??This Article was written for and published in the Sept 07 Newsletter of the San Francisco chapter of the California Association of Marriage and Family Therapists.

Why many anger management clients don’t get better.

“I no longer refer anyone to anger management groups because they don’t work”.   This intriguing comment was made by a seasoned clinician, someone for whom I have a great deal of respect.  She is a very smart, very skilled therapist who regularly refers her patients to a host of adjuntice services like twelve step meeing and group therapy.

This prompted me to thinking about the fact that even though I am a therapist who specializes in anger management, I largely agree with her comment.  It seems that there are many clients who spend time in individual or couples therapy but continue to “lose it”. I wrote this article to explain why some clients go for years without making much progress with their anger.

Clients are seeking “band aid” approaches. This is one of the most important factors.  The typical client with “anger issues” tends to minimize, deny and blame others for their anger.    They often lack the motivation to change and it is common that their chronic mismanaged anger is ego syntonic.  Similarly to substance abusers, the people who are most disturbed by their behavior are often those around them.  When they seek help, they often underestimate the enormity of the therapeutic task.  Those who struggle with the chronic anger habit often have personality structures that are organized around regulating core chronic shame.  Anger frequently is also used to cover up fear, hurt or grief. This can lead many patients to seek short term approaches as defensive maneuvers.  They may abandon treatment quickly, or seek superficial solutions in an effort to regulate profound feelings of which they are unaware.  For example, I get many phone calls from men and women who want to come in and meet with me even though they state directly that they “don’t really have a problem”.  Usually they are calling because a husband, wife, or employer has given them an ultimatum and their most pressing concern is to decrease the interpersonal pressure that is being placed on them.

Many “anger management” programs are not facilitated by therapists. When help is sought they are likely to attend a group that is facilitated by someone with no mental health training.  Many of the clients in my practice have attended groups run by clergy members, peers, or non professional “staff counselors”.  They have attended groups in which members are not screened for co- occurring mental health issues, or for motivation level. In the bay area, one well established anger management provider openly prides itself in running a peer led program that is free of any licensed professional staff.   Clients with mental health issues are regularly mandated into this program by the criminal justice system.  Those who have attended this program report to me that the “treatment” mostly involves lectures, confrontation, and presentations about gender roles and social power.  While perhaps interesting to some, for many they are insufficient for producing meaningful behavioral change.

Clients don’t meet the “three key requirements for permanent change.” Awareness of their own body’s arousal signals is the first skill that must be developed in order to permanently break the anger habit.  After years, or perhaps decades of ignoring the signs sent to them by their sympathetic nervous system, clients often have a robust tendency toward “disconnecting” or dissociating.  In order to change, they must reconnect with their body.  They must learn to respond to these signals early before the physiological responses sweep them away.  They must learn to calm themselves so that they then may think rationally and respond skillfully.  Developing these awareness skills requires monitoring and practice.  Those who attend anger management classes which are solely psycho-educational usually are unable to master this necessary first step.

Insight is the second thing that is required for permanent change.   Clients must have a good grasp on how they “do anger”.  This entails the traditional work of psychotherapy; making the client’s unconscious working models conscious, and identifying the particular beliefs that tend to lead to anger.  Unexamined beliefs about oneself and others can act like hidden embers and keep anger’s fire burning.   Sometimes, when clients learn only to take “time-outs” and do not learn to reflect on the underlying beliefs that fuel the anger, they are in a continual effort to “try to stay calm”.   While this works in the moment, it is an insufficient long term strategy.

Awareness and insight are not enough.  Every day I meet with clients who have spent years in individual or couples counseling.  Often this has resulted in no significant behavioral change.  Sometimes this is because the therapy did not include a skill building aspect, did not provide an accountability structure, or only gave the client a “place to vent”.  This backfires because it provides only a rehearsal space for anger and not a laboratory in which to develop new emotional regulation skills.  Once the client is working with a therapist who is able to help him or her master the first two steps, they must go further.  The third requirement for permanent recovery is that all of the common underlying co-factors must be treated.   Trauma history, relationship conflict, insecure attachment style, anxiety, depression, substance abuse, unresolved grief and personality disorders are all key factors in relapse.  When they are fully addressed, the client can expect a more stable and permanent recovery.

Michael G. Quirke, MA. M.F.T. practices in San Francisco and San Mateo.  He specializes in working with men and women who have decided that they want to stop anger from harming their relationships or careers.  Through individual counseling, couple counseling and group therapy he teaches the key steps that are necessary to break the anger habit once and for all.  For more information, call (415) 820-3943 or visit http:// www.michaelgquirke.com