Category: Anger Management

When Symptoms Overshadow a Diagnosis: Psychotherapy as Archeology

Posted on by Psychotherapy.net Team

When a prospective client makes an appointment to “work on my anger,” I can never be sure what other, deeper issues might lie beneath that common presenting concern. In my clinical experience, anger rarely exists in a vacuum, leaving me to wonder if it is driven, for instance, by personality pathology, trauma reactivity, or rooted in a specific mood disorder that will also need addressing. The person might hyperbolize or downplay their anger problem details during the phone screening. I have also come to wonder if their anger could fuel hair-trigger sensitivity and reactivity, which might add an element of danger to the therapeutic relationship.

Early in my career, I worked in a jail where I intervened with many acutely angry individuals. I knew my way around potentially dangerous people. While their anger required more immediate address, often with solution-oriented methods, what had always interested me more deeply was discovering the person beneath the anger. However, given the nature of corrections, inmates frequently moved for programmatic and security reasons, so my time with them was short, and my interventions were symptom- and situation-focused.

An existentialist at heart, I always wondered about peoples’ internalized experiences. What kind of meaning do they assign to phenomena? What defenses are at play? How does that all affect the clinical picture and what kind of material is in there to work with for better gains? Thus, what I later came to appreciate about working in private practice rather than institutional settings was spending more time with people and really getting to know them. I was better able to contextualize and understand symptom functions and help clients learn about themselves and to relate more effectively with others — especially when anger entered the clinical frame.

Robbie Needs Anger Management

When Robbie’s mother, Jane, called for an appointment for him, I was expecting him to be a child, perhaps even a teen as opposed to being in his early 20s. “He lives with me and is doing OK, but he’s been diagnosed with ADHD for years and can get rageful. He’s got to clean this up and stop living in the fast lane if he hopes to hold a job,” she shared.

I learned that at one time Robbie was on ADHD medication, but discontinued it after he completed high school, and had no interest in restarting it. Jane shared that it was questionable whether the stimulant medication had much of an effect, anyway. She was hoping that meeting with a male therapist, someone he might relate to, who encouraged exploring his emotions and aspirations, would prove more effective.

For his first appointment, Robbie arrived with Jane. They sat next to each on the couch across from me and seemed to interact amicably, something that didn’t always happen when family members arrived together. Robbie nodded along to Jane’s historical details about his development and family matters. He sometimes reminded her of a detail or filled in a blank with his personalized recollection. While Robbie was fidgety at times, he did not exude a hyperkinetic or inattentive vibe. Throughout, he maintained a bit of brightness, as if there were some contained excitement, but it was too early to explore deeply.

At first glance, I considered the possibility of ADHD. Clients I’ve worked with who have been diagnosed with ADHD have low frustration tolerance that often led to angry outbursts. Further, like the prototypical class clown who has that ever-present grin, Robbie had an ongoing light smile of sorts, and he could be a little interruptive and fidgety. “Perhaps, if he indeed has ADHD, he’s just learned to manage well,” I thought as the interview went on.

Therapy with Robbie Begins

On the day of our first therapy appointment, I heard a motorcycle pull up out front, and a second later, in walked Robbie with his helmet. “What a day for riding,” he beamed, taking off his jacket and making himself comfortable on the couch. “What do you enjoy most about being on your motorcycle?” I asked.

“It’s the thrill,” replied Robbie. “King of the road! Just taking off and maneuvering. It’s harder for a cop to get you, too!” he laughed.

Settling into the session, I said, “I wanted to ask, how was it for you last week when we met for the first time with your mom here?” “It’s all good,” said Robbie. “We have a great relationship. She told you everything.”

“She gave me a lot of information, for sure. Given it’s your time to meet with me, I was hoping to hear more of your thoughts about what you’d like to get out of coming here.” Robbie admitted he wasn’t sure.

He explained he knew he was directionless, watching friends finish college or settle into long-term relationships and jobs. Nonetheless, he said he felt free and like he was having a good time and that it would all work out. “Maybe I’m a ‘live fast, die young’ kind of guy. My mother always tells me I can’t last if I don’t get some direction,” he finished, rolling his eyes.

Clasping his hands behind his head and looking about the room, Robbie circled back to my question. He wondered out loud what one does in therapy. “I mean, I do get frustrated easily, and bored quickly. Those medications I took way back didn’t do much. Maybe I focused a little more in school, which was cool, but, you know, this is me. Why do people get frustrated with me if I get frustrated or want to do something? That’s ADHD, right?” he grumbled.

“What can you tell me about people getting frustrated with you for getting frustrated?” I asked.

“People can get under my skin. It’s not just my mom about ‘getting direction.’ She just wants me to be successful. I’m not too irritated with her. I get it. But other people, it’s like they can’t keep up with me or something. I’ve had girlfriends say it, and when I get people together for ski trips or rock climbing, they can’t keep up. If I want to have fun, it seems it’s got to be on my own. I get pissed off. I don’t want to, but people come with me, know I go all out, then complain I’m wearing them out when we’re skiing at first light until dusk. I don’t want to waste time, you know? Make use of time on that vacation!”

“What exactly happens?” I asked.

“Err, I got really pissed one time last year and smashed my GoPro camera as I let my friend know what I thought about his whining,” Robbie said, irritably. “I mean, c’mon, you come on a ski trip and don’t want to ski? Then I’m like, ‘f*&k it, I’m still gonna have a good time,’ and skied off.”

Robbie quickly lit back into a bright expression.

“Are you still friends?” I continued.

“Yeah, he knows it’s just me. He’s seen it before. I guess I’m an acquired taste,” laughed Robbie.

Throughout, Robbie could veer off course, getting distracted by a topic that seemingly popped into his head. It never seemed he had much attachment to the discussion.

Over time, I learned more about other relationships, such as when Robbie told me that dating was tough. It wasn’t because of aggression, but rather he felt he burned out girlfriends. “I’ll find a girl who I really vibe with, and we’re climbing and stuff, and hanging out a lot at the start. A lot of energy, you know? But then, like this one girl, she wanted to do more chill stuff like typical dates to movies and dinner and family events. I really tried to accommodate. I liked her a lot. I tried to have my cake and eat it too by getting together during the week for after work cycling or going to the climbing gym. She told me she just couldn’t handle that activity load. We’re still friends though.” Robbie’s brightness flattened.

I replied, “I can’t help but notice your expression changed, Robbie.”

“Hell, I do get lonely,” he admitted. “I want someone to do stuff with! I like sex and all, but I can get that on demand with girls I’ve known over the years. Chicks dig me, haha! But those girls don’t have to deal with me like a relationship girl would, I guess.”

“What more can you tell me about this loneliness?” I followed.

Robbie explained that he never quite felt “full.” On one occasion when he seemed dull compared to his usual energized self, I acknowledged that I noticed he did not seem the usual Robbie. He said it was one of the “not full periods.” Robbie was able to liken it to a silo that gets filled with grain but has a leak, emptying it again, then hearing an echo within. After some exploration, it seemed that Robbie’s activity level was the grain, keeping him feeling full, but even that had its limits when he couldn’t keep up with it.

“What happens on the occasions you encounter the echoing silo? What’s it like? How long might it stay empty?” I inquired.

“Dang,” began Robbie, looking away. “I lose my excitement vibe, you know?” He continued that he force feeds himself activity to try and get back the momentum and fill the silo, but it’s a trudge. He might have days of feeling apathetic and stuck in his head, thinking too much. He described how he can get to belittling himself for probably being a disappointment to his mom, who had it tough and had dreams for him. “It’s all kind of exhausting,” he finished. With half of his usual energy, he grinned and said, “But I’ve learned to accept myself.”

It sounded to me that Robbie was prone to crashes into depression and that he had a polarized self-concept.

Between sessions, I found myself realizing Robbie’s restlessness and impulsivity weren’t so ADHD-like afterall. When I combined this with how Jane denied any clear early history of typical ADHD symptoms in Robbie, and that she denied having any perinatal ADHD risk factors, I began drawing a different conclusion.

A Hypomanic Personality Dynamic

Robbie was clearly a depressed young man, and it seemed he had a sort of “keep active” or “moving target defense.” He was living a duality—a depressed inner world that he kept suppressed with a hypomanic defense. Perhaps the ultimate denial!

I didn’t realize it at the time, but Robbie was exhibiting what some have called a hypomanic personality, sometimes referred to as a hyperthymic temperament. While not included in the DSM or ICD, the hypomanic or hyperthymic personality are nothing new, and, in fact, have remained of interest to various personality experts (see references).

Millon provided descriptions of this personality style from historical giants. Kraepalin, for instance, said that these are patients who, “…throughout their entire lives display a ‘hypomanic personality’ pattern without severe pathogenic developments [i.e., crashes into full affective disorder episodes].” Schneider wrote, “hyperthymic personalities are cheerful, kindly-disposed, active, equable, and great optimists. Often, however, they are shallow, uncritical, happy-go-lucky, cocksure, hasty in the decision, and not very dependable.” McWilliams, perhaps the modern authority on this personality 100 years later, provides similar descriptions.

A movie character fitting a hypomanic personality that readers may be familiar with is Paul Mclean, played by Brad Pitt, in A River Runs Through It. Also, the portrayal of Scott Scurlock, an infamous 1990s bank robber, featured in the recent Netflix show called How to Rob a Bank, exemplifies a more intense case in that Scurlock’s personality also entailed sociopathic characteristics.

In time, I learned that those with what could be considered a hypomanic/exuberant personality may feel more alive chasing rainbows than the idea of long-term success, for this would require a type of settling, and thus, stagnation in their eyes. This is dangerous because they depend on being a moving target, lest their depressive ghosts catch up with them. Unfortunately, while an immediate salve, this perpetual motion encourages the cycle, for lack of success engenders a sense of failure, feeding depression, which the hyperthymic activity defends against.

Their solution to troubling emotions is the problem. As described by McWilliams, living this energized, unstable existence can become exhausting. Thus, the defense becomes weakened enough that the suppressed internal depressive experience crashes the gate until the energized state reconstitutes and corrals the depressive escapee back to the sidelines where it can only shout insults, which the guard ignores via enthusiastic distraction once again.

The Therapeutic Work with Robbie Deepens

After spending numerous sessions learning about Robbie and encouraging him to engage in sharing/self-revelation, we began more pointed work.

“Robbie,” I began, “from what you shared, correct me if I’m wrong, but it seems like that ‘being active’ protects you from having to deal with that hollow feeling?”

He agreed that it’s the pattern. “It seems like, if you really look at it, life has become a defensive act against feeling that hollowness,” I continued.

“I’m curious,” I began again, “have you ever thought about what life would look like when it’s really going your way?”

“Yeah, not having this moody stuff. Finishing things.”

I asked, “When can you recall that you weren’t moody?”

“I’m not sure. Maybe when I was pretty little. I remember playing and being happy with my dad and brother, the whole family.” Robbie had shared that his father eventually cheated on his mother and left, and she had to work, so wasn’t around as much. Eventually she got a divorce settlement and was able to stay at home more.

It became clear that Robbie harbored a lot of feelings of rejection and subsequent sadness; he was living two sides of the same coin with the ever-present sadness being defended against by an exuberant denial.

In order to stop this rollercoaster, since the hypomanic defense was a product of his bleak internal world, therapy would need to resolve his feelings of rejection that encourage the sadness.

“Like I said, I want a steady girlfriend,” explained Robbie.

“You’d like a meaningful relationship, some real intimacy?”

“Of course.”

“Strictly romantically, or?”

“I don’t want to have arguments with people like what happened with my friend, either.”

As if Jokey Smurf entered the room, Robbie laughed about breaking the Go-Pro camera and the horrified look on his friend’s face. “It’s crazy! I’m like some f**ked up movie character sometimes. But that’s being human, right?”

“Humans can act f**cked up sometimes, for sure, but I recall you saying you really didn’t want it to keep happening for you. I’m curious about what’s behind the laugh about it,” I inquired.

“Man, you therapists find stuff under every rock, don’t you?” asked Robbie, trying to evade my question.

“Hey, you told me you want to learn to make some changes, so it’s my job to notice things that might get in the way. To me, if someone has a contradictory response, it tells me they could be struggling to be real with themselves. Make sense?”

“So, what, I can’t laugh at myself?” he followed.

"Not taking oneself too seriously can ease the pain, can’t it?” I continued.

“It’s the best medicine!” Robbie added.

“Robbie, what are you medicating?”

With that, Robbie said he can’t escape some frustrations so laughs about them. Upon examination, his frustrations were rooted in painful ruminations, coupled with the exhaustion inherent in not being able to stop running if he is to “deal” with them. Distraction was corroding him, but admitting he had little steam left made Robbie feel vulnerable. He would often run on fumes, only to discover some psychological alchemy that provided fuel for the escape rides, which, over time, we saw were getting shorter, almost episodic. Whether this was the result of something therapeutic, such as feeling there was someone to help him manage what lay beneath, incrementally lowering his defenses, or a natural dip in childish energy that occurs as one eases into adulthood, it is hard to say. Regardless, Robbie’s more frequent low points were taken advantage of, where he would become more revealing of his years-long festering conflicts.

Effecting Deeper Therapeutic Changes

In months that followed, Robbie continued with an almost cyclothymic presentation. But the nature of the moods changed. There were peeks at more vulnerable parts of him. He kept up an energetic cheerfulness, but it wasn’t so charged. There were often peeks at actual lamentation and sadness that accented what was left of the hypomanic demeanor. At times, it was more of a reactive, temperamental mood. This seemed corollary to being more in touch with the depressive foundation; making contact with painful memories can be anger-provoking, and great therapy material.

There was still restlessness at times, but not in the old hypomanic sense. It was rather a more nebulous anxiety as Robbie edged into being more self-revealing and exposing his internal landscape. We seemed to be contacting bedrock issues, which, like in geology, would seem like stable turf, but if there are nearby fault lines, that could all change.

But Robbie learned more about the language of emotions and being real with himself. He realized that under it all, he hoped someday to discover it all never happened, but eventually accepted the idea he can’t somehow have a better best. With the disintegration of the denial, the smoke screen of exuberance he made for himself continued to lift. Relationships improved. When he felt more in them, he related better, leading to people being able to have more constructive, stable relationships with him and his fear of rejection no longer had a leg to stand on.

Over this two-year span of meeting with Robbie, I was never sure of how tenuous progress was. Would his psychological fault lines quake? He was invested, rarely missing an appointment, and had made strides in reducing the initial concerns and being more real. It often felt like skiing in avalanche country where anything could upset the delicate structure of snowfall and off it goes, taking everything established in its path with it.

As we wrestled with his long-simmering conflicts and learning to better understand himself and relate to others, Robbie began taking non-matriculated college classes to see what school was like. This was good grist for the therapy mill. Productive, real-world structure. In the meantime, Robbie still enjoyed his interests. Along came a part time job, then a girlfriend. Then the end of our sessions. Sometime after, Robbie left a voicemail asking for a letter about his having been in therapy and if he was ever a danger to anyone. Apparently, he was moving in with his girlfriend, who had a child whose father was contentious and heard Robbie had been in mental health care for being explosive in the past.

Postscript

I can’t help but feel that Robbie wouldn’t have reached this stage if his encounter with mental health care continued to see him as having ADHD, or as having problems with anger control. Some people say diagnoses don’t matter, that “we treat symptoms and not diagnoses,” which has the implication that symptoms can always be treated similarly. This can be a specious and dangerous outlook. Symptoms may occur across diagnoses, but that doesn’t mean they’re treated similarly. This diagnostic consideration of hypomanic personality, despite the debates about its legitimacy, allowed me to contextualize the nature of Robbie’s symptoms, which guided my approach to intervening with him. If merely addressing symptoms was sufficient, it wouldn’t have mattered if Robbie’s presentation was chalked up to ADHD or a hypomanic personality. The ADHD medications in theory would’ve fixed him.

We generally never know how our patients fare in the long term. Robbie’s hypomanic presentation was deconstructed, and an honesty about his life settled in. Consistent structure followed, highlighted with the activities he’d escape through, but now in more moderation. A semblance of a well-balanced interaction with himself and the world took form. Chances are, spot-reducing symptoms wouldn’t have allowed such a rich experience. Symptom reduction is great, but how does the person now live with their newfound experience? Does it have stability?

Personality is important, whether it’s pointedly treating personality disorders or helping someone integrate updated parts of existence into their being and work that into the world around them. Hopefully, Robbie is a reminder about the intricacies of therapy. It certainly was to me! It’s more than what’s observable, and what’s observable isn’t always what it seems.

References

Akiskal, H., Placidi, G., Maremmani, I., Signoretta, S., Liguori, A., Gervasi, R., Mallya, G., &Puzantian V.R. (1998). TEMPS-I: Delineating the most discriminating traits of the cyclothymic, depressive, hyperthymic and irritable temperaments in a nonpatient population. Journal of Affective Disorders (51),1, 7-19.

Jamison, K. (2005). Exuberance: The passion for life. Vintage.

McWilliams, N. (2011). Psychoanalytic diagnosis: Understanding personality structure in the clinical process. Guilford Press.

Millon, T. (2011). Disorders of personality (3rd ed). Wiley.

Oser, D. (2019) Hyperthymic temperament. Psychiatric Times, 36(9). https://www.psychiatrictimes.com/view/hyperthymic-temperament  

The CORE Approach to Therapy: Helping Jennie Find Resilience

Posted on by Psychotherapy.net Team

A 58-year-old CT scan technician at a local hospital, the youngest of three sisters, and a recovering alcoholic, Jennie came to therapy four months after healing from surgery to repair an atrial septic defect, one of two major congenital holes in her heart. The repair of one of the major defects, and other secondary repairs had been done during Jennie’s childhood. When we began her treatment, Jennie was about three months into a second episode of sobriety after a relapse prior to heart surgery.

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As Scott Miller’s research into therapeutic effectiveness has taught us, the relationship is the key variable in virtually any modality. With this in mind, I decided to utilize the CORE method with Jennie to develop a safe, trusting context in which a strong therapeutic alliance could develop. The method offers a schematic guideline for the utilization of intuition as a curative dimension, particularly in the treatment of trauma. The model is comprised of four components.

Connecting in a caring climate of calm and comfort

Orienting toward strengths, including inner wisdom

Resourcing resilience, evoking awareness of capacity

Establishing strengths that endure, including symbols and metaphors

Connection

When Jennie first came to therapy, my intent was to attune to her and to her story in a way that would communicate a sense of being heard and clinically “held.” My intention was to create an atmosphere of positive regard in which Jennie would experience acceptance and, with her nervous system sufficiently regulated, feel safe enough to address past painful memories and traumatic events of the past. My strategy was to build a connection with attunement to Jennie’s frame of reference, her beliefs, and her presentation and language, to create a context in which Jennie might better understand events of the present.

As our alliance flourished, I would look for opportunities to offer trance, possibly with a lengthier induction, but maybe a short absorption, in which Jennie might find latent or cut-off resources she could apply in future situations. In this way, I was able to help her to identify and integrate new resources in the service of managing her emotions and behavior in future situations.

For the first two sessions, I mostly listened to Jennie’s story, affirming the trials and problems she revealed. In doing so, I gently guided Jennie to express as clearly as she could what she hoped to get from her therapy. Although I didn’t know at first, or even at the start of any particular session how exactly I might utilize methods of hypnosis and trance in combination with ideas arising from my intuition, I hoped that the strength of our connection, characterized by validation of both Jennie’s struggles and her strengths, would ultimately lead her to recognize and absorb a belief in her own resilience and achieve her clinical goals.

I trusted that as I listened to Jennie’s story with compassion, attuned with an empathic gaze, and validating responses, that I would pick up both overt and minimal cues of what was most important for her. I also believed that as I scanned the impressions arising from my clinical observations, I would recognize cues for what might be needed to help her learn to recognize and shift into a state of calm when sympathetic arousal overwhelmed her emotional boundaries, and what points would stand out for me for utilization of trance.

It did not take long for Jennie to come to her goals. She wanted to deal with cumulative stress that would “pile up” and lead to “rage that can get out of control.” During exploration of her major life stressors, Jennie reported a difficult under-staffed work setting as well as on-going communication problems in the family of origin which included at the time a terminally ill brother-in-law and misunderstandings between herself and her two older sisters, Naida and Meg, that often involved the oldest sister’s daughter, Marcia, a niece who was close to Jennie in age and whom Jennie considered a close friend.

Although Jennie’s life partner, Tony, was dealing with a terminally ill mother, this added stress in Tony’s life was not causing conflict in their life together. From all reports, this primary relationship appeared to be a stable area and an island of support for Jennie. Clearly, she was more likely to be triggered into anger by relationship disturbances with her siblings or with coworkers when differences of opinion resulted in disagreements and distorted perceptions.

Such interpersonal static would cause Jennie to question her understanding of a situation, trying often with difficulty to determine her part in the problem. Often, the aftermath would be distance from her niece or from a sister or might form resentments toward a co-worker that could affect her morale and threaten her sense of competent efficiency at her job.

While Jennie reported no incidents of physical violence toward anyone with whom she would get angry, she expressed high motivation to learn to refrain from lashing out and making disagreements into larger issues that would disrupt contact with her sisters and leave her feeling bereft and disappointed in herself.

These types of painful emotional episodes reminded Jennie of the dysfunction and traumatic chaos caused by alcoholism in her family of origin. She wanted to understand how the old images, left-over impressions, and painful memories of the past affected her in her relationships now.

In the service of self-differentiation, Jennie longed to understand her personal role in these painful experiences. As therapy progressed, Jennie became even more consciously motivated to find strategies for reducing the emotional/somatic arousal that would break through her conscious intent to refrain from lashing out.

Orientation: Toward Strength and Inner Wisdom

My realization was that an inner wise intelligence was available for utilization as part of problem solving, and in this case, specifically for healing trauma via re-association of cut-off strengths and resources.

It seemed both clinically and intuitively advisable to consider orienting Jennie toward her strength and helping her to access via her intuitive, inner wisdom. Jennie, I intuitively hypothesized, would benefit from an approach that would utilize trance and also provide some solid stress management skills. Both the intuitive and the practical would serve to guide Jennie toward the resources she wanted for managing both her emotions and her behaviors, particularly during interpersonal stress and conflict. Like every feature of CORE, intuition would be best accomplished with the CORE features of an approach that would access the non-conscious processes of the intuitive dimension of mind to remind Jennie of strengths she had already used in her life, and access dormant and latent strengths that were, for the moment, dissociated from a consciousness plagued by conscious as well as subliminal memories from her past.

First Intuitive Impressions

As therapy began, so did both overt and minimal cues as well as intuitive impressions. My first initial postulation, based on Jennies wide, welcoming smile, was that she had relational resources she was evidencing, but not fully aware of. I sensed based on the way she connected on screen, face-to-face, eagerly listening to what I chose to say, that Jennie might be open to the focused attention of hypnotic trance, with or without eyes open. While later this proved to be true, at first it was more of a hunch as she was readily beginning to let me know her by revealing a background history of emotional neglect, family conflict, and multiple complex losses, as well as the recent operation to correct a congenital heart defect.

It did not take long for a certain current situation in Jennie’s work life to give me a chance to test out my hypothesis. The idea for the experiential moment came intuitively in the third session. I was working on two channels, the intuitive and the clinical, listening to Jennie, and paying attention to her non-verbals. I was also scanning my own hypotheses. As I was also sorting out clinically what direction I might go in next, Jennie’s narrative gave me the inspiration, an intuitive idea.

Resourcing Resilience

I was able to guide Jennie toward the realization that inner strengths existed and could be available — in this instance, using a brief trance and metaphor, as well as a dissociative moment in the service of integration of strengths.

Jennie revealed that in the imaging department, a complaining and underperforming co-worker was “driving me crazy!” (I was now in intuitive territory). Extremely conscientious in her work, Jennie could feel her anger brewing and escalating as the co-worker’s poor work ethic and performance was leaving her overwhelmed and frustrated. Jennie was adamant that she did not want to lash out or do anything to cause problems for herself at the job, as had happened in other situations in the past. She wanted some help to calm herself so she could cope in a different way.

“Just ignore this person and go about your business,” might have worked for some people, but Jennie’s anger was deeply embedded in her emotional and operational self. I intuited that reaching her non-conscious intuitive mind was the way to go.

“I am so angry when I go in and I see her! I feel like I am just a bitch!”

In that moment, I remembered her history of conflict with two older sisters who had blamed Jennie and called her a bitch! I also knew Jennie had not just a broad smile, but a way of seeing the world with humor. How to externalize this self-denigrating sense of herself was the intuitive question — the answer came quickly and surprised me with its humor and potential to utilize Jennie’s sense of humor — without formal trance. I also knew that I was going to trade in what had felt like a positive alliance.

“Jennie, I have this idea and you can tell me if it seems too odd. (She agreed to hear the idea) Have you ever seen a spray perfume bottle?”

“I just happen to have a very fancy one,” Jennie replied.

“What if you imagine that it is filled with a perfume called “Eau de Bitch?” And you can imagine that you can spray it all around when you go into work, so you know it’s just in the air and it’s not in you!”

Now chuckling, she said; “I love that idea!” I’m going to do it!

Evoking Endurance

“Well, let’s take it one step further, okay? You could also have another imaginary bottle that could be for you. This one could be sprayed in the air like an air cleaner, or on you like perfume. This one could be called “Eau de Calm.”

Now fully belly-laughing, Jennie reported that she was actually going to use the real spray bottle for “Eau-de-Bitch.” She later sent me a picture of the bottle and reported at the next session that not only did she no longer feel bothered by the co-worker, but Eau-de-Bitch could also be a go-to when she was upset by her sisters.

***

Over time, using intuition in my work, and teaching others how to use this psychic dimension of mind, I have learned that although people might understand the concept of what intuition is or can be, may clinicians want something more concrete about how to utilize intuition in the clinical setting — or in life.

[Editor Note: “Jennie” has given the author permission to share her story on psychology platforms for teaching purposes.]    

Spitting Truth from My Soul: A Case Story of Rapping, Probation, and the Narrative Practices- Part II

Posted on by Psychotherapy.net Team

Recapitulation

This is the second part of a two-part case story that focuses on a 24-year-old African American client named Ray who was referred to me (TH) by probation services. In this brief introduction I will try to summarize what transpired in Part I. Whenever possible, I will attempt to provide phrases or “pieces” of Ray’s language so the reader can begin to get a “feel” for him and our work.

Rap music was introduced as an entry point to our work. After our first session Ray could probably best be described as equal parts skeptical and intrigued. He enjoyed sharing rap songs that were meaningful to him as well as having the opportunity to create rhymes of his own.

We rather quickly discussed ways in which rap music was misunderstood (“Adults throughout my whole life telling me it’s violent and the music of the devil . . .”) and how others could not or were not willing to hear the important messages that can be contained within certain songs. We proposed a pair of magic headphones (“Magic Beats”) as a way to help those who would not listen begin to hear rap’s message. This idea will prove particularly important as our conversation progresses in Part II.

As our first conversation continued, we started exploring the sociopolitical implications of rap music and hip-hop culture. We framed rap as a kind of philosophy (“But without all the white cats . . .”) that served as a voice for the voiceless. We also stumbled across a connection between Ray’s grandmother and rap music (“I’m rapping about the same s**t she’s saying but in my own way . . .”). This struck him as perplexing (“That’s crazy bro . . .”) and also enlightening (“I never thought of it like that . . .”) given the disdain she had expressed for rap music throughout his youth. Our first meeting came to a close by having a conversation about our conversation.

We explored the difference between just talking and rapping, to which Ray responded, “It’s like when I rhyme . . . I spit truth from my soul.” We both agreed that inviting rap to our future meetings would be of benefit. More specifically, we discovered that rapping might serve as a pathway to liberation (“Remove the shackles from my soul . . .”). I invited Ray to consider composing a rhyme that paints the part of the picture that probation services doesn’t see. He responded enthusiastically but seemingly nervous that probation services would discover the way we were working and somehow veto it (“You’re the weirdest shrink they have ever sent me to. Not weird like bad, not bad at all, but does probation know you do this?”). We then decided that calling our work together a “studio session” was a better fit than therapy.

Ray picked up in our second meeting directly where he left off in the first. He came prepared with a rhyme that would be the foundation of a counter-story. He noted in that rhyme the importance of challenging rules (“Just because these are the rules you play the game by doesn’t mean these are the only rules . . .”). The conversation evolved into looking at whether or not Ray had found some ways of challenging rules more effectively than others. He then traced the relationship between rap and anger (“It’s like my anger would leave my mouth through my rhymes . . .”). Part I concluded with a pensive Ray searching for a rhyme that captured this most important function of rap music as an antidote to anger and aggression. The following rhyme picks up where our original story concluded.

An Antidote to Anger

Judicial system mad puzzling

DA presents two options
Jail cell or rat on my cousin
Death sentence if I’m released
Seen on the streets
All free
They’ll be like “who you dropped a dime on g’”
Obscene language make them ends
So I’m squeezing my pen
That’s mightier than the blade
Not trying to see death
Strategize and not be so impulsive
Quiet cats survive
Bullets for the ones boasting
Friday night drive on Colfax
Enjoying the madness
That was created by fascists
Reagan-nomics took our tools away it’s so savage
Regardless of politics
This my Mile High life
Shout out to my bail bonds-man.

Travis (T): What speaks to you in this verse?

Ray (R): The line, ‘So I’m squeezing my pen, that’s mightier than the blade,’ is the main one. I mean, the rhyme talks about the stress, the penitentiary, but then boom (begins rapping) So I’m squeezing my pen, that’s mightier than the blade.

T: Did you fight with your pen instead of your blade before you ended up on probation?

R: Usually, yes. But there are these times where I just lost it.

T: The pen was knocked out of your hand?

R: Yeah, you could say that.

T: What happens when the pen gets knocked out of your hand?

R: It’s like I’m a different person. I do these things I know are stupid, but I just do them, anyway. It makes no damn sense.

T: But when you have the pen?

R: I can do anything.

T: Would it be accurate to say that when you have the pen you can spit truth like you said in our last meeting and that’s when Ray The Philosopher comes out (I uttered the term Ray The Philosopher without giving it much thought and certainly without an understanding of how it would later be adopted in our work together)?

R: For sure. That’s kind of a dope name right there, brother… Ray The Philosopher (said with gusto)

T: Do many people in your life know Ray The philosopher?

R: My homies do.

T: Is there anyone else you can think of?

R: No, not really.

T: What do you think would happen if we introduced more people in your life to Ray The Philosopher and his rhymes?

R: I think it would be good, but like I said last time, nobody wants to listen. They think rap is corrupt.

T: What if we were to inform them that when you can think ahead and fight with your pen through rap it helps you avoid anger and thus probation? Do you think they know this about you?

R: Nah, they don’t know that. I still don’t know if they would hear me.

T: Even if they knew that it would help you avoid future relationships with probation, they still wouldn’t hear you?

R: (silence for 15-20 seconds) Maybe. I mean, I hope so.

T: What do you think your grandmother would think about rap as a way to fight with your pen instead of your fists? Have you spoken with her about how you and rap have this kind of relationship?

R: No. I’ve never spoken much about my rhymes at all with my grandmother. I’ve just always known how much she hates rap. Like if I bring it up, I know she’s going to roll her eyes at me.

T: Do you think the kind of rap she hates and the kind of rap you’re tight with when you’re fighting with your pen are different?

R: Oh, yeah! She thinks rap music is just about cursing, talking about hoes and drugs and shit like that.

T: If she truly knew how rap music unshackled your soul do you think she might begin to have a change of heart?

R: Yeah, I still just don’t know if she would listen, though.

T: What if we created a space in here where you could perform for her, and we constructed a marquee (points upward) that lights up and says Ray The Philosopher!?!

R: (Laughs)

T: If you rapped for her and she could feel the words instead of just hearing them, what do you think might happen?

R: I really don’t know.

T: Would you say that your grandmother’s wisdom finds its way into your rhymes?

R: Oh yeah, I know it’s in there a lot.

T: Can you think of an example in the rhyme that you shared with me at the beginning of our conversation today?

R: My grandmother has always wanted the best for me. That’s why I started out that first line with her. You know, (begins rapping) Grandma said I should reconsider law school. I was sampling from another rhyme that starts with mama instead of grandma, but it’s because I know she wants the best for me and that’s why she’s always bothering me about school.

The thing is, she also taught me to be street smart, which is why I like to challenge the whole foundation that student loans and shit are built upon. It’s like a scam for poor people. You know what I mean? I would have never thought about shit in these terms if it weren’t for her. I would have never looked deeper. And that’s what that second verse is about, too, with people on TV commercials acting like they can save your life and shit. You ever watched TV at like 2:00am?

T: I have a few times, yes.

R: Then you know what I mean, right? There’s these cats trying to sell hocus-pocus. They are saying shit like, (changes voice to that of a highly embellished television salesperson) “For 20 years now I’ve been helping people change their lives. For only three easy payments of $99.95 you can get the 7 secrets that will make you rich. Order now!”

(Both bellowing with laughter)

T: I didn’t know you were an actor, too, Ray?!

R: (Laughs)

T: In all seriousness, if I’m hearing you right, Ray, your grandmother’s wisdom is everywhere in your rhymes, and she doesn’t even know it?

R: Yeah, I guess you’re right.

T: Do you think we might be able to invite your grandmother to see, hear, and feel that rap can be a philosophy of street smarts and wisdom and not just a form of music that young people like to listen to?

R: I think so.

T: If we are successful do you think this would be sort of like putting the Magic Beats we talked about on your grandmother’s ears?

R: Yeah, but the rhymes will need to be just right.

T: Perhaps we should take some time in here to get them where you want them?

R: For sure.

Turn Up the Sound

Ray and I spent our next two conversations focused on taking the various rhymes rapped during our first two meetings and worked on creating a mega-anthology. It was a scintillating process that saw KRS-ONE, Tupac Shakur, and other artists rapping in unison through Ray’s mouth. I brought in my laptop computer to help with the process, and Ray made it do things I did not know it was capable of.

He turned my computer, and my office along with it, into a fully functioning recording studio. I even created a marquee (clearly the work of a second-rate artist) that read “Ray The Philosopher,” which always led to a hearty chuckle from Ray every time I hung it up at the beginning of our meetings.

“Yo, Travis. Turn up the sound a little bit,” Ray said as I scurried over to the computer. “Yeah, that’s good right there,” he reassured me making an ‘a-ok’ sign with the finger and thumb on his right hand. I watched, often in awe, as Ray meticulously perfected his craft. He was locked in his element, and I was an enthusiastic fellow traveler.

“Nah, we need to change up that baseline a little bit,” he said shaking his head and taking a swig of water. “It doesn’t quite pop. I need more time.”

I have had the great fortune of working on similar projects with people who had sought my counsel in the past, but this was among the most ambitious ventures I had encountered. As we started to make our way toward the end of our fourth session together, I started to wonder if perhaps we had bitten off more than we could chew. Now I knew that Ray had similar feelings. It wasn’t as though we hadn’t been aware of time but more like we had lost ourselves in it.

T: Ray, the last thing I want to do is rush you through this process.

R: But I only get to come here one more time.

T: Well, I know that’s the initial agreement you had with probation, but I can see you as many times as we think would be best.

R: What about you, though? I don’t want to be a leach?

T: What do you mean?

R: You’ve got to get paid, man. This ain’t no charity. This is your livelihood, bro.

T: I really appreciate you thinking of me, Ray. Tell you what, how about I give probation a call and tell them a bit about the situation and see if we can get some more time? In the past this is something they have often been willing to do.

R: What if they’re not?

T: Then we will see the work through to its completion anyway, Ray. As long as it takes. This is just too important. Don’t you agree? Besides, I have been thinking about something. Would it be okay if I shared it with you?

R: Of course.

T: I know your grandmother is going to come in at the conclusion of our work to celebrate with us. I was wondering what you thought about perhaps inviting other people to meet Ray The Philosopher? Is there anyone else you who you think it might be good to invite to wear the Magic Beats?

R: Hmm… I haven’t really though about it too much.

T: I’m just thinking out loud here, Ray, so stop me if this doesn’t make sense, okay?

R: Okay.

T: What do you think would happen if your probation officer were introduced to this idea of you fighting with your pen instead of your fists?

R: I mean, I’m sure he would like it. He just wants me to keep my hands clean for the next year.

T: What do you think would be the consequences of us not bringing him up to speed on this?

R: I don’t know.

T: As it stands now, do you think your PO views you as someone who is going to fight with his fists and get into trouble again or someone who is going to keep his hands clean?

R: (Laughs cynically) I damn sure don’t think he trusts me. I think he believes I’m going to be out gang-banging (a hip-hop term for engaging in violent acts as a member of a street gang), and I don’t even do that shit.

T: How has it come to be that you don’t even do that shit and yet your PO thinks you do? Do you think we should try and set the record straight and let him know how rap allows you to fight with your pen instead of your fists?

R: But he’s going to give me that same old bullshit about how I don’t take responsibility and blah, blah, blah (uses his right hand to imitate a talking mouth).

T: Do you think if you rapped for him and let him know how rap can strangle the advances of anger and aggression, he would look at you as more likely to keep your hands clean or less likely?

R: (Pauses for 10-15 seconds) More likely to keep my hands clean.

T: What do you think the consequences would be if we weren’t to set the record straight?

R: Yeah, I get what you’re saying now.

T: How do you mean?

R: Like, it’s not enough for just me to come up with this plan if he still thinks about me a certain way… like I’m a criminal.

T: Do you believe this is an opportunity for Ray The Philosopher to replace the other names that have been placed on you in the past like criminal?

R: Now that you mention it, yeah, I guess so.

T: Would you say that sometimes your PO is a tough nut to crack?

R: C’mon, now! That dude is like impossible to crack.

T: Do you think then that we might have to prove to him just how effective fighting with your pen can be?

R: Sure, but how the hell are we going to do that?

T: How long have you seen me for now, Ray?

R: (Pauses to think) Like about a month.

T: I know this is a tricky question because I’m asking you to guess what another person might be feeling, but do you have any sense for how your PO would say this last month has been for you.

R: I actually talked to him about this last week. I’ve been squeaky clean. Not one single issue, homie.

T: What do you think he would have told me about how things were going if I had talked to him prior to you coming to see me?

R: Man, he was always in my grill about shit saying I was defiant, I was going to go to jail, and this and that.

T: Fair to say then that he believes things are going better now?

R: No doubt.

T: Has one month been enough to convince him that you are on the right track?

R: Hell no! It’s like he’s just waiting for me to fuck up.

T: How many months do you think it might take to convince him that you are on the right track and ready to end your relationship with probation?

R: I mean, I still have over a year of this.

T: Do you think it will take all of that time to show him just how effective fighting with your pen can be?

R: Probably so.

T: What if we were to invite him in here, bring him up to speed on your philosophy of fighting with your pen and not your fists, and then make a commitment to this going forward?

R: I don’t know if he’ll believe it.

T: You make a good point. Like you’ve told me, he can be a bit stubborn and so can your grandmother! Even as tough as it is going to be, are you willing to fight with your pen and prove to your grandmother, your family, and your PO the true character of Ray The Philosopher? You already have one-month under your belt!

Ray paused after my question. I started to wonder if perhaps my query had pushed him a bit too far. His face remained stoic as the silence continued beyond 30 seconds. Just as I started to ponder my next move fearing I had lost him, he replied, “I’m down (a hip-hop term voicing agreement).”

After the conclusion of our fourth session Ray and I agreed that it would be good to check in with his PO together. We decided that in addition to talking about the need for more sessions, we would also let his PO know (a signed release was already in place) about how Ray had been fighting with his pen instead of his fists. The PO acknowledged that things were going better the past month, but he remained skeptical. He agreed to get payment covered for half of every session for the next month. The way the following month was structured it would afford us five more weekly meetings.

Two Different Stories

Ray seemed somewhat relieved that more sessions had been granted but also a little bit ticked that his PO was still unconvinced. He felt his PO was “playing games” and “testing me.”

Our next three meetings were spent wrestling with these feelings. Ray began discovering that restoring his reputation burned nearly as many calories as he was taking in. Instead of being consumed by anger towards his PO, Ray stayed true to his word to fight with his pen. He remixed a song by the artist Common:

We should name the block poverty
That rock stole our humanity
You hear that glock pop?
For dough we perform beastiality
“Fucking each other over
What you expect they animals”
Then act like they the ones offended
When TMZ release the audio
If life’s a game
They withhold that playbook
But playas make that scratch
We get the itch
Run your shit
This a jook
Or a lick
See that’s a stick-up if you down with my click
We starving in the darkness
Force upon us they man made eclipse
Is it a curse?
Mad poisons in our blood?
My pops tried to disinfect it
Chugging that rum
And I do the same (word?)
Like father like son.

Ray no longer waited for me to inquire about the lyrics. He would deconstruct them now almost as a natural part of our process. “See, this is what he (probation officer) doesn’t understand. I was born behind the god damn eight-ball. No father. Poor. I’ve always had to hustle to survive. He doesn’t know my pain. Does he even care to know it? But that don’t even matter. Is he testing me? I’m going to pass that test.”

Ray began rapping the second verse from this song:

To my reflection I scribed
What I be feeling inside
Can’t leave it buried in the dirt
Gotta breathe it and give it life
My neighborhood taught us no self-control
That boom-bap made us feel like it’s our right to explode
No positive role-model
The hustlers were our fathers
Rappers instructed us to spit rhymes
And don’t bother
With the life of an outlaw
It’s a trick to keep us blind
And deny our title as God
Preventing our rise
They been doing this for centuries
Stolen lands from our North and South American fam
Jews burnt
Japanese thrown in determent camps
Hatred can hide
Right in front of our eyes
But I flipped that same hate
Used it as fuel to survive
I’m of a mind that believes love will conquer hate
They be seeing black and white
While my crew is dazed by all the gray
So gather around the fire
Light it up
Continue the cipher
Cause in the darkness of nights
Our stars still shine brighter
This is my dream!

T: Ray, are there two different stories in the two beats you have shared with me today?

R: Yeah, the first one is the pain and strife. The second is what happens when I look ahead and fight with my pen.

T: Pain and strife and fighting with your pen… both of those are rhymes that you brought into our work earlier, right?

R: Yep.

T: Would it be right to say then that these last two verses are a sort of remix of all of the beats we’ve heard in here so far?

R: Pretty much.

T: Would these verses be good to share with the folks who join us for our final celebration of the work you’ve accomplished in here?

R: Yeah, but I might tweak them throw in a couple of other verses from different rhymes to get it just where I want it.

Our second to last session was a dress rehearsal. Ray came with the beats he wanted to perform and refined them. We also talked about how he wanted our final celebration to commence, what would happen, and who to invite.

He joked that it “would be kind of like a block party, but where a therapist lives in the house on the corner.” We also decided that those in attendance would have an opportunity to voice their support of Ray’s efforts over the past two months as well as hopes and dreams for the future. As this session came to a close I could detect a nervousness that was following Ray.

T: Ray, I could be wrong here, but I am wondering if some nervousness is hanging with us right now.

R: Yeah, I guess so.

T: Do you mind if I ask you what kind of nervousness it is? People I’ve worked with before have taught me that there are different kinds? Do you know what I mean?

R: You know, I’m not like a professional rapper or anything like that, but I’ve performed in my neighborhood before. It feels like that. Like, you think you have a good rhyme, but you never know for sure until you get on stage and the crowd is feelin’ it.

T: What gives you confidence that the rhyme you have created in our work together will deliver just the message you hoped it would?

R: I put my whole heart and soul into it. I didn’t leave one drop.

T: Do you think the people who are here with us next time will feel your heart and soul coming out through your lyrics?

R: (Pauses for 10 seconds or so) I really think so.

T: Do you remember when I first asked you about what would happen if you rapped for your grandmother or your probation officer?

R: Yeah, I said they wouldn’t hear it.

T: Are you saying that you feel differently about that now?

R: Yeah, I guess so.

T: What would you say has shifted?

R: These rhymes are me but just in lyrical form.

T: And you don't believe your grandmother or those who love and care about you would reject this gift that is a lyrical manifestation of you?

R: No, my grandmother always tells me that she’ll never run out of love for me.

T: Hey, something just struck me, Ray. Would it be okay if I share it with you?

R: For sure.

T: I wonder if you just discovered the Magic Beats?

R: What do you mean?

T: Do you believe that when you create a rhyme that fully represents you and comes from the deepest depths of your soul that even those who don’t prefer rap music could still hear it?

R: (A smile overwhelmed the now dwindling doubt on his face as he nodded affirmatively)

T: Ray! This is great! What an incredible discovery you have made!

Ray often tried to minimize any expressions of emotion, but even he smiled loudly at this development. In our excitement we almost instinctively exchanged daps (gesture similar to a handshake) with our right hands before giving one another a quick hug. With this we had established an unspoken agreement that we were ready for Ray’s performance and celebration next week.

A Celebration of Hope

Ray and I agreed to meet about a half an hour before everyone else to prepare the room for the celebration. As we moved tables and chairs and geared up the laptop computer everything was coming together. “Alright, I think we’ve got it,” I said looking in Ray’s direction. He then shook his head ‘no’ and looked upward to indicate to me to direct my gaze towards the ceiling. “What?” I said with a perplexed look.

He nodded upward once more. I stared skyward still trying to decipher what Ray was communicating. Then I realized that in my haste to make sure there were enough chairs for everyone I had forgotten to hang up the marquee. Like a dog with his tail between his legs I went back to my desk in the back room and removed from the top drawer the “Ray The Philosopher” marquee. I dashed back out to the main office and hung it up in its customary location. “Now we got it,” Ray asserted.

Soon, Ray’s grandmother, his sister, and a few other people from his neighborhood began making their way into the office. There was a sort of nervous excitement that filled the room. Lost in conversation, time had escaped me. I

reached into my pocket and pulled out my phone to take a quick look at the time. In doing so I noticed a message was waiting for me from Ray’s probation officer. Oh no, I thought to myself. He had left me a message stating that something had come up and he wasn’t going to be able to make it. Just as I was about to hold the phone to my ear to listen to it, he lumbered through the front door. “Sorry I’m late,” he said. “Did you get my message? I got caught up with a few things at the office.”

Relieved that everyone was now here, I looked at Ray to see if he was ready to go. Ray had asked that I start by saying a few words to give folks a sense of what today’s meeting was all about. After welcoming everyone and thanking them for attending, I began discussing a bit about Ray’s journey.

“During our two months together, Ray has reaffirmed how rap music can be an ally in helping him be the person he wants to be. He has composed a series of beats he would like to perform for you today. Ray suggested that

Anger and Powerlessness in the Era of COVID: Changing the Narrative

Posted on by Psychotherapy.net Team

Anger seems ubiquitous in our society, a pandemic, perhaps, if not an epidemic. Our clients come to us angry about a great many things, and have a right to be angry about many, if not most of them. Furthermore, while anger is usually thought of as a dangerous, uncomfortable, or even “negative” emotion, it can actually be very healthy—an emotion that alerts them to the fact that they might be in danger—that things are not okay. That a boundary has been crossed. That they are not safe or someone else isn’t. Anger can provide our clients with important information—that action needs to be taken to make things right or to create safety.

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That said, just like any emotion, while the initial feeling of anger might be justified, our clients’ understanding of the feeling, and the narrative that accompanies it, might not be. In other words, feelings are never wrong, but interpretations or narratives about them (and what to do about it) often are.

To give a simple and common example, a patient of mine, Jonathan, has struggled mightily with road rage. If he was driving and another driver made a dangerous move in front of him and nearly caused an accident—or even simply made a move he considered to be “inconsiderate” of him—he often felt a surge of adrenaline, experienced initially as fear and then as anger. Here his anger was telling him—in some cases rightfully—that the person made a dangerous choice that was not safe for him.

However, as we slowed down and analyzed his reactions and looked into the narratives he created around these incidents, we learned that there were layers of interpretations. The first was obvious and caused anger from feeling unsafe: that the other driver was being unsafe or not considering other drivers. But Jonathan was also creating a second narrative with that anger: he was interpreting the other driver’s behavior to mean that they didn’t care about him or, worse, that they were recklessly disregarding his safety on purpose. It is this second narrative that would cause him to become even angrier and lash out at the driver in some way that would lead to intimidation or unsafe behavior by him or both parties.

In our work together, Jonathan became able to suspend his second narrative and hold the possibility that it could have simply been that the person wasn’t paying as close attention as they should have at that moment—something that happens to almost all of us. Or that they were rushing to the hospital because of a medical emergency and paying less attention to safety in the interest of speed. Or perhaps something flew into their eye, and they were temporarily blinded. Or maybe even that people’s definition of consideration was different than his, and that was okay. In time, he was able to understand that he didn’t actually have the information that would allow him to attribute motive or intent to the other driver.

Allowing his anger to create that second narrative might have made him feel good or righteous at that moment, but ultimately it wasn’t based on fact and, more importantly, it frequently led to less safety rather than more. Most often, the reason he created that second level of the narrative was because of rage’s closest companion: powerlessness.

When hurt, our clients’ safety has typically been threatened, or a boundary has been crossed. It is not just anger that they feel, it is powerlessness. They feel out of control. Someone, or some group, has made a choice or choices that had an effect on them (or people they cared about, or the planet), and they hadn’t been consulted. The choice was made without them.

This points to an experience that is deeply uncomfortable and yet an undeniable fact of life: our clients don’t always get to choose how things go, even when it is painful for them. They come to recognize that to a degree, powerlessness is part of life.

This fact of the human experience is so difficult to accept. And it’s especially difficult to accept for clients who were traumatized as children—they were taught that powerlessness brings victimization and pain, so they feel terrified of being powerless again. This was certainly true in the case of Jonathan, who was severely abused as a child. Experiences of powerlessness would trigger that childhood trauma, and he would respond with rage and actions that instantly created a feeling—for a moment at least—that he could feel safe through feeling powerful, even if it was at the expense of the comfort of others (or ultimately even his and their safety).

But even among those who were treated well as children, our clients would all so much rather feel in control of their lives. Make no mistake—they should feel empowered to do all that they can and make the best of the life that they have. But the hard truth is that their power is limited. For some more than for others, but no amount of money or status will create immunity from powerlessness. If it rains when we are out for a walk, we will all get wet. Anyone could get cancer. Bullets won’t bounce off any of our flesh. If the global climate catastrophe in front of us continues, none of us will survive.

And so it is with COVID. Our clients feel deeply powerless when faced with the virus that is circulating the globe and wiping out millions of people in its wake. They come to understand, slowly in some cases, that they are all, to a greater or lesser extent, dependent on everyone else in order to create safety for themselves—in essence, as individuals they are powerless to stop it. This profound powerlessness is deeply uncomfortable and, along with the anger that naturally comes from feeling unsafe, many of our clients have coped with that by creating a second level of narrative to try to regain a sense of power.

Helen is an elderly patient in her late seventies whose husband of over fifty years had a kidney transplant several years ago due to a genetic disorder that caused kidney failure. Because of the transplant, he is on daily, lifetime immunosuppressants so his body doesn’t reject the kidney. Unfortunately, these immunosuppressants also make it impossible for his body to effectively fight off illness or respond to a vaccine in a way that would create immunity from COVID-19. Given his age and compromised immune system, he would in all likelihood die from COVID were he to contract it.

Helen and her husband are still full of energy, creative, and sharp of mind. They want to visit their children and grandchildren, travel, volunteer, and spend time with their friends. Instead, they are forced to be extra cautious and conservative in their actions and activities, reducing their world to one that is much smaller and less fulfilling than they would like. They feel trapped at home. When Helen reads on the news that people in her community are choosing not to get vaccinated because it’s their “right” or “COVID isn’t as bad as the hype” or “the government can’t tell them what to do,” she is deeply enraged. She talks bitterly about how they are “selfish” or “uneducated” and that perhaps dying from COVID as a result of their actions “is what they deserve.”

Helen is feeling enraged at the people who aren’t getting vaccinated or wearing masks. Some would argue justifiably so—their actions are denying her and her husband safety and dramatically affecting their lives. However, by attributing a lack of empathy, lack of intelligence, or malicious intent to those people, Helen is adding a second narrative to counteract her feelings of powerlessness about the situation.

Thus, whether our clients are calling the unvaccinated “stupid” or they are protesting mandatory vaccines or mask mandates, purchasing medicines not advised by the medical community, or grasping on to conspiracy ideology in order to feel more empowered by having “insider” information, these actions, amongst so many others, are ways in which Helen and others in similar or related circumstances are reacting to an experience of powerlessness and anger.

***

Anger and powerlessness are understandable under the circumstances described above in the cases of Jonathan and Helen, but their reactions, like most of those my clients experience, end up being destructive to self and others. As a therapist, I have found it useful to help my clients understand their feelings and then hold the discomfort of their powerlessness while letting the anger move through them. It has also been very helpful for me to guide them in avoiding the creation of secondary narratives, through which they attempt to grasp feelings of empowerment through frantic and unhealthy action that only serve to feed their rage. Instead, I encourage them to remain as safe as possible in this COVID era, while living with the uncomfortable feelings that powerlessness often brings.

Countering Client Hostility with Radical Candor

Posted on by Psychotherapy.net Team

“No offense, but I don't need self-awareness,” said Michelle. “That's not what I'm paying you for.” After a brief pause for emphasis, she proceeded. “I am not telling you how to do your job, but I need tools!” she demanded forcefully with a pen and notepad in her hand.

Michelle was self-referred after receiving multiple messages from friends and family that she was “difficult to deal with” and that she did not know how to “empathize” with others.

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Caught off guard, I sat silently and nodded. At that moment I felt powerless and ineffective. I also noticed my abdomen brace, as if preparing for a fight. I thought I had been doing well by actively listening to my client and helping her to feel understood. She had a gift for verbosity, which made it almost impossible for me to get a word in. By the end of the first session, however, I felt an impulse to refer her out. I even recall mentioning to her that I would find a list of providers who conducted strict CBT, as it appeared she would benefit from the structure. However, something in me then uttered out, “Let’s try my way first and if, after a few sessions you aren’t happy, I can provide you with some referrals.” I don’t know if I was slightly intrigued by the challenge or that I knew it would be difficult for Michelle to receive treatment elsewhere.

While Michelle’s intensity continued session after session, I began noticing patterns. The session would begin with some pleasantries, move seamlessly into an onslaught of reprobation, and then conclude with a slight glimmer of hope. I had never experienced anything like this.

She would admonish me for the session by saying that “it’s only me talking”—despite not allowing me to speak—and demanding that “in one of these sessions, I am going to need you to do most of the talking.” Further, she compared being in counseling to being in a “hospital” (the first time I had heard this reference).

“Don’t enact your rage on her,” said my own therapist, after I vented extensively about my exasperating and confusing sessions with Michelle. In my therapy, I would go on ad nauseum about how I wanted her to drop out of treatment. I even mentioned how I had dreams of Michelle being much larger than me and picking me up and repeatedly slamming me down. My therapist cleverly pointed out that being with Michelle felt like a rollercoaster ride (I am terrified of roller coasters). My therapist also helped me to realize that despite my criticism and Michelle’s seeming intractable intensity and displeasure with me and our work, she kept returning.

I persisted and became more optimistic over time as I noticed Michelle becoming easier to deal with, which I disclosed to her. She dismissed my praise by stating that I was lying and that the positive reinforcement was incentivized by the fact that she was paying me. I reminded her of how she had been telling me that her family noticed positive changes as well.

One of the strategies that seemed to be effective with Michelle—in addition to the basic attending skills—was my authenticity and self-disclosure. For instance, I disclosed the fact that working with her felt like entering a boxing match, and how I experienced her attitude as an attempt to push me away—even my dream about the rollercoaster.

With regard to payment, Michelle had mentioned the transactional nature of our relationship numerous times. For instance, she once accused me of using her to pay my phone bills. I wanted to be gentle but honest. “You think this is really about the money?”—pausing while Michelle nodded affirmatively—“I lose $700 per month by working with you, not including if you skip a session.” I noticed Michelle smiling. After inquiring about how she experienced my disclosure, Michelle mentioned that this was “good to hear” and inquired further about why I continued to see her at a reduced rate. This led me to mention that based on the way she initially presented herself, it would have been very difficult for her to find another therapist (she also had complained about struggling to find one in the past) and that it would cost her a lot more money for treatment that might not have been as effective (i.e., brief CBT as opposed to more ongoing relationship focused work).

***

Michelle still has moments that make it painful for me to work with her, but I do consider our work to be successful. She is recently much more likely to notice her maladaptive behavior in the moment. She often praises me for her progress, but I do not think I deserve it. I was simply the first person in her life whom she couldn’t push away. I was also honest about how her behavior affected me without discarding her.

I believe that we can do good work with most—if not all—clients if we are willing to travel with them despite their efforts to avoid meaningful connection. I also know that honesty is the best policy when it comes to engaging people who are resistant. Sitting with the discomfort that hostile clients like Michelle can stimulate and being the one person that stands by their side has often resulted in positive change for these clients—and for me.

Embracing Chronic Anger: A Prescription for Disempowerment

Posted on by Psychotherapy.net Team

“I’ve had a problem with anger all of my life… at work, in my relationships and everywhere in between. I was court referred because I assaulted a guy at a bar when I was drunk. That’s how I got this (pointing to the cast on his left wrist). I also took a class five years ago because I had slapped my wife. But she dropped the charges. In the past ten years, I’ve been married twice. I know my anger contributed to my divorces and I really don’t want to lose my current girlfriend.”

Anger Chose Him

Keith, a participant in one of my anger management classes, introduced himself in a deep, resonant voice. As an anger management specialist, I have offered these classes for over thirty years, with participants who have been self-referred as well as referred by their workplace, partners, friends and the courts. They have included individuals from various socio-economic levels, including professionals, blue-collar workers and students ranging in age from eighteen to seventy-five years old. Surprisingly, Keith became increasingly candid throughout the first session.

“You know, there are times I feel like maybe I was just born being angry. My father had a lot of anger too. So did his father. Maybe it’s just in my genes.” Keith described a life of chronic anger–anger that was frequent and pervasive, evidenced in his workplace, personal relationships and daily life. It entailed anger arousal not just as a situational reaction to a specific triggering event, but reflective of a general predisposition to hostility. Chronic anger encompasses “trait” versus “state” anger, which is more situational and short-lived. And like others who report issues with chronic anger, “Keith described his anger as if it chose him”, as if he was the victim of his anger and did not have free agency to choose it.

Keith, like others with chronic anger, views the world through a filter constricted by his anger. This filter inhibits self-reflection and access to more rational thought. And, like others with chronic anger, his narrowed vision, along with the rigidity of his reactions, saps his capacity to genuinely satisfy his desires and needs.

It appeared that disappointment in his life, coupled with an increased curiosity about his anger, enhanced his motivation for further exploration. The most recent arrest and being almost 40 years old also provided an impetus for his seeking help. As I later learned, he was also dealing with his father’s death two years before. Keith seemed increasingly committed to his desire to change, reflected in his active participation in the class as well as his request for individual therapy upon completing the course.

Keith, like others who exhibit chronic anger, appeared to embrace it as a core aspect of his identity. Chronic anger became a major aspect of his inner sense of sameness and continuity over time.

A Word on Identity

Consciously cultivating our identity requires that we answer the following questions:
“Who am I?” “What is my purpose?” “What kind of individual do I wish to be?” “What gives me meaning?”

Many of us fail to ask these questions of ourselves. Absent such reflection, we may subsequently become subject to a “script”, one that is defined for us by others. This script becomes the blueprint for the structure of our lives. It provides the guidelines for how we live, informing habits in how to think, feel and behave. And each time we practice these habits, we reinforce the connections in our neuronal pathways in ways that only increase our propensity for them. For this reason, it may require some life-altering event to prompt us to more fully examine what we are doing.

The self-reflection required to address these questions pits us against our fears, our sense of self-worth, and our difficulties in making decisions and choices and committing ourselves to them. Such reflection also moves us to address barriers we create regarding the opinions of others—those voiced by others as well as those we hear from the imaginary audience in our minds. It is then understandable that we may seek distraction from engaging in this daunting task–through our work, the immediate demands of our daily lives, our relationships and even our addictions. Embracing chronic anger as a major component of our identity may yet be another form of bypassing this intensely difficult challenge.

Chronic Anger

Anger, a natural emotion, stems from a perceived threat to our physical or mental well-being. Additionally, it’s a reaction to and distraction from uncomfortable negative feelings that precede it–feelings such as shame, guilt, rejection, powerlessness, inadequacy or devaluation. I’ve come to view anger, like other symptoms we may encounter, as originating from an initial impulse of self-compassion–an attempt to alleviate our suffering. Such anger hijacks our attention away from our our internal landscape and in effect offers us a temporary reprieve from enduring the intense suffering caused by these more uncomfortable feelings.

When managed in a healthy manner, we’re able to pause to take the time that is essential for understanding our anger–whether regarding our feelings behind it, our expectations or our key desires and needs. Anger can empower us to seek constructive ways to satisfy our desires and needs. It can fuel healthy assertiveness that moves us to act in ways consistent with who we are and who we wish to become.

By contrast, destructive anger moves us further away from satisfying our core desires and needs. It can lead to poor work performance, a stalled career, relational conflict, social isolation, depression, excessive guilt or shame and even the loss of one’s freedom. Additionally, extensive research shows that anger can contribute to illnesses like heart disease, high blood pressure and even back pain.

Chronic anger is one form of destructive anger. For some of us, such anger serves as psychological armor, intended to protect us from the sting of our inner pain. Such anger can be viewed as a form of “experiential avoidance,” as described by Stephen Hayes, and involves the suppression, minimization and denial of our feelings.

It is against the lack of a solid identity that individuals with chronic anger may be characterized as embodying a “negative identity,” described by Erik Erikson as an identity in opposition to what is expected of them. Lacking self-awareness and the self-reflection essential for such awareness, their default is to react. They may gravitate toward this resolution when they believe the roles their parents and society expect them to fulfill are unattainable. The psychological underpinning of this stance is reflected in the attitude “I don’t know whom I wish to be, but I certainly don’t want to be like you.”

Unfortunately for Keith and others, embracing chronic anger was a formula for disempowerment that only strengthened the tendency for anger arousal. And for Keith, like others with chronic anger, it appeared to be an outgrowth of aspects very much consistent with a negative identity.

Chronic anger has many forms. It’s reflected by the quickness to experience anger in daily life, in one’s relationships and especially with authority. Chronic anger appears in the numerous comments on the Internet, statements of opinion that are predominantly expressions of anger rather than rational argument. Such anger impairs the capacity to be civil, open, understanding or compassionate with others and ourselves. “It is a cataract that clouds our vision to the possibilities of looking for and noticing the positive in others and in ourselves”.

Chronic anger promotes disempowerment, which only furthers the propensity for anger. It undermines taking responsibility for our own lives. In doing so, it constricts the range of possibilities and minimizes the freedom for personal evolution and life fulfillment. It’s so much easier to blame others or circumstances for a difficult or painful situation and by doing so, renounce all our power to help alter our situation. In the process, however, we only further bolster our sense of victimhood. Even when others have truly contributed to our pain, embracing chronic anger may serve to protect us from the hard work of identifying and choosing alternative courses of action.

It then makes sense that individuals with chronic anger may resort to drug or alcohol use, or blame or hate others for their own misery. Certainly, such anger might foster or be a symptom of depression, especially when it is self-directed.

Furthermore, this vicious cycle of chronic anger and disempowerment fuels pessimism that inherently diminishes the capacity to envision a future without anger–a future that holds greater happiness, meaning and fulfillment. And, further, it undermines the capacity to develop an identity marked by greater individuation and resilience.

Like so many symptoms we observe in our clinical work, chronic anger is most often rooted in wounds–deeply felt hurt and trauma that have not been fully acknowledged. It is often a reaction to emotional or physical abuse, neglect, or loss. And while some studies suggest a genetic influence, as with much of personality, nurture helps determine whether these genetic predispositions are expressed. And while such anger may also originate with experiences in adulthood, being prone to chronic anger further strengthens it as a go-to reaction.

All too often, childhood trauma forms the underpinning of chronic anger. It may lead to a global sense of shame and accompanying feelings of inadequacy about oneself. This sense of shame is often the overriding and paralyzing feeling that creates a block to trusting one’s own thoughts, feelings or actions. These feelings then further weaken the capacity to engage in thoughts and behavior that would be essential for a more authentic choice in creating and living one’s identity.

The Case of Keith

Keith shared a history of physical abuse, occasionally being slapped or paddled by his father for his “bad” behavior. Like others with issues surrounding anger, he tended to minimize and deny the impact of these earlier experiences. And in doing so, he cut himself off from the range of feelings that surround such abuse. Unfortunately, a child in pain needs compassion and empathy from a caring parent but is unable to obtain it when a parent is the cause of that pain.

Keith learned to ignore his suffering by blaming himself for how he was treated. He experienced shame regarding his behavior but, more importantly, and without awareness, he experienced tremendous shame regarding the slightest surfacing of anger toward his father. As such, Keith, like others with early wounds, could describe the circumstances of early wounds as a matter of fact, but was unable to regard them as wounds–let alone be more fully in touch with the underlying emotions associated with them. “It didn’t hurt that much.” “I think I deserved it.” “That was how most parents disciplined their kids.” “I certainly wouldn’t call it abuse.”

Like others who have experienced such abuse and like many with chronic anger, these are just a few of the ways that Keith protected himself from experiencing his hurt and anger. This fear of experiencing anger with his father simply continued into his adulthood. Consequently, Keith had little awareness of how his earlier interactions and related wounds influenced his anger. “My father was a marine. He was always intensely demanding and perfectionistic. He constantly interrogated me, questioning me to justify myself, why I thought this or why I did that. He had little patience for pain or for a difference of opinion.”

Keith also revealed that if anything, he was angry with himself for not measuring up. This conclusion further informed his sense of shame and inadequacy. It’s important to note that, for Keith and others like him, chronic anger served as a powerful distraction from anger that was originally self-directed. While his father was perfectionistic and highly critical, his mother was distant and not available to help protect him or validate his pain. “She was quite anxious, quiet in general, and maybe depressed, I’m not sure. I know she was fearful of my dad. She always avoided conflicts and disappeared when they arose.”

Keith’s reported that his mother was closer with his younger sister who was rarely the target of his father’s anger. His ambivalent feelings toward his mother would only later become more apparent. His parents were divorced when he was in middle school and his father remarried within a year. Only then did Keith experience some relief, as his father became preoccupied with his new wife and stepchildren.

Keith reported that during this time, he experienced a growing distance from his parents and a sense of disorientation regarding his future. He described himself as kind of “floating” throughout high school. His tendency to be angry with teachers competed with any academic interest and, subsequently, his motivation to do well in school. Lacking a more solid connection with himself, he was unable to emotionally invest either academically or in his relationships.

“Like others with chronic anger, Keith was especially sensitive to criticism in many situations”, especially those involving authority. Clearly, his early interactions left him with an increased sensitivity for perceiving threat. As he candidly admitted, his tendency toward conflicts with authority undermined his ability to succeed in school and work and his capacity to maintain friendships. “I really wasn’t motivated in school and only did the minimum to get by. I spent most of my time playing video games, hanging out with friends, and I smoked marijuana often, beginning in my freshman year.”

Keith went to college for two years, primarily because he had no idea what he wanted to do, and his father had promised to pay the tuition for the first two years. His motivation and focus hadn’t changed during this time. While he occasionally dated, his quickness to have conflicts interfered with his developing any ongoing relationships. Unlike Keith, there are certainly individuals with chronic anger who are motivated to achieve, both academically and in their pursuit of a career. For some, the full impact of their anger may not surface until they are more involved in relationships, whether personal or work related.

Keith quit school after two years and his father suggested that he join him in a property management business, but Keith knew he could never work with him. Instead, he became a realtor, primarily motivated by his belief that he could make easy money with minimal effort. Within a year, he realized that he had little patience for dealing with the clients. After that he held a variety of jobs. He gravitated toward working with computers and by the time he enlisted in my anger management class, he had been working for several years in IT.

Keith also indicated a growing anger in recent years regarding the government. He complained a great deal, even commented on the Internet, but never demonstrated his anger in more aggressive ways. He didn’t consider himself an activist but he found himself also spending a good amount of time online, following the angry chatter of various groups.

Facing the Demon

Keith represents a small fraction of men with chronic anger who ultimately seek help for their anger. I view the courageous decision to seek therapy, although prompted by pain, as stemming from self-compassion–a desire to alleviate one’s pain. And while Keith had learned to renounce his need for such compassion, he sought help when he more fully recognized how anger contributed to his suffering.

Keith had grown to view the need for compassion as reflecting weakness and as threatening to his masculinity. He had learned to believe that being a “real” man involved cultivating an identity devoid of needing such compassion. However, ignoring his need for compassion further undermined his capacity to be more fully present with his feelings, in general, as well as with his underlying desires.

When we are truly compassionate and connected with ourselves, we know how we feel, recognize our key desires, and feel anchored in an identity that provides stability with flexibility to be open to both our thoughts and feelings. By contrast, the lack of such compassion and self-reflection can make us vulnerable to self-doubt. Keith’s lack of access to his feelings reduced his capacity to notice or be compassionate to the pain reported by his partners. This is very much consistent with individuals with chronic anger and was reflected in Keith’s description of a recent anger episode with his girlfriend.

“She’s always criticizing me. She’s always telling me that I don’t care for her–like I can’t do anything right. The other day she described a conflict she had with her supervisor. After listening, I told her that maybe her supervisor was right. I mean–based on what she told me–I could see his point of view.” It became evident that Keith was more concerned with facts than with feelings. His focus on facts competed with his capacity to be empathic with his girlfriend. Understandably, validating the supervisor’s criticism was experienced by his girlfriend as a demonstration of his empathy–with the supervisor. The argument escalated with Keith cursing and demeaning her. It ended by his leaving the house for a few hours, an evening of silence upon his return and then, the next day, gradually resuming their relationship as usual.

Consistent with his experiences in past relationships, if he couldn’t “fix” his partners’ problems, he would soon experience an overwhelming feeling of inadequacy. In effect, in his personal interactions, Keith re-experienced the feelings of inadequacy as well as his self-doubts triggered in his earlier interactions with his father. Additionally, he carried into his relationship the anger he had also experienced toward his mother for her lack of availability.

“The tendency to be vulnerable and to feel controlled is part of the fallout of not living a life grounded in self-connection”. A more mature identity allows us to hear opinions that stand in opposition to our own, living a life based on an identity of anger leads to hypervigilance to protect ourselves from self-doubt and feeling influenced by others. Others’ opinions may be experienced as threatening and viewed as overbearing and controlling. It is then no surprise that individuals with chronic anger feel isolated. And it is equally understandable how such anger promotes distrust that only strengthens the avoidance of genuine intimacy.

Keith had embraced this perspective for much of his life. The more he reacted to others in this manner, the more he cultivated his sense of victimhood and, in turn, had become more prone to anger arousal. His flight from responsibility was similarly reflected in our work together, most poignantly in his initial hesitation to actually practice the skills essential for cultivating healthy anger.

Part of my approach is to have clients complete an anger log, a structured journal that helps them review an anger-provoking episode and their thoughts and feelings related to such events. The log specifically asks them to identify feelings that immediately precede their anger, the knee-jerk conclusions they make about the event, expectations they may have held before the event occurred, body sensations and key desires that feel threatened by the event.

I advocate completing the log to review as many events as possible. Doing so promotes emotional intelligence not only regarding the reviewed event, but also fosters increased mindfulness to reactions for future events. Furthermore, completing the form helps to foster emotional awareness of one’s unique “hot buttons”–personal sensitivities regarding specific desires and the past experiences that intensify their current reactions. And, as always, “I emphasize that overly intense anger most often is a residual reaction to events of early wounds”. This is poignantly highlighted when I help them recognize that “It’s happening again!” is just one of their immediate responses to a triggering event. “At that distinct moment, it is as if your emotional brain is recalling all past hurts that are in any way similar to what you are currently experiencing. This is the power of global thinking and feeling.”

I emphasized with Keith that our global emotional mind has nothing to do with our age, intelligence or even our more rational thought. It is a part of us that, without our awareness, may override our rational mind as it impacts our thinking and behavior. Completing the log serves to offer psychological distance to the experience and fosters the cultivation of the “observing self” or “witness.” This strengthens one’s ability to not feel overwhelmed by such thoughts and feelings.

Keith repeatedly did not accept this recommendation. I suggested that it would be beneficial to understand what interfered with his completing the logs. I asked if he experienced my suggested assignments as controlling. His knee-jerk response was to deny this but after a pause he then admitted, “Maybe a little.” I then responded, “That makes perfect sense–to your emotional mind. You grew up with tremendous anxiety about expressing yourself. Understandably, you experienced safety by trying to avoid conflict with your father. Your inhibitions in expressing yourself contributed to feeling controlled.”

During the following session, I asked Keith if he was open to doing an exercise. He agreed. I then handed him a blank anger log. “Make yourself physically comfortable. Look at the anger log. Imagine that you are seated where you might be completing the form. Hold the pencil to the paper without writing anything. Now, think of an event that you would review if you were to complete the log. Do that for a few moments. Now, shift your attention from the event to what you are experiencing regarding writing it. What physical sensations are you experiencing? Are you feeling calm or tense? What are your thoughts about this task?”

Keith paused for a moment to reflect. With little hesitation, he answered, “Yeah. I guess I’m angry that I have to practice these skills while others don’t have to…others had it easier. They most likely didn’t go through what I went through.” I fully acknowledged and validated this belief that, yes, others may have had it easier in so many ways. And, yes, they may not have to do these exercises to better manage their anger. And, yes, engaging in this work arouses uncomfortable feeling regarding previous wounds and hurts. I then emphasized that he could choose to stay resentful and hold on to his anger or he could take steps to change, with the potential of having a more fulfilling life. Additionally, I highlighted to him that how we manage anger involves habits in our thoughts, feelings and behaviors–habits which he can change, but only with patience, commitment and practice.

Keith’s recognition of irritation with this task presented another opportunity to discuss mourning and grieving for what he didn’t have and felt he should have had. Much of anger is about this discrepancy. As part of such mourning, I encourage clients to find a picture of themselves at an earlier age. Over time, when they are ready, I help them recall the earlier suffering of that younger self. I help them work toward being able to fully express themselves as that younger version and say things like, “It made perfect sense that you suffered, were confused and even angry with your parents,” “How you were treated was not your fault” and “I’m sorry I could not help you.”

Such mourning and grieving is an ongoing process that in many ways never ends. Rather the rawness of such experiences just becomes more emotionally muted. Through our work together, “Keith increasingly began to develop a deeper connection with himself, his feelings and his thoughts”. He became more alert to his tendency toward anger and increasingly recognized it as a signal to direct his attention to self-reflection rather than act it out. He reported one incident, having to do with a homeless person that very much reflects this growth.

“You know that homeless guy who is always on the corner. I’ve always been annoyed when I walk by him. In the past, I’d usually tell myself that he was just lazy and that he should get a job. I started to think about that. I think that I was just feeling inadequate about not being able to fix him or others like him. I also reacted to feeling he was needy, a feeling I’ve always felt uncomfortable acknowledging in myself. There’s a lot in there!”

Keith continued with therapy and gained a variety of strategies to better understand and manage his anger. He expanded his compassionate self sufficiently to recognize and admit some of the hurt he had experienced that contributed to his shame and related anger.

As often happens when treating chronic anger, improving his ability to more constructively manage his anger reduced his motivation to more poignantly mourn and grieve his childhood. However, processing the loss of his father led him to attend to his earlier years. He became increasingly able to tolerate mixed and ambivalent feelings, essential for dealing with his complex relationship with his father.

Keith demonstrated progress in that he reacted with anger less frequently and it was shorter in duration when it did occur. At one point, Keith reported that he was pleased with his improvement and that he needed to take a break. Additionally, he was also able to recognize that spending more time on grieving and mourning had been very difficult for him.

Keith returned a year later, prompted in part by an anger-arousing episode that had surprised him. While he had continued to make progress, the event had pushed hard on one of his hot buttons. It was a reminder that learning new habits requires commitment, practice and patience.

Anger in Our Culture

It’s difficult to discuss chronic anger within the therapy session and ignore the larger expressions of chronic anger that we are witnessing in society. As previously indicated, we see evidence of such anger in statements made on the Internet, supported by anonymity and increased cultural support to “tell it like it is.” We see it on newscasts revealed by the “talking heads,” each predominantly focused on getting their points across rather than having a real discussion. Clearly, the media reflects our culture, but, unfortunately, it may only further influence those who already are defined by their chronic anger–just as violent videos have been shown to have an impact primarily with adolescents who are already prone to anger.

Additionally, we see increased evidence of anger as identity as the foundational core of the hatred of the “other”, those who may be different than us–whether regarding race, religion, ethnicity, gender or sexual orientation. A moment of intense anger brings with it a tendency to demonize the other. However, when chronic, it can lead to more fully dehumanizing them as well.

Furthermore, chronic anger may foster the belief that one’s happiness can’t be achieved because of one’s very existence. It is this rigidity of identity that gives far too much power to others and distracts those with such anger from the work required to explore and identify choices that can help them to feel and become more empowered. And far more serious for all of us, are individuals who associate with others with the same tendencies or, even on their own, promote activities to teach others a “lesson.” These facts only highlight the challenge we face as clinicians dealing with chronic anger.

Holding on to anger is often rooted in the need to protect ourselves from being hurt again as well as re-experiencing our past suffering. This is especially the case when this mindset becomes the foundation for one’s identity. So, while anger management strategies that focus primarily on behaviors and current knee-jerk thoughts can be effective, moving past chronic anger as one’s identity requires going deeper. It calls for helping individuals recognize and sit with the pain of grieving and mourning their past wounds. It requires that they become a witness to the suffering of their younger selves if they are to be able to live more fully and with greater emotional access in the present.

Dealing with chronic anger, as when dealing with so much of our client’s suffering, involves our sensitivity to dosage–sensitivity to the protective nature of symptoms, the degree to which they have become a part of a client’s identity and, of course, to their openness to change. For this reason, many individuals with chronic anger will never seek our services. Consequently, clinicians who address chronic anger may need to play a more active role as advocates for education and understanding of chronic anger in the courts, correctional facilities, substance abuse programs and schools.

One of my personal challenges as a therapist working with individuals with chronic anger is to “always be alert to look beyond the anger to the pain that it masks”. So, at any given moment within a session, I need to be mindful to be empathic with my client even when I find myself also focused on the pain they may cause for others. Such moments require my own comfort with anger and remembering the powerfully cohesive force that chronic anger may have in helping them to maintain their identity.     

Howard Kassinove on Anger Management

Posted on by Psychotherapy.net Team

“I can see your bald head”

Christian Conte: Dr. Howard Kassinove, how did anger management became a central focus for you?
Howard Kassinove: When I went to graduate school, the central focus seemed to be anxiety, and the physiological or biophysical aspects of emotion. So we studied heart rate, sweating, pupillary response to light—but all with regard to anxiety. I then went out to study with Joseph Wolpe and of course his major area was anxiety. But he really put me in touch with this notion of approach versus avoidance behaviors—moving towards, moving against, or moving away from. I was also trained by Albert Ellis and he was very interested in emotionality in general.
But with that background, once I went into private practice what I discovered was that lots of my patients were angry at each other. Husbands angry at wives, parents angry at children, adolescents angry at their parents, and I had been ill trained. I really didn’t know much about it, because anxiety was the major focus of my training. So I began to study and read and my practice moved along. But then in about 1992, I really decided I had to get some kind of a handle on this. So with my then Ph.D. graduate student Christopher Eckhardt, now a professor at Purdue, he and I just started cold calling people in the field of anger: Charlie Spielberger, Jerry Deffenbacher and a range of figures. We put together an edited book, which included all aspects of anger from Spielberger’s measurement to Sergei Tsytsarev and Junko Tanaka-Matsumi’s cross-cultural perspective, and this was the beginning of me becoming centrally involved.
Then I started doing more cross-cultural research—in India, Russia, Romania and many other countries. We collected data on anger in all these other countries and I did a number of doctoral dissertations on anger. One of the most important was with my colleague Chip Tafrate, who of course is doing books with me and did the video released this month by psychotherapy.net. He did a very interesting study in which we would try to insult people—“I can see your bald head!”—and Chip would ask people to respond in different ways. One was, “How could you say that to me? That’s terrible. I can’t stand it!” And the other was, “It’s unpleasant that you’re saying that. I wish you weren’t saying it, but I can tolerate it.”
CC: The old Albert Ellis stuff.
HK: Albert Ellis, exactly. We even had a controlled condition where I would kind of insult you like that, and you would say things like, “A stitch in time saves nine.” What we found was that both the Ellis rational ideas and the distracting statements led to anger reduction.
CC: So for you it centers on cognitive behavioral techniques—on changing the thoughts around and having people learn different forms of self-talk.
HK: Yes, but my original training was at Adelphi University, which is a very psychodynamic place. One of my great heroes always was Karen Horney, because she spoke about the tyranny of the shoulds well before Ellis did. She spoke about moving against, moving away from, and moving towards people. So I also have that background.

What Exactly is Anger Management?

CC: Obviously anger has been around as long as there were human beings, but in the news over the last several years it seems like anger management in particular is getting more attention than it has in the past. From your perspective, what exactly constitutes anger management?
HK: Let’s go back to the beginning of modern anger management—Ray Novaco’s 1975 book, Anger Control. Prior to that we were not really dealing much with anger management. Ray came on the scene and became a major figure, but the word “control” has kind of disappeared and now we talk about “anger management.”
I think of it as developing less intense disruptive responses to aversive stimuli. The fact is that we live in a world where there are lots of aversive stimuli:
People take our parking spots, students tell us we’re lousy teachers, our wives and husbands tell us that we didn’t mow the lawn correctly. We are kind of bombarded with this aversive stimulation environment. Lots of good things occur in the environment, of course, but the bombardment with the aversive stuff leads us either to be angry—”How dare you say that to me?! You know you don’t have any right! You should treat me with more respect!”—and it can also lead to anxiety, when we’re being threatened by someone in authority or someone with a knife or gun.
CC: Sure.
HK: So I think that anger management in a broader sense is emotion management or emotion regulation. I try to live my life in the most mellow way possible. Most of the time these days I succeed. But it’s not only anger or annoyance I want to bring under control; I also want to bring anxiety under control. This is where Rational Emotive Behavior Therapy (REBT) has played such a central focus in my own life. Lots of abrasive events occur in life that are overwhelmingly unpleasant. These days I try and leave them there—whether it’s difficulties with my own children or difficulties with my students or my car or whatever. So in the broader sense, it’s emotion management.
CC: That’s exactly the word I use: emotional management. You’ve developed what you call the “anger episode model.” Can you talk a little bit about the evolution of that?
HK: As the years were going by, I found myself becoming kind of disgusted with the notion that kids are lazy, people are stupid—this kind of broad overarching condemnation of people. Instead, because I became more and more of a behaviorist as time went along, I wanted to speak about how people behave in particular situations. You might become angry at your wife, let’s say, when she does something wrong, and you might yell at her and maybe even demean her verbally in some way. But I bet you wouldn’t do that if you were at a state dinner with President Obama, because in that environment you’re going to behave very differently.
So I found myself moving away from the notion of “he’s an angry person,” “she’s such an angry woman,” to the idea of—how can we deal with individual situations? We started to develop the notion that people have “anger episodes” and that led to the anger episode model. The more episodes we can help them bring under control, the more likely it is they will become more generally controlled.
It’s kind of like an incremental model. I don’t think we can really change broad-spectrum personality. If I define personality as the cross-situational stability of behavior, then what I’m trying to do is change behaviors in a number of situations with the hope that eventually through generalization people become less angry.
CC: That’s fantastic.
HK: We needed a very specific and relatively simple model that we could teach to our patients.

Triggers

CC: I really identify with what you’re saying. You put people in different situations, they respond in different ways. I say to people all the time, “If I gave you a million dollars, would you respond in the same way?” They say, “Well, I don’t know if I’d be that angry if somebody cut me off in traffic if I knew I was getting a million dollars.” So we really get at the heart of those thoughts.
You talk about triggers, and I wondered does it always, from your perspective, take an outside trigger to set someone off into an anger episode?
HK: I wouldn’t necessarily say it takes an outside trigger. Something has to initiate the sequence, but it can be an inside trigger. It can be a memory of what you did to me yesterday, how you treated me as a colleague or as a student or as a professor yesterday. I remember when you gave me the mid-term examination and you were unfair then. I’m quite sure you’re going to be unfair now. That’s an inside memory. But most of the time, I still see anger as a social, interpersonal process.
Most of the time, I’m going to become angry at a person or a group of people because of something that I perceive they did wrong. Let’s face it—I’m looking around in your office right now; I bet you don’t get angry at your bookcase.
You don’t get angry at your doorknob. You don’t get angry at your carpet. But you might get angry at your wife or your children or something like that. It’s always the social, interpersonal process. But it could be what the kids are doing today, or it could be you’re lying in bed and remembering what they did yesterday.
CC: That’s so powerful. I’ve specialized in working with people convicted of violent crimes and people are always really fascinated by the intense experiences I’ve had. I wonder if you could recall for us memorable and intense situation you encountered throughout your years in anger management.
HK: That’s an interesting question. I run an anger management program at Hofstra, and it’s housed in a generic building that has little children who are learning how to read, people who are having marital problems, and kids who are there all day as part of a child care center. So we’re always worried—is there going to be an intense anger problem? I’m always worried about my students, who are upstairs behind closed doors with anger patients, many of whom come from the probation department, and they’ve been convicted of anything from pushing and shoving to murder. They have histories. I’m always concerned. But I have to tell you that in the last nine years, we have had zero intense anger problems.
CC: Many new therapists are intimidated whenever it comes to working with angry patients. They’re scared of dealing with angry people, so I have my own approach to orienting them to the work. What’s something that you teach new therapists to do if they find themselves intimidated by the anger of their clients?
HK: Well, look at how I approached you, Christian, before we started this interview. I even made fun of your bald head.
CC: Yes, you did.
HK: Right? This is really important. The interpersonal therapeutic relationship, for me, is critical. You have to know how to not make every interaction into the most serious problem in the world. Most people, I find, are willing to kid around with me. They’re willing to take my barbs, my probes, my jabs, and that’s really what I say to students. Let your clients know that you’re in their corner. You know, “I understand you have been sent by your wife, sent by your husband, sent by the judge, from the probation department, and I’m going to be as respectful of you as I can, but I’m also going to jab you a little bit.” Then I ask, “Christian, would it be okay if I jabbed you a little bit? Can we play together like that?”
I think the only way people really get better is if we engage in reinforced practice in the office. So if I’m going to consider you as my patient for a moment, I might say things like, “Well, Christian, we’ve learned a bit about your life. You’re married and you have two children, and I know that you’re having troubles with your wife, who sometimes calls you lazy. Would it be okay if I called you lazy?”

The Comeback

HK: I’d talk to you a bit about that, and then I’d say, “Well let’s start off with some deep muscle relaxation.” I would make sure that you and I are on the same page, but then I would think about some kind of a hierarchy of insults. I’d start off with, “Well, Christian, take a deep breath. Just let your body relax. Consider what a nice day it is. I can see the sunshine behind you there. It’s really a nice day. Are you ready?”
CC: Yes.
HK: Here it comes. “You know, Christian, you seem very immature today. Take a deep breath in, and out.” So that was very mild.
CC: Very, yes.
HK: As the weeks go along, it’s going to escalate to, “Christian, you’re damned immature. Do you know that?” Then I’m going to go up to, “Christian, what the hell is wrong with you? How could a man of your age be so goddamned immature?”
CC: That’s awesome.
HK: And we’ll do two things. One, I’m going teach you to engage in those cognitive coping responses. So for example, say it to me.
CC: All right. Howard, you seem awfully immature.
HK: I understand what you’re saying. Thanks for sharing it with me.
CC: So you’re kind of putting me off there. That’s a sure sign of immaturity. You seem really immature.
HK: You have a real firm impression. It’s unpleasant to hear it, but I do want to thank you for sharing with me. It shows we have an honest relationship. Thank you.
CC: That’s great. That was a good comeback.
HK: What I’m trying to do is teach the patient a way of responding that, first of all, does not inflame, because—actually come at me again.
CC: Howard, you seem awfully immature.
HK: What about you? I mean, look at that shirt that you’re wearing. It’s like something I would wear around the supermarket or something, and here we are being interviewed! There’s that come back. Or, I could teach you another comeback—try it again.
CC: Boy, Howard, you really are immature.
HK: Yes, Christian. I bought a new hard drive for my computer yesterday.
You don’t know what to do with that, right?
CC: No, that totally threw me off.
HK: In my therapy, I try to, first of all, focus in on in your particular family or life, what are the adverse verbalizations that you might be receiving? That’s what I want to hone in on. I try to teach you either to relax deeply and not respond, to say something that’s really totally silly like, “I got a new hard drive,” to thank you for being honest, to say, “It’s unpleasant. I don’t like to hear it, but I can tolerate it.” So I’m teaching a variety of responses, you know?
CC: That’s great. It’s fantastic. I love the immediacy of the role-play right there in the moment.
HK: It works pretty well. Not all the time, obviously. I’m so interested about your work in the criminal justice system. Some of those people are kind of tough cookies.
CC: Yeah. Some of them are tough to crack, but overall, even though we’ve never met before this interview, there are so many things that you’re saying that I’m putting into practice. It’s so fun to be even in a role-play on the other end of that for even just a moment. It’s just great.
Tell me about your co-author. How did you get involved with Raymond Chip Tafrate?
HK: That’s kind of a funny story. Chip was originally my PhD student, and he was just going to become a practitioner and open up a mental health center. But then when he and I did this dissertation together on anger, we started to form this close bond. He went on to become a professor in a criminology and criminal justice department in Connecticut. We just bonded. He’s a wonderful man. If there is one thing I’ve learned—I’m sure you’ve been a professor also—there are just lots of things I don’t think about. We are both experts in the field, but you and I can really learn from each other.
And I thought I could learn from Chip. He’s thoughtful. He’s grounded. He comes out of a literature base now in criminology, that’s a little bit different from mine. Even though I taught him originally about REBT or relaxation training, he also studied with Ellis and he taught me about motivational interviewing. He really turned me on to that. So it’s just been a synergistic relationship.
CC: Well the book you wrote together, Anger Management: The Complete Treatment Guidebook for Practitioners, is extremely well done.
What’s something that you know now that you wish you could go back and tell yourself as a new therapist?
HK: I think I’d tell myself to be happy with small gains. If I can just teach that person not to rebel when the boss says, “I’d like you to stay an extra two hours tonight,” and not to flip off the boss, I’m happy with that these days.
CC: I think that’s so deep for people to get and really understand. Those little things, when people have been thinking one way their entire lives and all of a sudden now they can go that extra two hours and look at it differently, I think that’s big. I think learning to appreciate that is really big.
HK: I’m kind of unhappy when I go to some of the professional meetings these days. I hear about one-session or three-session or five-session treatments for Disorder X. I think we have a lifetime of learning. We have all kinds of reinforcements and punishments and incentives that are with us all day long. You really need time, and that’s something I didn’t understand as a young person.
Many times the judges here will mandate people to come see us for twelve sessions, twenty-four sessions. It’s not enough.

CC: I totally agree.

HK: I have a cousin who is a family court judge in California, and she says she recommends people for fifty-two sessions. I said, “I’m praying for that.”
CC: I just moved back to Pittsburgh, Pennsylvania, a year-and-a-half ago, but I was a professor at the University of Nevada before that. I co-founded a center for violent offenders in South Lake Tahoe, California. So in California, if they commit a violent crime, they are sentenced to fifty-two weeks of anger management. That’s standard. But in Nevada, just on the other side of state line, if they get in trouble there they were only sentenced to twenty-six weeks. I found in my own research that people did not make the kind of changes in twenty-six weeks, not even close, to the ones who were sentenced to fifty-two weeks. So I am a big proponent of a long treatment. Here in Pennsylvania, I’ve have judges say, “If they need a session or two.” A session or two to change a lifetime of anger? That’s just funny.
HK: Sometimes we ask patients, “How much anger management did the judge tell you you need?” “Today, just today.”
CC: “I just need to come to this one class.”
HK: If there’s anything I’ve also learned it’s that change comes about not from a class, not from education, but from practice. I teach my students practice makes better. We have to get these people into our offices and practice better behaviors with them. I even had one case, one of my students, where we started to transition from kind of barbing him and insulting in the office and frustrating him in the office, to out in the real world. So this patient happened to have worked as a shoe salesman, and what my student did is he went to the shoe store and without the patient seeing, pushed over a whole batch of shoes. This guy used to respond with great anger, but we wanted to see if we had done anything. Indeed, he responded very well. So I think practice makes better, starting in the office, going to the natural environment. That’s one thing I’ve learned that I really didn’t fully understand as a beginning therapist.
CC: I wholeheartedly and really sincerely appreciate this interview and this time with you because it’s tremendous to listen and hear and say I agree. I mean, two people practicing in totally different parts of the country and our experiences sound so similar. To me, that’s grounded in truth. There’s an essence to that change that obviously is just there regardless of words.
HK: Thank you.

Through the Anger Looking Glass

Posted on by Psychotherapy.net Team

On this past Sunday’s broadcast of “Weekend Edition” on National Public Radio, the focus was on the 50th anniversary of Betty Freidan’s The Feminine Mystique. In this book Friedan raged against the status of women in the 1960s. Although millions of people have read this feminist manifesto, it seems very few presently understand how anger in general and Friedan’s anger in particular could be a source of insight, motivation, and personal and social transformation.

Anger is an emotional state that has a bad rap. There’s far more written about anger control than about how anger, when nurtured and examined, can transform. As most mental health professionals already know, anger is an emotion, not a behavior. And emotions are acceptable and desirable. When anger fuels aggressive or destructive behavior is when it becomes problematic.

But since everyone knows about and talks about the destructive capability of anger—let’s talk about the constructive side of this emotion instead. Hardly anyone articulates anger’s positive qualities as clearly as the feminists. Feminist therapists consider “encouraging anger expression” as a meaningful process goal in psychotherapy for at least five reasons:

  1. Girls and women are typically discouraged from expressing anger directly. Experiencing and expressing anger without repressive cultural consequences can be an exhilarating freedom for females. Similarly, experiencing anger, but not letting it become aggression is a new and productive process for males.
  2. Anger illuminates. There’s nothing quite like the rush of anger as a signal that something is not quite right. Examined anger can stimulate insight.
  3. Alfred Adler suggested that the purpose of insight in psychotherapy was to enhance motivation. Anger is helpful for both identifying psychotherapy goals AND for mobilizing client motivation.
  4. During psychotherapy anger may occur in-session towards the psychotherapist. Skillful therapists accept this anger without defensiveness and then collaboratively explore the meaning of their in-session anger.
  5. Anger is a natural emotional response to oppression and abuse. If clients consistently suppress anger, it inhibits them from experiencing their full range of humanity.
For feminists, one goal of nurturing and exploring client anger is to facilitate feminist consciousness. Feminist consciousness involves females (and males) developing greater awareness of equality and balance in relationships. However, using anger to stimulate insight and motivation is useful in all forms of therapy, not just feminist therapy.

But working with (and not against) anger in psychotherapy is complex. The problem is that anger pulls so strongly for a behavioral response. Reactive anger is destructive. Clients want to let it out. Experiencing and expressing anger feels so intoxicatingly right. Clients want to punch walls. They want to formulate piercing insults. They want to counterattack. Unexamined anger is reactive and vengeful.

Imagine a male client. He’s uncomfortable with how his romantic partner has been treating him. You help him explore these feelings and identify the source; he recognizes that his partner has been treating him disrespectfully. But good psychotherapy doesn’t settle for simple answers. His new insight without further exploration could stimulate retaliatory impulses. Good psychotherapy stays with the process and examines aggressive outcomes. It helps clients explore alternatives. Could he be overreacting? Perhaps the anger is triggering an old wound and it’s not just the partner’s behavior that’s triggering the anger?

Relationships are nearly always a complex mix of past, present, and future impulses and transactions. When anger is respected as a signal and clients take ownership of their anger, good things can happen. It can be used to help clients become more skilled at identifying and articulating their underlying sadness, hurt, and disappointment. Clients can emerge from psychotherapy with not only new insights, but increased responsibility for their behavior and more refined skills for communicating feelings and thoughts without blaming anger, but in a way that serves as an invitation for greater intimacy and deeper partnership.

None of this would be possible without the clarifying stimulation of anger and a collaborative psychotherapist who’s able to help clients face, embrace, and understand the many layers of meaning underneath your anger. And it’s about time we learned a lesson from the feminists and started giving anger the respect it deserves.

Seeing Medusa in Every Client

Posted on by Psychotherapy.net Team

In Greek traditions, Medusa is the notorious stone-cold killer who was well known for turning people into statues. Her reputation became so brutal that she was often depicted as evil itself. However, like everyone who eventually comes to hurt others, Medusa had a life before she was the snake-haired statue-maker, but few seem to remember that. This is that story:

Medusa was a stunningly beautiful young woman. She was so striking, in fact, that everyone around her pursued her and longed to be her husband. Medusa had thick, gorgeous hair that men longed to see, and even be near. Suitor after suitor came and presented himself to her, transfixed by her beauty.

Medusa’s magnificence was so great that the gods themselves not only took notice of her, but also could not control their impulses to be with her. One of the gods, the ruler of the sea, Poseidon, became obsessed with Medusa. He sought her out while she was in Athena’s temple. There, in the midst of the holy place, beautiful, innocent Medusa sat praying to the goddess.

Poseidon did not attempt to hold back his urges, and sweeping in with a terrible ferocity, he raped Medusa on the altar of the temple. In an instant, he was gone. The deed was done. Medusa lay shattered on the floor of Athena’s house. “Why?” she thought. But she hardly had time to think. Athena was appalled that such a sacrilege would take place in her hallowed temple, and she swept in with almost the same speed with which Poseidon left.

Medusa, turning to the divine being with a look of desperation, did not receive the compassionate look in return for which she hoped. Instead, a fury overcame Athena. “How dare this take place in my temple!” she thought. Athena was enraged at Poseidon for defiling her sanctuary, but she could not punish a fellow immortal, so she turned with hatred and viciousness to Medusa.

Someone had to suffer for the atrocity to the goddess, and the victim was the target. With unquenchable anger, Athena blamed Medusa for her carelessness, for “enticing men,” and used her deific power to transform Medusa’s hair into snakes. As though the pain of serpent-hair were not enough to repel the sons of the world, she further cursed her in a way that ensured men would stay far away from her from that day forward. In a rage, Athena proclaimed, “He who looks on you will be turned to stone!”

And so a victim of rape, misdirected rage and hatred—and all for being nothing more than beautiful—Medusa, came to be known as she is today: the face of evil itself. The wrath and disgust for others that Medusa became known for were taught to her by the very figures she trusted.

There is no violent offender, no person who hurts another, and no villain in this world who does not have a story of how and why she or he came to be. We must learn to see Medusa. We must learn to see beyond the snakes and the curse that holds others at bay, and look into her deep, tragic history to get a fuller understanding of who she is… and we must also and equally do that with every client we encounter.

As therapists, we need to consistently evaluate our own personal judgments of others—not just in lip service, but in actual, in-depth explorations of who we are, and why we might hold the judgments that we do. Medusa had reasons for hurting others as she did, and so does everyone else. Our job as therapists is to assess, understand, and explain human behavior, without judgment or bias. The more we know about the past (others’ and our own), the more feasible that task becomes.

If we do not learn to see Medusa, we run the risk of remaining transfixed in our own sculptured, static mind-set: a place from which we will forever stand as judge, jury, and executioners in our own minds.
 

Christian Conte on Anger Management

Posted on by rezendevknowfully.com

"People Don’t Just Wake Up One Day and Become Violent'

Victor Yalom: Dr. Christian Conte, we’re here today to talk with you about your work with violent offenders, with anger management, and so on. You’ve chosen to work with a rather unusual and, most therapists might think, a difficult, challenging population. What got you interested in this kind of work in the first place?
Christian Conte: When I was an intern in a master’s program, I had an opportunity to co-run a group for sex offenders. The first group I ran was an adolescent sex offender group, and the way the person who was running the group started each group was that everybody had to introduce themselves by saying what they had done to offend on someone else. And then they had to follow it up with anything had ever been done to them.

So at the time I went in, my energy was pretty high because this was my first experience. I didn’t know what to expect. The guy who was training me said, “Look. They’re going to tell you about raping little kids. You’re going to hear all kinds of stuff.” So I sat down and the person to my left started. And, he talked about what he had done to someone else and then he said, “I, myself, have been physically, mentally, and sexually abused.”

So I thought, “Okay. I can see that.”

So then the next person goes, and same thing. “I, myself, have been physically, mentally, sexually abused.” As they went around the group, my energy started to calm down as I realized that everybody had had something happen to them. And over the last 14 or 15 years since then, I found that to be true for everybody I’m working with. People just don’t wake up one day and become violent. They don’t just wake up one day and hurt somebody. They’ve had past history that leads them to do what they’ve done. So that really got me interested.
 
VY: Other than your energy going down, can you recall what other kind of initial reactions you had, thrust into that group for the first time?
CC: I was studying CBT heavily at the time, so one thing I was doing was recognizing what my thoughts were. I think I was fairly judgmental in my thoughts when I started. And then my thoughts started to shift into thinking, “What would it be like to have to introduce yourself and say, ‘This is what I’ve done’?” Because that was the very first thing that struck me, is that someone would talk about their offenses so freely.
When you live in shame, you act out of shame.


I thought, “Well this is interesting. I’ve never had this experience before.” So I think my thoughts ranged from, “How could you?” to “Wow. How difficult would it be to actually be saying this?” That was my initial experience and I left feeling like I wanted to do more work with sex offenders. I worked at a mental health institution and I volunteered extra days of the week, so I was there 40 hours a week and it was just a practicum. I was doing that much time because I was so invested in it and I had the opportunity to do it.
VY: You said you were aware of some judgmental thoughts—which, of course, is natural. But how did you handle that? What did you do with that?
CC: Well I still look back on that very first session and I was really struck by the moment—I think it was the third person that went and I remember his face getting really red as he talked about what he did. This kid was about 15 and had forced his brother to give him oral sex and his brother was very, very young, like 5. And I thought, “My gosh. What would that be like to have to sit and tell these people that? How much shame must be coming up for him?” And I still reflect on that when I think about how I’ve tried to make getting beyond shame central to my work. Because when you live in shame, you act out of shame. 

"Oh Yeah? I’m Dr. Conte Too"

VY: How did your work progress over the years, in terms of the type of population and your ideas about it?
CC: I remember a guy came in who was straight out of prison, much bigger than I was, solid as a rock. And I just had a really good connection with this guy, I could really relate to him. When I talked to my colleague about how well things were going, he said, “Well look at you.” This might be a silly thing but I had just recently shaved my head—you know, I was losing my hair anyways so I started shaving my head—and I guess I didn’t even see myself in that way, but I think other people could see me in that way. 
VY: It’s not just your hair but you’re a big, muscular, stocky guy, and you sport tattoos to boot!
CC: All of that. I think I realized my persona fits, so I started running a group to see if my approach could be effective, which it turned out to be, and I ended up running groups for violent offenders.

On my first day there the guys were in line to sign in and, as they were getting in line to sign in, a guy said, “Hey go ahead, man.” I just had a t-shirt on so I had tattoos out and everything, and he said, “Go ahead, man.”

I said, “No, you go ahead. I’m Dr. Conte.”

He said, “Oh, yeah? I’m Dr. Conte, too. Go ahead.”

I said, “No. I really am. Go ahead and get in line.” So I learned early on that my persona does help. It certainly helps me to connect with people. And I don’t feel the same types of judgments that I hear other people feel about these guys. I really don’t. I look at people and I realize, “How do I know that I wouldn’t have been different if I didn’t grow up in their world and see the things that they saw and have their cognitive functioning?” I’ve thought that for a long time. And when I started to integrate into my personal life what I believed about counseling and psychology, and I really started to integrate it through meditation, it just became a part of who I am.

One thing that my clients have always reported is that they don’t feel judgment from me. I’m going to accept you. I’m not going to accept the behavior. I mean, guys knew I was not for violence. I wasn’t even a proponent of spanking. I don’t even spank my daughter. I’m not for violence in any way. But I’ll accept you as who you are. You may have messed up. That behavior is not acceptable, we’ve got to work to change it, but I accept the essence of who you are.
 

Yield Theory

VY: That speaks to the central theory you’ve developed—you refer to as “Yield Theory.” Can you describe that in a nutshell?
CC: In a nutshell the essence of Yield Theory is based on the fundamental assumption that if I lived every day as the other person, with that person’s cognitive functioning, with that person’s ability to experience emotions, and with that person’s life experiences, I believe I would have made every single decision that that person made in life. My experience is, when I throw that on the classroom, that causes a discussion right there.

People tend to respond with, “Well I had a hard life, but I didn’t do that,” but that is not what I’m talking about. You had a hard life, but you also had your cognitive functioning and your life experiences. You had your whole perspective. So it’s just a hypothetical assumption but what it helps me see is, I don’t know that I would have done this differently. That’s just radical empathy, I think, but what it allows me to do is if a person comes in and says, “That’s it. I’m going to kill that guy“—I don’t know how many tapes I’ve watched through the years of training counselors, the first thing they’ll say is, “Let’s just calm down. Let’s not do that.” Or somehow try to stop the person.

Where I go with the person, no matter how intense it is—if they’re saying, “I’m going to kill him,” I’ll respond in kind: “You kill him then. You need to kill him. All we need to do is sit here and talk. We’ll talk for a minute, then you go kill him.” And I really let them get out everything that they’re going to get out.

The analogy is like you’re driving down the road and you come to a merge sign and you yield with somebody, and your car’s driving along next to their car. After a while in this little hypothetical experiment, they say, “You know, we’re driving the same direction. I’m going to invite you into my car.” So you get into the other car with them and now you’re a passenger, but you’re starting to see things out of their window. And after you drive on a trip long enough with someone, they start to trust you and allow you to drive, then you can steer them down a different path.
 
VY: So that’s where the name “Yield Theory” comes from?
CC: That’s where the name Yield Theory came from. You give it up to join them.
VY: So philosophically you could get into a debate about free will and whether you would make the exact same choices they do, but what I hear you saying is, it’s a useful assumption in really deeply being empathic, understanding, and trying to see things from their point of view.
CC: Exactly. The very first time—this is just coming to me right now—the very first time I ever used it, after I really thought about it and wrote about it in a little journal exercise in a master’s program, I went into this group home to work and this adolescent female came down and she talked about how she stole this other girl’s shorts. And she was laughing about how she got away with it. So I completely went with it and even laughed with her: “that’s hilarious, and she didn’t even see that coming!”

And she said, “She’s so stupid.”

And I just kept joining with her: “I can’t believe how dumb she would be to let that happen.” And it went on like this for a while. By the end of the time that we were together, she said, “You know what? That was kind of messed up what I did.” And she gave the girl her shorts back. I went with her so much and then I would pose a questions like, “You know, I wonder though, as funny as it is, if there’s a point where, if she sees that, or if somebody finds out you’re stealing from them, if people aren’t going to start stealing from you? And I wonder what that’s going to be like?” And then she started to think about it.

So the point is that once people really believe and feel that you’re with them, then they don’t have to fight any more. So it’s a work around—getting around people’s fight-or-flight responses. That’s huge.
 
VY: Whose fight-or flight-response?
CC: The client’s. I know that’s a question for people because I think that’s what happens with violent offenders. Every time I’ve ever had an intern come in and sit with me doing my groups with violent offenders, they say, “Well that wasn’t anything like I thought it would be.” 

"I Picture These Giant Guys Sitting There with Knives"

VY: In what way was it different than they expected?
CC: They say, “Well some of these guys were like normal people. They just got really angry.”

And I say, “What did you expect them to look like?” I work with some gang members who have tattoos on their heads and everything else and on their faces and in that sense, that might be a little different for some people who go to school and train to become counselors. But for the most part, you see normal human beings who have issues. And I always say, ““There are two kinds of people in the world: people with issues and dead people.””] So if you’re alive, you got issues.

When people would walk out of the group, they’d say, “Wow, that guy was a normal guy,” or, “I could relate to that guy.” So I started to survey my interns before they went into a group for the first time, to see what they were expecting. They’d say, “I just picture these giant guys who are all like sitting there with knives.” That’s what their projections would be. And they’d get in there and say, “Well this is totally different.” I think if you’re not checking those assumptions, if you’re not checking those fears and projections, then you’re going to spew them all over your clients.
VY: You were saying earlier that you became aware that your physicality, your presence, helped you connect with the clients and helped them relate with you, but what about your more typical counselor, who might be rather bookish, and probably not at all physically imposing—can they do this work just as well?
CC: Anybody can do this work. Think of Aikido. You can take someone who weighs 80 pounds and they can throw me, because basically you’re taking the person’s own body weight and throwing them. If I push, they pull. If I pull, they push. I was trained in Akido, so I thought, well, this is the same thing mentally. I’m aware I’m 6 feet, 260lbs—I’d like to say 250 for the interview, but I’m at 260…
VY: Well, it’s right after New Year’s so hope springs eternal…
CC: Right, but I know I’m a big guy and that I can take care of myself physically, but I don’t put that out there. You can watch former cops come in and they’ll run groups or work with other cops and they talk in a tough way—I don’t do that. My intention is not to say, “Look at me. Look how tough I am. If it really comes down to it, I could kick your ass.” I always maintain that “you guys are tougher than I am.” I have no attachment to that.
VY: But have you noticed any differences or any particular struggles female therapists have working with violent or sexual offenders?
CC: The person I co-founded “Balanced Life” with in South Lake Tahoe, Lacey Noonan, was amazing. What she would do is she would handle herself extraordinarily well and then in supervision, she’d come in and say, “You know what? When so and so was standing over me, I felt all kinds of fear but I pushed through it.” She would step back and look at the person and say,
“You know, I wonder if you’re aware that you’re standing over me in an aggressive way?”
“You know, I wonder if you’re aware that you’re standing over me in an aggressive way?” She said that internally she had fear but realized that, through the years, she could trust the process, that she had to stay open and genuinely compassionate.

I would kind of stand in front of people and say, “Look. It’s me. I’m the person that’s stopping you from trying to get yourself locked up. So what I say to you when I give you this direct feedback, this is to help you.” And Lacey took on that approach, too. She’d say, “I’m not here to hurt you. I’m simply telling you the stuff that’s a little bit more direct because I want to help you.” She is a smaller female and she was tremendous at this. 
VY: But she did feel fear.
CC: Sure.
VY: So how do you help therapists that are new to working with this population handle that fear and not let it get in the way of being compassionate?
CC: Lao Tzu, the founder of Taoism, said, “ If you treat the people as though they are trustworthy, then they will be trustworthy.” If I look at you and I’m exuding peace and I’m trying to talk to that center in you that I know that you can exude peace as well, I think a transformation happens. I realize as I say it out loud, it can sound out there. 
VY: Well, it can, yeah. Just to play devil’s advocate, I have not worked with that population so I don’t have that direct experience, but it can certainly sound naive. These are people that have done some terrible things and just by being compassionate, you’re going to change that?
CC: I totally agree. I think it does sound naive. Except that I’ve seen it for thousands and thousands of hours of working with people. So it’s a matter of saying, “Look, I’m validating why you’re angry at something. You’re angry at something. You have a right to be angry. Just because you grew up in a certain area, because you look a certain way, because you look physically tough, I’m validating—hey, this is what you’ve done. But the question is, do you want the results of what you’re going to do?”

I mean, there are certainly moments when things get really intense. I had a guy one time—about 6’7”, 270 lbs—and he came his fourth time late to group. He was late by two minutes. And guess what? If you’re late by one minute, I’m calling your parole officer. I wasn’t attached to that. I didn’t have emotion around it.

But I remember going up, thinking to myself, “This guy’s bigger than I am. This could be interesting.” I went up to him and I said, “Look. I can understand you’re going to be really frustrated and will probably direct some of this anger at me, but you recognize that this is your fourth time late, and that your PO has to be contacted, and you’re likely going to go back to jail.” And he turned, and for a moment when he turned, and put his head off to the side, I thought, “Okay. Well he could turn around and swing right here. I’m aware of that.” But I said, “Look, I understand. I can understand you’re fired up. If you’re pissed off, you’re pissed off.”

And, he said, “No. I know. I want to be pissed at you guys but the truth is, I know I did it. I knew I did it.”

And I just jumped on it. I was like, “That’s huge. That’s huge for you to have that realization.” I just kind of praised that part before anything happened.
 

Avert Your Eyes

VY: Have you or anyone you’ve worked with or supervised ever been physically attacked?
CC: No. No, we have not. And we’ve have worked with a lot of people who have struggled with anger. One thing I’ll do is I also teach students about turning your body so that your body language isn’t inviting that. You know, if males sustain eye contact for too long, their testosterone actually increases, so I tell people to avert their eyes. You don’t have act tough and be like, “Let me stare you down.”
If males sustain eye contact for too long, their testosterone actually increases.


I turn to the side and make sure that I’m not in a threatening pose. I’ll put my hands in my pockets. I’ll do something to make somebody feel secure, that I’m not trying to threaten them in any way. The closest I think I’ve ever come—I had a guy who came in really high. He was really high on drugs and he wasn’t necessarily that big but he was just an angry guy and he was really high. So I was just very careful with how I approached him in regard to my body language and was very respectful that he was very pissed off and said, “You have a right to be pissed off.”
 
VY: We’ve been talking about underlying assumptions, the spirit of your work, you know, countertransference—if you want to put it in that language—but let’s back up a bit and get into some nuts and bolts. Have you worked with this population mainly in a group setting?
CC: Mainly in a group setting, yes.
VY: So how do these groups work? How are they structured? Are they mandated clients primarily?
CC: For the groups that I ran out there in California for six years, they were mandated by the State of California. If you committed a violent crime, you would be mandated to 52 weeks of anger management.
VY: And this is people that have gone to prison? Or doing this in lieu of going to prison?
CC: The majority of them went to prison. Every once in a while, you get somebody who, if they had no priors and depending on the nature of what they did, they would just get mandated to group therapy. That was few and far between.
VY: So they come out of jail and….
CC: They come out of jail or prison, and they’re mandated to spend 52 weeks in this two-hour anger management group. There were specific rules, obviously, that they had to follow for our program to maintain certification. So they had to be there at a certain time, they had to be two-hour groups, you get a 10-minute break. It was an open group so people were coming in all the time.
VY: About how many members?
CC: We would have 25 people in groups, which is way over the standard recommendation for group counseling which is eight to ten group members. But even though the groups were open and really big, we would get people sharing as though it was a closed group. I thought that was profound, the way that people would share, and I believe it was due to the atmosphere that was created for them. They were going to be accepted no matter what. I always said, “Whatever thoughts about what you want to do, talk about them. I don’t care what you want to do, let’s talk about it. I’d rather you talk about it then pretend like you’re not having these thoughts.”

So over the course of my career I developed over 100 exercises I would do with these groups at various times and I’m actually about to publish a workbook on anger management that includes all of them. So I’d take something like Gestalt therapy, the five phases of psychopathology—the phony, the phobic, the impasse, the implosive and the explosive—and I’d turn that into an exercise.

The Phony Phase

VY: What would an exercise look like, for example?
CC: So I’d start out by describing what the idea was—I’d tell them about what each layer was, but I would try to use the language that worked for them. So instead of saying, “there’s a phony layer,” I might say, “This guy, Fritz, called it a phony layer. It just kind of means that we’re superficial, we’re fake sometimes.” So then I’d teach this idea to them, and then I would give them a worksheet where they would detail, “How have I been phony in the past? How have I been phobic in the past?” I always asked, “How have you been this way in the past?” Rather than, “Were you this way?” Because if we say, “Were you?” they’re going to say, “No. Not me. I was never that way.”

Or I might take a Johari Window—I would take that and then I’d make a worksheet out of it. “So how are you in each one of those blocks?”
 
VY: So you do exercises like that where people would do some reflection, share with the group as a whole?
CC: Everyone would have something written down and then we would process what was going on. So I would give whatever topic I was going to do, and I’d talk about it for a little bit, and then they’d fill it out. If I had a particularly quiet member for a long enough period of time, and I wanted to draw that person out I could say, “What did you have there for that one?” And they’d feel confident to have something to look at. But basically we’d morph it into a process group at that point. Very powerful. Then I’d always end groups by asking them what they were taking away from the session.
VY: So when you say “a process group,” would you do much interpersonal here-and-now work, where people would give each other feedback in the moment?
CC: Absolutely. Right there in the moment, what was going on then, what was happening inside of them. Sometimes I would let things get heated, because I felt confident I could handle it. And there were one or two times where I would step in and say, “Okay. Now we’re going to step back for a minute and let’s talk about what just happened.” But again, it wouldn’t be judging them or scared or “break it up.” It would just be, “Okay. Let’s talk about this. Let’s stop right here for a second. Let’s hold on.” I tried to create an atmosphere of respect for one another by giving them respect, so they would listen when each other talked. There were 25 people in the room, so if somebody started a side conversation, I would say, “Hey, let’s stay focused right here. We’re always giving somebody respect, whoever’s speaking.” And they would. It was a very respectful atmosphere.
VY: Do any examples pop into your mind? Any recollections of heated moments that kind of stand out to you that you were able to use in a therapeutic manner?
CC: Well one time this guy was talking about how he beat this guy up, which ended with him kicking the guy in the head. He wasn’t proud of this moment, and his face started to get flushed as he told it. He said,
“I was kicking him in the head and I just, when they pulled me off, I was just, like, ‘What’s wrong with me? What did I just do?
“I was kicking him in the head and I just, when they pulled me off, I was just, like, ‘What’s wrong with me? What did I just do? I don’t understand what I just did.’”

And then, in the back of the room—boom, boom—this guy just started pounding on the floor, really loudly, with his foot, stomping on it. And it kind of echoed through you. And he said, “What the fuck is wrong with a human being that would step on somebody’s face?” He didn’t realize that, not only was he putting that guy down who finally owned up to what he did, but he was intimidating everybody in the room because he was getting so fired up, his testosterone’s flowing, as he’s pounding his foot.

I let it get heated and then somebody else defended the other guy: “Man, he just said he felt so bad about it, he couldn’t believe he did it. And look at you!” And he responded, “Look at me? I can’t believe you would do something like this.” Meanwhile, this guy himself had done some horrific stuff, so it was shadow projection.

And that was one of those times when I stepped in and I said, “Alright, now listen. Let me say something. Let me just say something. I don’t know if you’re aware of this, but as you were pounding your foot on the floor, the rest of the group members—and even me, I was feeling, ‘Whoa, this is some heavy energy.” He didn’t get it at first, so I switched it over to the other guy and said, “That was huge for you. I think he misheard what you were saying, because I saw your face and I saw how you finally had that feeling of, ‘Wow. I can’t believe I did that.’ And I really appreciate that you even got to that spot or that you would share that with us.”

So I’m trying to validate him. And then I said, “Now what else happened here? Do you notice how the group divided? Some people who happened to be sitting by him were were agreeing with him—let me ask you guys, were you really in agreement with him or was it because of where you were sitting?” So then we started to talk about how they would just naturally come to somebody’s defense just because they’re sitting right next to them.

It ended up being super powerful. We took a break—and I didn’t take a break until we had moved the energy in a different direction—but when we came back, I used humor to get it going at first, which was very helpful. And then we started to talk about it again, and the guy who had been pounding his foot said, “Man, I’m sorry, I just got so into that story.” And then he admitted, “I’m having a bad day.” So he was able to kind of work through it. That was one of the most powerful experiences; it was intense.
 
VY: Do you ever physically stand up?
CC: Most of the time I was standing already, but there were times that I would walk forward, just use my energy to cut somebody off or to say, “Okay, let me stop you right there for a second.” I definitely have used that energy in that way. I get that from being a professor. If somebody started to have a side conversation in class, I just walked over to that direction and, all of a sudden, there’s no side conversation.
VY: It sounds like to be effective, you need to feel in control.
CC: I think so.

Motivating Mandated Clients

VY: Would there be voluntary clients and mandated clients in the same group?
CC: Yes.
VY: So what was the difference? A lot of therapists think it’s hard to do treatment with mandated clients, that they don’t have the motivation. What are your thoughts?
CC: I’ve made a career out of working with mandated clients, so I don’t believe that at all. I think it’s our job to find out what their motivation is, and a lot of times people’s motivation, especially with this population, is, “I don’t want to be in prison. I don’t want to be sitting in this cell.” At the end of the day,
I’ve sat down with enough big, strong, tough people, who one-on-one will break down and cry and tell me how they don’t want to be sitting in that cell.
I’ve sat down with enough big, strong, tough people, who one-on-one will break down and cry and tell me how they don’t want to be sitting in that cell. That is a huge motivator.

I’ll say, “I’m going to make a wild guess that you don’t like rules. So why are you going to make decisions to put yourself in a place where they have tons of rules for you?” So I use that as a motivator for any mandated client, from adolescents all the way up. I had a new adolescent male in my practice the other day, it was my first time seeing him. His mother made him come, and I said, “Well that’s pretty shitty. She’s making you come sit across from this dude, a crazy bald-headed dude.”

And he kind of smiled and looked away. And I was like, “Man, I can’t believe she’s making you do that. It’s messed up. What do you need to do to not have to come here anymore?” And then we kind of worked through the goals that way.
VY: Any other general strategies, principles, to work with violent offenders, sexual offenders, that differ from standard therapeutic practice?
CC: Something that was a typical approach for anger management for the longest time was that people would have to write letters and read them out loud to the group about what they did and why they felt so bad. I strongly disagree with this type of perspective, forcing people to take accountability when they’re not ready to. All they do is learn how to say whatever needs to be said in front of the official people, without actually working to change.

So I never force people to take accountability. I never say, “You need to say this,” or “You need to feel shame about what you did.” Never. Because if you shame people, they’re just going to act out again. If you think you’re a no-good son-of-a-whatever, you’re going to keep doing it.
 

No More Letters of Apology

VY: So that first group that you led, where people had to start out saying what they had done, really made an impact on you.
CC: It did, but even more than that when I started to work with violent offenders because they had to read letters of apology for what they did, and the very first time I sat in on a group with violent offenders, I listened to what people really said: “No this is horse shit.” “You’re supposed to say this in it.” “No, no, hurry up, man, get an eraser. You’ve got to say this.” “Just say this word right here, you’ll make that dude happy.” They just said what they were supposed to say.

Since that time, all these years later, I’ve visited people in prisons and talked to people, and that’s still what they do. They’ll say in their writings whatever the therapist tells them they’re supposed to say so they can check the box and say they took accountability, but it’s not actually happening. So I threw that out before I started. There was no way I was doing that.

The first week I took over the groups I said, “No more of those letters. Those are out the window. We’re not doing that anymore.” Of course people would come in and think, “I did nothing. I didn’t do anything. I shouldn’t be here. I shouldn’t have to be experiencing this.” But over time, in accepting them and showing them and teaching them…Look if you meet one asshole in a day—what is the saying?
“You meet one asshole a day, that person might be an asshole. But if you meet five in the same day, you’re probably the asshole.”
“You meet one asshole a day, that person might be an asshole. But if you meet five in the same day, you’re probably the asshole.”

If you keep going to jail over and over again, you’ve got to be doing something wrong. So maybe everybody in the world’s messed up, or maybe it’s you. Maybe you need to start working on yourself. A statement I often said was, “Look, we’re all human beings. If a human being does it, it’s human nature. So if you do it, let’s just explain it. Let’s figure it out.” A lot of guys would comment that it helped them when I talked about it that way, “That’s just human behavior. So you got pissed off. So you hit somebody that you wish you hadn’t hit. Let’s learn from it; let’s move from here.”
 
VY: You’re passionate about what you do, and you take an optimistic and hopeful approach, which is certainly a good thing. I mean, if we can’t be hopeful about the clients we’re working with then probably we shouldn’t be doing it. But there’s certainly some thought in the field that there are certain people—we often label them “sociopaths”—that are just untreatable, unreachable. What are your thoughts on that?
CC: In all my years, I had only one person who I said was not right for the group setting. He was really locked into his worldview. He was intimidating physically and would get people to kind of join. I thought he was detrimental to the group setting, so I recommended him for individual treatment. I remember talking to his probation officer and he said, “In 30 years, he’s the only person who, when he goes to the bathroom, I have my hand on my holster on my gun.” He said, “My hairs on the back of my neck stand up.” The guy was an imposing figure, for sure. And I do think that some people probably need to stay locked up. I understand that that probably is that way for some people.

But I believe everyone can change. I still think human beings are worth it.
What I don’t see is how we’re not spending more time and more effort on trying to genuinely rehabilitate people.
What I don’t see is how we’re not spending more time and more effort on trying to genuinely rehabilitate people. Not make people write accountability letters that they’re faking, but genuinely change. Because if they’re going to come back out in society, why not have more intense programs that are really life-changing and affecting their whole psychology? Not just saying, “you’re angry,” but looking at their whole being. There are people that probably have a much more limited chance to change than others but I still want to remain hopeful that it’s possible for anybody to change
 
VY: Are there major mistakes or pitfalls that you’ve made or that you would caution other therapists about who are new to this population?
CC: Hmmm. Which ones do I want in print is the question?

I made a huge mistake one time with an adolescent male who told me about his drinking. I used Yield Theory, kind of went with him, validated him. I was a school counselor at the time and I ran out of time to talk to him, so all he got was validated about his drinking. He left and that was it. And I thought, “What the hell did I just do?” I validated his perspective, let him think it was okay, and I didn’t give myself enough time to actually complete what I was going to do.”

You Can Definitely Kill This Person, but…

VY: Yeah, you mentioned before that you validated this person’s desire to want to kill someone. So once you validate that, what do you do after that?
CC: You have to have the time to know that you’re going to finish the interaction. But what I can do faster now is I can move more quickly into options for people. So what I wasn’t able to do back then and what I can do now is within a statement or two, get into the options. “You can definitely kill this person but let’s think, let’s play it out real quick: If you do it, what’s going to happen?”

I’m kind of like a coach and I’ll use that metaphor a lot with men I work with—“You’re the pro. I’m just here to run some options by you. You can run this play and here’s the likely results; you run this play, here’s your results.”
 
VY: This reminds me a bit of Motivational Interviewing. We just did a video series and an interview on Motivational Interviewing, and I know that was an approach originally developed for addictions. It’s now been applied to healthcare and criminal justice. And it’s ultimately about respecting that the client—it’s their life and they’re ultimately going to make their own decisions. But given the challenges of your clients, when you’re discussing options with them do you really stay neutral? Because there’s a risk of just telling them what to do, which they’ve heard all their life; but it seems that there is also a risk of supporting, empathizing, validating them, and not taking a stand about, “Hey, maybe it’s not a good idea to kill someone.” What are your thoughts about that?
CC: That’s a really good question. It’s tough, especially when you watch yourself on tape, to say that your voice doesn’t go a certain way when you provide the option that you hope they’ll choose.
VY: Right.
CC: So I can say that I stay neutral, but I’m sure if I saw myself on tape, I make some options sound a bit more enticing than others. And not killing somebody—I want to make that sound good, so I probably end with it. I start with the option that they’ve been thinking of and I go with it. But I really play it out. “So you go kill him. Let’s play it out. So, you get arrested, or maybe you’re on the run for a little bit. What’s that like, when you’re on the run? Tell me about that.” My experience has been that when people do that, it’s almost like learning from experience in the future—now—by playing out their options.
VY: So your hope is that by doing that, they’ll make the right decision, but without pounding them over the head with it.
CC: Right.

Yield Theory for All

VY: So you’ve been talking mainly about your work in groups. What pointers would you have for a therapist who doesn’t have a particular focus or experience with this, but encounters in their private practice, a patient—maybe you’d call them “borderline” or whatever—but who really struggles with rage, aggression, acting impulsively and self-destructively. What advice would you have for them?
CC: Let’s say you’re struggling with someone with a borderline personality disorder, and you want to teach them a new skill, and you’re getting wound up in so much resistance and feeling stuck. That’s the moment to implement Yield Theory and really get into their worldview, and watch—just try it on, something as simple as that and watch how that will shift things for you.

And then it’s a matter of skill, of teaching the options. So for somebody struggling with borderline personality disorder, it would be about helping them become aware of what they’re doing, with mindfulness, and kind of going with them, yielding with them in a way that allows them to feel safe enough to become aware of themselves, and then helping them become aware of what’s happening in interactions between them and others.
VY: What would you advise students or beginning or experienced therapists who are wanting to work with this population or have the opportunity to work with them?
CC: As you said, I’m super passionate. I’m really an intense person and I’m really passionate about what I do. I was really passionate about students looking at their own lives, just like I’m passionate about looking at my own life and looking at mistakes I’ve made. I’m pretty effective at not repeating mistakes, but I’m really creative at making new mistakes every day. So I really try to look at my own life every day and ask myself, “Am I living according to what I’m trying to preach and what I’m teaching?”

But the reality is, as a supervisor for the last decade in this field, watching people’s tapes, listening to students, the bottom line is, the majority of people in our field are fairly judgmental. They’re opinionated, they try to get their opinions across in therapy sessions, and I see that a ton.
The bottom line is, the majority of people in our field are fairly judgmental.


One exercise I would do in class is, I would draw a normal bell curve, and I’d say, “This bell curve says that the majority of you, in this room right now, are going to fall right here. You’re going to be average counselors. That means when people come see you with their emotions, trusting you with their lives and telling you about their life, you’re going to give them an average response. You tell me where you want to be.”

Of course, every student would go and mark the top and say, “I’m going to be this elite counselor.” And I’d say, “Well what’s it going to take to be there? You have to read incessantly. You have to learn about your life incessantly. You have to be passionate about saying ‘What am I doing in my personal life?’ You can’t be super judgmental in your personal life and then walk into a session and just think all of a sudden you’re not going to be super judgmental.” So I really try to get people to practice what they preach. 

Let’s learn more. What are our biases? What do we think? What do we really believe? What are we attached to? I teach a lot about confirmation bias and the idea that people get so locked into, “This is my religion. This is my politics,” that kind of stuff. They hate the other side or don’t like the other side and then go into a counseling session and can’t separate themselves from that.

 
VY: Really attending to our own growth, our own biases, is a refreshing perspective, especially in this day of “empirically validated treatments,” where it’s all about the technique and not about the therapist. So I really appreciate your passion about that.
CC: I like the way you’ve rephrased it. That’s much more concisely said than what I said. I like the idea of counseling as an art, and it’s never which martial art can win, it’s which artist, as a counselor, can be effective? And so we’ve really got to learn about ourselves. I think we’re charged with doing that. I think we have an oath with saying that we’ll do that in our personal lives. People who do that become very effective counselors.
VY: Right. Well I think that’s a wonderful note to end on, so I want to thank you for taking the time to share this with us. For readers who want to get more of a sense of who you are and the spirit of your approach, we’re delighted that we’ll be releasing a video of you coinciding with the publication of this interview. I would urge people to take a look at that, as well.