Recently a man in his fifties came into my office and said, "Doc, you have to fix my wife." He went on to say, "She is really aggravating me because when I come home from work tired, angry and in a bad mood she doesn't even give me a hug. In fact, she just goes into the kitchen."

This client is like so many that present with issues involving anger. They show little or no responsibility for the outcome of an angry interpersonal encounter. It is always somebody else's fault. In addition, the person they are angry at is generally described as worthless, evil or morally impaired. Lastly, these individuals have God on their side. How many times have you heard some variation of the following: "It is all John's fault. He is a worthless ... and God knows I am right?"

One of the first things clinicians learn is that change is possible when a person takes responsibility for the problem and has some desire to change. At first glance, neither of these attributes is present. Only after discrepancy is developed between reality and the client's perception of reality can movement toward positive change take place.

Everyone gets angry. Sometimes the anger is justified and at other times, it is not. It is important to consider the outcome. If the anger is used in a violent way to hurt others or if it leads to aggression, then a problem exists. Although anger can supply short-term reinforcement, in the end it has a detrimental effect on interpersonal relationships, parenting and academic and professional achievement. Where does this anger and aggression come from? Many causes include genetics, medical problems, psychiatric disorders or old developmental themes from abusive childhood experience.

Certain character traits often associated with aggressive behavior include irritability, restlessness, vindictiveness and impulsivity. Numerous scientific studies have indicated that reduced serotonin levels and resulting impulsivity is a factor in aggressive acting-out.

Personality traits also contribute to anger and aggressive behavior. People who do not think highly of themselves become anxious and depressed, not aggressive and violent, when they think others are humiliating or threatening them. Egoists and narcissists are more likely to respond aggressively, partly to avoid having to suffer shame, loss of control or a loss of their high opinion of themselves.

Anger and aggression represent emotions and behaviors that psychiatry and psychology has struggled with over the years. The three core emotions are depression, anxiety and anger. The Diagnostic and Statistical Manual of the American Psychiatric Association categorizes both depression and anxiety in lengthy detail devoting whole chapters to anxiety and affective disorders.

However, no section in this manual categorizes anger or aggression. Anger and aggression are described as symptoms of numerous psychiatric disorders. For example, aggression in DSM-IV is described as a symptom of bipolar illness, paranoid schizophrenia, alcohol and drug toxicity, impulsive personality disorders and a multitude of other conditions. Anger and aggression are very problematic when the occurrence is secondary to personality disorders. These disorders include Borderline Personality Disorder, Narcissistic Personality Disorder, Paranoid Personality Disorder, and Antisocial Personality Disorder. Here anger and aggression appear to be more traits of temperament than a symptom of some underlying disorder.

Clinicians can recall encounters with clients who have been diagnosed with Borderline Personality Disorder. I recall a client walking into my office and verbally assaulting me. When I asked her what the problem was she stated, "I hear you are angry at me. Do you want to sit down and talk about it?" In reality, I had not been thinking of this client at all. This individual had projected her own feelings and now she truly thought her feelings were mine.

Aggression is rarely an event. Frequently it is a process that builds over time. Although there are exceptions such as Intermittent Explosive Disorder, and so it is therefore critical that the clinician is able to assess any potential buildup of anger and pending aggression. Since aggression develops over time, there are many points at which a counselor can intervene. Taking advantage of these opportunities is often the difference between managing a situation effectively and having to handle a crisis.

The most important area of any assessment process involves the clinician's understanding of his or her particular counter-transference response. Personal issues that might cause the therapist to react subjectively can influence proper client assessment and management.

Frequently, I have observed clinicians who have ignored symptoms that were leading to an angry or aggressive action. As soon as the anger or aggression built toward a boiling point, these clinicians have such an overwhelming subjective experience to the potential aggression that it is only comfortable for them to remove themselves from the situation.

The issue of character also seems to come into play in these situations. Upon many occasions, I have noticed that certain staff members can walk into a room full of acting-out clients only to watch the behavior escalate. On the other hand, I have noticed certain staff members who can walk into a room with "all hell breaking loose" only to have a calming effect on the clients.

It is critically important for the clinician to question the client about his or her previous history of aggression and violence. Many clinicians are afraid to ask these questions as if the asking of the question might hasten some violent episode. It is important to know your response and ask tough questions such as "Do you have a history of violent behavior?" When there is a history of past violence, the clinician should use common sense.

Never have your first session in the evening when you are the only clinician in the office. Make sure that your colleagues know about the client's history and ask them to pay special attention to the situation. It may even be helpful to keep your office door open during the first sessions.

It is difficult to predict violence. The leading predictor of potentially violent behavior is a history of violence. Add to this co-occurring psychiatric illness and alcohol and drug disorders and the fuse becomes shorter. Also, ask questions about the client's current social and work situation. If there is family disruption, difficulties on the job including being fired or laid off, or any other situation that the client defines as a personal loss, make sure that these issues are taken into account.

Possibly the scenario that presents the greatest potential for violence occurs when the client has a history of aggressive behavior along with certain psychiatric illnesses, including alcohol and drug abuse, during a time when stressful life situations are present.

To successfully treat the angry and potentially aggressive client, the clinician must first establish a relational platform to work from. A relational platform refers to the initial phase of treatment where the relationship between the patient and clinician is being established.

Two issues are important here. First:

• Establishing rapport with the patient

  For example, during a multi-family group a physically developed young man told me that he was going to break my head. What I said to him was this, "Whatever you do, don't stop acting the way you are because you know it has saved your life."

  I also stated, "I would like to talk to that part of you that made a conscious decision to never let anyone hurt you again."

  The client's background included physical abuse at the hands of his father. He had an issue with authority and historically had problems with male authority figures, but had at least ten peers with whom he drank and did drugs. This young man started to cry. I was in no way oppositional but was congruent with his mindset. The client truly believed that his anger was justified. What would have happened if I told this young man, "Cut that crap out or I will kick you out of this program"? This response gives the client only two choices. Since I was incongruent in the response he could either be compliant or he could choose Door Number 2 and really act out. If he were around his peers the choice most often would be the second door.

  I have worked with clients in group whose anger and aggression are a coping and survival skill. Generally, this is accompanied by an altered worldview. When someone gets too close, they fear getting hurt. They may see the world as an unjust place. The decision to not let anyone get too close is a conscious decision made generally between the ages of 8 and 16.

  When asked when she made a conscious decision never to let anyone hurt her again the client responded, "My mother and father fought a lot. When I was 11, I decided to not deal with this anymore so I ran away from home." Her coping strategy involved running away or withdrawing from stressful situations. Even in group when the heat was turned up she would actually push her chair back 18-24 inches out of the group circle.

  A young man once told me, "I remember being 12 years old and I heard my father on the steps. I knew he had been drinking and was going to hit me again with a belt. I decided that he would never hurt me again and when he came into the room I tried to kill him." Turn the pressure up on this individual and he would dare you to get close.

The second issue that must be understood and agreed upon is:

• Setting limits

  In a clinical supervision group was a young man whose first job was working with adolescents in a juvenile detention environment.

  One day during group he announced that he was adding new rules for his detention group because the kids were out of control. Like a comedic routine, he pulled a piece of paper out of his pocket and began to tell the group about 18 new rules that he designed. One of them was that the group room window could only be open during the spring, summer and fall and only when it was above 55 degrees, but never when it was raining.

  Overly strict rules increase anxiety and ultimately increase the acting out. On the other hand, a woman in the same group was proud to state "My clients never leave me." She lived vicariously through her clients and saw them in her home seven days a week. Each patient had her home number and was free to call at any hour.

  A loose set of limits makes it more difficult to get clients under control. They continue to drink, drug and act out. I believe that if you are going to help others heal that you must have a healing role within yourself. In this case, the therapist could only demonstrate a sick role.

  The object is for the clinician to be a good parent. This involves being fair, consistent and available. The rules should be so simple that even the staff can understand them. Staff as family or therapist as parent must apply these rules in a consistent manner and remain available to the client in accordance with the client-therapist contract.

Clients do not always present with a clearly defined psychiatric disorder, but might have histories of early life abuse or neglect. In situations where anger and rage are clearly symptoms of some underlying psychiatric disorder, the treatment of the disorder is approached first. In cases of early life neglect or abuse often the anger and aggressive behavior is used as a defense strategy and the anger and aggression can even be considered as a learned coping and survival skill.

When developing the treatment plan, three areas must be approached. These general areas to be addressed are the environment, medication and the use of psychotherapy.

1. Environment
   

   It is obvious that if you put a person back into a situation where anger and aggression are prevalent and the client has chosen these coping strategies as a means of surviving, that the group and individual skills taught in a safe place such as group have little chance of sustained success. Often the physical environment cannot be changed but the support network can. Church, Big Brothers and Big Sisters, YMCA, YWCA, mentor programs and school-based programs allow the clinician to spread the transference. These institutions and organizations can give support and model more positive problem solving strategies.

   These approaches are also helpful for clients who suffer from developmental immaturity and problems of attachment (i.e., the 18-35-year-old who acts like an 8- year-old and has no history of positive attachment to a role model). Often these clients may need "wrap around" services such as housing, medical services, childcare, vocational training, educational opportunities, HIV/AIDS treatment and support, etc. The best approach for this multi-system, multi-problem client is a concrete, behavioral skills building regimen that uses peers to experientially learn how to navigate their environment.

2. Medications
   

   As previously mentioned, medications can be used to treat any psychiatric disorder where anger and aggression are symptoms. If the anger and aggression still exists, or in cases where there are no overt psychiatric disorders but anger and aggression is a featured problem, the use of mood stabilizing drugs has been helpful.

   These medications include Lithium, Tegretol, and Depkote. Lithium, in particular, is an effective medication for mood swings where anger and impulsivity lead to aggressive behavior.

   Lithium was used in a double blind, placebo-controlled clinical trial with prison inmates. By the end of the third month subjects treated with lithium carbonate showed reduction to near zero in aggressive-impulsive behaviors.

3. Psychotherapy
   

   Behavioral strategies are effective in managing someone who is angry and potentially aggressive. I have refrained from solution-oriented cognitive approaches since asking an angry client how he would know that his relationship with another young man was improving. He stated, "When Charlie gets up off of the ground and I can hit him in the face again."

When working on anger and aggression in a group or individual setting there are strategies that have been empirically proven to be effective. These strategies are:

The goal of implementing relaxation strategies is to reduce emotional and physiological arousal. Typically these techniques are started early in treatment and complement other approaches.

The clinician should stay away from imagery techniques especially early in treatment since certain images may evoke anger and aggression. These images can be used later in treatment to evoke anger and allow the patient to practice learned techniques such as deep breathing, voice tone and tempo changes, and progressive muscle relaxation. The client can also use role-play to evoke the emotion and use the scenario to practice new strategies.

Cognitive interventions are designed to reduce anger inducing information and internal cognitive prompts. Cognitive approaches can be helpful when teaching a client how to think through a problem and design an action plan. Cognitive restructuring can help the client increase their awareness and acceptance of self-defeating pre-conscious thoughts. Positive counter responses can be developed and rehearsed. These new counter responses can be practiced during anger invoking imagery or role-play.

The goal is to change angry aggressive behavior to more adaptive behavior. Numerous interventions are helpful and include modeling, coaching, rehearsal reinforcement, role-play, problem solving, assertiveness training, negotiation and interpersonal skills building.

The use of humor is another approach. When describing an antagonist, an adolescent client said, "He is a real flaming asshole." I asked him to draw a picture of a large butt with flames coming out of it and from that point on when he saw the individual he would laugh as he recalled the drawing.

Many clients have histories of early life developmental pain. When a situation triggers the old fear provoking remembrance from the past, the cognitive, behavioral strategies generally will not stop the angry response. The old fear pushes through.

In these situations, insight oriented therapy or approaches such as EMDR may be extremely beneficial. Grief work, especially a letter-writing technique that helps the client approach the perpetrator at their own pace, may produce the desired outcome of moving the client from there to here or from subjectivity to objectivity. In other words, the client is able to see the situation through adult eyes as opposed to the eyes of a child.

To be effective in diffusing the angry client, the clinician needs a tool bag that includes many approaches. Anger and aggression is a multi-determined phenomenon. There is no one approach. If you see a book titled 10 Easy Ways to Solve Your Anger Problems, please don't believe the premise. There are no easy ways or menus for success. Every client has his or her own history, genetics, and ways of looking at a situation.

Hardening of the categories and clinical psycho sclerosis on the part of the clinician is a recipe for failure. Understand the client's map of the world, your own personal issues, establish a relationship, and have a flexible approach when it comes to clinical strategies. 

Cardwell C. Nuckols, PhD, is president and chief
operating officer, American Enterprise Solutions, Inc.,
president Cardwell C. Nuckols and Associates, Apopka,
Fla., and author of Healing an Angry Heart, HCI.

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