I want to apologize in advance for this post, which is really an esoteric debate between therapists. Yet I urge present and potential consumers of psychotherapy to skim it, along with Dr. Diamond’s cited post, to appreciate the importance of doing your own research on the ideology of any psychotherapist you might hire. Most therapists have websites that, with careful perusal, indicate whether they rely on dogma or research. You can also ask them directly whether they do objective follow-up evaluation of their work. To escape the blind spots inherent in all our professional ideologies, therapists must be able to frame hypotheses drawn from those ideologies in empirical terms and, whenever possible, test those hypotheses with real-world data. Otherwise we merely derive assumptions from other assumptions of the ideology, which reduces it to the status of dogma, i.e., there is no way to know it is true apart from our faith in it. A few of the fundamental scientific questions for psychotherapy are: "What are the sources of the data on which the therapist bases hypotheses, how valid and reliable are those sources, and how do you know that your ideological blind spots are not influencing your observations and interpretations of the data. These fundamental questions bring us to the major reasons why it is not the therapist’s job to tell clients whether their anger is "appropriate." First of all, the term, "appropriate" is a social construction, contextually-dependent and embedded with personal and cultural biases. More important, if the therapist does not objectively test hypotheses, he interprets data through the blurred lens of his own ideologically-biased assessments of the client. (To put it in terms Dr. Diamond prefers, how can the therapist ever really know that he is not projecting?) Still more important, the descriptions of their experience that angry clients make in the artificial environment of psychotherapy are inaccurate , as demonstrated by the empirical evidence of substantial cognitive and memory impairment that occurs during anger arousal. To the extent that their accounts even approach accuracy, they are woefully incomplete , omitting all other perspectives and mitigating information. Just as therapists can suffer confirmation bias in regard to their ideologies, angry clients suffer acute confirmation bias when it comes to their anger – because they feel like victims, they process only confirming evidence, ignoring all disconfirming evidence. Angry clients can easily sound like they are married to Norman Bates’ mother – they’re just minding their own business when she hacks at them with a kitchen knife. Videotapes of anger occurring in real-world interactions show that it differs greatly from the way people describe it after the fact. (More on the relevance of real-world interactions later.) In short, the therapist has no way of knowing whether the client’s description of his anger in real life is contextually "appropriate." The crucial point here is that the therapist doesn’t just validate the client’s anger but also the construction of reality that makes the client feel like a victim. In other words, the grandiosity of the therapist who doesn’t test hypotheses validates the narcissism of the client. To be sure, everyone is narcissistic when angry. In the adrenalin rush of even low-grade anger, everyone feels entitled and more important than those who have stimulated their anger. Everyone has a false sense of confidence (if not arrogance), is motivated to manipulate, and is incapable of empathy, while angry. The therapist can hardly validate the sensations of anger without also validating (at least in the client’s mind) the distorted construction of reality associated with the sensations, as well as the motivation for retaliation that go with anger arousal. Evidence Dr. Diamond agreed in his original response to my post that there has been a worrisome increase in anger and violence in recent decades. He attributes it to the suppression and repression of anger. He cannot support that hypothesis with mere ideological iterations; rather, he needs to present objective evidence that suppression and repression of anger are on the increase or at least that there was an outbreak of infantile suppression of anger 20 years ago. (Something in the water supply got into breast milk?") If he can establish that, he then has to explain why reasonable people should suppose that increased suppression/repression has caused the increase in anger, rather than facts like children viewing 11,000 murders on TV before the age of 14, wide-spread media glorification of anger-displays, and other potent effects of modeling demonstrated in the social psychology research literature. If Dr. Diamond really believes that we have more anger now because we more often shame people for experiencing anger, he needs to count the number of angry displays by "heroes" highlighted in the news and entertainment media. Our heroes freely display a righteous, passionate anger, while the villains are passionless psychopaths. The all too familiar stereotype of masculinity, very much a product of cultural conditioning, proscribes only one emotion for men, and that is anger – any softer emotion is unmanly . In contrast, women are permitted to express all emotions except anger, which is oppressively deemed unfeminine. So if the hypothesis that attaching shame to anger causes pathological anger is to be supported, women would have show a lot more of it and, subsequently be acting out more pathologically than men. Of course, the empirical literature shows the opposite. To merit credibility, Dr. Diamond’s hypothesis that "narcissistic wounds" cause problem anger, like the suppression/repression hypothesis, would have to account for the observed increases in anger. Are we to believe that parents started wounding their children more two decades ago, when the steam engine theory of emotions and that infamous psychodynamic derivative – blaming parents – was well established in the vernacular? Of course, the heaviest blow to the "childhood wounds" hypothesis is the empirical finding that most abused children grow up to be fairly good parents, no angrier than anyone else. Emotions are not Steam Engines Dr. Diamond is correct in noting that the 19th Century steam engine view of emotions was, indeed revolutionary and widely accepted by therapists for quite a while, but it was never accepted by scientists. A revolution also occurred in medicine around the same time, yet Dr. Diamond would not expect his personal physicians to use 19th Century methods and techniques in their treatment of him. Therapy clients have the right to similar expectations of their therapists. As I understand Dr. Diamond’s rendition of the steam engine theory, "appropriate" anger should be experienced and expressed – but not acted on , as the retaliation motive of all anger would risk turning "appropriate" feelings into inappropriate behavior; in other words, it’s good to feel but not do . He also seems to think that suppressed/repressed "appropriate" anger, like egg salad, eventually turns rotten when stored somewhere in the body, where it "festers" and causes inappropriate anger. Functional MRIs show what happens when a person experiences anger – within or without conscious awareness – but, alas, do not show where or how it builds up and festers. We can measure other kinds of invisible festering by things like white blood cell counts and depleted immune system functioning. If there were such a thing as festering anger, it would show up in elevated rates of cortisol in the saliva. I know of no such empirical confirmation of the fester hypothesis. I’m curious to learn how, apart from dogma, Dr. Diamond knows that suppressed appropriate anger festers, indeed, knows it with enough certainty to risk the iatrogenic effects of validating the anger of angry clients. Certainly the empirical literature – as opposed to those early 20th Century case studies embedded in dogma – indicates that there is no lasting therapeutic benefit of catharsis and that anger expression worsens anger problems. Neurological evidence vs. conceptual descriptions Dr. Diamond’s term, "pathological anger," is a conceptual description. (At least it is more precise than "appropriate," which piles personal and cultural prejudices on top of conceptual blind spots.) Neither "pathological" nor "appropriate anger" has neurological meaning; it makes no sense neurologically to distinguish between pathological and appropriate anger. Habituation, an observable phenomenon, occurs through repetition; hence the expression of "appropriate" anger has the same habituation effects as the expression of inappropriate anger. Expression of anger doesn’t let off steam or get anything out of your system; it gives you a temporary amphetamine ride that reinforces the synaptic association of vulnerability with anger arousal, entitlement, and motives for retaliation. This bears repeating: through habituation effects, the expression of anger is conditioned to occur in response to gut level feelings of vulnerability that are not subject to higher and much slower cognitive judgments about the presumed childhood source of the vulnerability. When it comes to regulating anger, inferences about Mom or other remote "sources" of anger will be too little too late. Viable psychic theories must account for neurological evidence, not merely dismiss it as "another way of looking at the same thing." In fact, anger is not nearly so complicated and difficult an emotion as Dr. Diamond suggests. It is a simple response to perceived vulnerability in the face of perceived threat. Some authors have developed convoluted ways of thinking about anger and hyperbolic ways of describing it (e.g., "existential integrity"), but those merely justify or cover up the empirical shortcomings of their ideologies. Notably, none of the convoluted ways of thinking about anger predict anything verifiable about the phenomenology of an emotion that is observed and measurable in all animals, emanating from a region of the brain common to all animals. Real-world interactions In the fog of trying to distinguish "appropriate" from inappropriate anger in the consulting room, Dr. Diamond misses the real-world significance of emotional interaction. One law of emotional interaction is negative reactivity , which can be understood in this way. If you approach a person – or an animal – with anger (appropriate or not), what percentage of the time can you expect a negative response? Another law relevant to aggressive emotions is feed-back escalation . Anger is not for ties – you do not want to hurt the saber tooth tiger as much as it hurt you; you want to destroy its capacity to hurt you. People (and animals) who receive anger cues do not match them but top them, which is why anger escalates so quickly in real-life interactions. The angry person interprets other people’s negative reactions to his anger as unfair and deserving of retaliation, which prompts a like response in the other. There are two naturally occurring antidotes to the reactivity and escalation effects of anger in human and animal interactions: fear and shame. Fortunately for other animals, these important emotions still serve that healthy function. But we humans have developed a fear/shame phobia – most of the time we choose the temporary power of anger over the transitory powerlessness of fear and shame. (That is why, in the course of an ordinary day you will witness far more displays of low grade anger, resentment, agitation, and irritability than fear and shame.) Thus fear/shame phobia is implicated in the observed increase of anger, along with empirically supported hypotheses about social modeling and social conditioning, the high contagion of aggressive emotions, and a growing sense of entitlement that makes us think we have the "right" to feel good most of the time and to manipulate and control other people, a la "My ‘existential integrity’ is superior to yours." In contrast, the "suppression/repression" hypothesis offered as scientific explanation of the increase in anger, seem "reductionist," embarrassingly univariate, and impoverished by failure to account for the remarkable adaptability of human and animal central nervous systems. Ethics Dr. Diamond inadvertently highlights an important ethical issue in his comment: "It is typically in reflecting on such angry outbursts retrospectively (my emphasis) in treatment that inappropriate anger–and often the fear, guilt and shame about it–are recognized." In other words, someone has to get hurt to create a window of opportunity for Dr. Diamond’s insight about "appropriate" vs. inappropriate anger. My experience with many clients whose previous therapists subscribed to the steam engine school of anger suggests that a lot more hurt than Dr. Diamond imagines occurs between his sessions. Although he is right about "acknowledging that anger is present in the consulting room," it is quite another matter to encourage its expression and to validate it. The client will have more compelling motivation in the heat of real-world interactions to use expert validation to justify his anger, than to recall whatever insight about Mom-transference the therapist may have pointed out earlier in the week. I believe it is an ethical imperative when working with angry people to objectively evaluate the effectiveness of your work, not just through the unreliable self-report of the client, but from reports of those who live with him, both during treatment and for a good year after termination. Reducing the Need for Anger In daily living, humans have little need of primary anger – that stimulated by threat of harm to self and loved ones. The vast majority of the anger we experience is in response to rather petty ego offense, hyperbole about existential integrity and "the individual’s most basic right to being an individual" notwithstanding. In the vast majority of anger experience, we feel devalued in some way and blame it on someone else, which creates an illusion of threat, which, in turn, stimulates anger. Here, too, therapeutic focus on the appropriateness of the anger or its presumed roots in childhood tragically misses the point. Anger in response to feeling devalued substitutes a temporary feeling of power for value – you don’t feel more valuable when angry, you simply feel more powerful, as long as the amphetamine effect lasts, after which you crash. Therapy is about teaching clients to raise their self-value when they feel devalued in the real world. (Ultimately, the only way they can sustain true self-value in our highly socialized world is to become more compassionate.) They don’t need to know whether some therapist thinks their substitution of power for value is "appropriate." Rather, their attention must focus on whether their anger is helping them be the kind of person, parent, and intimate partner they most want to be. The focus of therapy is on helping them achieve those ends, not in reinforcing their unfortunate association of perceived vulnerability with anger by pronouncing it "appropriate." Of course no one should feel ashamed for feeling angry, and I doubt that many people do. But we all feel shame for violating our values. Most people violate their values when they perceive others, particularly loved ones, as menacing characters who are nothing other than whatever ego threat they seem to pose at the moment of anger. But the shame is not punishment for the anger; it is motivation to be true to one’s deepest values, i.e., to see others not as a source of emotion but as complex, separate people, independent of emotional reactions to them. When we follow that motivation, there is no need to express or manage anger; it simply becomes unnecessary for protection. I sincerely hope that Dr. Diamond can transcend dogma and present verifiable evidence for his views on anger, which, so far, seem far more literary than scientific. If he does come up with something verifiable, we can have a meaningful debate. © 2009 Psychology Today. This RSS Feed is for personal non-commercial use only. 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Anger Problems in the Fog of Dogma