How a Dangerous Patient Got That Way

Brave Merida

When I first saw “Mr. X” in my waiting room, I thought his head was on fire. Striking, spiked red hair aflame. My mistake. It was his heart.

Before long, he would be on the verge of doing harm. Or, as he saw it, putting things right; being something like an avenging angel on the side of all that he believed to be just and good; a kind of holy warrior.

This is the story of how he went from being depressed and disgruntled to someone who might kill. But it is also a story about what happens when hearts are inflamed with rage.

Until only a short time before the “X-Man” consulted me, he was the sort of guy who, when you saw him in a crowd, the crowd stood out. Hardly a mutant superhero. His physical stature and undistinguished facial features made him appear to be an average man in every way: average nose, average mouth, average height — you get the picture. Back then his hair was conservatively fashioned, not spiked, and my patient colored it a less startling shade.

Mr. X did not welcome attention, you see. Attention in his life had never signaled kindness.

His parents were unkind. His teachers had been unkind. His first wife was unkind. And his kids wanted no part of him other than financial support. They believed his first wife, who said that he was a scoundrel. Thus, we have a man who was abused and neglected, bullied by school mates, and badly treated by wife #1. The divorce had been financially ruinous and somehow that woman had managed to win his children’s favor.

The X-Person was reasonably bright and worked in a technical field of endeavor. He’d made a decent living, but watched as others surpassed him. Some of them were minorities, and rather than looking at possible short-comings in himself (his relatively clumsy social skills, for example), he thought that they were getting unfair promotion. In short, he became a bigot.

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Then the final blow: a financial downturn and the loss of his job. He came to me after several months of a futile job search. He was both depressed and embittered. My patient had tried to play by the rules and, it seemed to him, the referee was always penalizing him. Having no close friends, the only things he could count on were his second wife’s support and that of his religious faith, which he relied on more and more. It was not the religion of his parents, but one that he’d chosen some time after his divorce.

Therapy was aimed at keeping him afloat emotionally so that he could succeed in finding a proper job. To the extent that he opened himself to looking at his life of travail, the treatment attempted to help him grieve his losses. But, let’s just say that the goal of keeping him from curling into a ball was working, while relieving him of his back-pack of unresolved grief was not.

Several months in, however, it was clear that he was beginning to think about violence. Acting out. Targeting others. And he increasingly saw the religious texts that he faithfully read as indicating that wrong was being done in the world and that it was his job to right that wrong. Indeed, he felt that it would be irresponsible and sacrilegious not to.

Interestingly, Mr. X was untroubled by war and wished to have no part in supporting it or protesting it. Nor was he concerned with children who were abandoned or starving. No, his concern was for the unborn, but his anger was against those who conspired to prevent their birth. Specifically, physicians who performed abortions.

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This X-Man was uncomfortable after telling me this. He was more than smart enough to recognize that, if he talked about a plan of action or specified a target, I was required to report him to those authorities who might prevent the worst. When I questioned him about the inconsistency between valuing the lives of the unborn and the likelihood of destroying lives of innocent bystanders in addition to the “murderers” he hated, he brushed-off the thought. When I mentioned the commandment “Thou shalt not kill,” he was unfazed. Yet it came from the book he called “holy.”

To my patient, there was no problem in killing the MDs, and anyone else who might die in addition to the doctors would be “collateral damage,” worth the accomplishment of his goal. He did not expect to be punished by the god he worshipped and didn’t care what civil authorities might do to him.

It was clear to him and to me that my concern about potential carnage (he denied “yet” having a plan and claimed he hadn’t definitely decided to do anything) was getting in the way of his treatment. Within a few weeks he indicated that he could no longer trust me because I seemed too concerned about “the others” who, he believed, were beneath contempt. He wasn’t sure if he wanted another therapist when I offered to help him find one, because, he said, “They’d have to report me, too.” Assuming, of course, that he went further with his thinking and actually did come up with a plan and a specific target.

When he terminated therapy I was worried. I continued to try to keep phone contact, calling him every few weeks. And, before long, there was a change. The X-Man landed a job. He sounded buoyant, no longer angry, and free of the obsessive preoccupation with going out of this world in a glorious bloodbath, along with the evil soul or souls whose existence he wanted to erase. This frustrated man was frustrated no more, throwing himself into a job that felt fulfilling and interesting. And I breathed a sigh of relief.

As I look back on that man and that time, I sometimes think about what it takes to go over the line. Would this X-Man, lacking X-Men-like super powers that might have made him feel better about himself, have killed if he hadn’t found work just then? I think he might have. Would he have killed only because his religion saw his targets as sinning? No. With a different religion or no religion, he still could have justified his action. Righteous anger is always self-justifying.

Most, if not all religious documents are like a Rorschach Inkblot: one person looks at the picture and sees a butterfly, while another looks at the same picture and sees a vampire bat. The Bible recommends stoning as the punishment for adultery, but we haven’t heard of too many Jews or Christians taking that point seriously lately. In religion, interpretation is everything. No, this man could have been almost any isolated soul who had a sorry history of disappointment, heartbreak, and failed attempts to make his life better; and a bunch of anger ready to blossom into a mushroom cloud.

Nagasaki, 20 Minutes After the Atomic Bomb Explosion in 1945

Nagasaki, 20 Minutes After the Atomic Bomb Explosion in 1945

We humans look for justification for our actions, sometimes before we act, but always after. And we tend to find it. “They’ve got weapons of mass destruction,” said the government, “so let’s invade Iraq before they kill us.” “Slavery is in the Bible (and is not there rebuked) so God intended for us to keep slaves,” as the slave-holding Southern States used to argue. Even the god described in the first book of the Bible, the Book of Genesis, is the intelligent designer of the first-ever genocide, which we conveniently think of as the benign story of Noah and the Ark. God’s reasons?

The LORD saw that the wickedness of humankind was great in the earth, and that every inclination of the thoughts of their hearts was only evil continually.  And the LORD was sorry that he had made humankind on the earth, and it grieved him to his heart. (Genesis 6.5 and 6.6).

As Blaise Pascal said, “The heart has its reasons of which reason knows nothing.”

The top image comes from the movie Brave. Some details of this story have been changed to protect the identity of the patient.

Anger Anyone?

Some of the very logical or morally upright folks out there believe that you should never get angry. Never ever.

I’m not one of those folks. First of all, we are all human, and to be human means to have emotions. Second, it is hard to imagine a humanity capable of defending itself, the spouse, and the kids, who can’t get in touch with some needed anger when we or our loved one’s are imperiled.

When danger appears, we are built to fight or flee. The sympathetic nervous system readies you for action. Adrenaline starts to pump, the big muscles of our body receive more blood as the heart rate increases, breathing becomes more rapid, the pupils widen (the better to see danger, my dear!), and sweat gland activity heightens to keep you cool in the event of a major exertion of energy (as well as to make you slippery, so that an aggressor can’t get a firm grip on you).

All of this has been “selected for” in the Darwinian sense: if our ancestors hadn’t successfully fled the tiger or defeated the enemy with the help of these physiological changes, we’d not be here and their genetic line would have stopped.

The same logic suggests that the female of the species historically tended to choose males who were capable of defending her and the kiddies, especially when pregnancy and child-rearing made them particularly vulnerable. But, since the female couldn’t always depend upon the male when he was out hunting and gathering, she needed some anger too.

So, if you get angry, as you almost certainly do, you have come by at least some of it honestly and through no particular effort of your own.

That said, how do you know when your anger goes over the top? Some people will tell you when that happens, of course, and sometimes the authorities will in the form of police. If you are no longer a child and get into fist fights or find yourself yelling a lot, you’ve almost certainly got a problem, either as an aggressor or as a victim. Alcohol might add to your combustibility since it tends to disinhibit people, making big emotions more likely. For some otherwise mild mannered men and women, drinking turns them to the dark side. As the old Chinese saying goes, “first the man takes the drink, then the drink takes the man.” Substitute the word “anger” for the word “drink” and you have an equally valid way of looking at anger. Do you have the anger, or does the anger have you?

On the subject of old sayings, there is an Italian saying that also applies to this issue: “If you want revenge, you should dig two graves.” This means, of course, that revenge is likely to consume you (and perhaps even lead to your demise) just as much as it is likely to succeed in hurting the other party. Lives have been eaten-up and made perpetually miserable by the preoccupation with righting wrongs. Think of the centuries long enmity that exists in the Balkans or the long standing animosity between the Greeks and the Turks. Numerous other examples could be cited. One act of revenge causes the victim to look for his own revenge and back again in a circle without end.

Anger is often the result of a real injury, but the danger is in becoming the thing that you learn to hate because of that injury. The data on the likelihood of child abuse being perpetrated by parents who were themselves abused¬† is fairly well known. Such a parent is much more likely to abuse his children than a parent who was not himself abused as a child. When I tell people this they often find it puzzling. Surely, they say, the abused child would learn what not to do from the parent’s bad example. But think of cigarette smoking or drug/alcohol abuse. Again, the child raised by an addicted mom or dad is at greater risk of duplicating the parent’s behavior than one raised by parents who are abstinent. Not only does the child have the model of the parent as a bad example in these homes, but, in the case of abuse, the youngster has to deal with the anger and hurt inside of him, which comes from being targeted. As children these kids can rarely succeed in retaliating against their parents, but they can take their feelings out against other smaller children (including their siblings) or against their own helpless children when they have become adults. Indeed, unless the abused child is able to obtain relief from the feelings of anger and sadness that come with abuse (and this usually takes therapeutic intervention), he is likely to carry some of these emotions and their behavioral consequences into adulthood. A good book on the subject is For Your Own Good by Alice Miller. A first class movie that depicts exactly what I’ve described is Good Will Hunting.

Back to the question of how you might know whether you have an anger problem, there are a few additional indicators. Do you (or do people tell you) that you react out of proportion to events that are not seen by others as being that big? Do you find yourself feeling angry or irritable much of the time, or awakened by resentments in the middle of the night? Do you have road rage? Have you every punched a wall or thrown an object due to this sort of upset? If you are an athlete in a contact sport, do you enjoy inflicting pain on the opposition?

Even if none of the above apply, there might be other ways that you express your resentment. Do you intentionally delay or put off tasks that others (a spouse or a boss) want you to do, but you don’t believe are that important? Are you sarcastic to others, rather than direct? Do you grumble in discontent or talk behind the back of others at what they’ve done (or not done) or complain about their personal qualities, but put a friendly face on in front of them? If you’ve answered “yes” to some of these questions, you might just be “passive aggressive,” expressing your ire indirectly.

Again, I’m not saying that all anger is inappropriate. And, certainly, one shouldn’t always turn the other cheek, lest one regularly get taken advantage of. But anger can be a problem for you and for those around you. Like a big dog, it should be kept on a short leash. If you can’t manage that, think about counseling.

A recent review article in The Behavior Therapist by Kulesza and Copeland concludes that cognitive behavior therapy is the current treatment of choice for anger problems. The authors emphasize the need for both training in behavioral skills and the use of cognitive restructuring to insure the best results. Therapy for anger issues is therefore likely to include direct instruction about antagonism and its management; self-monitoring of angry feelings, thoughts, and behaviors; relaxation training; assistance in new ways of thinking about the events that trigger rage episodes; social skills/assertiveness training; direction as to how to think about and undercut anger when it does occur; and practice in being exposed to triggering events so that new skills can be employed and the patient can learn to tolerate or diffuse the emotional intensity and stop short of vehement outbursts.

Among self-help books, one of the best is Stop the Anger Now: A Workbook for the Prevention, Containment, and Resolution of Anger by Ronald Potter-Efron.