Last Updated Dec 8, 2022|ACT for PTSD

Coping With Anger in ACT for PTSD

This presentation is an excerpt from the online course “ACT for Trauma: PTSD and Beyond”.

Highlights

Anger is a frequently co-occurring problem with PTSD.
Anger is often addressed indirectly in trauma-focused therapy.
In ACT, the trauma survivor is engaged to approach anger as a valid source of information about values.
Slow down the moment of the anger response and choose more workable behavior.

Transcript

Anger is another frequently co-occurring emotional response for individuals with PTSD. And even when someone has had a successful course of trauma-focused treatment, they may continue to have problems with angry behaviors. However, anger is often only indirectly addressed in a number of trauma-focused treatments.

The feeling of anger and the actions associated with anger are closely linked.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

For instance, clients with PTSD who experience angry outbursts frequently report that the emotion and reaction are simultaneous and, therefore, can’t be helped. This issue can be addressed in ACT in a few ways.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

First, the therapist can draw attention to emotions that may be underlying anger and help the client to notice how connecting with and holding on to angry feelings can often serve as a tool for avoidance of some other emotion.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

So, for example, it’s often easier, or more comfortable, or activating to feel anger than to feel sadness or disappointment, which are more vulnerable sort of feelings. In many instances, we suggest that if the client could sort of peel the anger back and see what’s underneath, there’s often a feeling of hurt or being wronged in some way.

So, drawing from mindfulness skills aimed at allowing those feelings to be present and paying attention to their origin, the therapist can validate the client’s experience and help the client to act in accordance with his or her values, even in the presence of those painful feelings.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

One way that I talk about this, I talk about slowing down the moment. So often, anger seems like an automatic reaction. Clients will say that when they’re overcome with anger, there’s no thinking involved. They just act. Whatever the precipitating situation happens, the anger shows up, and they just automatically act in an angry, or sometimes even violent, way.

And they may resist the idea that they could’ve done anything differently, not because they’re being resistant, but because their perception, the way it feels, is that it just happens to them. It just overcomes them, and there’s not a lot of choice involved.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

So, the goal over time in therapy is to help them slow down that moment to find or create a brief pause where there’s an opportunity to choose a reaction.

Again, they may tell you that, from their experience, there is no pause; there is no moment.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

And so what we do in therapy is practice sort of playing back the tape to slow it down frame by frame to understand what the trigger was: what the thought was that showed up, the emotion, the physiological sensations, and then the act.

They may be microscopic moments, but these things do happen, and it’s not just that it goes from trigger to action.
And so we practice in treatment, going back to the event in their imagination and slowing it down so they identify each of those steps. And after you’ve done this over and over with the person with multiple situations and examples, the person can themselves gain the ability to actually pause in the moment as the next angry situation happens and make a different choice.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

Now, anger is often related to conceptions of right and wrong. So with many clients who have PTSD, there’s a fundamental conceptual link between being right vs wrong and being safe vs threatened. Those 2 things are connected oftentimes.

And in this case, to give up taking up the right action means to put your own or other’s lives at risk. And so defusion techniques can be really useful when addressing that issue.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

One exercise that can be used is the right and wrong card game. In this exercise, the therapist uses a set of 3-by-5 index cards that say “right” on half of the cards and “wrong” on the other half.

Using experiences that are linked with problematic anger either that emerge in session or that can be elicited from the client’s history with the client’s permission, the therapist engages in a demonstration of the ultimate consequences of being right or wrong.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

So while the client generates thoughts about an anger-provoking experience, the therapist listens for connections with being right or wrong, either for themselves or someone else in the experience.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

When the therapist detects an “I’m right about this” kind of thought or response, he hands a right card to the client. And the therapist takes a wrong card. If the client makes him or herself wrong for what they did or thought, then the client takes a wrong card, and the therapist gets a right card.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

The goal is to get a stack of right and wrong cards for both players. Once a good-sized stack of each has developed, the therapist can suggest to the client the result of the game is that sometimes the client was right and other times wrong, yet the problem remains unsolved.

By defusing from right and wrong, the therapist makes some room for the possibility that aiming all of one’s actions toward always being right may not bring the person the happiness or sense of safety he or she is seeking.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

The therapist can then introduce the possibility of an alternative: to let go of the importance of having to be right in exchange for focusing efforts on actions and behaviors that will bring the client a fuller, and more vital, and effective life.

Some therapists are hesitant to do this exercise with clients for fear that it may invalidate the client’s experience or even elicit anger in session.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

But once a strong therapeutic relationship is established that involves a radical respect on the part of the therapist for the client and a compassionate understanding of the struggle we all engage in with our internal experiences,
an irreverent approach to dealing with difficult issues, such as acted out anger and the struggle to be acknowledged as right, can be a powerful tool for increasing defusion and making room for radical changes in how clients relate to their own internal experiences.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

Over time, the client can learn that anger is a much richer experience than just a seemingly reflexive physiological response that’s accompanied by angry behavior. After peeling back the immediate reaction, the person can begin to contact that anger is another source of information about what the individual values.

The anger often arises because something that the person values has been disrespected or disregarded in some way.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

When the client can look to understand what it is that the anger is trying to tell them and can slow down enough to mindfully choose how to respond, anger can actually become a powerful marker that it is time to find a way to engage in valued behavior.

References

Batten, S. V., Orsillo, S. M., & Walser, R. D. (2005). Acceptance and mindfulness-based approaches to the treatment of posttraumatic stress disorder. In S. M. Orsillo & L. Roemer (Eds.), Acceptance and mindfulness-based approaches to anxiety: Conceptualization and treatment (p. 241–269). Springer Science + Business Media.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger: The new acceptance and commitment therapy guide to problem anger. New Harbinger Publications.

Toohey, M., Santanello, A., Van Orden, O., Soll, M., & Batten, S. (2017). Dispositional anger and experiential avoidance in veterans with PTSD. Journal of Military and Veterans’ Health, 25(3), 11–18.

So, some key points. Anger is a frequently co-occurring problem with PTSD for many trauma survivors. However, although it’s often a major source of distress or behavioral dysfunction, anger is often only addressed indirectly in trauma-focused therapy.

In ACT, the trauma survivor is engaged to not focus on trying to reduce or manage anger—in fact, even the term anger management has a symptom reduction quality that isn’t consistent with ACT—but to instead learn to approach anger as a valid source of information, often about values that the individual needs to be protecting or attending to.

Over time, the ACT client can learn to slow down the moment of what seems like an automatic anger response and instead choose more workable behavior, even in the presence of the emotion of anger.

ACT for Trauma: PTSD and Beyond

Coping With Anger in ACT for PTSD

Transcript

More ACT for Trauma: PTSD and Beyond