Anger Management

In his blog Exquisite Corpse, writer and NPR commentator Andrei Codrescu this week offered his views on the dangers of anger management. He writes, "Anger is such a great feeling. I would hate to see it lost to management."

The poet and novelist goes on to list some historical horrors, such as slavery and child labor, that would still be common in this country were it not for anger. He also alludes to circumstances and people that would evoke outrage in practically anyone.

I realize that all of this is offered in the sublime, ironic style that Codrescu so deftly employs. It requires no rebuttal. In fact, his points are some of the same points that I would make to anyone seeking help due to anger issues: Anger can be justified. Anger can be useful. It is a basic emotion and therefore helps define us as human beings.

The point that I would add, coming from a CBT perspective, is that anger management is about staying focused on your goals. Say you're in a hurry to get to an important meeting, when you're stopped by a police officer for speeding. Now you're really running late, and that makes you angry. Your goal is to get through the interaction as soon as possible so you can be on your way. If you allow your anger to influence your behavior, perhaps getting mouthy with the cop, then you'll likely be kissing your goal goodbye. If, on the other hand, you're able to use techniques to temper your anger's intensity, you're more likely to move things along.

In other words, managing anger doesn't give others a free pass. It rather gives you a leg up.

Major-League Anxiety

Some people spend much energy keeping their symptoms of mental illness private. If they work hard enough at covering things up, the average person might be able to get by without too many people noticing that anything is wrong. When you're a major-league baseball player, that's not going to happen.

For more than a month, St. Louis Cardinals' infielder Khalil Greene has had a very public battle with social anxiety disorder. He reportedly has experienced increased self-consciousness during games, resulting in verbal and physical outbursts. The problems also didn't help his level of play. On May 31 a St. Louis Post-Dispatch article quoted Greene as saying:

"It's so strong. It's a very intense feeling and it's very unpleasant. It's not life threatening. I'm not putting myself at risk. But at the same time those responses are there automatically. I really have to concentrate to slow down, focus and stay in the game."

As a result of his problems, Greene was placed on the disabled list May 28, and later began a "rehab assignment" in the minor leagues. He returned to the Cardinals last week.

Whatever Greene has been doing to address his disorder has not been reported, but if quality of play is any measure, his treatment is working. Over the weekend Greene hit a home run in each of the three games he played in Kansas City, helping put the Cardinals back in first place. Even more encouraging, two of his homers came after he'd fallen behind in the count by two strikes. Further, Post-Dispatch columnist Bernie Miklasz reported Greene played "fine defense" at third base, having been moved from his position at shortstop.

The quickness of all of this calls for caution. Relapse both large and small is the norm for people dealing with any mental illness. Let's hope that Greene is learning effective techniques that he can call upon during times of stress, which must be constant during the long baseball season. If CBT is part of his treatment, then he is learning how to be his own therapist--something any professional athlete (not to mention those of us who are not so rich and famous) could appreciate.

Whether or not Khalil Greene can keep up his comeback is yet to be seen. Support from Cardinals fans can only help. Having grown up in St. Louis, I proudly count myself among them.

Go Khalil, and go Cards!

CBT podcast

The hour-long radio program on CBT that aired May 6 is now available for listening as a podcast. Host Jeff Frey, MD and I discuss topics such as how CBT works, automatic thoughts, mindfulness, medication vs. talk therapy, and similarities and differences between various types of mental health professionals (licensed clinical social workers, psychologists and psychiatrists). The show is called Your Health Matters, and it airs every Wednesday, 6-7 p.m. Central on KOPN 89.5 fm in Columbia, MO.

Mindfulness and options

Mindfulness has found its way into the work of many cognitive-behavioral therapists, and for good reason. Any practice that has the potential to increase awareness, improve focus and reduce harmful judging deserves our consideration.

Someone practicing mindfulness is noticing their inner experiences (thoughts, feelings, urges and body sensations, for example), without necessarily acting upon them. The practice is designed to enrich whatever one chooses to focus upon, by allowing them to fully participate.

In my last post I wrote about how black-and-white thinking occurs when someone is limited in their ability to see good options for themselves. In her book, Mindfulness, Ellen J. Langer describes how the practice of mindfulness can serve as an antidote to this type of thinking. She writes:

A model of mindful receptivity is the inertial navigation system in modern aircraft. This device is constantly receiving new information, constantly letting the pilot know where the plane is at any particular moment. We have a similar mechanism operating within us as we walk or balance ourselves in other ways. Our minds, however, have a tendency to block out small, inconsistent signals (p. 67).

The inconsistent signals Langer mentions can be any bit of information or alternative point of view that we don't normally consider. Many times, we limit our own options by the way we think, which means only considering the options that come to us readily. Being mindfully aware of all information available allows us to see possibilities that we'd either dismissed or never considered. As Langer points out, the results can be liberating.

Thinking in black and white

An important part of any therapy is helping people make sense of things. As a therapist, if I can help someone figure out what’s really driving their emotions and behaviors, then there’s a chance they can do something about it.

One of the ways that CBT makes sense of things is by helping people identify the thoughts behind their moods. Once you pinpoint the thoughts, then you can start to examine them for accuracy.

I’ve found that many of my clients benefit from a list of thought categories that drive moods. These lists have various names—cognitive distortions, irrational beliefs, thinking errors—none of which I particularly like because of their pejorative nature. They’re simply ways of thinking that everyone engages in from time to time. The important thing is to recognize when your thoughts fit into one of the categories.

In this post, I’d like to look at one of the most common thought categories: black-and-white thinking (a.k.a. all-or-nothing thinking or dichotomous thinking). This happens when you see yourself as having very limited options in a situation, and none of them is good. Further, the options often represent opposite extremes (hence the “all-or-nothing”).

Some examples:

“I’m either a complete success or a total failure.”
“I can either stay in my job forever or quit right now.”
“If I don’t bottle up my anger, then I explode.”

When feelings are running high, it’s easy to lose sight of your options. Depression and anger can narrow your view even further. The CBT way of addressing these kinds of thoughts is to challenge them by asking, “Are these really the only options?” “Is there some middle ground or alternative that I haven’t considered?” Often it’s helpful to see your options as a continuum, with extremes at either end. This can help highlight the possibility that other choices exist somewhere in between.

CBT on the air!

For an hour of radio discussion about CBT, tune in or log on to KOPN 89.5 FM in Columbia, MO, Wednesday, May 6, 6:00-7:00 p.m. Central. I’m scheduled to be the guest on Your Health Matters, a weekly call-in program hosted by Jeff Frey, MD. I’m looking forward to answering all sorts of questions about CBT. The on-air phone number is (573) 443-TALK.

Awareness and automatic thoughts

One of the often-cited benefits of CBT is that it can work quickly. Some people achieve their goals in just a few sessions; for others, the process can take a year or more. Some of the people who report rapid progress tell me it's because they feel more aware--aware of their own thoughts, feelings or even just the "issue" that brought them to therapy.

There are many paths to awareness: meditation, yoga, reading and group therapy are but a few. In CBT, people often start to increase their awareness by noticing their thoughts, or more specifically, their automatic thoughts.

Psychiatrist Aaron Beck coined the term automatic thoughts after noticing something interesting. His patients' moods, such as sadness or nervousness, didn't always match the thoughts that they were expressing to him. He discovered that people often have two streams of thought going at any given time--thoughts they are fully conscious of, and others that happen "automatically," without any real acknowledgement or reflection. People notice the moods that happen as a result of these automatic thoughts, but they don't stop to articulate or question the thoughts themselves.

CBT helps people get into the habit of noticing their automatic thoughts. You can try this the next time you experience a strong emotion, and aren't sure why. Ask yourself, "What was going through my mind when I started to feel this way?" Other questions to try include "What does this situation mean to me?" or "What do I think this says about my life?"

Identifying these thoughts is the first step. In CBT, people also learn how to evaluate their thoughts for accuracy. Of course, some thoughts are 100 percent accurate. But when depression or anxiety is part of the picture, people often focus on the worst or most scary things they can think of. CBT can help broaden the view, helping people see their lives in the most realistic, balanced way possible. They may still feel sadness or worry, but their feelings will be more appropriate to the situation.

And it all starts with awareness.