Prof. David Forbes: Before we do a deeper dive into the issue about anger I do want to put upfront, and I do so every time, the fact that we know that disaster impacts on multiple domains, and community, on social environment, on the built environment, on the economic and financial environment, on the natural environment.
And while we’ll be doing a deeper dive on one of the specific human psychosocial impacts of anger, today it’s recognizing that that intersects and has a multi-directional relationship with each of these other components. As will be clear as the talk proceeds.
Part of the reason for this deep dive today on anger, it is often neglected. It’s not neglected in the minds of disaster survivors and trauma survivors. In fact, it’s often one of the most prominent features. But if we look at the clinical literature, we look at the clinical research, anger is often significantly underrepresented and done. my colleague Tony McHugh will no doubt talk about this on the panel. But Casanova and Sadowski in 1995, calling it the ‘forgotten emotion’, Cassiello-Robbins & Barlow 2016, ‘the unrecognized emotion and emotional disorders’ and I did a keynote at the International Trauma Society conference titled ‘Anger, the neglected sibling in the affect family’. What we do find is whilst there’s often discussions about all manner of mental health outcomes after trauma and disaster, PTSD, depression, anxiety, substance use, and other factors often anger is is dramatically neglected so hence the focus on that today.
So what is anger? And it seems a bit silly to be saying, what is anger it seems really obvious to some degree but I will say it’s probably one of the most misunderstood emotions but also it’s one with the most varied opinion about what it is, and when we’re thinking about anger, really we’re talking about an emotion that’s characterized as an approach emotion – to address threat, to overcome barriers, contrasting with fear, anxiety which seem to be triggered by threats but really lead to behaviours like avoidance.
So anger serves as a motivator or mobilizer for productive action, and has a very, can have a very adaptive and appropriate expression of emotion in order to be able to address the barriers that are being faced, or the challenges that are being faced, and often a very understandable reaction to certain situations or circumstances. So in focusing on anger today it’s not necessarily, it’s not saying that anger is inherently problematic. It’s saying that anger can, as a normal emotion, as a really productive and adaptive component that can become problematic under certain circumstances.
So what is it we think about when we talk about problematic or pathological anger, because for some people the anger has actually become an all encompassing experience. Their experience of anger impacts on their health, on their wellbeing, and starts to pose a risk to the safety of themselves or others. So simply put, and there’s a whole range of definitions about what problematic anger means, but simply put, when it occurs with a level of frequency, intensity or duration that causes significant distress so it happens a lot it happens intensively and it goes on for a long time. Causing distress where it interferes with interpersonal relationships, family relationships, social relationships, occupational relationships, and interferes with functioning. So if we’re thinking about anger as a mobilizer to address goals or to right wrongs and do what needs to be done, sometimes the anger is so severe that it actually becomes self-defeating in impacting the person’s ability to address the goal or address the barrier that they’re trying to get through to achieve their goal. So it can become self-defeating when it’s in this problematic form and potentially as a trigger for aggressive behaviour towards others.
And when we think about anger we really think about it in a multifaceted way. And again this is a simple model but it allows us to disaggregate it or break it up into component parts and that can often be helpful in the way we think about it but also in the way we deliver care or support to people who are, who we’re dealing with, trauma-affected individuals who experience significant anger so it helps us to think about it this way. One is the cognitive element, so the thinking element, the pattern, the way the person might be interpreting or appraising the situation. The attributions they might be making about it, the physiological component of anger, which is very much about the summit of visceral physiology. So the level of hyperarousal that goes with the anger response in order to get the body ready for action, to mobilize the body for approach towards the the difficult or threatening situation. So the physiological mobilizer for action. There’s the feeling component which can vary in intensity from mild irritation through to fury and rage. And then the behavioural component really which is very much influenced by the situation, the intensity of the anger experience, what the expressive repertoire of the individual is, what are their patterns of behavioral response in the aftermath of anger and the experience of anger, and what’s been the reinforcement history in relation to those behaviours.
So when we’re thinking about the, and I just wanted to highlight the appraisal element, the cognitive element if you like, because there’s a reasonably strong evidence base about what are the patterns of thinking, interpretations or appraisals of events that we know are likely to increase the intensity of the anger experience. Useful for us to know what the literature and research tells us around that, what our clinical experience tell us around that and I’ve highlighted a number there whilst there’s a much larger list than that these are probably the strongest the most common and these are some of the ones that also find expression in the post-disaster context in different ways, in different times, along the trajectory of disaster and recovery. So these include perception of the event as having been intentional which can be certainly the case in some cases in relation to trauma and disaster, including natural disaster, where it may have been deliberately triggered or lit. So to have been preventable or controllable where there’s the sense that it may have been unintentional but that there’s a degree to which it might have been something that could have been mitigated or actions could have been taken to have resulted in a different outcome by neglect or by omission.
The degree to which the event is perceived as unwarranted, unjust or unfair. So one in relation to the manner in which the disaster or the trauma might have occurred the way it might differentially affect people in an impacted community, but also particularly and not uncommonly referring to or associated with the way in which services are provided, access to services is available or the distribution of resources might occur in the aftermath of disaster. Where there’s a sense of injustice around some of those actions, delay or inadequate distribution, where the event is viewed in all or nothing or black and white terms, so that it’s seen very dichotomously. And also when the source of anger is externalized it’s all about what they did, and when the personal responsibility is minimized; it’s had nothing to do with me or any of my actions. So these are some of the common cognitions or interpretations or appraisals we see in the aftermath of trauma and disaster that we know when these are present they up the ante in relation to anger and certainly in combination do so more so.
Really important is that we distinguish anger from violence. When we talk about violence we’re talking about physical and verbal behaviour intended to hurt or intimidate causing physical injury and damage. And when we’re talking about intimate partner violence we’re referring to behaviours in a relationship causing physical, psychological or sexual harm. So they can include physical violence, sexual coercion, psychological abuse, but various forms threatening, coercive and controlling behaviour. So intimate partner violence is very heterogeneous. Anger may feature anger to a lesser or greater extent. But we are distinguishing anger from violence. Anger is an emotion, violence is a choice and it’s very common for anger to be experienced without aggression and aggression and violence to be experienced without anger. So we’re in intimate partner context where it’s often in the context of coercive and controlling forms of power gender dynamics or in the context of situational couple violence we might see escalations due to emotional dysregulation.
So to just reiterate that graphically and it’s a really important point, we are distinguishing between anger, aggression and violence where we can have anger without aggression, we have an instrumental aggression without anger but we can have anger triggered aggression or violence as well.
So why does it matter to think about anger after disasters? Why are we focusing this webinar on this topic? We know that actually problematic anger is highly prevalent after disasters with 33% following earthquakes, 50% following the hurricanes in the U.S. We often see in the media headline that’s not uncommon, we see in the aftermath of bushfires particularly in context of community responses, we see the headline of ‘burning with rage’ that the notion of that anger in a post-disaster context at some point in the trajectory is not at all uncommon. It’s also an issue within the first responder agencies themselves, for the first responders, for police emergency services or other service providers including health service providers in responding to disaster. So we know that anger is not only in the community. Anger is experienced by a lot of the first responders as well as part of their extraordinarily difficult job and Amy Adler and I have just recently put a book out that details anger in high-risk organizations but probably a story for another day.
So what do we know from the Black Saturday bushfires? So this is a long study, in the aftermath of the Black Saturday fires, we’ve just recently had the ten year follow-up of that brilliantly led by Lisa Gibbs from public health Melbourne university. One of the things the Black Saturday study tells us is that there’s a nearly a three-fold increase in problem anger in high impacted areas compared to low and moderate areas. We also saw that problematic anger is associated with a thirteen-fold increase in people reporting having engaged in aggressive behaviour in the previous 12 months and an eight-fold increase in suicidal ideation. So we also know that problematic anger is associated with increased risk to self and to others and this is something that’s replicated across problematic anger across different populations as well. We also learned that experiencing intense anger combined with life stresses actually then mediates the relationship between those events and subsequent mental health problems down the track.
The other issue is its impact on quality of life. That those in the high impacted areas reported a much lower quality of life mediated by anger, so those in the high impacted areas with problem anger reported lowest life satisfaction than those in the same areas without problematic anger. And this is something we’ve seen also in a longitudinal study it’s a different population but it’s a replicable finding where we followed over a thousand traumatically injured individuals. We followed them up seven times over the course of six years and found that at each timepoint anger, particularly anger and vigilance, were significantly predicting their quality of life at each time point more so than their mood, more so than their PTSD symptoms. Anger specifically was driving the relationship between perceived lower quality of life.
So what do we know about risk factors in relation to anger? So again, drawn from the disaster bushfire study, we know it was higher among women, higher among participants aged 18 to 44, and higher amongst the unemployed. It really emphasises the gendered nature of disaster impact, possibly connected to economic vulnerabilities, care giving roles and increased rates of family violence in the post-disaster context. We know from international research that rates of family violence are increased in the aftermath of disasters and the Molyneaux paper referred to down below in the Black Saturday data, identified that women in the high impacted areas were reporting having experienced violence at rates of four or five times those in low and medium affected areas. We didn’t ask about the perpetrator of the violence in that research but that’s very much consistent with what we see in international research. Anger was associated with a twelve-fold increase in the development of PTSD, twelve-fold increase in the likelihood of depression and a sixteen-fold increase in the likelihood of psychiatric distress more broadly. We also know that the likelihood of problematic anger was increased in the context of those who experienced exposure to violence or assault before, and critically, the question we often get asked, is this just a subset of other problems? What we find is actually it was uniquely differentiated so for those reporting problematic anger 37% of those weren’t meeting criteria for probable PTSD or depression they were just problematic anger as their primary presentation. So we know that it’s a presentation in its own right, it’s not just a signal for PTSD or depression.
The other thing to just mention is around the recovery from disaster. We know that in relation to the anger experience it matters where in the disaster trajectory we are. I won’t go through each of these phases in detail but the reality is that we can see these basic responses and you can all read what’s on the slide. We can see emotions change over time, the process of recovery differs depending on which phase we’re in. The engagement in rebuilding, the engagement with other stresses like insurance and other kind of financial supports is all different at different points in time coming up to anniversary periods. So while anger is ever present it manifests differently at different phases of the recovery and the trajectory.
The other thing to bear in mind is as we’ve seen recently in New South Wales and Queensland is that what we often see is compound disaster or multiple disasters. So what we see is the overlay of the recovery trajectory of one, from one disaster feeding into the next so what we get is anger, is a response to one disaster as a potential barrier then to the capacity to adapt to the next disaster which then comes with new stresses and then those new stresses further destabilize relationships, finances, occupation, community integration, further heightening anger as people get socially irritated and isolated.
As Alex mentioned in the introduction it’s the 25th anniversary of the extraordinarily famous paper by Hobfoll and co. ‘The five essential elements of mass trauma interventions’ and they identified and these are the basis of psychological first aid, safety, calming, self and collective efficacy, connectedness and hope as being the seminal points of focus in disaster recovery. We were invited to write a commentary in relation to that the anniversary and the point that Tony McHugh and I made is nowhere in that paper despite the multiplicity of emotions that are outlined in that paper nowhere does the word anger appear even once. So our point was one we really need to be considering anger and how do we think about anger in relation to each of these elements and, an element we felt was missing from those five is the issue of dignity and one thing that happens in the aftermath of disaster is that people are in very vulnerable positions, people who have never experienced vulnerability or had to ask for help before or receive help before are in positions where they’re potentially asked to do so or need to do so and they are excruciatingly sensitive to the help that’s provided and not only what is provided but how it’s provided. So we recently had a PhD student look at this in disaster survivors and found that recovery was as much predicted not by what resource support was provided, but also the sensitivity to the manner in which it was provided – the beliefs about the intentions of those providing it. So maintaining the dignity of disaster survivors, even as help is provided, we believe should be added to those five essential elements and be made a sixth.