Question about emotions

[bkennedy]

I have a patient in his 60s I’ve worked with a bit over the last year. He has a history of significant abuse from his step dad as a child. He desribed his anger and physically fighting back when he was a teenager. Most times I see him he has tears bubbling up. He is skeptical that I can help him because he has done so much work over his life: processed his history of trauma for years with therapists, lots of MBSR, part of a mens group that leg out anger, his wife is a psychotherapist. He has chronic itching that is so bad it is painful. It is clear to me this model can help him (he stay with me because he literally has no other options :)). I spoke with him about EAET ideas around anger. He said ‘that is the opposite that I have been taught, that the anger is the easy emotion. It is the sadness and hurt underneath it that I am not accessing. I get angry very easily. I talk with my wife regularly about my anger’ (all of his children are estranged from him. One of his adult sons is transgender now which upsets him greatly). I still think it is anger that he needs to release, but wondering what your thoughts are. I spoke with a female patient today and had a similar conversation about tears often being a protective mechanism for anger. She said the same thing that she was taught by a therapist that anger is covering up sadness and hurt. However, the ideas about anger actually made sense to her. Wondering your thoughts. Thanks.
(and fyi I may not be able to attend the session next week)
Becca

[hschubiner]

This is a very important question, Becca.

We discuss this in our EAET course, quite a bit. The purpose of releasing anger is to get to other emotions, such as guilt, sadness and compassion. Anger is not an end in itself. And, it is clearly true that some people are “good” at anger and therefore, that may not be the emotion that will help to free them.

Many people hold in a relatively low level of anger (in his case, a higher level), but are unable to let that anger go. One object of EAET is to help them to express such a high level of anger that they can then more easily let it go; and also, often feel some guilt for having the urge to physically hurt the other person.

We would like for the patient to see if they can find some amount of pity or caring or compassion for their parent who was abusive. We may ask them to “visit” their parent when they were a child to help them see that their parent was a victim in some ways.

I have a video showing me doing this with a patient, if anyone is interested.

Best, Howard

[bkennedy]

Thanks Howard. I appreciate it. I would like to see the video of you doing this if you could share it (I may have seen it before, but need a refresher).

Kindly,
Becca

[Lilia Graue, MD]

Hi Becca, thank you for sharing these thought provoking reflections and case.

I have some notes from the EAET & ISTDP training I thought I’d share.

From the EAET training:
A consideration about the “right emotion”, ie what’s appropriate for the situation, and looking for two possibilities:
– secondary (defensive) anger is not the “right”/core emotion, but it is blocking hurt, sadness, connection
or
– anger is the “right” emotion but at the wrong target
Encourage the person to explore if there is a part of them that feels angry, guilty, ashamed, sad, longing for connection.

From the ISTDP training:
Allan Abbass was very emphatic about the fact that “it’s not about the rage, but about the guilt over the rage” – we feel guilty and/or ashamed that we feel such anger or rage, because we’re good people and we don’t really want to hurt our loved one, even though they might have hurt us. There is guilt laden rage because of attachment. It is really important to keep bringing back the guilt every time the rage arises to protect the patient. He elicits rage and the wish to act it out and then the guilt that the person experiences from having hurt someone in this imaginary scenario, so he’s not encouraging murderous rage or even catharsis, just making space for the complexity of it all. He surfaces how there is a part of the patient that responds somatically to the feeling as though it was the same as the action. And when the activation/anxiety goes up, he goes to recap and reflecting, he doesn’t keep pushing. He helps patients connect to the awareness that they’re a good person, and highlights the need to keep the love and positive feelings in there as well.

He deliberately acts in ways that are mildly irritating for the patient throughout the session, at the same time as building a strong therapeutic alliance to elicit the full range of emotions in the patient, so that anger/frustration will surface in the relationship in real time and it can then be worked with (engaging transference to work with emotions in the context of the therapeutic relationship), at the same time that there is appreciation for the fact that the therapist is there to support the patient in finding freedom from symptoms. He stays steady, careful to keep the patient safe and not push beyond threshold, while at the same time not shying away from anything and staying calm.

Something that has been very clear to me from observing therapists skilled in ISTDP and EAET is that they are incredibly comfortable and skilled in welcoming and handling conflict and frustration, particularly in the context of the therapeutic relationship.

[bkennedy]

Thank you for that Lilia. That is a clear, thorough synopsis. Really rounded out pieces of my thinking on this! Thank you.

[Lilia Graue, MD]

So glad it was helpful Becca!

[hschubiner]

I will send a link to this video to Grace and she can send it out by email.
Best, Howard

[Jessy Glaub]

Howard, Would you be able to send that video my way as well? Also any other resources for patient demonstrations? I’ve always found any post-grad ed that has live patient demonstrations to be the most beneficial.

[abatson]

This is a great conversation – and a complex one. My understanding from taking a couple of Allan Abbas’ courses is that it is not the anger/rage that is causing the symptoms, rather the guilt and shame that we feel when anger/rage rise up that is causing the conflict of emotions which is causing the symptoms. So, anger arises when my brother tells a sexist joke, I begin to feel angry and hurt, I then feel guilty for feeling anger at my brother because I also love him dearly, so then I feel guilty and ashamed that I felt or expressed anger and then I get …..xyz symptom. I explain this to the patient and then guide/encourage them to feel the anger without the shame/guilt. I help them see that they should not be ashamed for having normal human emotions, or for standing up for themselves. I get them to connect with the hurt, sad part of themselves that is trying so hard and doesn’t deserve to be treated that way. I don’t encourage compassion for the other in the beginning because that is often just taken as more guilt and shame for having the original emotions of anger and shame, but now our therapist/doctor is telling us that our original emotion isn’t “right” or “good”. When the patient seems comfortable with the idea of the guilt suppressing the anger and the anger “just wanting to be seen, acknowledged and felt”, NOT acted out or RAGED OUT, then they are often ready for an ISTDP-type exercise of imagining a past situation when anger was arising and asking them to feel how it feels in their body, where is it? (…my arms are starting to shake, etc.). Then, what does it want to say? and what does it want to do? in the Allan Abbass style. Patients can destroy their abusers in their imagination and that is not dangerous. It can also come out in dreams. The anger wants to just move through the body and once it is out, it is out. I feel that moving to quickly to concepts of “forgiveness” or “compassion” towards the other, the perceived abuse, just works to further repress/suppress difficult to feel emotions like anger.

[hschubiner]

I completely agree, Alicia.

The beauty of ISTDP and EAET is that it allows/encourages righteous anger to such a large (extreme?) degree in our minds, that it then allows us to really let it go and take a deep breath. Then we have room for guilt and sadness; and eventually compassion (even for the other to whatever degree makes sense for the situation).

It’s a beautiful process to observe and participate in!!

Best, Howard

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