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ANGER in GRIEF

William G. Hoy

Elizabeth Kubler-Ross likely broke entirely new ground in her 1969 book, On Death and Dying by suggesting that anger was the second stage of the dying process. Following on the heels of denial in her schema, Kubler-Ross suggested that virtually all people, after an initial protest of, “This can’t be real,” go on to conclude, “Why should this be me (or my loved one?”)

Of course, decades of clinical research and experience has dismissed Kubler-Ross’ simplistic five-stage process as a reliable picture of what the dying, much less the grieving, experience. But without question, her assertion that most people experience anger could hardly be debated. Anyone who has cared for a hospice patient or very many people in bereavement knows the widespread nature of this often-misunderstood emotion.

Anger may be directed (or misdirected) at a variety of objects and persons. Some people direct their anger at the illness or accident that is claiming or has claimed their loved one’s life. In the case of a car crash or industrial accident, survivors legitimately blame people who are legally, or at least morally, culpable because of a failure to prevent the incident. And of course just because survivors blame a party does not mean the blamed individual could possibly have prevented the outcome; just because physicians are powerless to stop the spread of a disease does not mean they are not blamed for the failure.

Anger is often directed at God. Even people of devout faith are prone to wonder where God is and why He seems to remain so silent. Many people live with a fantasy of how “the divine” works in the world, seeing God as almost a “Magic Genie” on call to do one’s bidding. When God doesn’t respond as expected, the patient or family member is left feeling let down and abandoned. However the “spiritual battering” some people receive from well-meaning friends and even religious leaders does nothing to dispel the anger.

Sometimes, it is the person who most wants to help who becomes the object of anger. A bereaved individual or seriously ill person might be in great physical and/or emotional pain and in his outburst, simply explodes on whoever is close by. Hospice nurses and family caregivers are the ones most often caught in the shrapnel of such an explosion.

Regardless of the person or force to which the anger is directed, anger lies somewhere on a continuum between two poles I call circumstantial and dispositional. Circumstantial anger comes about purely because of the nature of the event; in its purest form, the expression of circumstantial anger is most “out of character” for the person feeling this emotion. People close to the individual experiencing circumstantial anger might even say to themselves, “Where is this coming from?” because the reaction seems so unusual. One patient’s wife expressed her surprise this way: “He is always so calm and cool; this outburst really scares me.”

Dispositional anger is most often referred to in psychological research literature as “trait anger.” The classic Type-A personality who frequently demands his way and lashes out at everyone who blocks his goal is clearly “dispositionally angry.” Unlike the person who is angry about the present circumstances, this individual seems to go through life as an angry person; it is a clear marking on his or her personality.

In caring for a dying or bereaved individual, we rarely have the luxury of unpacking all the factors that might have led to the development of this personality trait. Certainly early developmental experiences had a role since frequently a pattern dates back into adolescence or childhood. Others seem to have developed the trait of anger later in adulthood, perhaps even as a response to several disappointing circumstances piled one on the other.

In psychotherapy, the root causes are important; in crisis intervention or short-term caregiving, our best hope is likely to protect ourselves and to intervene as effectively as possible. Here are some important guidelines.

First, make sure safety is guaranteed. No healthcare provider, school counselor, or family member should be repeatedly subjected to verbal abuse because this can lead to physical abuse. And though it goes without saying, never try to intervene with a patient or client who is physically aggressive. If there are people who need to be protected, work with local law enforcement agencies to assure the safety of minors, the elderly, and others who need advocacy.

Second, listen fully to what is being said. People get angry for many different reasons. Unless there is deep-seated clinical pathology, however, they most often stay angry because they feel they are not heard. Increased volume, swear words, and abusive tone might be how they have learned to get attention for their message. When the angry person “takes a breath,” try saying something like, “John. I know this really angers you; let me see if I’m hearing what you are saying. . .” and then paraphrase what you think you’ve heard. At the end of your brief restatement, ask, “Did I get it right?” If you respond with quiet, slower and more deliberate speech, you may find the angry person’s pitch drops to match yours. Perhaps even the bulging veins on the neck return to normal size, too!

Third, remember that anger that is addressed toward you is not necessarily about you. Caregivers get caught in the explosions from angry patients and clients. Remembering that the anger is likely a response to something beyond your control helps you respond calmly. Nevertheless, remember that “taking verbal abuse” is not in your job description. You can calmly inform the patient or client that you will discuss the matter when he or she chooses to quit screaming.

Fourth, remember where the patient or client is and has been. The healthcare system delivery and payment systems can often be a maze to the patient and his or her family, making it difficult to make reasonable sense of the process. The old expression to not judge until you have walked a mile in the other fellow’s shoes serves us well here.

Fifth, keep in mind that your goal is resolution of the client’s problem (or perceived problem) rather than the proving of your point. Many conflicts are diffused when the caregiver, acting as the “bigger person,” chooses to lay aside his need to “be right.” You don’t have to agree on every point in order to resolve the conflict in a way both parties can be satisfied.