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    As shall be demonstrated in this series, cultivating the quality of deep-seated contentment constitutes a key cornerstone in integrating a wellness mindset and lifestyle into recovery from alcoholism, drug addiction, and other addictive disorders. 

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  • National Perspective

    Over the past few years, the federal government has made a noticeable investment in fighting opioid abuse. Traditionally this subject was the purview of federal agencies such as the National Institute on Drug Abuse (NIDA) and the Substance Abuse and Mental Health Services Administration (SAMHSA), or even the Veteran’s Administration (VA).

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Healthy Anger: A Mind and Body Approach

Feature Articles

Addiction, regardless of the form it takes, is often a distraction from anger and the underlying pain that triggers it. While some individuals with addictions impulsively act out their anger, others avoid and deny it. In effect, substance abuse and addictions serve as a form of self-medication, minimizing uncomfortable emotional states that may include anger. At their core, substance abuse and addictions are just one form of experiential avoidance, that is, “the avoidance of negative inner events such as feelings, thoughts, memories or physical sensation” (Hayes & Strosahl, 2004).

 

 
Consequently, individuals with addictions require skills for constructive anger management, whether their anger is expressed as overt aggression, ongoing hostility, irritability or harsh self-criticism. These skills provide increased emotional resilience to deal with life’s challenges and are especially meaningful during recovery, when confronting anger can easily lead to relapse. Participation in anger management programs for alcohol-dependent clients reduces anger and drinking (Walitzer, Deffenbacher, & Shyhalla, 2015) and are especially indicated for those inclined to suppress their anger (Norström & Pape, 2010). 

 

 
Additionally, the ability to effectively manage anger may be a significant factor in determining whether a predisposition for anger arousal will lead to intoxication aggression following a provocative triggering event (Parrott & Giancola, 2004). With regard to alcohol use, intoxication leads to narrowly focused attention on cues in the immediate moment that might most elicit a perceived threat and resultant aggression (Giancola, Josephs, Parrott, & Duke, 2010).  

 

 
Anger: An Uncomfortable Mind-Body Experience

 

 
Anger, a powerful and challenging emotion, stems from a perceived threat to our physical or mental well-being. Anger is a total mind-body experience, one that is tension-filled and based on the interplay of feelings, thoughts, and physical reactions within the body. How we manage anger—our quickness to anger, the situations that trigger our anger, and how we respond to anger—becomes habit. It is the result of our biological makeup as well as life experiences and their combined impact on the neuron pathways in the brain. 

 

 
Anger is part of the primal brain’s fight-or-flight response and it can help us survive a dangerous situation. But acting impulsively when angry, in an attempt to release the tension of threat, can also be destructive. And substance use can impair judgment, thus lowering the threshold for experiencing threat.  
 
Destructive anger, especially when coupled with substance abuse, can lead to poor work performance, a stalled career, relational conflict, social isolation, depression, and excessive guilt or shame. In addition to ruining relationships, research shows that anger can contribute to illnesses like heart disease (Suls, 2013) and hypertension (Schum, Jorgensen, et. al., (2003). 

 

But good news lies in the brain’s neuroplasticity, the ability to create new neural pathways (Siegel, 2015). Regardless of the habits developed over a lifetime, we are able to reeducate our brains to form new neural connections and break old, negative patterns of behavior.

 

 
In all of its forms, anger can also be viewed as an outgrowth of a need for self-compassion. When angry, we direct our attention outward—on the person or situation that contributes to our anger. In this way, anger diminishes awareness of our bodies and the inherent tension associated with anger: feelings of threat and other negative feelings that precede it. However, it is only by pausing that we can identify the true meaning and message of our anger. Cultivating “healthy anger” enables us to pause before reacting, which can help us assess whether the threat we feel is real or perceived, determine the urgency of the situation, and respond appropriately and constructively. As such, any effective treatment approach needs to include strategies that support calmness in mind and body. These are essential for the practice of healthy anger.

 

 
Healthy Anger

 

 
Throughout my years of work with clients, I have come to observe the very positive aspects of anger and to define specific skills that are essential for the practice of healthy anger. These include the following:
 

 

  • Healthy anger means observing and experiencing anger without being overwhelmed by it and reacting to it.
  • Healthy anger means recognizing our anger as a signal to explore the feelings, thoughts, and bodily sensations that precede it.
  • Healthy anger means viewing anger as a signal to direct our attention inward to identify our core desires, needs, and values.
  • Healthy anger calls for developing self-compassion, which includes skills to enhance our sense of safety and connection.
  • Healthy anger includes developing strategies to let go of anger, which may include forgiving others and yourself.
  • Healthy anger encompasses compassionate practices that don’t cause suffering for others or for ourselves.
  • Healthy anger means learning how to communicate assertively with others.
  • Healthy anger enhances our resilience and overall well-being.
 
 

 

All of the strategies presented in the remainder of this article focus on helping individuals to cultivate the practice of healthy anger.

 

 
A Novel Approach to Anger Management

 

 
The major focus of any anger management program is to help clients strengthen their capacity to activate the rational mind (the “new” brain) so that it overrides the emotional mind (the “old” brain). Yet, few treatments have been developed to specifically address the anger issues experienced by people who abuse substances (Shearer, 2010). Traditionally, such programs have been based on cognitive behavioral therapy (CBT) and include psychoeducation regarding addiction. CBT treatments have been found to be effective, time-limited treatments for anger problems (Vecchio & O’Leary, 2004). Increasingly, in recent years, mindfulness and mindfulness meditation have also become part of such programs (Bowen et al., 2014). 

 

 
The approach I offer is based on a blend of skills from three broad areas of understanding and practice: self-awareness, mindfulness and mindfulness meditation, and self-compassion. Skills in self-awareness offer clients increased understanding of their anger, including the recognition of what they most desire and value. Such awareness is essential for promoting healthy relationships and achieving meaningful life goals. 

 

 
Mindfulness and mindfulness meditation teach us that we can observe our inner experiences without overly reacting to them. These practices help us to experience our thoughts, feelings, and body sensations as temporary, rather than a fixed part of who we are. And they help to expand our freedom to choose how to react to them.

 

 
Practices in compassion for oneself and others help to arouse calmness and make us feel safe (Germer, 2009; Gilbert, 2010; Neff, 2011). It is especially noteworthy that practices in self-compassion offer a powerful antidote to shame and self-criticism, characteristics that are so highly prevalent in individuals dealing with addiction (Luoma & Platt, 2015). 

 

 
A Framework of Anger

 

 
Self-awareness skills help us explore how anger relates to our desires, needs, and expectations as well as other feelings. The framework of anger presented here helps clients recognize the detailed interplay of their thoughts, feelings, and body sensations that precede and accompany anger arousal. See Figure 1. 

 

 

 

efi_15032386473_fig1

 

 


 

 
I teach clients the use of the framework by first presenting the following guidelines.

 

 
Recall an incident that triggered your anger and envision it as if it were on a video recording, including all aspects of the scenario: the setting, the people involved, and their behaviors. Make it as detailed as possible. This video also allows you to observe what occurred in the situation, including your inner experiences during this episode—your thoughts, feelings, and body sensations.

 

 
Clients are then asked to rate their anger on a continuum in which the number one reflects slight irritation and the number ten reflects the most severe, intense anger. I then help them to review their experience and take a moment to note negative feelings that precede their anger, as well as body reactions, inner dialogue, and images that accompany such feelings, including anger. I then support “rewinding” their “video” in an effort to identify the various components of the framework. I provide clients a list of feelings, as the task of identifying feelings is often daunting, especially with a history of ignoring them. 

 

 
By using this framework, clients are assisted in recognizing appraisals: the meaning, implications or conclusions they form as knee-jerk thoughts immediately following the event. A major task of anger management is distinguishing between expectations that may be realistic and those that are overly influenced by emotion—in effect, those that are really wishes and hopes. For example, individuals are helped to understand that rigidly holding on to expectations of how others “should be,” may only contribute to their anger. Most importantly, this framework offers clients a way to identify key desires that may feel threatened, such as the desire for safety, trust, connection or respect. 

 

 
I then provide clients with an anger log, based on the framework, which they could use to review anger episodes. See Figure 2.

 

 
efi_15032386473_fig2

 

Figure 3 provides an anger log completed by a client regarding his being abruptly cut off by another driver on the road. 

 

 
efi_15032386473_fig3

 

By reviewing the log, James, age twenty-four, recognized the range of feelings he experienced when his girlfriend decided she would not yet move back in with him. She indicated that James needed to be in recovery longer before she could trust him. James was helped to also recognize how his past sensitivities to lacking trust as well as his history of self-doubts and shame contributed to his intense reactions.  

 

 
The more frequently clients complete such logs, the more they gain understanding of a specific episode and, most importantly, become more mindful in real time when facing new potentially triggering events. Through this process they are helped to recognize “hot buttons,” personal sensitivities that make them prone to anger. Such recognition offers an opportunity for choice, rather than reaction. 

 

 
Mindfulness and Mindfulness Meditation

 

 
Practices in mindfulness and mindfulness meditation help promote the ability to detach from and not overidentify with our thoughts, feelings or sensations. This calls for learning how to be self-soothing, to accept, to sit with, and to move past the negative mind-body state that is a part of anger. Mindfulness practices have been shown to increase the capacity for directing attention inward and reflection on our internal experiences (Farb, Segal, & Anderson, 2013).

 

 
Typical guidelines for formal mindfulness meditation suggest wearing loose clothing and sitting on a chair or floor. They call for closing the eyes and noticing the breath, at the nostrils or in the rise and fall of the chest or abdomen. Some practitioners find it helpful to place a hand on the abdomen to enhance focused attention on the breath. The practice entails focusing on the breath, noticing inner experiences—whether thoughts, feelings or sensations—and gently redirecting attention back to the breath when they occur. 

 

 
As clinicians, it is especially important to inquire about the details of how clients practice meditation. All too often, meditation may be used in an effort to more fully deny feelings and thoughts rather than observe them. Some practice meditation as if it was a competitive video game and warily push away feelings as soon as they arise. Cultivating an attitude of nonjudgment and open curiosity is a major component of meditation. Additionally, clients should be advised that thoughts or feelings that frequently surface may need further exploration at a later time. 

 

 
Mindfulness, especially as it relates to anger arousal, includes becoming increasingly attentive to body states. All too often individuals with anger issues are as out of touch with their bodies as they are with emotions that trigger anger. By engaging in muscle relaxation exercises clients develop the habit of evoking physical calmness, enhancing their ability to do so actually confronted by their anger or that of others.

 

 
Body Relaxation Exercise

 

The following exercise is powerfully effective for increasing awareness and sensitivity to the body.
 

 

  • Find a quiet place to sit or lie down. Gently close your eyes and spend a few minutes engaged in relaxed breathing.
  • Picture and feel the muscles of your forehead stretch slightly and release tension, as if the muscle fibers are saying, “Aaaaaah.” 
  • Shift your attention to the muscles around your eyes and temples, as you picture and feel them stretch and relax, releasing tension.
  • Shift your attention and visualize and feel the muscles of your upper jaw releasing, as they relax and let go of tension. 
  • Gradually, shift your attention in the same manner to the muscles of your lower jaw, your neck, shoulders, upper arms, lower arms, hands and fingers, upper back, lower back, chest, abdomen, lower torso, upper legs, lower legs, and then your feet and toes.
  • Upon completing this exercise, slowly scan your body from head to toes and notice what calmness feels like. The more frequently you practice this exercise, the easier it will be to evoke physical calmness when you need it to interrupt the escalation of anger.
 
 

 

 
Informal Mindfulness

 

 
Practices in informal mindfulness are essential if formal practice is to have a genuine impact on daily life. Mindfulness meditation is not a mental massage, but rather a practice for increasing our capacity to observe our inner experiences and the choice we have in being more fully present in daily living.

 

 
Our day is filled with opportunities to practice mindfulness principles. On waking in the morning, we may choose to be mindful of the various sensations of stirring from sleep and rising to face the day. Walking easily lends itself to being mindful. We can focus on how the muscles in our legs and feet feel as we take steps and make contact with the ground.

 

 
Taking our mind-body pulse (i.e., assessing our feelings, thoughts, and physical sensations) a few times daily is another way to cultivate mindfulness. 

 

 
Self-Compassion

 

 
Research in the past decade shows us that practices in self-compassion and compassion for others, whether reflected in our thoughts or actions, can dramatically intensify our sense of calm and safety. Specifically, visualization regarding compassion for oneself and others can help us to lower cortisol (Pace et al., 2009); may be associated with increased oxytocin, the hormone that leads to a feeling of calmness; and connection and activation of the vagus nerve that also fosters calmness (Keltner, 2012).

 

 
Self-compassion includes being kind to oneself, nonjudgment, recognizing and honoring our humanity, and not overly identifying with our thoughts or feelings (Neff, 2003). As described by psychologist Christopher Germer, “Self-compassion is a form of . . . acceptance of ourselves while we’re in pain” (2009). Most significantly, this approach has been found to promote self-compassion for individuals with problematic alcohol use (Brooks, Kay-Lambkin, Bowman, & Childs, 2012).

 

 
Practices that help foster self-compassion include those that support evoking our compassionate self. This is the part of ourselves that can be nurturing, kind, empathic, and nonjudgmental with ourselves.

 

 
Cultivating self-compassion calls for attending to the relationship we have with ourselves: how we treat ourselves in general and specifically with regard to our suffering. It entails being nonjudgmental regarding our observations. Practicing self-compassion further emphasizes that we can be both the observer of our pain as well as the one who experiences it. This calls for acknowledging our humanity; that, like everyone, we have weaknesses and flaws, and we make mistakes. Embracing compassion for oneself and others is key to combating the shame that is so often a part of addiction.  

 

 
The following exercise highlights one strategy for cultivating and practicing self-compassion. You should have your clients stop doing this exercise if they become too uncomfortable.

 

 
Self-Compassion Exercise

 

 
  • First engage in relaxed breathing or the body relaxation exercise. Then, imagine being asked to play the role of a compassionate parent in a play. Envisioning this scenario is one way to access your compassionate self.
  • You will be asked, as part of your role, to show compassion to a child who is experiencing some form of emotional pain. Rather than reasoning with the child in an attempt to “fix” the feeling, try to help him or her simply sit with it. For example, you may picture yourself saying the following:
    • “I know this is difficult to sit with.”
    • “It is a feeling that, like other feelings, is temporary. It will pass.”
    • “I will sit here with you.”
    • “This is what suffering feels like.”
    • “I am not going anywhere.”
     
 
 

 

Practicing this type of visualization exercise helps to cultivate both awareness and intentionality to create a similar dialogue with oneself when experiencing the anguish associated with anger. Cultivating their compassionate self allows clients to become increasingly self-soothing and offers them increased capacity to pause, recognize, accept, and sit with discomfort aroused by thoughts and feelings associated with the tension of anger. When practiced together, mindfulness and self-compassion skills “reduce reactivity, strengthen autonomy, promote emotional sensitivity, enhance understanding of historical sources of our hurts, and provide guidelines for safe, effective communication” (Aronson, 2004).

 

 
Cultivating self-compassion can be especially challenging for a variety of reasons. Individuals who have experienced more severe emotional wounds, especially those associated with attachment disorders or intense self-criticism may become extremely uncomfortable even discussing self-compassion, yet alone engaging in practices to boost it. It is not that they are afraid of compassion. Rather, they are afraid of the feelings that such compassion might generate (Germer & Siegel, 2012). A discussion of compassion may very quickly lead to experiences of limited compassion or its absence. In reaction to these wounds, clients may associate compassion with weakness or even suppress their longing for compassion. For such individuals, some form of insight therapy to help address these issues may be a prerequisite to more fully engaging in compassionate practices.  

 

 
Strategies for Dealing with Intense Discomfort

 

 
The ability to recognize, accept, and sit with uncomfortable emotions is a hallmark of emotional resilience and key to overall emotional well-being. These skills are especially relevant when in recovery. And, as facing uncomfortable emotions may not be an easy task, it is inherent that we offer clearly stated practices for clients to use when such feelings seem overwhelming. 

 

 
Your Peaceful Place

 

 
Envisioning a peaceful place is a very powerful means for achieving calmness and safety. Guidelines for this visualization exercise are as follows.

 

 
Find a place where you can sit comfortably without being disturbed for about fifteen minutes. Gently close your eyes.
Picture a place where you have been or would like to be—a place where you feel safe, relaxed, peaceful, and content. Use your imagination to make the scene as real as possible. Imagine yourself there. You may find your mind wandering at times, and that is all right. Just redirect your attention to your scene. As you envision this place, observe its colors, light, and shadows.
Notice the air around you. Imagine how it feels on your face and hands. Is it dry or humid? Is it moving or still? Try to make this place real. Does this very safe and peaceful place have a smell? Inhale deeply to imagine any fragrance that is part of the scene.
Observe any sounds that occur in your safe, comfortable, and peaceful place. Or, imagine the stillness if it is quiet. Observe the objects in your scene. Notice their colors and their shapes. Notice their lines. Are they straight or curved? Observe their composition. Now picture the objects and pay attention to how they might feel. One may be smooth and another rough. Imagine all of the different parts of your scene.
Now envision yourself reaching out and touching one of the objects in this setting. Notice its colors, texture, and lines or curves. Feel it in your hand. This is just one of many objects making this a peaceful, safe, and relaxing place.
If you have not yet done so, find a place to sit in your very peaceful and safe place. Shift your attention from your scene to your body. Watch your chest and notice how relaxed your breathing is. Notice how relaxed the muscles in your face, neck, and shoulders feel. Observe your arms, but do not move them. Just note how relaxed they feel. Now notice your belly, arms, hands, torso, and legs and how relaxed they feel. Enjoy this relaxed and safe feeling for a moment.
Return your focus to your peaceful scene. Observe your scene using all of your senses, once again noting the colors, shapes, air, scents, and sounds— everything that makes your scene safe and peaceful. Do this for a few minutes and then gradually open your eyes.
 

 

RAIN

 

 
The following is a meditation intended for use when especially challenging feelings arise (Brach, 2013). Sitting with eyes closed:

 

 
  • R - Recognize what’s going on. Be mindful to the thoughts, feelings, and behaviors that are affecting you. These may include unrealistic expectations, shame, fear or anxiety. Just notice whatever you are experiencing.
  • A - Allow the experience to be there. Allow the thoughts, feelings or sensations to be there without judgment and without trying to fix or avoid them. This may be supported by a simple acknowledgment such as “Yes” or “It is okay.”
  • I - Investigate with interest and care. This involves curiosity and focused attention as you ask yourself, “What needs attention?” “What does this vulnerable place want from me?” “How am I experiencing this in my body?” The investigation is especially helped when you identify the specific area of your body in which you are feeling the discomfort. Doing so with care and nonjudgment further support being present with it.
  • N - Nourish with self-compassion. Try to identify what the hurt place inside you most needs and then offer it some message of compassion. Might it need forgiveness? Love? A validating witness? It might then be helpful to offer yourself a compassionate inner thought such as, “I know it hurts,” “I am sorry,” “I love you,” “It is not your fault.”
 
 

 

Gently placing a hand on the heart or cheek to further convey compassion. This exercise offers an opportunity to cultivate and practice compassion with oneself.

 

 
BEAR

 

 
The practices identified in this article offer a means to achieve physical and emotional calmness when confronting difficult feelings that include anger. Together, these practices help clients to become more open to explore the deeper meaning and message of their anger at the moment that it arises. 

 

 
I offer the acronym BEAR as a useful reminder of practices that can be used during the moment of anger arousal.
 

 

  • B - Breathe deeply. This includes inhaling and exhaling deeply, with special attention to exhaling.
  • E - Evoke physical calm. This is achieved by evoking the calmness achieved through the ongoing practice of exercises in physical relaxation and body scanning.
  • A - Arouse compassion. Evoke your compassionate self to address the inner suffering you are currently experiencing. 
  • R - Reflect. Reflect on the feelings and appraisals that precede your anger. Reflect on and identify expectations, whether you are too rigidly holding onto them and if they are unrealistic. And reflect on key desires that may feel challenged.
 
 

 

Dealing with anger is especially difficult for those with addictions. Expanding the emotional resilience to constructively manage anger is built upon being able to self-soothe and to recognize and sit with discomfort, rather than react to it. The strategies presented here offer a broad range of practices to help those with addictions cultivate healthy anger. 

 

 

 

 
 
 
 
 
 
References

 

Aronson, H. B. (2004). Buddhist practice on western ground: Reconciling eastern ideals and western psychology. Boulder, CO: Shambala.
 
Bowen, S., Witkiewitz, S., Clifasefi, S. L., Grow, J., Chawla, N., Hsu, S. H., . . . Larimer, M. E. (2014). Relative efficacy of mindfulness-based relapse prevention, standard relapse prevention, and treatment as usual for substance use disorders: A randomized clinical trial. JAMA Psychiatry, 71(5), 547–56. 
 
Brach, T. (2013). True refuge: Finding peace and freedom in your own awakened heart. New York, NY: Bantam.
 
Brooks, M., Kay-Lambkin, F., Bowman, J., & Childs, S. (2012). Self-compassion amongst clients with problematic alcohol use. Mindfulness, 3(4), 308–17.
 
Farb, N. A., Segal, Z. V., & Anderson, A. K. (2013). Mindfulness meditation training alters cortical representations of interoceptive attention. Social Cognitive and Affective Neuroscience, 8(1), 15–26.

Germer, C. K. (2009). The mindful path to self-compassion: Freeing yourself from destructive thoughts and emotions. New York, NY: Guilford Press.

Germer, C. K., & Siegel, R. D. (2012). Wisdom and compassion in psychotherapy: Deepening mindfulness in clinical practice. New York, NY: Guilford Press. 
 
Giancola, P. R., Josephs, R. A., Parrott, D. J., and Duke, A. A. (2010). Alcohol myopia revisited: Clarifying aggression and other acts of disinhibition through a distorted lens. Perspectives on Psychological Science, 5(3), 265–78. 
 
Gilbert, P. (2010). Compassion-focused therapy. New York, NY: Routledge.
 
Hayes, S. E., & Strosahl, K. D. (Eds.). (2004). A practical guide to acceptance and commitment therapy. New York, NY: Springer.

Keltner, D. (2012). Secrets of the vagus nerve [Video file]. Retrieved from http://greatergood.berkeley.edu/gg_live/science_meaningful_life_videos/speakers/dacher_keltner/secrets_of_the_vagus_nerve 

Luoma, J. B., & Platt, M. G. (2015). Shame, self-criticism, self-stigma, and compassion in acceptance and commitment therapy. Current Opinion in Psychology, 2, 97–101.
 
Neff, K. D. (2003). Self-compassion: An alternative conceptualization of a healthier attitude toward oneself. Self and Identity, 2(2), 85–102.
 
Neff, K. D. (2011). Self-compassion: The proven power of being kind to yourself. New York, NY: HarperCollins.
 
Norström, T., & Pape, H. (2010). Alcohol, suppressed anger, and violence. Addiction, 105(9), 1580–6.

Pace, T. W. W., Negi, L. T., Adame, D. D., Cole, S. P., Sivilli, T. I., Brown, T. D., . . . Raison, C. L. (2009). Effect of compassion meditation on neuroendocrine, innate immune and behavioral responses to psychosocial stress. Psychoneuroendocrinology, 34(1), 87–98.

Parrott, D. J., & Giancola, P. R. (2004). A further examination of the relation between trait anger and alcohol-related aggression: The role of anger control. Alcoholism, Clinical and Experimental Research, 28(6), 855–64.
 
Schum, J., Jorgensen, R., Verhaeghen, P, et. al. (2003).Trait anger, anger expression, and ambulatory blood pressure: a meta-analytic review. Journal of Behavioral Medicine, 26(5), 495-415.
 
Shearer, R. (2010). Anger management for substance abuse and mental health clients. Retrieved from http://www.ceumatrix.com/cart/images/anger_management_KAP.pdf
 
Siegel, D. J. (2015). The developing mind: How relationships and the brain interact to shape who we are (2nd ed.). New York, NY: Guilford Press.
 
Suls, J. (2013) Anger and the heart: perspectives on cardiac risk, mechanisms and interventions. Progress in Cardiovascular Disease, 55(6), 538-47.
 
Vecchio, T. D., & O’Leary, K. D. (2004). Effectiveness of anger treatments for specific anger problems: A meta-analytic review. Clinical Psychology Review, 24(1), 15–34.
 
Walitzer, K. S., Deffenbacher, J. L., & Shyhalla, K. (2015). Alcohol-adapted anger management treatment: A randomized controlled trial of an innovative therapy for alcohol dependence. Journal of Substance Abuse Treatment, 59, 83–93.