ANGER AND CHRONIC PAIN

Note: Some of the material in this section was drawn from the book, When Anger Hurts: Quieting the Storm Within by McKay, Rogers, & McKay (1989).  I also drew upon the work of Albert Ellis in his book, Anger: How to live with and Without It (1977)

Many people with chronic pain experience problems with anger. Unfortunately, even though anger can sometimes temporarily distract your mind from pain, it is ultimately self defeating.

Unhealthy Consequences of Anger

Negative effects on your physical health. Whether you hold your anger inside or frequently express it outwardly, you can be causing damage to your physical health. People who have chronic problems with anger are more likely to develop high blood pressure (hypertension), coronary heart disease, digestive disorders including ulcers, headaches, skin rashes, and increased susceptibility to infection. Anger also increases muscle tension that can cause additional pain.

Negative effects on your relationships with others. Anger and aggressive behavior can seriously damage your relationships with family and friends. Anger makes people much more rigid and defensive and destroys both trust and open communication. It triggers counter aggression in others, or others try to avoid being around the angry person. As a result, the chronically angry person is often left feeling isolated, lonely, and alienated from others.

Functions of Anger

To learn constructive ways to manage problems with anger, it is important to understand the major functions of anger. It may come as a surprise to learn that the primary function of anger is to reduce emotional and physical stress. Following are the major types of stress that anger tries to dissipate.

Painful emotions. Anger can actually serve to temporarily block your awareness of other painful emotions such as anxiety, fear, depression, hurt, guilt, shame, and feelings of failure and worthlessness. When you are angry at someone else, you don't have to take personal responsibility for your problems. Anger can also serve to discharge some of the tension created by these other painful emotions.

Painful physical sensations. Anger can temporarily divert your attention from pain and can serve as a way of discharging the muscle tension created by pain and emotional stress. For those who have problems with fatigue and feel tired all the time, anger can serve as an energizer.

Frustrated desires. Anger is often used to cope with frustration caused by not being able to do the things you want to do or get the things you feel you need. It can serve to discharge high levels of tension created by your many frustrations. Anger is also commonly used as a way of exerting control over other people and trying to get them to behave the way you want them to. Finally, it can be used as a way of resisting others' attempts to control and dominate you.

Perceived threat. Whenever you perceive some threat to your physical or psychological well-being, anger can serve to mobilize you and seek to overcome or destroy the perceived source of the threat.

Although the basic function of anger is to reduce stress, it is rarely effective. That is because anger usually involves irrational and distorted thoughts regarding both the sources of the stress and how to cope with it.

Anatomy of Anger

Anger involves two basic components. The first is the subjective sense of arousal that results from stress. Most people experience the arousal as a buildup of physical and emotional tension. The second component is anger triggering thoughts. These thoughts often focus on blaming and shoulds. Blaming thoughts involve statements such as "You did this to me deliberately." In other words, it is the belief that you have been intentionally harmed by the actions of others. Shoulds involve statements such as "You should not have _______, instead you should have ________." A basic idea behind shoulds, musts, and oughts is that others should know how to act correctly but, due to their selfishness or stupidity, they do not behave in what you consider to be the proper manner.

There are two types of anger cycles: Arousal/Stress- Trigger Thoughts - Anger

In the first type, the arousal associated with stressful situations leads to anger trigger thoughts that serve to generate angry feelings and more trigger thoughts, and so on.

Triggert Thoughts- Arousal/Stress - Anger

In the second type, anger trigger thoughts create a stress reaction which then fuels more anger.

Thoughts, Feelings, and Actions: Vicious Cycles

It is important to notice that in both types of anger cycles there are interconnecting arrows between the anger trigger thoughts and the angry feelings. That is, the anger trigger thoughts (shoulds and blaming) create angry feelings. However, angry feelings also lead to anger generating thoughts. This means that if you are prone to having angry feelings, it is very likely that your thinking is going to become very distorted through the processes such as filtering, magnification, global labeling, and overgeneralization.

As an example, let's say that a friend, acquaintance, or neighbor says or does something to you that makes you very angry. First of all, you might become aware of your anger trigger thoughts which probably involve some type of shoulds (e.g., "he shouldn't have said or done what he did") or blaming (e.g., "he is such a careless, mean, stupid, ignorant, selfish, etc. person for doing/saying what he did to me"). In this part of the cycle, your trigger thoughts fuel the angry feelings. However, as you really get into the anger, the feelings themselves generate additional anger-reinforcing thoughts. That is, in addition to thinking about the specific situation that led to your current anger, you may think about (recollect) all the other times that this person has done something to displease you while filtering out any positive interactions you might have had. Furthermore, you may find yourself thinking about how other people have mistreated you in a similar manner and begin to magnify and overgeneralize way beyond the current specific situation. This is an example of a vicious cycle involving your thoughts and feelings.

When you add aggressive and hostile behaviors to the situation, another vicious cycle often emerges. That is, if you act in an aggressive, hostile, or threatening manner toward the other person, you will often generate aggressive and hostile counter reactions from that person. This in turn will only fuel your own anger and rage. Heated arguments then develop and effective communication goes by the wayside.

Underlying Irrational Beliefs

Underlying the blaming and shoulds are some underlying irrational beliefs. Both types of trigger thoughts involve the core beliefs that others are responsible for your problems and that others are bad or wrong and deserve to be punished. Here is the basic form that these anger triggering ideas often take:

How awful for you to have treated me so unfairly.

I can't stand your treating me in such an irresponsible and unjust manner.

You should not, must not behave that way toward me.

Because you have acted in that manner toward me, I consider you to be a terrible person who deserves nothing good in life and who should get punished for treating me so.

A fundamental core belief which underlies these anger-triggering thoughts relates to one of the basic distortions mentioned earlier. This is the error of global labeling which involves the failure to separate the person from his or her actions. In other words, you assume that if a person does something which you consider bad (i.e., unjust, unfair, immoral), they must then be a bad person. If that were true then only good people would perform good acts and good people would never do anything bad. Likewise, it assumes that bad people can perform only bad acts.

Obviously, such overgeneralizations are based on faulty logic. The truth is that we all do good acts and bad acts. No one is perfectly good anymore than anyone is 100% bad. To make it even more complicated, we can't always agree on what we consider fair or just. You may do something which I consider unfair or unjust. However, you don't consider it unfair or unjust at all. Unfortunately, anger is associated with an erroneous underlying logic which globally condemns the entire person whenever they do some action which you consider unfair or unjust.

Other aspects of faulty thinking associated with anger is the tendency to awfulize and I-Can't-Stand-It-Itis. It is inevitable that from time to time other people are going to say or do things to you that you consider unfair, unjust, and unwarranted. Of course, most of us would prefer to be treated fairly, justly, and nicely at all times. Rational thinking in response to being treated unfairly and unjustly may indeed lead to feelings of hurt, disappointment, frustration, irritation, and annoyance. However, when you demand that people must treat you fairly and that it is awful and terrible when they don't, you end up creating unnecessary anger and rage. When you go around ranting and raving about this and that, you are in effect saying to yourself "I Can't Stand It the way things are." As a result of your irrational thinking, you have created a low tolerance for frustration. You then overreact to the inevitable frustrations and disappointments in life and end up making yourself miserable.

Anger Management

Once you clearly understand the unhealthy consequences of anger, the maladaptive stress reduction functions that anger serves, and the irrational distorted thinking that is nearly always associated with anger, you are in a position to do something about the problem.

Acknowledge Your Anger and Take Responsibility For It

The first step in anger management is to acknowledge your own anger. That is, admit to yourself that you are angry. Second, and most important, you need to take responsibility for your anger. Unfortunately, when anger dominates your thinking, the focus tends to be on something external to yourself. As long as you can blame someone or something else, you don't have to feel responsible for any of your problems. One false statement which we try to avoid is, "you made me angry." No one makes us angry. Rather we make ourselves angry by applying certain ways of thinking to another person's actions. Also, while anger deceives you into placing the problem entirely on the other person (blaming), in reality it is your problem. You are responsible for doing something constructive about your own problems.  Consequently, you can ask yourself (along with the signal breath), does the anger I am feeling right now help me to get what I want? While angry behavior may work in the short run, it is rarely effective in the long run for changing the behavior of others.

Challenge Anger Trigger Thoughts and Underlying Distorted Beliefs

The primary anger trigger thoughts that need to be identified and changed are shoulds and blaming. Another very common constellation of anger trigger thoughts which combine both shoulds and blaming is the sense of entitlement.

Shoulds, musts, and oughts are based on a set of rules that you use for judging the actions of others. People who follow your rules are correct and those who break them are wrong. You assume that others know and accept your rules. When people don't behave the way you want them to, you assume that they have deliberately chosen to violate what you consider to be proper, reasonable, intelligent, or moral. The problem is that the people you get angry with may not share your particular rules. They have their own rules and needs, and they may see the situation entirely different from you.

Shoulds are associated with several other distorted beliefs. The fallacy of fairness assumes that there is an absolute standard regarding what is correct and fair, and that others ought to be aware of this standard and live up to it. This fallacy fails to consider that what seems fair to one person may seem unfair to someone else. In actuality, the idea of fairness is usually just a disguise for personal desires and preferences. What you want is considered fair and what others want is unfair. The fallacy of change assumes that you can really control or change the actions of others. It is the mistaken belief that you can always get people to do what you want them to do if you apply enough pressure on them. The truth of the matter is that people change when they want to change and not when you want them to. Conditional assumptions are based on a set of faulty syllogisms such as, "If you really cared about me, you would....(do what I want you to do)," or "Since you are a doctor and are supposed to help me you should ...(give me something to make me feel better)." These assumptions are based upon the faulty belief that, just because you have a particular relationship with a person (e.g., husband-wife, patient-doctor, friend-friend), they should always do exactly what you want them to do. The deserved punishment fallacy is the belief that other people who hurt you or upset you in some way should be punished. This fallacy assumes that you are not responsible for your pain and distress, rather, someone else is. It fails to consider the fact that punishing people with your anger serves to destroy relationships rather than getting them to see your point of view.

Blaming triggers anger by making your pain and suffering someone else's responsibility. Blaming also frequently assumes that the people you are angry with are deliberately doing bad things to you. This set of anger triggers is often based on several types of distorted thinking. Good - bad dichotomizing assumes that people are either good or bad, right or wrong, competent or incompetent, etc. It fails to see any shades of gray between these polar opposites. Assumed intent is a type of mind reading in which you make inferences about how other people think and feel. This distorted belief triggers anger when you assume that your pain and distress is a result of someone's deliberate effort to do you harm. This assumption fails to consider that it is very difficult to accurately assess the true motives of another person. Global labeling contributes to anger by viewing other people as totally bad and worthless. Some common global labels are "stupid," "inconsiderate," "selfish," "dishonest," "untrustworthy," and so on. Sometimes people are globally dismissed with pejorative labels such as "jerk" or "idiot." Global labeling is based upon overgeneralization because it looks at particular actions that a person does or does not do and then assumes that this applies to the entire person.

If you find that you are going around feeling angry much of the time, then you need to carefully and honestly evaluate how shoulds and blaming are dominating your thinking. You need to accept the fact that other people have their own needs, desires, and preferences, and may often see things differently then you do. Although conflicting needs, values, and viewpoints are inevitable in human relationships, it is important to learn more healthy and effective ways of dealing with these differences.

The sense of entitlement is the belief that somebody or some entity owes you something (e.g., medical treatment until a cure is found, disability compensation, special considerations) for the pain you are experiencing. People who are injured at work believe their employer is responsible for taking care of them. Veterans who have an injury during their military service believe the VA system is responsible for meeting their needs. People who live in the U.S. and feel unable to work because of pain believe the government should provide compensatory income. Those with a strong sense of entitlement feel that if their lives are disrupted or limited in any way due to pain, then somebody should pay. While some of these beliefs or shoulds may be correct from a strictly legal standpoint, the attitude of entitlement can be very self-destructive from a psychological standpoint. When the shoulds are not met, blaming soon follows. One can direct blame toward an employer, an insurance company, a hospital, a disability system, the Department of Veterans Affairs, or even the entire government. The combination of shoulds and blaming associated with the sense of entitlement can generate a great deal of anger and like a cancer can grow and spread until it consumes you. This is not to say that you shouldn't fight for those benefits and services which you are legitimately entitled to. Rather, you must take whatever constructive actions that are available to you and then let it go. Dwelling endlessly on the entitlements you feel you are not getting, losing sleep over it, or getting angry at everything and everybody does absolutely nothing to get you what you want.

Alternate approaches to stress management

Rather than responding angrily in an automatic or reflex-like manner to all forms of stress, you need to learn alternate ways of managing the stressful problems in your life, including problems associated with your pain and disability. In that way, you can pick and choose the methods that are most appropriate to the situation. Following is a partial list of alternate ways of managing stress and discharging tension in your life:

Physical exercise

Distracting recreational activities

Work or work-like activities including voluntary work

Time-out relaxation and meditation exercises

Constructive problem solving

Assertive communication

Identify and modify your distorted thinking

Humor and laughter

Write down your problems

Listen to music that you enjoy

Learn to accept the things you cannot change

Prayer, reading religious literature, going to church or synagogue

Talk things over with a counselor

Take classes at a community school or recreation center

Join a pain support group, a veterans group, or political action group

Many of these alternative ways of managing stress give you an opportunity to channel the increased tension and energy associated with anger into constructive action. Rather than bottling up the tension and angry feelings or doing something self-destructive, you can channel it into something healthy and constructive.

Cope with early signs of tension and anger.

As you learn to become more in tune with yourself, you can begin to recognize the early warning signs of tension building up. They may be physical signs (e.g., increased muscle tension, fatigue, indigestion, etc.) or they may be psychological signs (e.g., feeling rushed, impatient, annoyed, hypercritical, careless, etc.). These early signs can serve as cues for using a coping response. An excellent coping response discussed earlier is the Signal Breath. Other useful coping responses are suggested by the phrase, "move your muscles and change your thoughts." Sit down for a moment and lean back, stretch your muscles and limbs, slowly rub your tense muscles, take a series of slow deep breaths. Get up and go for a walk, get yourself a cold and refreshing drink (preferably non-alcoholic), go outside and breathe some fresh air, pay more careful attention to your surroundings, try to talk more slowly.

In addition to these coping behaviors, you can use coping thoughts (self-reminders). Examples of anger coping thoughts listed by McKay, Davis & Fanning (1997) in their Thoughts and Feelings book include the following:

Take a deep breath and relax

Getting upset won't help

Just as long as I keep my cool, I'm in control

Easy does it - there's nothing to be gained by getting mad

I'm not going to let them get to me

I can't change them with anger; I'll just upset myself

I can find a way to say what I want to without anger

Stay calm - no sarcasm, no attacks

I can stay calm and relaxed

Stay cool, make no judgments

No matter what is aid, I know I'm a good person

I'll stay rational - anger won't solve anything

Their opinion isn't important - I won't be pushed into losing my cool

It's just not worth it to get so angry

This is funny if you look at it that way

Anger means it's time to relax and cope

Maybe they want me to get angry. I'm going to disappoint them

I can't expect people to act the way I want them to

Stay cool; take it easy

I can manage this; I'm in control

I don't have to take this so seriously

I have a plan to relax and cope

To these I would add:

No need to let my pain make me feel so tense and irritable

Taking out my irritability on others won't help my pain

All of these coping actions give you an opportunity to let go of some tension, mentally reassess the situation (e.g., look at your shoulds and blaming thoughts), regain your perspective, and decide on the most reasonable course of action. The better you get at identifying the early warning signs of tension, the better you will be at managing your anger. Most people get into trouble with their anger and act out inappropriately because they have allowed their tension to build up to the boiling point. It is also important that you be aware of some common anger amplifiers. These include the pain itself, use of alcohol and other mind-altering drugs (including prescribed pain pills), and lack of proper rest.

Anger management takes practice. Don't get discouraged if you let the anger get the best of you from time to time. If you have a long-established habit of responding to stress with excess anger and aggressive behavior, you will not be able to change over night. If you do make a mistake and let anger get the best of you, you can always regroup by carefully analyzing what went wrong and trying to do better next time.

Assertive Communication

Another important technique that has been used in anger management is assertiveness training. In order to understand what it means to communicate assertively, it is useful to contrast two other communication styles, aggressive and passive.

Aggressive. You feel angry at others for blocking or interfering with your wants and desires. You express your anger by angrily demanding, bullying, accusing, threatening, and fighting. Being aggressive means generally stepping on people without regard for their feelings. The advantage of this kind of behavior is that people are less likely to push you around. The disadvantage is that most people do not want to be around you and, depending on how aggressive you are and who you are aggressive with, you may feel guilty afterwards.

Passive. You want something but do not honestly express your wants and desires. Instead, you either do nothing or resort to indirect, passive, and somewhat dishonest forms of communication. You may not even admit to yourself what you want and don't want. You passively allow others to push you around or resist their attempts through passive-aggressive behavior (e.g., procrastination, making lame excuses, whining and complaining to others). The advantage of being passive is that you rarely experience direct rejection. The disadvantage is that you are taken advantage of, and you end up feeling anxious, hurt, resentful, and angry.

Assertive. You act assertively when you honestly acknowledge to yourself what it is that you want or don't want and then communicate this openly and persistently to others. When you are assertive, you stand up for yourself, express your true desires, and do not let others take advantage of you. At the same time, you are considerate of others' feelings. The advantage of being assertive is that you are more likely to get what you want, usually without making others mad. If you are assertive, you can choose to act in your own best interest, and not feel guilty about it.

Learn to Let Go of Anger

Many persons with chronic pain and disability strongly believe that they have been treated unfairly and unjustly by other people, as well as by the medical and disability systems. Assuming that this is true for you, it may be worthwhile to ask yourself questions such as, "What do I really accomplish by hanging on to these feelings of anger, bitterness and hatred? Does my anger and thoughts of revenge rectify the situation in any way? Do these angry feelings make me feel better or help me to deal more effectively with my chronic pain?" You may feel that by letting go of the anger, you are somehow letting the guilty party off the hook or justifying whatever wrongs were done to you. As a result, you remain perpetually stuck in the cycle of blame and anger, which in many cases leave you as the primary loser. I am not suggesting that you must forgive everyone who has wronged you in some way. Rather, it is recommended that you do an honest self-evaluation and consider the pros and cons of forgiving versus not forgiving the offending person or entity. Keep in mind that forgiveness is not the same as excusing, pardoning or absolving the guilty party. Instead, forgiveness involves a change in the way you think and feel. In Dr. Margaret Caudill's book on self-managing chronic pain (see list of recommended readings), she discusses the five phases of forgiveness, drawn from the book, Forgiving the Unforgivable: Overcoming the Bitter Legacy of Intimate Wounds, by Beverly Flanigan (1992). In the final phase, choosing to forgive, you are, "ready to let go of the negative feelings that until now have imprisoned your mind, spirit, and heart."