Setting Effective Treatment Targets for Angry Patients

We've been focusing on addressing anger and rage for the past several weeks. Before we move on to other topics, let's think about how to set effective treatment targets. I thought I'd end the anger/rage sub-series within "Free Range Psychology" on something that you might consider trying at home.

Consider the phrase, "Make love, not war." Lean in close and you will hear the faint whisper of…a very basic psychological theory. The theory is that it is more difficult to just stop a behavior instead of replacing the undesired behavior with a healthier behavior. Habit replacement therapy - in the cognitive behavioral therapy tradition - banks on this principle.

To take a simple example, let’s say that you want to kick a soda habit. You could probably increase your odds of success by switching to seltzer water any time you would have had a soda rather than just telling yourself to simply stop drinking soda. Trichotillomania, which is the impulse to pull one’s hair out, is often very hard to treat. However, I have seen habit replacement therapy used to good effect in this and other stubborn conditions.

In fact, habit replacement therapy can be deployed to help us overcome a variety of compulsive or addictive behaviors, including snapping in anger at others in our lives. Specifically, for some patients, it is helpful to craft a treatment mission to learn to “wage peace” rather than to “stop blowing up at people.” Perhaps it is easier for us to make effective advances when we have an active target.

To help set this mission, what I might ask is for my patient to identify an emotionally safe person they know well who is very good at waging peace. What is waging peace? I’m not aware of any official definition, so here is my working definition: it is the thing that you do when you want to unleash your rage but instead you dig deep, and generate creative solutions rather than simply trying to annihilate a perceived threat. It’s what you do when you value relationship over being right or the instinct to dominate others.

The phrase “waging peace” suggests doing something active – it gives us an identified treatment target. At the same time, it is an odd combination of words that can cause mild cognitive confusion which sometimes gets the mind thinking more creatively. Framing the goal this way may help put patients in a curious stance as they think about the various people they are close to and who is unusually good at the target task – “waging peace.”

Once they have identified such a person, the next step is for the patient to go to that person and recruit their help in the mission at hand. They explain what they hope to do (learn to “wage peace”) and why they are asking that person to help them with this effort. What they essentially ask is for that person to discuss with transparency what they do to wage peace when that is not the easy choice. Waging peace is not easy for any of us – some of us have just had more practice at developing this skill than others. I also encourage them to ask that person to come alongside them and mentor them in this work - maybe like a temporary AA sponsor that they invite to give them feedback as they try to make different choices.

A safe and trusted person can be an incredible asset for stimulating the growth of new behavior - an asset that mental health professionals too frequently overlook. To recruit the support of a person that a patient has deep love and trust with can help change behavioral patterns that we sometimes mistakenly perceive are a fixed part of who we are.

A mental health professional might be able to share information about how he or she “wages peace” but, in my experience, it won’t land as deeply as hearing it from someone that the patient really cares about in their private life. And teaching this solely in a classroom format (e.g. psycho-educational group) may have relatively limited efficacy as well. The difference I have observed here mirrors the difference between the language acquisition a child picks up from passively watching sesame street in spanish relative to a loved one communicating spanish directly to them in a living, breathing, personal way. Moreover, the accountability loop that is created in this kind of formulation can make all the difference.

Ultimately, the humbling truth that I believe we must integrate is that people don’t change for their mental health counselors.They change because their behavior impacts the people that they do life with outside of the therapy space. If we really integrated this understanding, both as providers and consumers of mental health services, it would change our entire approach to a number of mental health concerns. But that's a topic for another day.

References

Azrin NH, Nunn RG (November 1973). "Habit-reversal: a method of eliminating nervous habits and tics". Behav Res Ther. 11(4): 619–28.

Bate, K.S., Malouff, J.M., Thorsteinnsson, E.T., & Navjot, B. (2011). The efficacy of habit reversal therapy for tics, habit disorders, and stuttering: A meta-analytic review. Clinical Psychology Review, 31 (5), 865-871.

Gupta, S. & Parshotam Dass, G. (2012) Habit Reversal Training for Trichotillomania. International Journal of Trichology, 4 (1), 39-41.

? Shauna Springer, Ph.D. (2016).