A Conversation About… Working with Anger – Part 2

Disclaimer: The following transcript has been autogenerated and may contain occasional errors or inaccuracies resulting from the automated transcription process.

Host (00:01):
Hi there. Welcome to Mental Health Professionals Network podcast series MHPNs aim is to promote
and celebrate interdisciplinary collaborative mental health care.
Tony McHugh (00:19):
Welcome to MHPN presents a conversation about maintaining effectiveness and achieving outcomes for
and with clients challenged by dysfunctional anger. I’m your host, Tony McHugh, and today we’re
wrapping up our two part exploration of anger. In the first episode, we discussed much including the
importance of addressing anger, some of the issues that might be encountered in anger work, the
nature of anger, and the importance of conveying that to clients, the importance of client insight and
motivation for change, the prevalence of dysregulated anger on what increases it and what makes for
understanding around sharing processes that are important in working with anger. In this second and
final episode, we’ll turn our attention to the utility of explanatory theories or models of anger, the
problem of anger and rumination, the duality of anger and the problem of anger blindness, a very
interesting concept, the signs of the need for anger focused work, anger interventions with established
evidence supported utility, and what support and resources there are for mental health professionals
working with clients with dysregulated anger. Joining me once again is Professor Glen Bates. Welcome
back Glen.
Glen Bates (01:38):
Thanks, Tony. Good to be here.
Tony McHugh (01:39):
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Great. Let me ask the first question. In this second episode, there are explanatory models of anger.
What are some of them? What do you recommend and how might such theories be used to assist
clients with dysregulated anger?
Glen Bates (01:55):
Right. Well, there’s been theories of anger going back to the time of Freud and so on, so there’s a lot of
different writing out there and some that turned out to be rabbit holes, if you like, that we went down
and one very powerful one at one stage was the reservoir theory that we had to let the anger out and
that would make us better and directed at a safe object and not at the person that we were angry with.
We learn very quickly that expressing anger, acting out in whatever way actually increases anger. It
doesn’t make it go away. So we’ve moved away from reservoir sorts of ideas. I think the most integrative
sort of framework that I’ve come across started with the original ideas of people like Ray Novaco more
recently, Deffenbacher, and those who focused on that management point that we were talking about
last week.
(02:51):
It’s about anger management. It’s not about anger removal from people and in clients. We’re trying to
get the clients, as we’ve also said, to get an idea of a roadmap. I think it was one of your terms last time,
that will help them understand their own reactions, potentially the reactions of others and let them to
make better choices. And I think Novaco’s theory, which he developed over time, and again is broadly in
the cognitive behavioural framework, but what Ray was focusing on is that first of all, anger is
something that happens in context. Dysregulated anger occurs in situations, and we need to know what
those situations are for the client now, it’s not just the situation they’re in, it’s not that they’re in their
car and they’re having some sort of road rage experience. It’s not just what’s happening, it’s how they
interpret what’s happening.
(03:48):
And this we would argue, happens very quickly and there’s both cognitive elements of that. And your
point earlier about this lack of justice might well be experienced consciously by the person, or I’m
justified in my anger or sense of suspicion. So there’s those cognitive can become conscious processes
and combined with physiology. And I think from this framework, we know that anger always involves an
increase in arousal. You may not tune into it or you may not be aware of it, but there is an increase in
arousal. We measure you heart rate and so on. It goes up even if you don’t attend to it. So there’s a
cognitive and physiological component that happens largely unconsciously, largely unrecognised
perhaps. And that leads to an urge towards being aggressive. That urge to being aggressive does not
translate into aggression. A point made at different times is anger is not sufficient for you to be
aggressive, but it is an internal urge.
(04:53):
And if that is not inhibited, if the person doesn’t manage that, that can lead to behavioural aggression,
verbal aggression, impulsive acts, breaking things, whatever. So the behaviour stuff flows from this
process and when you act, that changes cognitions, it changes your physiological arousal. If you smash
an object, your physiological arousal will increase, that sort of thing. And it also changes the
environment. So if you act aggressively towards someone, obviously the situation changes. So I think
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that framework to me is useful because it captures the idea of you’re in situations, it elicits a series of
responses that lead to an urge perhaps to be aggressive, and it then depends on how you actually
restrict or manage that urge in terms of what goes on. So to me, I found Novaco’s model and it
translates into many other areas, allows us to focus in on cognitions, emotions, physiology, as well as
behaviour, and provides a framework that you can work within.
Tony McHugh (06:07):
I like that enormously. You Glen may not be aware that there are rage rooms in metropolitan
Melbourne and provincial cities in Victoria. We are not endorsing rage rooms, are we?
Glen Bates (06:23):
No. That’s going to increase rage.
Tony McHugh (06:26):
That’s right. So thank you. I believe there are some questions that you would like to ask of me.
Glen Bates (06:32):
Yeah, certainly Tony. Look, I wanted to build a bit on what we’ve talked about these broad frameworks
and I know that rumination can often be a central feature of dysregulated anger and I know you’ve been
involved in looking at ways in which that might be addressed in terms of repetition, experience of
negative emotions. So I think you’ve been looking at problem maintaining cycles.
Tony McHugh (06:55):
Yeah, I think Glen, our audience would endorse the idea that rumination and anger are front and
central. There’s a great connection between them and for many reasons, anger is an especially selfreinforcing emotion. It’s going to be really important for clients to repeatedly engage them in the
discussion around that. And I say repeatedly because I think we fall for the trap in psychology sometimes
of talking at people potentially in educating them when the point is for them to become their own
educator based on their coaching, tuition, supervision, et cetera. So I think it’s really important to
repeatedly engage them around the futility of rumination that is thinking beyond a point. So to illustrate
that, I think a principle reinforcing factor which clients would profit from knowing about is that anger is
what might be termed a unifying emotion. Anger falsely gives people the idea of strength and often
people might be coming from a point of view of, I dunno what the correct word is, but a lack of
confidence and anger gives them the strength that is preferable to experiencing sensations of
disintegration or weakness that might be associated with worry or similar emotions.
(08:18):
So in those circumstances, anger has an emotionally camouflaging effect, and that’s to go back to
Greenberg and Paivio that talk about primary, secondary and instrumental emotions. And if a person’s
primary problem is anxiety, they’re not going to get better at dealing with anxiety by being angry. Angry
is a defence and avoidance emotion if you like. So in essence, discharging angry emotion brings
temporary short-term relief from discomfort or distress. The problem is anger episodes. And remember
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there’s that statistic from the 1983 Averill paper that says 10% to pick up your point of anger might be
associated with aggression, but it says this nice people get angry and they evaluate their anger positively
and they’re still thought of as nice. So these anger episodes are positively anticipated for their utility. I’m
going to go over there and fix that, whatever that is. But they’re retrospectively regretted for the loss
and harm for which they are associated.
(09:24):
And I’ve had the experience many times of clients saying to me, I went and did it again, I on the basis of
presumption, on the basis of impetuosity, sailed in and did something and then I regretted it. Why do I
get caught up in these cycles? We would do well to explain to them that short-term gain leads to
medium and long-term pain in anger and it’s counterproductive and a powerful exemplar of what is
called ironic process theory. People are trying not to be something, but they get exactly what they’re
trying not to be. So sailing in leads to more anger and I think it’s really important to think of that in a
cyclical manner.
Glen Bates (10:13):
What you’re touching on in some of that response there is the sort of a duality of anger that there’s an
award but there’s also a risk. Could you elaborate a bit more on that?
Tony McHugh (10:25):
Happy to. This is what I refer to as the hedonics of anger and here I’d encourage people to look at
Jonathan Height’s work on hedonics. Anger is a remarkable emotion. I made that point a fortnight ago in
episode one. It is connected to so many other emotions. The benefits of anger are probably more than
any other negative emotion. It’s good for communication, it’s good for pursuit of issues that are
important to people. There was a saying in the 1960s, civil rights movement in America, keep your eyes
on the prize. And sometimes anger helps people keep their eyes on the prize. Social movements need a
bit of the petrol of anger at times. But of course on the negative side, it’s so damaging to health. I think
we made this point last year in the 2024 podcast series. It can’t be emphasised enough. It’s associated
with coronary heart disease strokes, it’s associated with immune system disorders.
(11:34):
It exacerbates physical pain. The circularity between pain and anger is kind of well understood. So while
anger has benefits more perhaps than any other negative emotion, I think the negative consequences go
on and on and on. And the trouble is that that’s not recognised by clients. So this is where I think the
term, it’s not necessarily in the literature, but the term anger blindness is potentially important. I don’t
think angry people are deliberately blinding themselves to this, but they just don’t get it. And the
hedonics are, if we can help them understand that it alienates them from loved ones, it causes illness,
loss of employment, loss of function, and so on and so forth, I think that’s going to be really important.
Now why are they blind to this? I think, and again, I’m personifying an emotion here, the emotion of
anger, I say, and I’ll own this, it is seductive. It promises people things. It’s associated with goal
attainment. It’s associated with defensive self and loved ones, legitimate defensive self and loved ones.
And it kind of is like a creeping fog. People don’t understand the problems of being seduced by anger. I’ll
show them they’ll never do that again, but I don’t have any friends anymore. So I think really important
to convey this duality problem.
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Glen Bates (13:11):
I liked your point about Greenberg and Paivio about the primary and secondary and if you’re seeing
anger as you’ve described, so clearly there is being an integrative emotion where they feel justified at
least in the short term. But part of it is that that is underscored by some other emotion. I’m thinking of a
particular client who she was extremely angry woman about how she was being treated at work and she
gave me the account of her interaction on a Friday where she attended a meeting and someone
presented all of her ideas as their own while she was in the meeting, and anger, rage, she spent the
entire weekend ruminating, which you’ve gone into there about that event and wasn’t able to move on
from that. And the anger about, I’ll show them, I’ll get them sort of stuff came up because when we
unpacked it, it wasn’t just angry at being badly treated.
(14:11):
There was a whole lot of stuff about being hurt and being left out, which actually fitted into her whole
background. And the anger, I like your term seductively, the anger gave her a sense of integrity so that
I’m actually not weak. Whereas the hurt was a much disintegrated sort of emotion and harder to
manage and harder to be able to recognise. So when she saw the duality, if you like, of the two
emotions, the hurts was the first emotion, the anger came second. That was a real important insight for
her in terms of what am I getting from my anger?
Tony McHugh (14:49):
And I think that then invokes the notion of coping, coping with challenge. And it’s not very well done
using anger as a tool.
Glen Bates (15:00):
Now we are picked up on anger blindness, which you’ve talked about there and the duality. I’m
interested in signs of the need for anger focused work. Too often the clients with dysregulated anger
sort of fail to understand the signs and symptoms of their anger is a point we’ve just been making. What
do you see as key indicators of this increased need for anger work?
Tony McHugh (15:24):
Look, I think this is one of the simpler things to talk with clients suffering from dysfunctional anger to
talk to them about. It’s really a simple rubric. It’s problematic or dysfunctional when it has a frequency,
an intensity, a duration or a pattern that leads to any or all of impaired cognitive performance. Anger is
not an aid to good judgement , decision-making, goal setting and task completion. It’s also a problem
and it becomes the go-to emotion for just about any life challenge. And there’s no joy to be
experienced. And if I can just go sideways for a minute, I dunno that we will necessarily cover off on this,
but it’s really important to say to angry people that it is possible to experience joy and to keep the
candle a light for that. They will often say to quote them, you’ve got to be joking mate.
(16:30):
But I think it’s really important that we work optimistically and keep that possibility in place. But of
course if they’ve got incapacitating distress resulting in mistakes, accidents and loss of function from
anger, that’s going to be a hard ticket to sell. It’s also important I think, to make it clear to people that it
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causes relationship damage, social disapproval, alienation, and sometimes really regrettably that
perception of friends and family as enemies. And it’s a really telling stat. I can’t remember the reference.
I can just remember knowing about the reference from a long time ago that 90% of the world’s anger is
experienced at home. And I think that’s really telling. And I think the final indicator is when it does get
into that 10% bracket of being associated with frank irritability, rage aggressive behaviour and violence.
So when I think any of those things are apparent, it’s time to work with the client to convince them on
that hedonics again that it can be better if they’re not like that.
Glen Bates (17:41):
I’m wondering, there’s a lot of repositioning of the client’s thinking that we need to do, and clearly we
can’t all rely on one therapist to do that. You’re going to have a therapeutic relationship but you’re going
to need others. I’m just wondering how you utilise a team and where a team might need to be added to
by other people.
Tony McHugh (18:04):
I think that’s a really important question and one of the things we don’t do well enough, if I can use the
we as a series of professions is talk to each other. And I’ve had really telling moments where I’ve
managed to catch another person involved in the client’s care, most commonly a GP and talk to them
about how a shared approach might be important. And I think when that occurs, it can be really
successful because talking to gps without shining a light on them in particular, they are so many things
to so many people and it’s really hard to conceptualise clients struggling with dysfunctional anger or
dysregulated anger and they can be really important conversations. I think then there’s other
professions that it might be important to liaise with around psychiatry for example. But I think the really
important point is for complicated presentations, whether they’re related to anger or psychosis or
personality should really be the province of teams and expertise. It’s not about individuals working in
isolation in treatment settings. I think teams are where it’s at, putting a team around the person.
Glen Bates (19:28):
We could move on a bit to anger interventions. So we’ve talked in or theory section when we were
talking earlier about these different locations of where we need to make interventions. So there are
cognitive interventions, physiological emotional and behavioural interventions. I wonder if we might
reflect a bit on what are particular interventions for each of those areas that we might want to
emphasise for listeners.
Tony McHugh (19:55):
Very happy to do that and perhaps we’ll share a back and forth here, but I just want to offer a number of
caveats for the audience. I think the first point I would like to make is, or I think it’s important to make, is
that evidence-based treatment works. It’s a matter of optimism and sometimes determination. I also
secondly think it’s for the client to own and recognise and work on it because we can’t effectively do
things to people. For them to recognise that there is a gain to be made by regulating one’s anger is really
important and they have to be prepared to do the drills, the kinds of things that we’re going to talk
about there is inevitably a phased process treatment starting with recognition of problem and going
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through to active treatment. And then the final thing I’d say before we get onto some of these
interventions is face validity is a really important thing and treatments do need to be matched to the
client’s cognitive, emotional, physiological or behavioural skills and abilities.
(21:14):
So with those caveats in mind, I guess the first thing I talk about is working with emotion and the
importance of ultimately separating anger from other emotions for the reasons that we’ve both
expressed already that anger is not good for reducing anxiety, it actually incubates anxiety, but a telling
example is guilt emotions of responsibility or social emotions as Height would call them. Things like guilt,
shame, disgust, and they’re never too far from anger at all. And I think it’s really important to think
about the work that has been done on anger and what I call emotions of responsibility, guilt, shame, et
cetera. And I’m channelling someone from the past, but I thought his work was really good. And that’s
Ed Kubany who talks about things like hindsight bias in relation to guilt. I was totally responsible if I
knew then what I know now, but you can’t know. It’s that riddle. And he also talks about things like
catch 22 guilt and their inevitable connection to anger. I think separating emotions and taking away the
carapace of anger so that people can work on primary emotions is really, really important. I have other
things that I would like to mention, but maybe you’ve got one or two yourself, Glen, in the intervention
area.
Glen Bates (22:52):
I suppose I’d go to the arousal one as an addition to what you’re saying there because this is a fragile
therapeutic relationship that we have and it’s because of the nature of dysregulated anger and the
tendency to struggle with hearing information that they don’t like. And one thing that I’ve found as an
early intervention was to look at physiological arousal. Now we’ve said all the theories and there’s clear
evidence that physiological arousal goes up and when angry people come into the room, you can often
see there’s high – you feel it when they arrive.
(23:30):
And you can almost see the clenched fists are already there. So what I’m looking for is something that’s
going to be helpful to the clients, a bit of information about how things can be different that we can do.
And I’ve always found that early on first couple of sessions looking at how do I reduce my arousal and
the deep muscle relaxation stuff here. Not too much imagery because that brings in a whole lot of
cognitive things that could disturb it, but just straight physiological reduction there are already tense.
Getting them to release. Now I’m not talking about doing that in terms of use this technique when
you’re next confronted with someone that you’re having anger with because you’re doomed to failure.
(24:18):
What we’re looking at is having that experience of actually general reduction of arousal. You’ve talked
about the physical damage that anger does and largely that’s of course you are in a high state of arousal.
You are in a fight fright all the time. And I think we get this general level of tension. So something that
allows ’em privacy of own home to reduce that arousal and feel what it’s like when you’ve got a bit more
space for cognition. I think that’s something very useful to bring in. At the same time emphasising your
other bit about understanding my patterns, understanding what my profile of anger is.
(24:59):
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So in the arousal space you can have people who, and this is some of Novaco’s work who have spikes of
arousal. They just see something and goes up short term more common, you’ll get the spike plus you’ll
get this ongoing physiological arousal that may not be acknowledged, but is there a longer duration? So
if people then are picking up what happens to my body when I’m in these anger situations or when I’m
thinking about them, you can do a lot in imagination. Then we’ll pick up things about a general tiredness
that a lot of angry people talk about. If you are on high vigil stuff all the time, you’re tired and you
become irritable. When we’re tired, exhausted, we become grumpy. So that’s one pathway that I’ve
found is really good at the start of treatment. There’s other things you might want to comment about
physiological arousal, but that to me is important. One of these caveats. We’re not going to tell
someone to start doing it. When you are in a crisis situation, it’s like we are giving you a weapon that’s
not going to work and you’ll lose confidence. What we are looking for is building up an understanding
that I can get in touch with my body and my body’s state can change.
Tony McHugh (26:18):
I would then Glen go to something that you and I have talked a bit about and that is the importance of
self instruction training to the remediation of anger and so that we are clear about it. It’s from one of
the giants of psychology of the seventies, Donald Meichenbaum, sometimes known as self inoculation
training. It’s the idea that known events that are associated with irritability and I would say underlying
that a sense of anxiety often is to use self-talk to cope with it and reframe anger, justifying beliefs and
thoughts, setting up a hierarchy of events that titrate the stress to develop gradual adaptive responses
using instructions at different points in a challenge situation so that things that proceed and surround a
stressful event can be taken account of typically done classically in a written form. And I might speak a
little bit more again shortly to the importance of writing and rehearsed as a script and it requires
planning, it requires repetitive skill development commitment. The literature is not well known but it’s
really clear. I can remember a study that was done at Melbourne University around self instruction
training and the effect sizes that it had in helping people be less angry and they were mighty impressive.
So I like self instruction training. What do you think of it?
Glen Bates (27:49):
I think it’s a crucial technique with this group of people. I think a couple of things make it attractive and
helpful for the client. To me, one of the key things of self instruction training is not to do personal
therapy in the situation. To come up with a script, a language to yourself that helps you get through that
moment. And so in the classic sort of version of that, it’s anticipating this difficult situation, what I do
during the situation and afterwards and what language do I use to myself to keep me focusing on
managing the situation and moving away from my old pattern. And I think that’s the strength of it and
its utility is that the person is not engaging in some sort of discussion of the thoughts. It’s even almost
separating from them. And I’m pausing there. I think there’s some similarities to the acceptance
commitment therapy ideas and one of their major statements is thoughts are not facts. While ACT and
CBT have different views of the world, that can be useful as a self instruction statement to clients not to
engage in the thought that is magnifying the anger that a thought is not a fact. But the broader focus of
self instruction training is finding a language for me that keeps me focused on what I’m trying to do in
this situation, which is management and it’s not distracting, but it’s actually not engaging with the
underlying stuff that might magnify the anger.
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Tony McHugh (29:30):
And to emphasise something you said as part of that, it’s so important in pattern recognition and
because it’s sequential and it’s a form of inoculation against stress, people can see and are pleasantly
surprised by hitting winners at times and then they might go onto the next challenge situation. So it’s
structured, it’s not personal therapy as you say. I just think it’s a very, very important tool for working
with dysregulated anger. There’s a couple of other ones I’d like to throw in and I’d be interested to see
what you think about them. There’s an article by McCloskey, Kross, and Bushman and Brad Bushman
does a lot of research in the area of anger and I think the world is better for it really. So they wrote a
paper in 2012 and it was about distancing and they mentioned the term fly on the wall. And it comes
from the idea that when people are in dysfunctional anger world and they’re meeting someone else
who is in dysfunctional anger world, and let’s understand that there is a assortative relationship thing
that goes on in the world.
(30:43):
So people fighting with people they actually care about. The point is to not be up close and personal.
And it sort of struck me that were talking about distancing skills, things like forward planning, problem
solving goal and priority setting, preparing, written rehearsal, adopting a fly on the wall perspective. It’s
the similarly for distancing de-automating, understanding that humans argue over small things using
positive functional distraction, being aware of behavioural chains and engaging in behavioural
experiments. A lot of these things are kind of the 101s of psychology. I can’t begin to emphasise how
much I believe that behavioural experiments are just such powerful tools in thinking about the costs of
an affect like anger distancing. I think it makes sense.
Glen Bates (31:36):
I like both thoughts there. The first one being the capacity to step back from the situation and to be able
to see what is happening in front of you in a more detached sort of way. Not dissociated but detached
and seeing it in a broader perspective. Because what we see with the dysregulated anger is that we
focus in, there’s stuff like attentional focus. They focus on one small thing and that exacerbates what’s
going on. So if they see a particular symbol that they don’t like, the anger gets narrowed to that.
Whereas this distancing idea is coming back to see well the rest of the world and what’s there. And to
me that’s a particular skill. And I think when clients get better in whatever their problem, they are able
to enter situations that they were avoiding or couldn’t do before, but they go into that situation sort of
feeling aware of the factors that’ll influence them and recognition an important part of change, then
what they then get is that the intensity of their reaction, their tendency to jump to conclusions,
impulsive actions slowly recede. I think the distancing stuff is really important, but I think it reflects a
fundamental process of experiential evidence that I don’t have to engage in the old script.
Tony McHugh (33:03):
A new perspective perhaps. The other thing I’d like to get your thoughts on what I call mindful slowness.
And I got this idea from reading Kahneman’s book, thinking Fast and Slow of 2011, and it is a tour to
force. He then wrote a book called Noise, which is pretty good too. And he’s 90 years of age and he’s
writing these things that I think are so impressive. Why do humans make bad decisions? It’s because of
noise, psychological noise. But anyhow, in his earlier book, thinking Fast and Slow, I took from it mindful
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slowness. So I would say this in the context of stress and trauma, we can often feel rushed. We humans
and anger can erupt on account of that. And we do impetuous things, impulsive things, and we think
frantically and sometimes behave frantically. They are the enemies of peace, calm and the psychological
allies of the anger response I think.
(34:08):
So mindful slowness, and I’ve used this many times with clients and they think that makes sense and the
calm that comes from it I think is a potential antidote to irritability. And then people will say, well what
does that mean? How do I implement that? And I think it’s kind of a really simple elegant thing. You walk
slowly, you think slowly, you engage in deliberate thinking, you emote slowly, you eat slowly. All kinds of
things can be done slowly. I think they’re easily practised and they’re critical to implement. Do you have
any thoughts on that?
Glen Bates (34:45):
Yeah, other than to endorse it by taking that sort of control of your experience of the world, you step
back from getting engaged and narrowing and the fast thinking that Kahneman’s talking about. So I think
the other side of the mindfulness people of course is that it’s saying you’re not avoiding the issue that is
there. We’re not sort of going in and playing happy families here. We could be in a situation of intense
disagreement, but that doesn’t mean that I have to get carried up and blow up. The slowness stuff is
about me recognising what’s going on and just introducing that sort of regulation and that connected to
some of these other thoughts we’ve talked about. The distraction, the physiological arousal reduction is
more of that evidence that I don’t have to stay in this pattern, I don’t have to respond in the same way.
It’s not a secular sort of thing that I have no control over that what I’m doing is I’m stepping aside from it
a whole range of different ways.
Tony McHugh (35:54):
I’d sum it up in two words with a little bit of a coder. We’re talking about choice and control. That’s what
I think we’re talking about. The choice to not be angry and developing control over a tendency to be
angry. And then people can deal with the things that when people are in the throes of anger display, and
that’s things like emotional reasoning, black and white thinking, rigid thinking, involving the shoulds, the
oughts, the musts and personalising things. I think it’s possible to make choices around those things and
gain control.
Glen Bates (36:28):
I agree.
Tony McHugh (36:28):
I think you have one final question for us. Is that right?
Glen Bates (36:32):
Think about resources that are out there for mental health professionals working with clients with
dysregulate anger. Now we know that there are no clinical guidelines that we might look at. What sort
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of things would we see mental health can draw upon in introducing these sort of interactions and
finding their own ways of managing clients?
Tony McHugh (36:54):
I’m an empiricist and I do encourage people to look to the literature. So there’s data, and again, I’ve
made it a point today to say that anger treatment works, clients will do well to understand that anger
treatment works. There are RCTs, there are meta analysis, there are about 20 on anger to date and two
systematic reviews, one in 2009 and the most recent one in 2024. I think in the absence of guidelines,
these are important things to be aware of. So they say things like the worst thing you can do in a
relationship is to emotively cathart. So the evidence is really clear, I think. Then there are also guidelines
around disorders. For example, the Australian guidelines from Phoenix on acute stress disorder and
PTSD and the NICE guidelines from the UK, they talk to anger, they talk not enough perhaps to anger,
but they talk to anger.
(37:59):
So I think there’s the data, there’s the summary of the data that’s available in and systematic reviews.
And then there are guidelines about some of the disorders where anger is more likely to occur. And I
think it’s really important to say that the first systematic review that was done 2009 by Glancy & Saini
said treatment dose. The treatment dose, the modal number was eight sessions for people with anger
related problems. It’s just a toe in the water. So there needs to be more treatment, but it needs to be
driven by the things that we’ve been talking about. High anger presentations will get in the way of
treatment for stress or and trauma related disorders, for example, they say manualized treatments. And
again, I don’t think the ultimate manual in this has been written yet, but manualized treatments work
better. And this might be a point of some debate, but they also say strong effects apply where classical
CBT approaches are used like relaxation skills, cognitive therapy and skills training.
(39:10):
They say lesser effects apply where the variance of CBT are used. So it’s an argument for classicism and
orthodox work. The most recent systematic review in 2024 by Kervyn and Bushman is really telling, it
goes back again to, and Bushman’s been writing about this for bordering on 20 years. Don’t do the bobo
doll thing, don’t hit things, don’t smash things. Rage rooms, again, don’t go to them. That’s what it’s
saying. And it says the most effective approach is to turn down the heat. I’ve never forgotten something
that he wrote about in a 2002 paper. If you are going, he said to an event that has some challenge in it.
He says after the event, don’t do arousing things like go to the gym because it doesn’t work. But
remarkably, the data says don’t do arousing things before you go to the challenge situation. So I think
there’s a story in the literature if we really want to help people become the best version of themselves
and dial down the dance with anger. I think we need to know the literature. And I think one of the things
is also talking to people, being engaged in things like this. You may want to talk about supervision for
example. I know you do a lot of supervision. What would you say there?
Glen Bates (40:39):
Yeah, supervision for, everything’s crucial, but particularly with these clients and the reflective or
reflective supervision techniques of bringing up your own responses to the client, how they might be
getting in the way or what was happening in the session. I think that’s really valuable with these clients.
12
As I said, you feel the arousal when you go into the room with an angry client and that arousal and they
may well be justifying what they’ve done, which might really conflict with your own values about the
world and how people should behave and so on or just be foreign to you. And so supervision to me is a
real vehicle for where you can bring those things up, deal with them, and then work out how you can
continue with your contract to be helping this client to come grips with what’s going on. If you work with
dysregulated anger people, if you get into the more aggressive ones, you’re going to be confronted very
much with alternative values, morals, behaviours that you wouldn’t count on it.
(41:46):
That doesn’t mean you can’t work with them. It means that you’ve just got to be aware of them. So
supervision to me is a major feature. And I would think whenever you’ve got a really complex client, you
need more supervision or you need regular supervision where you can focus and not just debrief, but
actually understand your own reactions to that person. And help go back to that principle is that this
anger and even violent behaviour is always a choice and choices can be changed. And I talked I think in
the last session about a person who saw red all the time. They don’t have any perception when they
come in to see you that that can be changed in any way. That’s just a process that happens. So what we
are doing is, the idea is that actually all of what happens in your anger reaction is a choice that’s been
made for whatever reason. And choices can be changed, people can change. And as you say, anger
treatments work and they work I think for largely because of that because people get to a stage where
they realise their choices and they realise they’ve got other choices and can implement some of the
techniques and approaches we’ve been talking about. One thing I wanted to add though from you is
how important do you think is support from colleagues and other professions in working with anger
clients?
Tony McHugh (43:14):
Oh, I think incredibly important. There’s been two things resonating in my head that I wanted to speak
about. We are running out of time, but they illustrate this very, very well. In 2009, Brett Litz put moral
injury on the psychological landscape and it’s been going around now for about 15 years or so. It’s a
really important construct. It’s inevitably bound up with dysfunctional anger, but there’s another
construct that’s even more recent and it’s 2003 and it’s Lyndon’s idea of Post-Traumatic Embitterment
Disorder. Now, when you have clients who have a grievous sense of moral injury about being let down
or undermined or whatever it is, as a soldier, for example, as a survivor of sexual assault as a police
officer, the anger is palpable. It’s really difficult to work with, but one needs to be aware of the existence
of such a thing as moral injury for those choices.
(44:29):
You were talking about Post-Traumatic Embitterment Disorder, and I encourage people to look it up is
the idea that what has happened to me is unforgivable and I will only be better when this is
acknowledged publicly as a crime against me. And it’s kind of working on an insoluble problem in some
ways. And Lyndon does talk about wisdom therapy and the insoluble problem. If you don’t talk to a
network of people or a valued supervisor, you don’t get to have any idea of how to work with such
difficult constructs. So I think it’s incredibly important, incredibly important, and hopefully the key
messages from today and last fortnight will be things for people to think about. Thank you. This has
been a really rich and enjoyable thing to do. Thank you to all for joining us in this episode of MHPN
13
presents a conversation about maintaining effectiveness, achieving outcomes for and with clients
challenged by dysregulated anger.
(45:33):
You’ve been listening to me, Tony McHugh and –
Glen Bates (45:36):
Glen Bates.
Tony McHugh (45:37):
Glen, we’ve covered a lot of territory today. As we did in the first podcast. Today, we talked about the
problem of anger and rumination, the importance of explanatory theories and models of anger, the
duality of anger, the problem of anger, blindness, the signs of the need for anger focused work, anger
interventions that have evidence and utility and how we might support each other and available
resources for mental health professionals working with clients with dysregulated anger. If you want to
learn more about myself or Glen, or if you want access to the resources that we have mentioned along
the way of these two podcasts, please go to this episode’s landing page and follow the hyperlinks. We’d
love to hear what you thought of this series. On the landing page, you will find a link to a feedback
survey. Please fill it out and let us know whether what you received from the conversation met your
needs, and provide comments and suggestions about how MHPN might better meet your listening
needs. In the meantime, if you want to stay up to date with MHPN podcasts, make sure you subscribe to
MHPN presents. Thank you for your commitment to ongoing learning and to multidisciplinary mental
health care. Farewell.
Host (46:51):
Visit Mhpn.org.au to find out more about our online professional programme, including podcasts,
webinars, as well as our face-to-face interdisciplinary mental health networks across Australia.