Anger

Anger is a natural emotion. It is an emotion that activates our “fight, flight, or freeze” response or tells us that something is happening that we should pay attention to.

Definitions

• Anger refers to a strong feeling of annoyance, displeasure, or hostility.
• Threatening refers to showing intent to cause harm to others and making others feel vulnerable or at risk.
• Aggression refers to hostile or violent behaviors or attitudes toward another person. Aggression is often an act of attacking without being provoked.
• Bullying is one form of aggression in which the aggressor uses his strength or influence to intimidate a victim. Bullying targets a specific victim repeatedly. It may include teasing, name calling, picking on, or making fun of another person. Bullying can happen in all age groups, though it is most common in middle and high schools.
• Cyberbullying occurs when a child uses electronic technology to send aggressive messages, spread rumors, or send embarrassing pictures or videos. These can be sent using emails, text messages, or social networking sites, such as Facebook, Twitter, or YouTube.
  Note: Cyberbullies are often more brazen and cruel; they can be anonymous, often leaving victims feeling helpless to take any action.

Anger is not a “bad” emotion. Anger can be a normal, expected, and healthy emotion. It can be a “good” emotion because it alerts the person feeling it to an internal reaction to something. Anger can be expressed in healthy, controlled ways that allow clients to process their anger without consequences.

If anger is not expressed in a healthy, controlled way, however, it will usually show up in harmful ways that often have consequences.

Anger and aggression may involve one or more aggressors and victims. Anger and aggression can be verbal, physical, or both.

Anger can be the expression of other emotions or needs. People can appear or act angry when they are actually experiencing another difficult emotion, such as fear, sadness, loneliness, grief, or vulnerability. Clients can also experience anger if their basic needs for food, water, shelter, and sleep are unmet. Make sure that a client’s basic needs are being met before moving on to the assessment and treatment process.

• If someone is hungry and having difficulty accessing food, prioritize this need. Help her brainstorm places where she can get food and water and how she can manage her money or food stamps. It may be beneficial to have snacks in your office for those who are unable to focus during your appointment due to hunger, especially with children.
• If someone is homeless or doesn’t have a stable place to live, it will be very difficult for him to work on mental health issues. Use some of your appointment time to work on obtaining a safe place to sleep and long-term solutions to their homelessness.
• Sleep deprivation can trigger or exacerbate mental health issues. If your client shows signs of sleep deprivation, brainstorm sleep hygiene strategies during your session and consider referring your client to a medical provider if needed.

Clients who have been perpetrators of anger-related domestic violence will often make excuses for their behavior and blame the victim or others involved by saying things like “she deserved it” or “if he didn’t talk back, then I wouldn’t have hit him.”

Be aware of the potential for clients to use alcohol and other drugs as a way to cope with anger. Other clients may become more angry or aggressive when using alcohol or drugs.

People express their anger in different ways; for examplesome are more likely to act rude, inconsiderate, or mean when they are angry, while others are more likely to become quiet or passive when they are angry.

Working with clients who are angry can be exhausting for providers. Make sure you have strict boundaries and that you are being treated with respect. Practice good self-care to allow yourself to have the energy to continue making a difference in clients’ lives.

Be aware that anger can coexist with medical problems, such as:

• Headaches.
• Stomach problems.
• Tension.
• High blood pressure.
• High heart rate.
• Increased risk of stroke, heart disease, ulcers, and cancer.
• Fatigue.

Be sure to rule out the following medical problems that can cause anger by reviewing the client chart and consulting with a local CHA/P or medical provider, if needed. See Chapter E-3: Behavioral Health and Medical Conditions .

• Traumatic Brain Injury.
• Chemical imbalance.
• Overactive thyroid.
• Diabetes.
• Epilepsy.
• Stroke.
• Certain medications.

Anger in Children and Youth

Children will often express anger in the same ways that they’ve observed adults around them express anger. Invite parents and caregivers to learn about healthy parenting and discipline to help their children appropriately express anger. See: Parenting.

Children often have difficulty identifying their emotion as anger. Instead, they may complain about physical problems or pain or they may look or act depressed.

Uncontrollable anger often makes children uncomfortable, and they are generally very open to learning how to manage their anger.

Referral information, including reports from medical providers, school staff, clinicians, or other sources regarding the client's wellbeing.

Releases of Information ( ROIs ) that are current or updated before getting information about the client from other sources.

Client history related to past trauma, significant losses, medical conditions, and the current problem.

Treatment Plan:

• Collateral information from OCS, if applicable (case notes, report history, etc.).
• For children and youth, school records and school social worker records.
• For adults, collateral information from probation officers, such as police reports and probation violations, and online court records from Alaska's Court System site.

Common ways that people may express anger:

• Shouting, yelling, swearing, and name calling.
• Fighting, hitting, kicking, and punching.
• Perpetrating abuse and neglect.
• Bullying.
• Throwing things.
• Destroying property and belongings.
• Sulking or being unusually withdrawn.
• Erratically driving cars, ATVs, boats, and snowmachines.
• Taking risks.
• Demonstrating low impulse control.

Common things that trigger anger:

• Grief and sadness due to loss of a loved one.
• Rudeness or poor customer service.
• Tiredness.
• Hunger.
• Cheating or relationship issues.
• Humiliation or embarrassment.
• Sexual frustration.
• Money problems and debt.
• Stress.
• Feeling like a failure.
• Alcohol and drugs.
• Experiencing a crime committed against the self or a loved one.
• Having a physical illness or being in pain.
• Experiencing frequent mood swings in the self or others.

Anger that is not expressed in a healthy way can often lead to:

• Marriage or relationship conflicts.
• Problems with friends and family.
• Problems at work.
• Substance use.
• Depression.
• Other mental health concerns.
• Incarceration or legal problems.
• Escalation of anger, leading to violence or abuse towards others.

The symptoms of anger and aggression can be similar in victims and aggressors. Both may show the following signs:

• Emotions and Mood
  • Low self-esteem.
  • Sadness or hopelessness.
  • Mood swings.
  • Frequent anger towards others.

• Personality
  • Shyness or social awkwardness.
  • Described as “different,” “scary,” or “rude.”
  • Poor impulse control.
  • Problems with power and control.
• Physical
  • Frequent bruises, cuts, or other injuries.
  • Signs of self-harm or self-mutilation (cutting, burning, scratching).
  • Restlessness in people who are trying to manage their anger but are amped up inside.

• Social
  • Not feeling like they belong.
  • Withdrawn from others.
  • Loss of friends and social supports because others don’t want to be around the anger.

• Past or Present Family Environment
  • Trauma, neglect, or abuse.
  • Substance abuse in the home.
  • Witnessing violence or anger in the home.

There are also some key differences in how victims and aggressors react to anger.

Aggressors may:

• Lack empathy towards others.
• Act dominant.
• Have a desire to be powerful and in control.
• Use violence to settle conflicts or show dominance.
• Not know how to properly handle conflicts without violence.

Victims may:

• Have changes in behavior or appearance.
• Act excessively submissive.
• Report being injured by others.
  • Note: If the client has injuries that require medical attention, call a CHA/P or other medical provider.
  • If the victim is a child or vulnerable adult, make a report to the appropriate organization (see Chapter B-5: Mandatory Reporting and Duty to Warn ). Report to the Office of Children's Services for suspected child abuse and Adult Protective Services for adults.
• Avoid going to school, work, or social activities.
• Complain of being “picked on” or “bullied.”
• Say, “everyone is against me.”
• Engage in bullying behavior to compensate.
• Blame themselves for how they are being treated by an aggressor.

Children and youth with anger may behave differently than angry adults. The following symptoms can signify anger in children and youth:

• Emotions/Mood
  • Anger can often be an indicator of depression in children.

• Personality
  • Shyness or social awkwardness.
  • Described by peers as “different” or “weird.”
  • Multiple trips to the principal’s office, excessive time-outs, or exclusion.
  • Frequent absences from school.
  • Low or failing grades.

• Parents
  • Parents say the child doesn’t spend time with others.
  • Parent or child reports the child is being bullied or is bullying others.
  • Children who are angry or aggressive may have limited supervision, and their parents may ignore or excuse their aggressive behavior.

Emotions/Mood

• Do you notice any particular feelings prior to becoming angry (e.g., loneliness)? How often do you feel those feelings?
• Do you feel down, sad, or depressed now? Have you recently?
• How often do you feel angry at other people?
• Do you have difficulty controlling your anger?

Physical

• What do you do when you are angry?
• How often are you physically angry (e.g., punching the wall, throwing something, or hurting someone)?
• How does your body feel when you start to become angry?
• Have you ever threatened anyone with physical violence or a weapon?

Social

• What triggers your anger?
• Are there certain situations in which you feel angrier than others?
• Are there certain people you feel angry towards?
• Who do you talk to or what do you do when you get angry?
• What are the consequences you’ve had from anger?

Environmental

• Are you angrier when you are drinking alcohol or using substances ?
• Do you get angry in certain places, or everywhere?
• Did you witness violence or anger in your home as a child?
• Have you experienced a traumatic event, abuse, or neglect as a child or adult?
• How does your family express anger?

Routinely review Chapter C-4: BHA/P Services and Common Interventions for how to prepare for and conduct interventions during appointments and for information on the levels of service available throughout Alaska.

Specifically, you may consider helping the client develop strategies to manage aggressive or impulsive behaviors through applying skills based on DBT, such asEmotionRegulation, Interpersonal Effectiveness, and Distress Tolerance.

You will also want to consider substance abuse treatment, if applicable. Clients under the influence of alcohol or drugs are prone to aggressive acting out. Helping them resolve problematic substance use can be helpful for managing aggressive behaviors.

Be sure you are familiar with the information in Chapter B-5: Mandatory Reporting and Duty to Warn and Chapter B-8: Documentation and Billing. Report instances of the following, consistent with your organization's policies and procedures:

• Child abuse or neglect.
• Suicidal thoughts or plans.
• Intentions to cause harm or injury to the self or others.