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Adaptive Anger – a homeostatic factor in psychotherapy

October 29th, 2009 by Robert DePaolo | Posted in Psychotherapy | No Comments » | 2,942 views | Send article | Print this Article |


Abstract

This article discusses anger as a psycho-biological adaptation and suggests ways by which to utilize and incorporate it into the counseling process. Anger is further discussed as a homeostatic adjustment by which anxiety, depression and ego diffusion can be temporarily ameliorated in order to facilitate symptomatic improvement and self-restoration for the client.

Anger has various connotations in both social and clinical circles. It is often viewed as a destructive emotion, leading to aggressive behaviors that are antisocial in nature and must be avoided at all costs. Raised voices, defensiveness and a caustic mood are often causes for concern and in some cases, legal intervention. Children are often taught to walk away, count to five, “not let it upset you” and use various anger-avoidant strategies rather than express this particular emotion.

Interestingly, anger is accompanied by an increase in norepinephrine (Ax, Bamford et al 1969) a neurochemical, that is, within the domain of physiology and behavioral science, considered quite beneficial. Indeed Stosny (2008) has referred to it (and to anger) as a “psychological salve” that numbs both physical pain and psychological distress. Norepinephrine also enhances attention span (Biederman & Baldesarini, 1993). It has been used successfully in treating depression (Delgado 2002), obesity, addiction (Hodziak,2002), and panic disorders (Sanacura, 2002) and has been discussed by Korn as a substance that improves motivation, energy, interest and concentration (2002). Without it we could not set and meet goals, defend ourselves, attain a focus, fight disease, overcome fear or remain resilient in the face of duress.

The effectiveness of norepinephrine as a treatment for respiratory, skin, neurological, cardiovascular and gastrointestinal disorders is well documented, but its range extends beyond that. It is more broadly a curative, homeostatic facilitator that has been shown to trigger or facilitate immune responses throughout the body (Kohm 2000), (Zhiping, Oben et al, 2005). It is a restorative substance with enormous evolutionary value, since by masking discomfort it enables organisms (including therapy clients) to continue functioning despite injury or duress.

Norepinephrine has one other benefit with significant implications for the treatment of psychopathology. It provides the invaluable benefit of experiential continuity. By inhibiting the re-absorption of neuro-transmitters, it facilitates the passage of neuro-chemical signals among brain cells. This smooth transition provides a neurochemical substrate of “hope” by allowing neuronal activity to continue unfettered. That means that with sufficient norepinephrine volume the brain will continue on its connective path to the next neuronal cluster, then to the next – and so on. That increases the likelihood that a person will be able to extend his thought process, which in turn increases the likelihood of attaining perspective, or, in effect “seeing light at the end of the tunnel.” With that he can transcend the impact of any given immediate and stressful experience. Conversely, a lack of uptake inhibition would attenuate experience, which would increase and exacerbate the singular impact of any given experience. In simpler terms norepinephrine dissuades us from making mountains out of molehills.

A Temporary Fix…

There is a problem with norepinephrine. If present chronically in high volume it uses up a great deal of energy, which leads to stress. Thus while an adequate volume is needed to provide the benefits alluded to above, its spike benefit is only temporarily, serving as a means by which a living organism can invoke and sustain some necessary behavior or physiological adaptation despite a weakened body or depleted mental state. In that sense norepinephrine is, as Stosny suggested, the source of an important defense mechanism (anger) enabling organisms to compensate in the face of vulnerability.

Norepinephrine, Anger, Efficiency and Adaptability…

It is well known that norepinephrine is a pervasive neurotransmitter that operates somewhat ironically. Since it arises from the endocrine system its affects on brain and body are global.  Yet while that might imply a non-specific effect on functioning, the opposite is true. An increase in norepinephrine actually creates an enhanced focus, almost to the exclusion of peripheral stimuli in the immediate environment. The stimuli upon which the individual is focused become more vivid, target-friendly and operant – in the sense of being acted upon more efficiently.

That has clinical implications. Despite its negative social connotation, norepinephrine-fueled anger provides resolution within the mind/central nervous system because it sidesteps complexity, confusion, uncertainty and inhibition. Since uncertainty and inhibition are well documented antecedents of anxiety and psychopathology (Masserman, 1971), anger is, in a psychophysiological sense, at least temporarily adaptive.

As with many emotions, anger serves two masters: first the internal environment (within which it provides enormous homeostatic benefit), second, the external environment (where it tends to invite disapproval).

In light of that, questions about use and proportion come to mind. More specifically; can  norepinephrine/anger be used in counseling, not just in terms of acknowledging and redirecting anger, but also in soliticing, orchestrating and sculpting anger to stabilize clients, dull the pain of duress and ultimately foster growth?

Anger as a Tool in Therapy…

The idea that anger can be used to facilitate positive outcomes in therapy is certainly not new. Andrew Salter, the originator of assertive therapy, used anger as the raw material from which socially acceptable, assertive behavioral skills could be taught. His method was based not on the prophylactic value of anger as suggested here, but on the Pavlovian principle of reciprocal inhibition, which states that anxiety and anger cannot be activated simultaneously in the central nervous system and that the activation of one blocks activation of the other (2001). Davanloo (2005) also incorporated anger into an abbreviated psychoanalytic methodology through a rapid rage-inducing catharsis.

However, for the most part anger has been more interpreted, redirected and corrected than actually used in clinical practice. Seldom has this emotion been viewed as an adaptive device. In fact, the one method that does utilize anger – assertive therapy – has received a fair amount of criticism (McCartan & Hargie 2004), Grenander (1981).

In light of the need to incorporate social mores and the need for self regulation into the clinical picture one could ask whether there is a way to use anger in a dynamic, rather than strictly behavioral/tactical manner (as with assertive therapy) to facilitate the processes of emotional healing and growth. Before addressing that question, some aspects of anger must be considered, particularly with regard to the factors of self-regulation  and homeostasis.

The Importance of Psychic Stability…

As Freud suggested, all clients come into the counseling process with two problems. One is external, i.e. how well they function and/or are perceived within their social environment. The other is internal, i.e. how they feel under certain social circumstances, and more specifically, what is occurring in their central and autonomic nervous systems. The Greek philosopher Democlitus once said (in paraphrase), “Nothing affects man but his own interpretation of events.” This notion was adopted by Albert Ellis in developing the Rational Therapy format. While some might argue that the Ellisonian premise is a bit simplistic, or that the correlation between external stimuli and internal reactions is so isomorphic as to override the “self-talk intervention” that is typically used in this approach, it is difficult to challenge the idea that the outside world is different from the inside world. Since there is a temporal and linguistic-cognitive separation between the two, one can consider them separately.

Homeostasis is always the goal of the internal environment. Keeping emotions, arousal levels and neuro-humoral volume within limits is what we all strive for. Sometimes that coincides with the expectations of the outside world and sometimes it doesn’t. For the person who achieves high moral and performance goals, there is an internal satisfaction resulting from those achievements. In other words there is congruence between social behavior and internal reactions.

For others, the internal and external world might not coincide. For example an individual with a violent streak who feels alienated, threatened and detached might only attain psychological stability by hurting or dominating others. Through pathological control of people and events he can preclude the possibility of threat or personal harm. In that case, psychic stability is maintained only by acting in ways that create instability in the social environment.

One could argue that inappropriate social behaviors always work against the person employing them and that any stability derived from them can only be temporary. That argument would certainly apply if the individual could not insulate himself against social feedback and override its potential impact on stasis. It would not apply if the individual formulated a world-view (i.e. schemata) to support antisocial but internally satisfying behaviors. As all clinicians are aware, that type of ego-insulation does often occur in clients. Indeed the combination of behavioral impropriety and psychic insulation could reasonably define many characteristics of psychopathology.

Resolution to the internal/external problem is not easily attained. Perhaps that is because it is really a question of proportion. In that context, one could ask whether an approach using anger as a temporary prophylactic against internal duress could, if appropriately sculpted, lead to improved social functioning and adaptation?

Methodology: The Client Presents himself…

Many clients enter the counseling office as they would a law office – as “Plaintiffs.” Their complaints often revolved around persons or circumstances that create a discomforting emotional state and/or unfortunate set of social circumstances. Some clients are angry and resentful, some are despondent and feel helpless. In that case it is conceivable that the angry clients are at that point more adaptive and homeostatic than their passive counterparts. Ostensibly, anger makes their psycho-immune system stronger.

This could be true for several reasons. First, the self can be a source of stability, growth and adaptation. The angry client often believes in himself, at times to the point of being narcissistic. Based on that, one can assume he has more psychic integrity and energy than the despondent client as he enters into the counseling relationship. He will also tend to be more focused.  Indeed, the fact that he blames others is a result of that focusing capacity. Thus he might be more capable of setting goals.

That doesn’t necessarily mean his pathology is less severe. The despondent or passive client might have a mild pathology requiring less compensatory anger; a pathology that can be overcome with brief counseling and some astute cognitive restructuring. Yet with severity on both counts, the angry client might tend to be more functional.

Intervention…

Those considerations can help the counselor formulate a first diagnostic impression. e.g. how homeostatically functional or dysfunctional the client might be upon entering therapy. More to the point, the question could be asked: Is the client angry and self supportive enough to override the impact of stress, summon the energy for therapeutic work and warrant an optimistic prognosis?

The process of supporting the client’s anger and self-support mechanisms would, in the course of therapy dovetail with the need for changes in the client’s behavior and schema. It would be a gradual process whereby the client’s anger would be “surfed” rather than confronted or re-directed immediately. With regard to a counseling topography, the client’s rants and raves could be dealt with in a quasi-Rogerian manner that goes beyond the typically phenomenological Rogerian method. For example while Rogerians typically reflect clients’ statements without challenging their anger-laden percepts, this method would consider anger to be a necessary adaptation. For example a counselor might state…

“I can see why you’re angry. In some ways that might be a good thing. People get angry for a reason.” It probably keeps you above water. I’m not going to challenge your anger or ask you to calm down. Instead let’s see if we can put it to good use.”

As the counseling process unfolds and the client’s perspective broadens, he would hopefully assimilate the good and bad in others, himself and his circumstances. At that point the anger would tend to be subside quite naturally – as does the volume of norepinephrine when physical and psychological threats are removed.

To reinforce the de-escalation of anger the counselor could (in typical cognitive therapy fashion) begin labeling the transition. For example

”You were a lot angrier when you first began counseling. It seems that now you don’t need your anger as much. That’s probably a good thing because while anger can fortify clarify, it can also be exhausting.”

As resolution begins to permeate the psyche, the need for an anger prophylactic would diminish. At that point a new homeostatic level will have been established, hopefully with congruence between the internal and external environments.

The interactive features and vocabulary inherent in this approach might not be any different from those used in cognitive, psychoanalytic or other dynamic methods.  Moreover there would be no “script” or life-style cue words for future adaptation. This method would focus on a dual concern for internal stasis and environmental behavioral efficiency. It would advocate that anger has restorative, curative potentials that can, if properly utilized, prevent deeper pathologies from developing, keep the client stable and  enhance the therapeutic process.

Counseling in this context need not be esoteric. It could be didactic. A client could be coached on the benefits of self-supportive anger under duress. For example…

“If you’re susceptible to severe episodes of depression and find yourself getting angry at others prior to the onset of an episode, don’t be too concerned. Anger might be the lesser of two evils. It is a strong emotion with curative potentials and sometimes one needs to be strong – one needs a shield – in the face of adversity.”

However, indoctrination into the “benefits of anger” would not be necessary, nor, considering its potential to create tumult, even appropriate. Certain ethical and clinical criteria should be applied by the counselor. A sample template might be as follows:

Accept anger when it occurs and support its expression, on the assumption that it is neither right nor wrong, and only to the extent that no threat or harm is implied in the language.

Solicit anger when it is covert or absent, observing the client to see if anxiety crops up. If this proves to be ego-alien, discontinue the method.

Inform the client (as would a physician with a medical disorder) that anger is a useful, helpful and adaptive defense and will perhaps only subside when healing has occurred.

For example:

“You don’t seem as angry. Your language and tone seem more benevolent.  Perhaps that means your life is getting better.”

A Caveat: The Passive Client…

Clients who do not present with anger could present a variety of challenges for the counselor interested in using this method. Clients who display no overt anger might harbor suppressed anger, which can be drawn out in therapy and prove cathartic. Others might be fearful of their own impulses, in which case anger might be completely ego-alien to them. Consequently, the clinician must take into account that anger-sculpting will not be useful in all instances.

Even for clients comfortable with the anger response, caution would seem appropriate.   While anger is restorative, words that convey threat, self harm or other antisocial acts must be dealt with in socially and clinically ethical ways. One the other hand, language that implies self justification, resentment, even some choice epithets could be incorporated into the method and viewed as temporarily adaptive and necessary – even if somewhat obnoxious.

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