout treatment.

Relaxation strategies target heightened emotional and physiological arousal on the premise that relaxation training produces changes in the response of the autonomic nervous system, including response to anxiety-evoking stimuli. As relaxation takes the place of arousal, the individual gains a sense of calmness and control over disruptive emotionalphysiological arousal. This may free him or her to gain a different cognitive perspective and employ other coping skills.²⁷ Some study even suggests that relaxation training may improve the effectiveness of the immune response.

In contrast, cognitive strategies focus largely on biased, anger-engendering information processing: namely, cognitive content, process and product errors, underlying negative schemes, and cognitive deficiencies. These strategies focus most relevantly on dysfunctional primary and secondary appraisal processes, some enduring personal characteristics, and the cognitive components of the anger response. As individuals become aware of “hot” cognitions and replace them with “cooler”, less distorting, more problem-orientated styles of thinking, they perceive provocations in more realistic manners. Presumably this lowers emotional-physiological arousal and facilitates problem-solving and coping strategies. In practice, cognitive change procedures often involve one or more related but conceptually distinct interventions of cognitive-restructuring, humour, and task-orientated, problem-solving self-instruction.²⁷

It stands to good reasoning that relaxation training employing individualised anger scenes for anger arousal within sessions may be effectively combined with other interventions such as cognitive restructuring and social skills training.

Relaxation intervention

Relaxation is a valuable anger-management strategy that can soothe emotional turmoil and suppress problematic physiological arousal. Techniques like muscle relaxation, rhythmic breathing, exercise biofeedback and self-hypnosis can elicit relaxation response. They are based on the proposition that the individual who is furious and is constantly imagining actions creates a situation in which the body learns to adapt by maintaining a chronic state of muscle tension. The solution is, once he begins to catch himself going into a huff, to release the tension the moment it arises.

On the assumption that body tension can be used as a warning signal of working up into a passion, the basic objective of relaxation training is to teach the individual to relax the muscles at will by first developing a cognitive awareness of what it feels like to be tense and then what it feels like to relax. If one is able to distinguish between tension and relaxation, control over tension follows almost effortlessly. Muscle relaxation can also help the individual to learn to remain calm throughout the day by differentially relaxing unneeded skeletal muscles during everyday activities. One reason muscle relaxation reduces physiological arousal is that the technique tends to arouse pleasant thoughts in the person.²⁸

As it is almost impossible to be tense and have slow, smooth, deep breaths, controlling breathing is supposed to be able to control tension, and conditioning breathing can in turn condition the nervous system to be more tranquil. It follows that breath control is conducive to the control of the mind.²⁹

Relaxation is of particular value if it goes hand in hand with enhanced body awareness. With increased body awareness the individual becomes conscious of this the moment the tension sets in, and immediately allows the breathing to relax back into its usual rhythm or the body to be unclenched and restored to its natural basal state. This forms the basis of a technique called biofeedback in which the individual’s physiological functioning is systematically monitored and fed back to him, usually in the form of an audio or visual signal. He is then trained to modify the signal in order to change the physiological function.

In the same vein, it is useful for an individual to identify the triggers to his anger so that whenever they are found looming, he can prepare himself to take a different direction other than acting out. These triggers, which precede the imploding or exploding of anger, can be any sights, facial expressions, words, names, gestures, behaviours, sounds, etc., that cause him to react. It is therefore possible that with awareness, he can choose to react differently.

For example, the individual can be encouraged to use various kinds of distraction techniques (e.g. Yoga, meditation) to calm himself down. Transcendental meditation can elicit dramatic physiological changes, including decreased heart rate, lowered blood pressure and reduced oxygen consumption. Mental distraction as a form of anger management is helpful in achieving greater control of the emotion when he is in a infuriating state, because, more often than not, he is incapable of disputing well his irrational beliefs or distorted inferences and of believing rational selfstatements, which will be explained in the next section. As an alternative, constructive action may serve as a good diversion from hostility. Several kinds of enjoyable, constructive, and even neutral distractions can interfere with and at least temporarily ease hostility. Some kinds of competitive activities, such as organised sports and politics, may successfully serve as forms of sublimation for anger and violence.⁴

Cognitive change interventions

Many angry people jump rashly to egocentric, negative conclusions and attributions, even when situations are ambiguous or when available information might suggest alternative and more benign possibilities. They are too quick to accept uncritically attributions as true and explain events in negative terms, attacking ways that are coded as directed intentionally towards themselves. They react as if their attributions were valid, whether or not they in fact are. Even where there may be validity to their attributions, they tend to respond stereotypically with anger, defensiveness, and potentially attack, without entertaining other cognitive or behavioural options.²⁷

In this circumstance, it is necessary, first of all, to challenge the person’s idea that bad things must not happen by asking him for the evidence for this belief. The second step in dealing with unrealistic anger is to tackle any ‘awfulising’ about the frustration, where the person is exaggerating the negative consequences of what has happened. It is important to find out the meaning of an event for the angry person, because a seemingly innocuous event may have major significance for the person. The third part of angry thinking to tackle is the person’s damning of the perceived cause of the frustration, be it a person, an organisation, a circumstance, or himself. A key to overcoming this blaming attitude is to help the person to realise that other people are also fallible and make mistakes, and that just because they act badly does not mean that they are bad people.⁵

This procedure is called cognitive restructuring, whereby a person is made to identify and dispute his implicit assumptions and irrational beliefs that spark and maintain anger, and to say more accurate and kind words to himself through ‘self-statements’, which are perceived by the person as plausible and logically related to the situation at hand. These self-statements underpin cognitive functions such as self-instruction, self-control, self-evaluation and selfreinforcement. When people, particularly children, are in anger arousing situations, the self-instructions serve to disrupt their reflexive aggressive responses, and to facilitate more adaptive problem-solving.

One way that seems to help almost all kinds of disturbed emotional reactions is learning effective problem-solving skills. Consciously engaging in effective coping procedures can eventually lead to significant anger reduction. It follows that people with real life or social problems can be helped to identify their anger and recognise the conditions which provoke and maintain it. In this case, the problem situation is analysed, broken down into its component parts, and represented in a manner that would most likely lead to a solution.

In a similar manner, a person who becomes aware of anger triggers may also learn where the triggers originate. The person may then work on them by deactivating the loaded areas of life. One of the ways to act is to reach out to another person when a trigger is activated, because reaching out moves the focus away from his behaviour.²

Likewise, verbalisation or “talking it out” can be valuable in dealing with anger. Talking or writing about traumatic or offensive events can have beneficial effects.²⁸ There are two ways of doing it: self-disclosure refers to being open as a person, being able to share thoughts and feelings with others, while catharsis means release or purification of emotions.

Overall, the ideal is to maintain a balance between control and expression of emotions. Extreme or inappropriate emotions need to be controlled to some extent, whereas less extreme and appropriate emotions can be expressed more openly. The process of ventilating emotions can have a therapeutic effect and reduce stress. Similarly, self-disclosure can be beneficial if it is not too rapidly paced or done under duress.²⁹

Another way to act in a different fashion is to take a more light-hearted approach to respond to one’s triggers or to use humour. Humour lowers anger by introducing angerincompatible affect, by assisting individuals in gaining cognitive distance or perspective shift, and by providing alternative interpretations and attributions.²⁷ Like cognitive restructuring which also changes the meaning of an event or changes perceptions of personal adequacy to handle the situation,³⁰ finding a humorous aspect in a stressful situation redefines the situation in a less threatening way. People can reformulate ordinary problems and misfortunes through humour. They gain a new perspective, a novel frame of reference induced by humour.

Laughter and mirth can indeed serve to discharge pentup emotions. A good sense of humour functions as a buffer to lessen the negative impact of stress on mood.³¹ Some studies support the belief that learning to laugh can save our lives. Cousins³² personally found a connection between laughter, which he referred to as “inner jogging”, and the healing process. He found that laughter not only caused a decrease in what had become constant physical pain but also began to turn the tide of his illness. A sense of humour can also help save important relationships.

However, patients should not be encouraged simply to laugh off and deny difficulties. To the contrary, they are encouraged to develop humour as a way of gaining a brief emotional release and change in perspective so that they can better think through and cope with difficulties. If possible, humour should be of the silly type. Hostile and sarcastic humour have little place in anger reduction and may actually increase anger and dysfunctional means of expressing it. Preferably, humour interventions should follow the stages for cognitive restructuring: that is, becoming aware of the impact of humour and developing, rehearsing, and transferring new humorous self-dialogue and imagery for anger control. It should be borne in mind that some patients initially react negatively to humour, thinking that they are being laughed at or made fun of. Humour generally should be introduced when the therapeutic relationship is strong or the therapist assesses that the patient can handle humour.²⁷

Of course, there is always another alternative, that of Christian forgiveness. It involves compassionately turning the other cheek. But in our often exploitative and hostile world this can be impractical or futile. People will merely feel less intimidated by the person – but perhaps are all the more tempted to take advantage of his or her passivity or good nature.

Conclusion

Injustice, loss, dissatisfaction, frustration, hurt and pain are parts of life. Even when individuals cope with and manage anger well, a level of mild anger such as displeasure or annoyance is appropriate as the need for different choices is obvious and adaptations, however difficult, are vital to survival. After all, anger does possess an adaptive value and there are real positive aspects.

In the event that when anger does go beyond limit, obviously it needs to be managed and controlled. However, it is evident that the causation of anger is multifactorial, so that management strategies derived from different explanations abound. In this context various attempts have been made and interventions designed, with variable successes. It is useful to remember that cognitive-behavioural anger management interventions such as those described in this article focus on anger reduction, not anger elimination. While they may enable people to free resources in order to cope with and enjoy life, it remains indisputable that life can be frustrating, disappointing and painful at times.

Key messages

1. Anger is precipitated when a person is frustrated beyond his or her limit of tolerance. In order to ameliorate the anger response or even eliminate the probability of anger, the clinician needs to help the person seek and understand the origin of the anger on the one hand and boost his/her coping capacity to manage anger on the other.
2. Among the relaxation strategies, slow deep breathing is more convenient and easily applied than progressive muscular relaxation.
3. Among the cognitive strategies, cognitive restructuring or refining is useful in enabling a more lasting change in attitudes particularly to life or adversity. Use of humour has been under-employed and its judicious use should add a light flavour to the modern-city hectic life.
4. The combined use of strategies is recommended and introduction of medication for symptomatic control of anger responses should be a last resort. Here the influence of the doctor-patient relationship is of tremendous importance.