Exploring Different Cost Benefit Analysis related to Anger

 Jay asks: Are you EVER going to do a podcast on anger?

Dr. Burns,

Also are you EVER going to do a podcast on Anger with Rhonda and Matt? You have done many podcasts on depression, anxiety, interpersonal relationships YET there is not one podcast addressing anger.

Given the world we live in right now maybe it's time to address Anger from a TEAM-CBT perspective and give it the attention you have given anxiety and depression.

All the Best,

Jay

In today’s podcast, Rhonda and David address this important but neglected topic that is perhaps more important than ever in today’s angry and violent world.

David began by pointing out that in the feeling Good App, anger improved as much as six other negative feeling clusters, with fairly dramatic reductions in just a few days. This was completely unexpected and exciting, and has been replicated in numerous beta tests.

Maybe there IS a small glimmer of hope in this troubled, angry world!

David pointed out that anger is addictive

• Depression is not addictive because in depression you are thinking I am no good, and you have negative and painful distortions about yourself.
• Anger, in contrast, is addictive because you are directing the distortions at other people, telling yourself that they are no good, and they will never change, and so forth. These distortions directed at others trigger feelings of moral superiority and those feelings are intensely addictive.

Any group that is at war tends to feel morally superior and sees the “other” as scum, the enemy, and these distortions give you justification for hurting and killing them and feeling good about what you are doing.

What makes the treatment of anger fairly challenging is that most angry people are not looking for help.

• Distortions directed at others are key in conflicts with friends and loved ones as well as racial and religious hatred, and war and violence.

How do you treat a patient who is angry?

You always start with T = Testing. David’s research on therapist accuracy indicates that therapist accuracy is recognizing anger in their patients is incredibly poor. If you want to assess and deal with patient anger,  the Brief Mood Survey at the start and end of every session can be invaluable, and the Evaluation of Therapy session at the end can also help.

E = Empathy comes next. However, empathizing with someone who is angry can be challenging because they are often provocative, or want the therapist to align with them in their belief that the person they are angry with is to blame. We want the client to feel accepted, and have a warm relationship with their therapist so the therapist can easily get sucked into the patient’s blaming mind-set.

David calls this “reverse hypnosis,” and this can sabotage the chance for effective treatment.

Empathy can be challenging if the anger is directed at the therapist, or if the client is saying they are so angry they want to hurt someone. That can be ethically challenging because of the Tarasoff duties to warn the victim and notify the police. That is tough because the client can get upset with the therapist.

A = Assessment of Resistance comes next, starting with the Straightforward or Paradoxical Invitation. With someone who is angry, we nearly always use the Paradoxical Invitation. Here’s an example:

You have been talking about person X, and I can see you are pretty fed up with her. You said, you’ve tried everything and nothing works, and she won’t change.

I have a lot of tools that could be very helpful if you want to do work on the relationship and turn it around. But I did not hear you saying that, and I am assuming that is NOT what you want.

Don’t get me wrong, if you want to work on this relationship, I’d love to do that so you can develop a closer relationship, but at the same time, there’s no law that says you have to get along or like everyone.

I’m assuming you DON’T want to work on your relationship with X, but want to make sure I’m understanding you. Am I reading your right?

M = Methods

Two invaluable tools are the Straightforward or Paradoxical Cost-Benefit Analysis for anger, blame, or for the relationship.

• Anger CBA

What are the Advantages and Disadvantages of feeling intense anger at the other person.

• Blame CBA

What are the Advantages and Disadvantages of blaming the other person for the problem.

• Relationship CBA

What are the advantages and disadvantages of having a relationship with this person?

David provided this example of a Paradoxical Anger CBA. A man was hospitalized involuntarily in Philadelphia who was brought in by the police. He was working at Savings and Loan company with disgruntled customers. A customer came in who was whining and complaining. The patient was a large and powerful man, and he got so angry at the whining customer that he picked him up and threw him against the wall. They called the police who arrested the man, but he seemed psychotic, or in a manic state, so they brought him, instead, to the hospital.

He was sent to Dr. Burns’ cognitive therapy group shortly after he was admitted to the locked unit, and defiantly stated at the start of the group that he was sent here for “anger management!”

Dr. Burns said he never tried to “manage” anger, and instead suggested that they could list some of the advantages and benefits of his anger with the help of the group, and also list what his outburst showed about him that was positive and awesome.

Together, the man and the group listed more than a dozen positives on the white board, including:

• Truth was on his side
• People are too entitled, making demands on other people.
• The patient has a strong value system and was willing to put everything on the line for his beliefs
• He was willing to show his true feelings.
• And many more.

At the end of the group, Dr. Burns reviewed all the really good reasons for his angry outburst, and said he did not see any reason for him to change or to give up his anger.

The patient said he totally agreed.

At the start of the group, the man’s anger had been 100 on a scale from 0 to 100.

Dr. Burns asked him how angry he was now, and the patient said zero!

The dramatic change came about because of the Paradoxical Cost-Benefit Analysis.

That strategy can be tremendously helpful when you are working with an angry patient. You won’t get any buy-in by trying to convince the patient to manage their anger. David was actually siding with the patient’s resistance, and the patient could sense that David actually liked and admired him. This can form the basis of a trusting and productive therapeutic relationship.

But many therapists are afraid of this type of paradoxical strategy and reluctant to let go of their addictions to “helping,” in spite of the high failure rate with that approach.

You and your patient have to be on the same team if you want to use tools for effective change.

If the patient is motivated and wants help, you can work on the inner dialogue or the outer dialogue, or both. The inner dialogue is the way you are thinking about the situation, and the outer dialogue is the way you are communicating with the other person.

Anger always results from your inner dialogue—your thoughts about the other person, and those thoughts will nearly always be distorted. The Daily Mood Log can be very helpful at eliciting and challenging those distortions.

The focus with the DML is on the inner dialogue, which will nearly always include a rich mix of positive and negative distortions including

• All-or-Nothing Thinking: Seeing the other person as a total loser.
• Overgeneralization: Generalizing from a negative moment or characteristic and seeing them in an entirely negative way based on this one negative habit, or feature they have. We all have features that are not likeable. WE generalize from the person’s actions to their SELF. You think the person is bad.
• Mental Filtering: Noticing and focusing and all the things about the other person that you find offensive.
• Discounting the Positive: Ignoring the person’s positive qualities, or telling yourself that they’re fake or don’t count.
• Mind-Reading You imagine the other person’s motives. When you feel angry you nearly always attribute malignant motives to them. Sometimes there are some truths and other times there are no truths.
• Fortune Telling: Telling yourself that the other person will never change.
• Magnification and Minimization: Exaggerating the other person’s “badness” and minimizing their good qualities.
• Emotional Reasoning: I feel angry at you, therefore, you are scum and I want to get back at you. You must be very bad.
• Labeling: We label someone as a terrorist as if the person’s entire person can be reduced to a label. There are terrorist actions but…a terrorist can be considered a freedom fighter by someone else.
• Shoulds He shouldn’t be like that. She shouldn’t have said that.
• Other Blame: Telling yourself the other person is to blame and that you are the innocent victim or their badness.

Once you’ve identified the distortions in a thought, you can use any of the more than 100 M = Methods I’ve developed to challenge it, such as

• Explain the Distortions
• Externalization of Voices with Acceptance Paradox, Self-Defense, and Counter-Attack Technique
• Semantic Technique for Should Statements
• Forced Empathy
• Positive Reframing of the other persons feelings and behaviors
• Individual / Interpersonal Downward Arrow
• Examine the Evidence
• How Many Minutes Technique
• Paradoxical Double Standard
• Many more

If our listeners (meaning you) want a Part 2 podcast on anger, we can describe helping the patient with the Outer dialogue, which is how you actually communicate with the person you’re feeling angry with. This was not discussed in great detail on today’s podcast, but we just touched on a couple points.

The first topic is the difference between Attacking with your anger vs Sharing your anger. It’s not bad to be angry, but it is how you share and express your anger that’s most important. There’s a huge difference between healthy and unhealthy anger.

If your goal is to hurt and demean the other person, it’s unhealthy, destructive anger. You may want to get back at the other person, hurt them, or put them down.

Healthy anger is very different. Martin Buber, a 20th Century Jewish theologian, distinguished an “I-It” vis and “I-thou” relationship. Buddhist philosophy is similar. They say that the cause of all evil is the belief that you are separate from an external reality, so you see other person or group you’re angry with as the “enemy” or the “it,” that is separate from you, and “different,” as opposed to the “thou.” Then you can rationalizing using, hurting, or even killing them in order to advance your own interests, or so you think!

Sharing your anger involves letting the person know directly and openly and respectfully that you are angry with them because of something they DID, and not because of something they ARE. The goal of healthy anger is to develop a deeper and more loving (or satisfying) relationship with the other person.

Healthy anger is the decision you make to share your anger, rather than to attack with your anger out of vengeance, frustration or rage. Healthy anger is not the choice that most people seem to make, since unhealthy anger gives feelings of vengeance and moral superiority.

A Part 2 podcast on anger might include

Forced Empathy

Relationship Journal (RJ

1. What did the other person say?
2. What did you say next?
3. EAR Checklist / Bad Communication Checklist
4. Consequences
5. Five Secrets of Effective Communication
6. List of 12 GOOD Reasons NOT to

• E = Empathize using Listening Skills
• A = Assertiveness—Sharing vs attacking with your anger
• R = Convey Respect

The RJ Requires insight, communication skill, and the painful death of the “self”

Examples:

• Why does my husband constantly criticize me? Why are men so critical?
• Why does my wife treat me like crap?
• Why can’t men express their feelings?

Thanks for listening!

Rhonda, and David