If you’ve grown up on Marvel Comics, you know the Incredible Hulk’s line: “Don’t make me angry. You wouldn’t like me when I’m angry.” Some of our patients are like that. Underneath their seemingly calm presentation, they are angry. They are angry at the world. They are angry at life. They are angry at everyone they think wronged them. They even get angry at us! When such patients are triggered, they can be as intimidating as the Hulk.
If we are to deal with significantly depressed patients or individuals who have been terribly wronged or people with borderline personality disorder or those in the throes of a schizophrenic episode, or couples who are at war, we need to be able to ride out the storms of patient anger unafraid. Those of us in private practice who work alone need to have confidence that we can keep ourselves and our patients safe if they get enraged during a session. Here’s a brief overview of what to consider for your protection and theirs and for managing treatment:
Prepare your office: Set up your office for safety. Are there objects easily within reach of a client that could do you or a client harm? That letter opener on your desk could stab someone. Those decorative paperweights or that tape dispenser could be thrown. Stick to soft decorations like pillows, a throw blanket, fabric wall hangings and rubber stress toys. An office can look inviting without sacrificing safety.
Prepare yourself: Does anger frighten you? Do you want to run away when someone begins to threaten and yell? Do you get uncomfortable with anger because of events in your own history? If so, you have personal therapeutic work to do. It’s inevitable that someday, somehow, you will trigger a patient’s anger. You will only be effective if you know how to manage your own responses to someone’s rage.
Make a plan with your patient: If you assess that a client is likely to become so angry in session (or if prior records indicated) that they may lose self-control, spend time in the initial sessions talking about how the two of you will manage it. Stay empathetic. Ask what the patient wants you to do if he or she gets out of control. Remind the person that anger is a normal response to frustration, disappointment and fear but we all make choices about how we express it. Be clear about what is and is not acceptable behavior while you work together to develop more constructive choices. For example: You might tell clients that yelling and cursing is okay at first but throwing objects or threatening to hurt you is not.
Be sensible about which patients you decide to treat: Private practice isn’t the appropriate setting for all clients. If during an intake you discover that the client has hurt other people (including other therapists) when enraged, it is only reasonable and self-protective to refer them to a clinic where there are other people around to help and where emergency plans are in place. Yes, we need to be able to manage patient anger. But, in solo practice, it isn’t sensible to treat those whose rage may lead them to do us serious harm.
Responses to the Client who Gets Angry During Session
First, keep yourself and the client safe. Acknowledge the feelings but pull back from the discussion that seemed to precipitate the emotional spike. Stress that the client does have things to be angry about but that it is difficult to think when so upset. Use a calming voice. Ask what you can do to help. Refer back to your plan.
Do not suggest that the patient punch pillows, throw or break things or shout to “get it out”. Research has shown that such actions do not diffuse anger but rather rev people up more. Instead, help with de-escalation techniques such as controlled breathing or a relaxation or mindfulness exercise.
Recommend a time out. Suggest that the patient take a bathroom break, get a drink or water or simply stand up and stretch.
Be curious, not defensive. Support the person’s feelings but suggest that the anger indicates that something important is going on. Ask the client if it is okay to explore it together. Often, being encouraged to talk both brings down the affect and helps the client start to make sense of it.
Reframe the anger as a statement of trust in you and progress in the therapy. Give the patient credit for having the courage to show the feelings and express appreciation for having been let into that scary place. Emphasize that this is usually an indication that the two of you are getting to what is most important.
If the client can’t settle down, suggest that you stop for the day and make another appointment to talk over what happened. If the client isn’t safe enough to leave, suggest that he or she simply sit quietly with you or in the waiting room until he or she feels calm enough to go on with their day.
If you find yourself in a situation where the patient continues to escalate regardless of what you do or say, leave. Tell the person you are just going outside the door. Emphasize that you are leaving the anger, not the client; that you need to keep you both safe by getting out of range until he or she can settle down.
Treatment Over Time
Angry people are not like tea kettles who need to “let off steam” so they won’t burst. Angry clients are individuals without sufficient skills to express frustration, to manage conflict or fear, or to solve problems constructively. Their repertoire is limited to aggression, intimidation, destruction and generally “turning up the sound” to be heard or to make the problem go away. Treatment therefore will weave in and out of the following areas:
When the client is ready, explore the history and function of anger and rage behaviors as well as what triggers their explosions.
Work with transference that includes anger. By being unafraid, you can help your client develop insight and reconsider old learning and patterns.
Empower the patient to take control of the anger instead of letting it control their behavior. Remind them that getting angry is a normal response but they have choices about how they express and use the feeling.
Your mutual task in therapy is to help your client practice those other choices. Teach and practice self-soothing and calming techniques. Help the client develop other, more functional and more socially appropriate ways to express anger. Work on developing new skills for managing his or her feelings and new confidence in the ability to resolve problems. Support the client in learning and practicing new social and self-advocacy skills.