Keywords

Introduction

Young men are particularly likely to present for help with anger difficulties. They may be referred by educational institutions, families, or they might come along themselves. They are often quite clear that the difficulty is with anger, that they suddenly explode, see a red mist, or can be fine one minute and raging the next. Clinically, it is a familiar presentation (Armbruster et al. 2004). In spite of the relative frequency of this presentation, however, the support available and the interventions offered fall significantly below that available for other presentations. The evidence and knowledge base lags significantly behind and, as a result, clinicians report less confidence and competence in this work, when compared to fear-based difficulties (Lachmund et al. 2005).

In this chapter we bring together the available knowledge and evidence in an attempt to better support young men presenting with anger problems. We draw on emotion science, gender and masculinity research, trauma and therapeutic research to try to bring some clarity to a neglected but highly important area.

Why Are Young Men Angry?

We will begin by considering the reasons behind young men’s anger, starting with exploring the impact and functions of anger, before looking at the relationship between anger and shame, and the psychological development of boys and men.

What Is Anger?

Anger is included as one of Aristotle’s 14 emotions (1954), and alongside happiness, fear, and sadness as one of four basic emotions (Jack et al. 2014). Despite a theoretical acceptance of anger as a fundamental human emotion, anger is often labelled by society as ‘toxic’ or ‘harmful’ and many scientists have come to view anger as more of a liability than an asset (Izard 1991). Many scientific authors also appear to conflate aggression and anger, writing as though anger is responsible for the violence in the world and should somehow be eliminated (e.g. Tucker-Ladd 1996). These societal views risk reinforcing the difficulties with anger that young men face, an idea to which we will return later.

Anger is an emotion that is experienced relatively frequently and can last for periods of hours or days, but can also dissipate fairly quickly. It is experienced as hot and intense (Scherer and Wallbott 1994) as well as aversive; the majority of individuals report disliking the feeling of anger (Harmon-Jones 2004). Anger has a dramatic impact on the body that involves the activation of the sympathetic nervous system and is very similar to that seen in fear responses. This activation leads to increases in heart rate, respiration, muscletension, and an attentional focus on threat. While the physiological processes underlying the experience of both anger and fear are similar, the felt sense is almost opposite: anger feels hot, whereas fear feels cold. Anger is associated with a great deal of thought in two main areas: past-focused thoughts about the cause of the anger and future-focused thoughts about action. The main behavioural impulses associated with anger are approach behaviours varying in intensity from a hardening of the body and words, through to extreme aggression and violence. It is important to note that aggression and anger are not interchangeable concepts. Whilst aggressive behaviour can sometimes be a component of the emotional experience of anger, anger can be experienced without aggression, and aggressive behaviour can be displayed in the absence of anger.

From an emotion science point of view, anger is, like all emotions, a functional, coordinating response to an environmental stimulus. Specifically, anger is one possible response to threat: it functions to protect. The other possible response to threat is fear; hence the fight or flight response (Cannon 1927). Anger is ordinarily a response to an interpersonal threat: the most commonly cited precursor to anger is a sense of being ‘misled, betrayed, used, disappointed, hurt by others, or treated unjustly’ (Izard 1991, p. 235). The result is that anger protects individuals from the threat posed by others by gearing up the individual to counter the initial threat.

Anger and Shame

Interpersonal threats such as being poorly treated, undermined, or humiliated do not always result in anger, but can evoke other powerful emotions including shame. Shame is an aversive emotion that is linked to strong, negative self-evaluations, such as being flawed or defective in some way (Dearing and Tangney 2011). Due to the painful and self-focused nature of shame, individuals who are particularly prone to shame may be less likely to express these feelings, as they are so aversive (Tangney et al. 1996). Instead, common responses to shame include hiding away (Lewis 1971), or re-directing these feelings onto others through anger or aggressive behaviour (Zlomke and Hahn 2010; Scheff and Retzinger 1991).

Stronger feelings of shame, higher levels of shame-proneness, and greater shaming experiences have all been associated with greater levels of anger and aggressive behaviour towards others (Hundt and Holohan 2012; Aslund et al. 2009; Harper et al. 2005; Rand 2004). Other research has explored the relationship between anger and the capacity for empathy, or being able to understand the perspective, thoughts and feelings of others. Perhaps counter-intuitively, empathy and perspective-taking were the strongest predictors of self-reported anger in response to provocation, in a group of offenders (Day et al. 2012). This may suggest that people who are prone to anger are, in fact, better at accurately assessing the viewpoint of others. In turn, this may lead to a stronger focus on the negative judgments of others, thereby triggering uncomfortable feelings such as shame.

Angry feelings and the expression of anger may help to soothe and regulate feelings of shame (Bushman et al. 2001; Berkowitz and Harmon-Jones 2004). This may be particularly true in people who have experienced trauma and in whom the associations between anger and shame are particularly strong (Schoenleber et al. 2015). Conversely, Kaufman (1996) referred to the ‘shame-rage cycle’, in which a shaming incident provokes anger and rage, which in turn elicits greater feelings of shame.

Anger and Male Development

There are significant gender differences in the experience and expression of anger: peer groups and adults appear generally less negative about overt expressions of anger in boys than in girls (Zahn-Waxler and Robinson 1995). Mothers have also been found to actively encourage boys (but not girls) to respond to provocations with anger and retaliation (Brody 1996; Zahn-Waxler and Robinson 1995). Furthermore, mothers are more likely to react warmly to boys when they react to provocations with anger than with sadness (Brody 1996; Fuchs and Thelen 1988). There are also generational differences: older people are significantly less likely to have a close friend or family member with anger difficulties, or report that they themselves struggle with managing angry feelings, than younger people (‘Boiling Point’ report, British Association of Anger Management2008). Younger people are far more likely than older people to engage in aggressive behaviour that is driven by impulsive or explosive anger, rather than pre-planned acts driven by incentive or reward (Hecht et al. 2016; Connor et al. 2004).

These societal trends are thought to be driven by desired or valued male identities that revolve around demonstrating strengths, such as being athletic, competent, or individualistic; when these are violated strong negative feelings may arise (Lewis 1992). Relatedly, men may feel strong feelings of shame and discomfort in situations that require them to display feelings such as fear, or show intimacy (Schenk and Everingham 1995). These have sometimes been described as ‘unwanted male identities’, as they represent characteristics that undermine or clash with an internally-held male ideal and have been associated with a range of difficult feelings (e.g. Ferguson et al. 2000). Jakupcak et al. (2005) investigated predictors of anger and hostility in a group of 204 males, with fear of emotions predicting a small but significant amount of variance in overt anger expression.

Jakupcak and colleagues suggested that anger expression could be an effective means of reducing or managing painful emotions which, if successful, would be reinforced and used again as a strategy. It is suggested that many young boys are socialised to not express vulnerable emotions (e.g. Kuebli and Fivush 1992), or expect negative responses if they display emotion (e.g. Fuchs and Thelen 1988). Consequently, distressing or vulnerable emotions come to be experienced as shameful and to be feared (Gilligan 1996). Men’s fear of emotions was predictive of anger, hostility, reduced angercontrol and aggression within relationships (Jakupcak et al. 2005; Jakupcak 2003). The authors concluded that internalised malegender roles limited men’s options for emotional expression and their ability to tolerate difficult or painful emotions.

Other research has highlighted the significance of ‘gender role identities’ in determining how other people are perceived in conflict situations, and the extent to which they respond with anger. Angry emotion and behaviour appears to be more likely when an individual’s identity justifies or allows for such a response, with a strong masculine identity giving a greater ‘cultural mandate’ to respond in angry or aggressive ways (Coleman et al. 2009). It also appears that negative emotional events are more likely to be retained in memory and ruminated upon, which in turn increases the emotional experience of anger, when this was compatible with one’s internalised perception of masculinity (Rusting and Nolen-Hoeksema 1998; Bushman et al. 2005; Bushman 2002).

Young men who have been exposed to negative influences within their families, such as chaotic or inconsistent discipline, are strongly influenced by these experiences in situations of conflict (Larkin et al. 1996). Larkin and colleagues compared young men (18–25 years) in role play situations that involved disagreement and conflict, who were from family backgrounds assessed as being either ‘balanced’ or ‘extreme’. ‘Extreme’ families were described as having either excessively high or low levels of cohesion (e.g. family members being either enmeshed, or highly independent of each other), as well as either excessively high or low levels of flexibility (e.g. family members being either overly rigid, or chaotic and inconsistent). ‘Balanced’ families were defined as operating with moderate levels of cohesion and flexibility, qualities that have been associated with better communication and improved ability to cope with emotional issues and challenges (e.g. Olson 2000). Young men from ‘extreme’ families were seen to exhibit higher levels of state anger than those from ‘balanced’ families, and significantly more than young women from similar backgrounds (Larkin et al. 1996, 2011). Larkin et al.’s (2011) findings suggest that young men were more strongly influenced by exposure to negative family environments than young women, as reflected by their behaviour and feelings in conflict situations.

From another perspective, social learning theory suggests that young children learn about their own emotions by listening to how their parents talk about feelings, looking at how their parents react to their own emotions and imitating these emotional expressions (Bandura 1977; Eisenberg et al. 1998). It appears that some key factors that influence angry affect and behaviour in young men can be traced back to some of their learning experiences within early social contexts. These may include experiences of family communication and relationships being extremely unclear, chaotic, and unpredictable, or of family rules being excessively rigid with little breathing space or ‘room for manoeuvre’. When boys and young men have been taught few effective ways of managing challenging interpersonal situations, they are more likely to respond with angry feelings and actions. Parents often get caught up in responding to their child’s anger in unhelpful ways that leave the young person feeling trapped or powerless, such as imposing strong, rigid, or non-negotiable boundaries. Over time, this can have the effect of disrupting communication and healthy patterns of interaction within the family, as well as doing little to reduce or contain the felt anger of the child or young adult (Currie 2008). Research has found that men are less likely than women to experience empathy and guilt, making them less likely to engage in behaviours aimed at reparation (Lutwak and Ferrari 1996; Zahn-Waxler et al. 1991). Lutwak et al. (2001) reported that in a sample of 265 college students, shame-proneness was related to both inward expression of anger and reduced angercontrol in men. The authors concluded that shame-prone males attempted to ‘bottle up’ unmanageable feelings (including anger) but remained at high risk of losing control of these feelings.

Others have suggested that anger may be an effective strategy for avoiding feelings of shame altogether, by guarding against these before they arise. For example, expressions of anger may enable respect from one’s peer group, for example where the strong masculine ideal is valued, thereby promoting self-esteem and keeping feelings that are incompatible with a person’s self-concept (such as shame) out of conscious awareness (Farmer and Andrews 2009). In a similar vein, Gilbert (1998) has argued that angry feelings enable people to move up the social hierarchy as they provide them with a powerful and valued identity. As such, expressions of anger may be seen as effective ‘face-saving’ strategies that promote a positive identity. There is a sense in which shame renders an individual passive and helpless, whilst anger brings back feelings of power and agency (Miller 1985).

Finally, research has indicated that people exposed to trauma of a violent nature, experience higher levels of anger and aggression (Jakupcak and Tull 2005). It appears that ‘experiential avoidance’ and ‘emotional inexpressivity’ are both significant predictors of anger and emotionally-dysregulated responding (Campbell-Sills et al. 2006; Feldner et al. 2003). The former refers to avoidance of an internal state (i.e. emotion), whereas the latter relates to the inhibition of the outward expression of an emotion. It is suggested that suppression or avoidance of emotion (both the emotional experience and the emotional expression) may reduce distress in the short-term but prevent the processing of traumatic experience and result in greater emotional dysregulation longer-term (Tull et al. 2007).

In summary, there are a variety of reasons why young men are particularly likely to experience and express anger to a greater extent than other members of society. There are societally valued male identities that value strength and encourage the expression of anger in young men more so than other emotions. There are societal and family interactions that may lead to males having reduced access to effective means of resolving conflict and managing feelings. Finally, the presence of trauma, violent trauma in particular, is likely to significantly exacerbate these difficulties.

As a result, clinically, it is this population of young men who have been exposed to violent trauma, often very early in life, who are particularly likely to experience heightened levels of both shame and anger. They are likely to experience a variety of difficulties as a result, including difficulties with violent or aggressive behaviour, interpersonal difficulties, bullying, and criminal activity (Espelage and Swearer 2011; Schoenleber et al. 2015). They may also experience a range of potential emotional difficulties including sadness, worry, eating difficulties, school refusal, withdrawal, self-harm, or substance use. Despite this high level of need in young males, the accessing of help and support is much lower (Yousaf et al. 2015), which is likely to be one of the reasons for the much higher rates of suicide in this population (Pitman et al. 2012).

Anger and Traditional Models of Service

There are few psychiatric diagnoses that link directly to anger. Indeed, many young people frequently request help with anger only to be told that they are ‘depressed’. This, clinical practice suggests, is deeply frustrating and invalidating for young people, and only tends to fuel problems with anger. At other times, clinicians in the UK are commonly heard to say that ‘anger is not a mental health problem’, that problems are ‘behavioural’ or that anger is ‘comorbid’. Consistent with this are findings that the majority of people experiencing difficulties with anger have never received interventions targeting their anger (Kessler et al. 2006). Despite an apparent reluctance to classify anger as a disorder, adolescents, and young adults frequently present with anger difficulties (Armbruster et al. 2004). Clinicians also report frequently working with anger difficulties but report less confidence and competence in this work, when compared to fear-based difficulties (Lachmund et al. 2005).

When young men are offered help, it is too often ineffective and ill-informed. This is perhaps unsurprising in light of a review in 2007, which found 185 references mentioning treatment and anger, compared with 6356 mentioning treatment and depression (DiGiuseppe and Tafrate 2007). The knowledge and evidence base to inform treatment of anger difficulties is extremely limited and is plagued by methodological issues around such basics as defining what constitutes an anger difficulty (Lee and DiGiuseppe 2017). Most young men will be offered “anger management” which is often extremely basic and is too often premised on an idea that anger is ‘toxic’ and should be eliminated, and by extension takes a judgemental and condescending attitude towards people who have anger difficulties.

The next part of this chapter aims to provide clinicians and young men with an understanding that validates their experience and provides some clear direction in terms of interventions that are likely to be beneficial and useful.

The Anger Trap

The anger trap (Howells 2018) is a psychological formulation based on cognitive behavioural therapy, but also informed by more relational models such as cognitive analytic therapy (e.g. Ryle and Kerr 2002). The anger trap is illustrated in Fig. 1 and is made up of two interlinking vicious cycles; the existence of each serves to prevent change in the other. The core of the two cycles is repeated experience of interpersonal conflict, appraisals characterised by interpersonal threat, and resultant anger and shame.

Fig. 1
A diagram of the interaction between thoughts, interpersonal conflict, and anger that leads to behaviors with short and long term consequences.

Anger trap (Howells 2018) (Reproduced with kind permission from Taylor & Francis)

Full size image

Difficulties with anger arise when the emotional response is no longer a helpful response to environmental stimuli but is disproportionate and over-estimated. In the anger trap, this is illustrated by appraisals of over-estimated interpersonal threat. A tendency to appraise situations in this way is particularly likely to result from early experiences of frequent conflict, abuse, humiliation, and trauma, as outlined earlier. Importantly, another common appraisal in anger is the sense that the anger and the associated behavioural responses are out of control; the individual is unable to control their own behaviour. These appraisals result in the experience of anger and shame. Interpersonal conflict, the two groups of appraisals, and anger and shame represent the core of the anger trap.

There are two possible behavioural responses to these emotional states. One is the outward expression of behaviour, in the form of aggression and violence, the other is the suppression of emotion. Each of these behavioural responses forms one of the two vicious cycles around the trap.

The outward expression of anger in the form of aggression, either verbal or physical, is consistent with the behavioural urge of anger. Sometimes this outward expression is done in thought or fantasy: in a survey of college students, the majority of thoughts following an incident prompting anger were of revenge, attacking others and destruction (Izard 1991). Sometimes these thoughts can develop into fantasies of action and individuals might imagine screaming at people or being aggressive towards others, perhaps even have violent or murderous fantasies. In the short term, outward expression of anger results in a reduction in the feelings of shame so often associated with the precursors to anger. Young men often feel powerful and in control which is an almost opposite experience to the powerlessness they feel in relation to the eliciting event. This is a powerful maintaining factor in repeated episodes of aggression, even against an awareness of the more problematic long-term outcomes. In the longer term, outward expression of anger leads to one of two significant outcomes. One is an escalation in conflict, which serves to confirm the initial appraisals of interpersonal threat and a lack of control. Another outcome is an increase in shame as a result of the consequences of the aggression (for example saying or doing things that are later regretted), or humiliation and devaluing by others. These serve to confirm the initial appraisals.

The suppression of anger, in which the young man ‘walks away’ or ‘leaves it’, avoids the potential for escalation or shame following the outward expression of anger. It is also often praised by others when young men are struggling with anger. However, in the longer term, the feelings remain and the young man still feels anger and shame following the precipitating event. Frequent suppression of anger and shame can also lead to interpersonal situations in which young men are taken advantage of or devalued as they do not stand up against this behaviour. As a result, the initial appraisals of interpersonal threat are confirmed.

The two vicious cycles of the anger trap can be labelled ‘bottle up or explode’ and both parts of the trap are always present, although one might be emphasised over the other. It is a powerful formulation as it places the experience of anger at the centre of the formulation and is based on an understanding of anger as an emotion that is ordinarily functional and helpful. In doing so, it also makes the links between anger and other emotions that are often more difficult for young men to experience and express, such as shame, fear, sadness, and guilt.

Intervention

One of the major challenges of working with angry young men is to reach the point of seeking a receiving help. There are well-documented barriers to malehelp-seeking (Yousaf et al. 2015) and once they reach services, the barriers continue. The anger trap can be used to inform decisions about early engagement as well as later intervention.

Early Engagement

The anger trap highlights the difficulties that young men face. Often young men present to services and experience assessments that are focused on their risk to others, the impact of their actions on others, and their level of remorse. Clinicians may also take overt measures to protect themselves from perceived threats, for example conducting assessments in pairs or refusing to visit the home. All of this is experienced as threatening and shaming by young men and fuels the trap. Sometimes this will result in appointments characterised by tension and aggression, at other times young men might refuse to engage in the process at all. Often, both of these types of behaviour result in a lack of provision of support to the young man and he is left feeling devalued, rejected, and abandoned.

Our approach begins with an understanding and validation of the feelings and the associated behavioural responses, as outlined in the trap. Attempts are made to reduce the level of threat the young man is likely to feel from the beginning of the process. It is assumed that angry young men have already been through a long process of debate and inner conflict before seeking help (Yousaf et al. 2015) and so any request for help is taken seriously, even where the words or actions in the moment do not appear to support this. Interpersonal processes that might be experienced as threatening or shaming are kept to a minimum, which include avoiding direct lines of questioning, writing lots of things down, and using language associated with vulnerability. Potential Threats within early assessment sessions are kept to a minimum, one-to-one appointments are offered if possible, a confrontational stance in terms of room arrangement and clinician posture is avoided, care is taken to avoid questions that might be experienced as threatening or shaming and initially to stick to subject areas where the clinician can remain curious and interested. Over time, aspects of the anger trap can be brought into the conversation, including links between early history and types of appraisal, appraisals and emotion, emotion and behaviour. During this process, the focus remains on the young man themselves and on validating their experience, rather than switching position and asking about how others might feel (a line of questioning often used to determine remorse or regret, but which can be experienced as devaluing or shaming). Drawing the anger trap might take a number of sessions done in this way and represents a piece of collaboration between the young man and the clinician, and the bond of trust between them.

Feeling Angry

Once the anger trap is drawn, it can be used to begin the process of intervention, which is outlined in more detail in Howells (2018). Many clinicians operate under the misconception that whilst working with fear involves the experience of fear, working with anger should somehow involve its eradication. This leads to the kinds of ineffective interventions that young men have often experienced—anger management which is targeted towards eliminating the experience of anger as shameful and bad. In the context of the anger trap, effective intervention for anger needs to involve exposure to anger-inducing situations and different behavioural responses. Over time, this leads to a modification of the appraisals of over-estimated threat, and hence reduced experience of anger and shame.

The process of exposure to the feelings of anger and responding differently usually requires some work around anger regulation in the moment, and some challenging of the appraisals around underestimates of control, so that young men learn both the skills to regulate their anger, and also learn that they can experience anger without losing control. Only then will they be willing to expose themselves to anger-inducing situations and better assess the interpersonal risk. The first stage of intervention involves the active regulation of anger, both upwards in intensity and downwards in intensity within the context of intervention. Clinicians can use a simple anger scale and use this to rate anger on a changing basis and to ensure that the intervention is carried out in a safe and contained way. Clinicians can then invite young men to think of recent events that made them feel angry, to focus their attention on the anger-inducing qualities of the events, to focus on the building tensions in their bodies, to notice any shifts in their thought processes, to think, perhaps about how they would have liked to respond. Behavioural experiments can be used to predict what young men think they might do if they get 7 out of 10 on the anger scale and then see whether they really do lash out or trash the room. This process can enable young men to learn that they can manage their responses to the emotional arousal produced by feeling angry.

Assessing Interpersonal Risk

Once young men understand the anger trap and have experience of feeling angry and regulating it differently, they can move on to more direct work on the appraisals of interpersonal threat that lead to anger and shame. There are a variety of different options to target the appraisals of interpersonal risk. One clear option, particularly in the case of young men who have experienced a great deal of trauma and abuse is to work on processing the memories of these events. This will involve experiencing the feelings, including anger, shame, rage, fear, sadness, etc. and re-evaluating these events against a more safe and secure present state (e.g. Ehlers 2010).

Alternatively, young men can be supported to use a whole variety of re-appraisal strategies commonly used in CBT in more current and present situations. This might involve the use of thought records or continuum techniques (Padesky 1994). It might also involve behavioural tasks such as learning particular social skills, experimenting with different forms of communicating and interacting, including details such as posture and eye gaze, as well as developing skills and competence in particular areas (see Howells 2018, for more detail).

Most work with angry young men involves a variety of these different techniques, some work processing past events and some work on supporting them to better manage present situations. The key is that the work is based on an understanding of anger and related emotions that is used to validate the experience of young men and support them to make change in their lives.

Case Example

A 17-year-old male has been referred to the mental healthservice because of the concerns of one of his teachers at college. He has been talking to a tutor at college and has expressed thoughts of harming others, and of gaining pleasure from these thoughts. He has also spoken of fighting frequently. He lives with his mother and siblings, and at assessment it appears he is also frequently angry and aggressive in the home environment and will shout and bang doors. He attends the assessment with his mother, is tense and curt in the meeting, and talks freely of moments of aggression and fights with others, as well as talking in detail about his violent fantasies.

The staff of the service are worried about his risk to others, but on further investigation, it does not appear that there is a significant documented history and members of his family deny violence against them. The next appointment is with two senior clinicians and he again presents in an aggressive and uncooperative manner saying that he does not want any help, that everything is fine. The service plans to close.

A third meeting is offered for the young man and one clinician alone, who thinks that he is less likely to feel threatened on a one-to-one basis. In this meeting, the clinician begins by avoiding any potentially conflictual areas of conversation (for example ‘what do you want to change?’) and takes an interested and curious position. During the course of the meeting, the clinician gradually works to reference the ideas of the anger trap, avoiding putting pen to paper too soon. A link is made between early experiences of violence and a subsequent expectation of violence and attack from others. Anger and aggression is named as a helpful way of keeping others away. Care is taken to avoid language of vulnerability as much as possible: ‘challenge’ rather than ‘struggle’, ‘tension’ rather than ‘fear’. Over time, the anger trap is drawn and the young man begins to talk about his early experiences, begins to process memories of being told to ‘man up’, and of early experiences of violence and abuse. He learns to talk more openly about his experiences, about his emotions, and learns practical ways of managing his emotions and managing social situations.

Conclusion

In this chapter, we have examined the reasons why young men should present with anger difficulties. We have highlighted the shortcomings of traditional approaches for this population, in spite of a high level of need. We have outlined a psychological formulation with anger at its core, which is designed to support the processes of validating the experiences of young men and supporting them to make change. A case example highlights the potential issues that angry young men face, along with some ideas about how these can be tackled.