Mike was crying. He sat in a plastic chair, in the corner, his head in his hands. We were having our first meeting since he had been admitted the day before to the psychiatric hospital where I worked. The room had windows overlooking trees on one side and a parking lot on the other, it had sunshine and fluorescent lights, it was safe and sterile. He said, “I’m angry all the time. I’m sick and tired of feeling so angry.”
When someone is struggling with their mental health, in the world of psychology and psychiatry, a textbook called the DSM is used for diagnosis. This stands for the “Diagnostic and Statistical Manual of Mental Disorders”. In the current DSM- 5, or 5th edition, anger is not listed in the index. According to the DSM-5 anger is not an emotional problem. This is madness!
People with anger issues do not necessarily have “intermittent explosive disorder” or “conduct disorder” or “oppositional defiant disorder” the three anger-like potential DSM-5 diagnoses. If someone gets mad too fast, too often, too intensely, like this young man Mike, they recognize they may have an anger problem. Angry feelings are normal, just like nervousness and sad moods are normal, as opposed to clinical anxiety or depression. Yet frequent anger, or rage, is of course a departure from healthy into psychopathology.
Mike grew up in a coastal fishing community. In the past few years though, he didn’t like fishing any more. He didn’t like being on a boat all day with his dad and uncles, who were themselves “angry men” he said. They were in a fight with the environmentalists over the state of the ocean, and, he told me, “they take it out on anyone who is around them”. He could see his father’s point of view, who had been a fisherman because his father had been a fisherman, and his father before. Mike could see why his dad believed it was his right, in a way. But he could also see that the oceans were changing, there were far fewer fish. He could see that over fishing was real and not sustainable. Mike could see both sides.
This ability, which was tearing him up inside, was also what allowed him to heal. Despite not yet having a working diagnosis from the DSM on that morning of our first meeting, I introduced Mike to cognitive behavior therapy (CBT). He understood it quickly. Seeing both sides of a situation, or perhaps, even more, seeing other sides of a situation, is the goal of CBT. For when we are locked into only one point of view, it can be a kind of prison. As Aaron T. Beck, MD, the father of CBT, wrote in his book “Prisoners of Hate; The Cognitive Basis of Anger, Hostility and Violence”.
CBT is based upon the fact that each of us has highly significant thoughts at the fringe of our consciousness that we are barely aware of, and we are not concentrating on. The experience of an emotion (and then action or behavior) is preceded by such thoughts. I asked Mike, “What is going through your mind right now?” He quickly learned to focus his attention on these thoughts and it was clear to him that his thoughts were responsible for his feelings.
When we used the simple technique of CBT to capture his fleeting automatic thoughts, Mike was amazed to discover what was going through his mind. There is, of course, a big difference thinking a thought and believing a thought. Researchers have noted that our automatic cognitions are involuntary, we neither initiate them nor can we suppress them. Our automatic thoughts can be adaptive and reflect an actual loss, gain, danger or transgression, but they are often maladaptive, or, in other words, disproportionate to the particular circumstances that triggered them.
After working with CBT, Mike began to see that his dad’s anger came from fear that there would one day be no fish to fish. This realization helped him to feel compassion towards his dad. He saw that his dad’s anger and his own anger was a way to protect themselves from the vulnerability of feeling helpless, fear and sadness about the oceans. Mike also realized that his dad felt intimidated around the environmentalists, so he didn’t actually listen to them, to hear that they actually were not telling the community to stop fishing, but to fish differently.
Each of us has our own unique stressful thoughts that cause our anger, but underlying them all is a universal thought: “this should not be happening”. When we believe this thought, that something which is happening should not be happening, we are in an argument against reality. This is also madness.
Mike realized that he may not have power to change others, but he had power to change himself, to listen to himself, using CBT. He had learned that his outer expression of anger came from his inner life. Mike realized he also wanted to try to listen to this dad instead of arguing with him, and maybe he could even be a bridge between his family and the environmentalists. Mike could see that the fishing community and the environmentalists ultimately wanted the same thing, to live with and respect the sea. He now had something of a plan. Mike began to feel calmer and hopeful.
It has been noted that the DSM is a product of culture, a system of nomenclature inherited through scientific endeavors, usually with a Western perspective. It is important to know this, since a cultural perspective can help us become aware of hidden assumptions, and limitations, of current psychology and psychiatric theory and practice. In so doing, we can identify approaches, like CBT, for treating increasingly diverse populations around the world who are suffering. With or without a diagnosis from the DSM.
Whether we identify madness as irrationality or anger, CBT is a universal tool for finding sanity and peace.
Beck, A. T. (1999). Prisoners of Hate; The Cognitive Basis of Anger, Hostility and Violence. Harper Collins, New York, New York.
American Psychiatric Association. (2013). Diagnostic and statistical manual of mental disorders (5th ed.). American Psychiatric Publishing, Arlington, VA.