Anger Management

Anger Management is a term that describes a broad array of approaches that are on offer to assist an individual in reducing the intensity of their angry feelings or to control their outward expressions of anger.

There are a host of Anger Management programs, therapy techniques, books and philosophies all dedicated to the subject of Anger Management.

Suggesting an Anger Management system approach is one of the first tools produced from the arsenal of a typical non-personality-disordered person when trying to deal with an angry spouse or family member who suffers from a personality disorder.

What doesn't work...

Anger Management is sometimes prescribed toperpetrators of abuse more than it is requested byperpetrators of abuse.

• Employers force employees into anger management classes out of retribution for unprofessional conduct at the workplace.
• Judges order from the bench that parents seek anger management professional help in exchange for custodial access to their children.
• Husbands and wives threaten to leave unless an angry spouse "gets help"

The trouble with forcing someone into an anger management program with a carrot or a stick is that it's much easier to force someone into a program than it is to force them to get anything out of the program.

One of the assumptions pervading the popular anger management industry is that the people it addresses are fundamentally mentally healthy. However, when one considers that approximately 10% of the population reportedly suffers from some form of personality disorder and may be struggling with issues such as dissociation, denial, engulfment, dependency, identity disturbance, fear of abandonment and self-loathing, it becomes easier to understand why anger management programs and enforced treatment therapies are sometimes ineffective. Both the management course provider and the attendee get something out of it - the provider gets a fee for the course or therapy program. The attendee gets tangible proof that they have worked on their issues. Consequently, many anger management programs are little more than a business transaction between personality disordered people who have little incentive to change and program facilitators who address the symptoms and not the source of the underlying personality disorder.

Therefore it is rarely beneficial to force someone into an anger management program.

What DOES Work...

When a person decides FOR THEMSELVES that they need to take a look at their anger and how they express it, they have an opportunity and an open mind to look at more productive ways of managing their anger.

Anger in itself is neither good or bad. Anger just is. It is a spontaneous emotional reaction to perceived injustice.

Most anger management systems address two modes of anger.

Anger turned inwards:

• Feelings of anger - where they come from, their physiological roots - how anger is part of a basic survival instinct of all animals to self-protect, protect the community, the food supply, offspring and property from outside aggressors and threats.
• Why suppressing anger can lead to depression - why anger is not evil, that it is OK to feel angry and to suppress those feelings is neither reasonable nor effective.
• Techniques for feeling better - from breathing exercises, mental exercises, physical exercise, recreation, doing things that make one feel better about oneself.
• Exploring sources of anger and triggers.
• Making commitments to make healthy choices in regards to feelings of anger

Anger expressed outwards:

• The difference between feeling angry and acting angry.
• Unproductive communications versus effective communications strategies.
• Techniques for diverting anger at others towards more neutral targets through sports, gainful employment, productive pursuits.
• The consequences of uncontrolled anger.
• Making commitments to make healthy choices in regards to expressions of anger.

You can read an excellent article about dealing with personal anger at the APA site here.

Eye Movement Desensitization and Reprocessing (EMDR) Therapy

EMDR is Eye Movement Desensitization and Reprocessing (EMDR), a psychological technique sometimes used in the treatment of post-traumatic Stress Disorder (PTSD).

EMDR is sometimes used to treat PTSD patients by asking them to focus on traumatic memories while moving their eyes from side to side following the therapist's finger or some object. Ssometimes headphones with alternating sounds from left to right ear are used. It is hypothesized that the switching from left brain to right brain establishes connections which allow the patient to access locked memories and emotions.

EMDR is a controversial treatment and has not been scientifically validated in clinical trials. You can find more info on EMDR at http://www.emdr.com.

Couple's Therapy & Family Counseling

Less rigorous forms of therapy such as couples therapy, marriage therapy or family counseling are extremely common. Visits to a therapist’s office are the most common form of treatment that anyone who suffers from a personality disorder will see. Techniques vary across the board as does the efficacy of treatment.

Many forms of couple’s therapy come under criticism for being ineffective and prone to manipulation by the personality-disordered individual. Therapists who treat personality-disordered patients as merely having communication difficulties, needing validation without acknowledgement of the underlying mental illness or confrontation of the abusive behavior are generally ineffective.

Many psychotherapists assume a validating advisory role rather than an assertive or intervening role with their clients, which can be counter-productive when addressing a relationship between a non-personality-disordered individual and a personality-disordered individual. It can easily be manipulated by the person with the personality disorder into a means of controlling the non-personality-disordered individual.

A common scenario is where the therapist offers both disputing parties validation of their feelings - which can be misrepresented by the personality-disordered individual as an endorsement of their position or support of their abusive behavior. This is usually followed by a suggestion from the therapist that both parties make some sort of compromise, meet in the middle somewhere. This approach makes perfect sense when both parties are rational, reasonable individuals who just have competing interests.
However, in the typical PD-Non-PD relationship, both parties are not rational, logical individuals. What usually happens is that the non-personality-disordered individual yields ground (while increasing their level of resentment) while the personality-disordered individual makes a verbal commitment to yielding ground which is not followed through on or maintained over a significant period of time.

The result can be a short-term appearance of progress, which is very gratifying for the therapist, with a long-term return to the old roles when the deal is broken. This increases disillusionment for the non-personality-disordered individual and an overall increase in resentment. They have yielded ground on something that was important to them and lost one of their bargaining chips because the personality-disordered individual has gone to therapy and can thus argue that this proves that they are “working on it”. Even worse, some of the confessions of their feelings made in therapy can be turned into weapons which are subsequently used against them.

It can also be frustrating and confusing for a non-personality-disordered individual in couples or family therapy with a personality-disordered individual to witness a therapist validating a personality-disordered individual’s dissociative memories. Sometimes the non-personality-disordered individual is characterized as stubborn for refusing to validate or agree to memories, beliefs or events that the non-personality-disordered individual knows or believes to be exaggerated, distorted or false. The non-personality-disordered individual is cornered into a defensive posture, afraid that the therapist will believe the unflattering stories about them and afraid that the personality-disordered individual will use the validation as encouragement to fabricate more. Once this happens, therapy sessions can easily descend into a he-said-she-said type of bickering back and forth with no resolution - other than the payment of the therapist’s fee at the end of the hour.

Both Seeing the Same Therapist Separately

Once it becomes clear that progress is not being made in joint therapy, it is common for therapists to advise couples to replace the joint sessions with individual sessions alternating between the two parties. This is generally more effective than joint sessions together as it allows the therapist to address each of the parties as individuals. However, there are 3 fundamental conflicts of interest that prevail:

1. Conflict of interest for the therapist. The therapist normally wants to validate both parties. This is very difficult when the parties are alternately contradicting one another. You are spending good money but instead of just listening to you and giving you good advice, your therapist is sitting there worrying about how his/her actions or statements might come back to haunt them via the other party.
2. Conflict of interest for you. Instead of working on yourself, you are spending your money and a valuable portion of your time thinking about the relationship between the therapist and the other party. You may be tempted to begin competing with your significant other for the therapist's approval and validation.
3. Conflict of interest for the person who has the personality disorder. Instead of working on themselves, they may begin to compete with you for the therapist’s validation and approval. They may also be tempted to try to “send a message” to their non-personality-disordered partner via the therapist.

Triangles are not a great setup. For this reason it makes more sense for people to see separate therapists.

As long as the therapist maintains a validating posture towards the PDI and avoids any sort of accountability for their behavior the therapy is unlikely to accomplish much more than an emotional back-rub. Most therapists deliberately keep their sessions at that level as it is less strenuous for them and breeds less conflict in the office. Many therapists are afraid of how their client will react if they adopt a more assertive role.

Cognitive Behavioral Therapy (CBT)

Cognitive-Behavioral Therapy (CBT) is a structured form of therapy based on the belief that thoughts - not outside circumstances - control our feelings and behaviors and that our feelings and behaviors are consequently under our own control.

Description:

In contrast to traditional psychotherapy, most CBT regimes are time-limited. The average number of sessions is 16. Homework assignments are an integral part of CBT.

CBT sessions focus on teaching rational thought processes, establishing life goals, learning to accept disappointments, analysis of the patient's personal world view, learning cause and effect and rationalizing feelings to match facts.

Click Here for a CBT Description at the NAMI Site

Dialectical Behavioral Therapy (DBT)

Dialectical Behavioral Therapy (DBT) is a psychosocial treatment developed for patients with borderline personality disorder which combines intensive individual and group therapy.

Dialectical Behavioral Therapy (DBT) was developed for treating Borderline Personality Disorder by Marsha M. Linehan. Some therapists avoid treating patients whom they suspect may suffer from BPD, because of the demands some BPD patients put on the therapist. These demands include multiple phone calls after hours, suicidal ideation and suicidal threats, lack of respect for the therapist's boundaries or the boundaries of other patients and staff, aggressive outbursts and stalking.

DBT incorporates an intense program of weekly individual therapy sessions and weekly group therapy sessions.

Individual therapy focuses on addressing a prioritized set of issues starting with self-injury, then behaviors which disrupt therapy, then behaviors which disrupt healthy living. Patients are trained in a regime of four skills known as mindfulness, emotion regulation, interpersonal effectiveness and distress tolerance.

Individual Therapy

Individual psychotherapy varies greatly from practice to practice and is generally dependent on the personal style of the therapist and the condition of the patient or client.

Therapy for people with personality disorders varies from validation and listening on the part of the therapist to more rigorous programs such as DBT and CBT.

Most therapists will not give a diagnosis of a client or patient. Psychological diagnosis is generally only performed by clinical psychologists or psychiatrists only and reserved for people who are hospitalized, criminally prosecuted or ordered to take a psychological evaluation during a child custody dispute.

The most effective therapy situations are those in which the person with a personality disorder is committed to getting help, following up on treatment, substituting healthy behaviors for destructive behaviors and taking medications where necessary,

Therapy & Psychological Intervention

Therapy is a term used to describe a wide variety of interactive programs offered by mental health professionals to mitigate personality disorder symptoms.

Personality disorders are notoriously difficult to treat and are sometimes even avoided by some mental healthcare professionals. The most effective strategies involve an intense process of individual and group therapy extending over a number of years, often shored-up with medication. This requires a serious, sustained  commitment on the part of the PD sufferer to their own recovery.

Some therapists avoid patients with certain kinds of personality disorders because of the risk to themselves and their practice. PDI's are not good at respecting the professional and personal boundaries of therapists and can become just as demanding to a therapist as they are to the others in their lives.

More information on Medications

Some reputable sites with information of Pharmaceuticals:

American Psychiatric Association Practice Guidelines - The APA makes the practice guidelines freely available here to promote their dissemination and use. Contains their medication recommendations for some disorders including Borderline, Bipolar, OCD and Major Depression.

Medline Plus - Medline Plus is operated by the National Institutes of Health (NIH) and has a searchable database of drugs on the market.

Centerwatch - Clinical Trials in Psychiatry/Psychology - This contains a searchable database of currently active and completed clinical trials by condition. CenterWatch is a publishing company that focuses on the clinical Trial Listings industry. The information provided in this service is designed to help patients find clinical Trial Results that may be of interest to them, and to help patients contact the centers conducting the research. CenterWatch is neither promoting this research nor involved in conducting any of these Trial Listings.

ClinicalTrials.gov - ClinicalTrials is a registry of federally and privately supported clinical trials conducted in the United States and around the world. ClinicalTrials.gov gives you information about a trial's purpose, who may participate, locations, and phone numbers for more details. This information should be used in conjunction with advice from health care professionals.

MAOI's - Monoamine Oxidase Inhibitors

Monoamine Oxidase Inhibitors - or MAOI's increase levels of neurotransmitters in the brain, known as monoamines (serotonin, norepinephrine, and dopamine), by blocking a protein known as monoamine oxidase, which is normally responsible for burning them up. Increasing the level of monoamines in the brain has been shown to reduce symptoms of depression. MAOI's are powerful antidepressants.

MAOI's have been shown to have serious side effects, most notably a sudden, sometimes fatal, increase in blood pressure. Consequently, MAOI's are sometimes considered the last-resort antidepressant for serious cases.

Tricyclics

Tricyclics are less commonly prescribed now due to the development of newer antidepressants which are considered safer. Tricyclics work by blocking the re-uptake absorption of two neurotransmitters - norepinephrine and serotonin in the brain.

Side effects of Tricyclics include increased heart rate,blurred vision, dizziness, confusion, constipation, urinary retention, drowsiness, and sexual dysfunction.

Tricyclics can be highly toxic at high doses. However, they are still prescribed in serious cases because of their efficacy.

Bupropion

There are three neurotransmitters in the brain called serotonin, norepinephrine and dopamine. SSRI's increase the levels of serotonin in the brain but not the other two.

Bupropion increases the levels of the other two neurotransmitters - norepinephrine and dopamine - in much the same way as SSRI's, by acting as an absorbent inhibitor.

Bupropion is often prescribed as an additional medication when SSRI's - which increase serotonin, are ineffective at treating depression.

Bupropion is also commonly used to treat nicotine-withdrawal effects for smokers who are trying to quit.

Unlike SSRI's, Bupropion does not normally cause weight gain or sexual dysfunction. However, side effects do include an increased risk of seizure.

Common brand names for Bupropion include Wellbutrin or Zyban.

SNRI's Serotonin Norepinephrine Re-uptake Inhibitors

SNRI's work by increasing the levels of two of the three neurotransmitters in the brain - serotonin and norepinephrine. SNRI's have reportedly increased efficacy over SSRI's - which only work on serotonin - with comparable side effects. However, there is an additional risk of withdrawal symptoms associated with the use of SNRI's

Commonly prescribed SNRI's include Effexor and Cymbalta.

SSRI's - Selective Serotonin Reuptake Inhibitors

Selective Serotonin Reuptake Inhibitors, are the most commonly prescribed antidepressants for people who suffer from personality disorders. Popular SSRI's include Celexa, Lexapro, Prozac, Paxil, & Zoloft.

SSRI's relieve symptoms of depression by blocking the re-absorption (re-uptake) of a neurotransmitter in the brain called serotonin. More serotonin in the brain has been shown to improve mood.

SSRI's are generally considered milder than other types of antidepressants. Therefore, SSRI's are typically the first line of approach for practitioners.

Side-effects include: nausea, sexual dysfunction, headache, diarrhea, nervousness, rash, agitation, restlessness, sweating, weight gain, drowsiness and sleeplessness.

Yielding Control

Relationships with people who suffer from personality disorders are often all about control. There is an underlying struggle for control between the personality disordered individual and the Non-PD.

One of the necessary ingredients for recovery of a personality-disordered individual - and perhaps one of the most difficult, is to relinquish control of the relationship and to give the Non-PD back control over their own life.

Some key areas of control which may need to be yielded include:

• Relationships - who the Non-PD is allowed to interact with, how and when they associate with others and how often.
• Interests - Social groups, churches, hobbies and activities which are attractive to the Non-PD but which may not be a priority or of value to the personality-disordered individual.
• Finances - How the family finances are budgeted, what takes priority and how to resolve conflicts.
• Children - How children are cared for, how they are disciplined, what freedoms they are allowed and how medical and educational decisions are made.
• Roles & Responsibilities - Who does the chores and when, who is responsible for what, what to do when there is an unexpected issue or problem.
• Household Rules - What is acceptable and unacceptable behavior. What boundaries are to be respected so that everybody can feel safe.
• Freedom of Independent Thought - Allowing others to believe what they want, think what they want, like and dislike what they want.

If someone is working on recovering from a personality disorder, yet is not able to yield control over these and similar issues, there is likely to be conflict down the road.

Self-Work

The second necessary ingredient of real recovery in a personality-disordered individual is self-work.

Recovery from a personality disorder is not a sprint but a marathon. And just as it is impossible to run a marathon without putting in a lot of self-work over a long period, it is impossible for a person to recover from a personality disorder without a sustained, determined and costly personal effort.

It is impossible for one person to do the training for someone else who wants to run a marathon. Likewise, it is impossible for a non-personality-disordered individual to do the critical work on behalf of another person who is trying to recover from a personality disorder.

Longevity

Because of the rapid, dramatic mood swings that personality-disordered individuals sometimes experience, it can be difficult to tell whether a change in their behavior is evidence of a substantial improvement or just part of the normal up and down of their feelings.

Perhaps the most reliable indicator of real recovery in a personality-disordered individual is longevity.

Whenever you observe a significant change in behavior from a person who suffers from a personality disorder, you should always ask: "How long ago did this happen?" Changes which last 12 months or more may be indicators of a significant long-term shift.

The 12 month threshold may seem over-conservative, but it is necessary in order to observe the effects of

• Seasonal events - including the effects of climate changes in spring, summer, fall and winter.
• Personal events - and holidays including Birthdays, Christmas, Easter, Mother's Day, Father's Day and important anniversaries.
• Circumstantial events - including financial worries, employment stress, disappointments and opportunities.

Changes lasting shorter than 12 months and much shorter durations - such as weeks or days, are more commonly part of the normal ebb and flow of the personality-disordered person's changing moods and emotions.

Acknowledging the Problem

As with many things in life, acknowledging that there is a problem is often the first step in recovery - and sometimes the most difficult.

Stigma - Coming to a point of acknowledging that you may suffer from a mental illness is a tremendously courageous thing to do - and many are afraid to do that. There exists a social stigma about mental illness that often makes it harder to acknowledge than physical illness.

Swallowing your Pride - Acknowledging that your words and your actions may have hurt others is equally difficult. There may be reparations to make. You may have to turn from blaming others to blaming yourself. It takes great courage and humility to do this.

Fear of the Unknown - it's normal to feel afraid of things which you do not understand or know well. When it comes to seeking help for a mental illness it is even more so. Baring your soul to strangers who will analyze you, observe you, possibly judge you. Possibly spending time in a mental health facility or coming into contact with other mentally ill people. Taking medications which may have unwanted side effects. These are all frightening ideas to most people.

Elements of a Successful Recovery

Just as it is important to understand that not everything that looks like a recovery is a real recovery, it is equally important to understand that not all attempts at recovery are false.

It is a commonly held myth that nobody ever recovers from personality disorders.

People do.

There are many who do commit themselves to recovery, make a genuine effort to stumble and fight for themselves first - and for their loved ones second. You will find many such people in recovery groups. 

Most successful recoveries for a person who suffers from a personality disorder exhibit some degree of the following components.

1. Acknowledging the Problem
2. Longevity
3. Self-Work
4. Yielding Control
5. Medications
6. Therapy

The "Cum Hoc Ergo Propter Hoc" Fallacy

"Cum hoc ergo propter hoc" is Latin for "with this, therefore because of this" or, in other words "A and B happen at the same time, therefore A must be causing B to happen". The "cum hoc ergo propter hoc" fallacy is a common mistake in the diagnosis and treatment of medical and psychological conditions.

"Cum hoc ergo propter hoc" is Latin for "with this, therefore because of this" or, in other words "events A and B happened at the same time, therefore A caused B"

Examples of the "cum hoc ergo propter hoc" fallacy:

• The rooster crows every morning, therefore the rooster causes the sun to come up.
• Hospitals are full of sick people. Therefore hospitals make people sick.
• He sometimes behaves violently when I am around him. I don't know what it is that I am doing to make him become so violent.
• When she spends money on herself she seems happier. I need to think of a way to earn more.

The “Cum hoc ergo propter hoc” fallacy is sometimes described as “Correlation is not causation”. In other words, when two events happen at the same time, one event did not necessarily cause the other event to happen. The two events may still be related, but a more thorough investigation is necessary to determine which causes which.

The “Cum hoc ergo propter hoc” fallacy occurs when a conclusion about cause is drawn without considering three possible alternate explanations for the correlation:

1. A 3rd event is the real source of the correlation. Shoe sizes are positively correlated with handwriting skill. One could assume that increasing the size of your feet will improve your handwriting, but the real cause of the correlation is the general developmental growth of children.
2. The direction of causation may be reversed.One could conclude that a railroad crossing bell causes the train to come, but the reverse is actually true.
3. The correlation is purely a coincidence. Mark Twain was born in 1835 - and died in 1910 - both events occurring within days of Halley's comet passing over the Earth.

The fallacy is often referenced using the expression "correlation is not causation"

The "Post Hoc Ergo Propter Hoc" Fallacy

The "Post hoc ergo propter hoc" fallacy is a common mistake in the diagnosis and treatment of medical and psychological conditions. "Post hoc ergo propter hoc" is Latin for "After this, therefore because of this" or in other words "If A happened then B happened, then A must have caused B to happen".

"Post hoc ergo propter hoc" is Latin for "After this, therefore because of this" or in other words "If event B happens after event A, then A must have caused B to happen".

Examples of the "post hoc ergo propter hoc" fallacy:

• A train always passes after the railroad crossing alarm sounds and the gates come down. Therefore the railroad crossing causes the train to pass.
• I wore my purple sweater and my team won against all the odds. Therefore I am going to wear that sweater to every game.
• Most divorced couples go to see a therapist before they separate. Therefore going to see a therapist will increase the chances that you will get a divorce.
• Children of divorce, on average, perform poorer academically. Therefore, if you get a divorce you will hurt your child's chances of going to college.
• Since we moved in together she has become very depressed. I feel like I've ruined her life.
• Since I stopped smoking we haven't had an argument. Who knew the answer could have been so simple?