The Challenge of Therapy... Why Is There No Diagnosis for Rage??

The podcast episode discusses the topic of rage and its lack of a diagnostic category. The hosts question why there is a diagnosis for excessive sadness or anxiety, but not for rage. They discuss how anger and rage differ, with rage being an emotion that takes over and lacks ego strength. The hosts also explore the idea that rage is a combination of anger, helplessness, and entitlement. They debate whether there are appropriate situations for expressing rage. The conversation highlights the need for a diagnostic category and treatment plan for individuals struggling with rage. Alright, so we're doing this second podcast for us, so following the challenge of therapy, we're now going to move into, how do we deal with rage? What an interesting second episode. We started with Rogers and Unconditional Positive Regard, it took us two episodes to get to this dream. I love it. So, thinking about rage, right? Like, why isn't there a diagnosis of rage, do you think? Yeah, it's such a great question, right, because, like, you know, if you think about, if we're too sad, we call it depression, if we're too anxious, we call it generalized anxiety disorder or panic disorder or whatever, right? And those are both based off of just clusters of symptoms, right, and, of course, everybody has the right to be sad and everybody has the right to be anxious, but when it gets too much and it causes a loss of functioning, right, it hits the boundary of, like, depression, it hits the boundary of anxiety, and yet with anger, it's, you know, well, actually, before you turn 18, you can be too angry, right, we call that oppositional defiant disorder, right? It's too simplistic, but you get what I mean, right? It's such a great name for too angry, right, like oppositional defiant disorder. Right, right, and then at 18, you go from being OVD to just an asshole, and you could argue, well, some people meet the criteria for impulse control disorder, and, like, I'll give you that, but rage isn't always impulsive, right, and so what do we do with this criteria of people that I think we can all see in our society that really struggle from a rage disorder even though we don't have a diagnostic category for it? What an interesting distinction between diagnosis of the felt sense of distress, right, the felt sense of too sad, the felt sense of too anxious, the felt sense of too enraged, we diagnose the symptom, right, we diagnose the, the, oh, the phrase is intermittent explosive disorder, right? Yeah. And so we're not really diagnosing because the individual is in distress necessarily, we're giving it the diagnosis of the behavior that we see in society, you know, but also just to know, wouldn't it be amazing if we had an asshole not otherwise specified? That is amazing! How many times have you went into the footnew chart as asshole in a way? That's amazing, I love that so much. But it is interesting that it's not diagnosed, though, right, because, like, and I know you and I have spoken about this before, where it's like, it feels kind of, the moment that you get that rage, where you, you, the other person's experience no longer matters to you, right? Empathy goes out the window. Empathy goes out the window, right? I always think about when somebody, someone gets cut off on, on the road, and they suddenly feel like they have the right to now chase this person down and answer for cutting them off, right? Yeah. And in that moment, you, you're not dealing with your integrity, you're not dealing with why did this person cut me off, what are they dealing with, who will I have to answer to for my behavior? You just feel righteous in that enraged moment. Yeah, right? It's such a powerful feeling, right? You feel bad in that moment. Yeah, right. Yeah, I think, like, it's been something I've been thinking about for years and talking to people, but it all came to me, like, this idea came to me when I was listening to a psychiatrist talk about a school shooter, and she was saying, if this school shooter had come up to me the day before and said, hey, this is what I'm thinking about doing tomorrow, of course I'm going to involuntarily commit this boy, and she specifically said boy, and if we're playing the odds, right, typically male, she said, you know, of course I'm going to find a way to involuntarily commit this person, but I may have to make up a diagnosis to do it, because this person may have some criteria for depression, but may or may not meet the criteria. They may meet criteria for anxiety, but maybe not. They're over 18. They may not meet an oppositional design disorder or a conduct disorder, and you know what the fact of the matter is, is that they're talking about a long-term plan that they're going to enact tomorrow. Impulse control disorder doesn't really fit, and so how hard is it for us to say to the mental health community that even if this kid or adult is coming to us saying, I'm wracked with these feelings and it feels compulsive and there's nothing I can do about it, there's nothing we have for diagnosis, and because we don't have a diagnosis, we don't have a treatment plan. Because we don't have a treatment plan, we don't have standards of practice, and because of all of this, we see this in our society, and nobody says this is a mental illness. Yeah. Right? Yeah. As you're saying all of that, I just think about like the moments when you do feel like you come across some rage like that in somebody, but it feels percolating, right? It doesn't feel like it's being enacted in the moment, and that lack of better phrase impotence that comes up of I don't quite know what to do with this. Yeah. Right? Right? Yeah. And I think this brings up a great question of what is the difference of anger and rage, and is there a difference? Are you asking? Yeah. Okay. Well, you know, like put you on the spot. I guess I'm a proponent of anger. I like anger. I think anger is really this wonderful, useful emotion that occurs regularly inside of us. My constant joke when I meet with clients who struggle to embrace and accept their anger, and it comes out through eating disorders and depression and shame and self-hate, and I don't know if it's a good joke. It's a bad joke. But like I say, every morning I wake up and I'm slightly angry that I don't have a butler, right? Right. A realer. Yeah. Right. Like there's always something that if we're really in touch and in tune with our emotions, there's something that's, you know, there's a little bit of frustration of what we want in our like just most id place, and then being met in that moment. And then I think when I hopefully embrace that anger, we can then mindfully become aware of how do I want to use this anger? For me, when I hit those low spots of anger, they make me laugh, and I think about this as great father. The next time one of my clients is not letting themselves have anger, right? Well, and sometimes anger is so wise, right? Yeah. It's like we have an interaction with a family member or a friend, and we walk away sort of ticked off, and we say to ourselves, huh, I wonder what makes me angry about that. And many times it's because a boundary we want to be withheld, you know, gets violated or something. And so I totally agree with you that anger is to me the wisest of all emotions and a very protective one if we respond to it rather than react to it and let it teach us its lesson. But what's the difference between that and rage? Well, I think that rage feels like, oh, it was, I think it was Ruth King that said that rage is like any emotion that comes out sideways, right? Mm-hmm. And so rage feels, I think my point in saying this, anger feels empowering. Like anger tells me information. Anger feels harnessable to me. Rage feels like the emotion has taken over, and it's now in control, and I don't know what its message is anymore. Yeah, so it's sort of like anger holds with it like ego strength from your perspective, and rage takes over and ego strength goes away, because what you were talking about earlier is you lose your integrity, you lose your sense of future consequences, you lose empathy. I think anger can have ego strength, right? Mm-hmm. I think, yes, but I think rage does not. Got it. Okay. Yeah, I've thought through, you know, I always have a working definition of almost anything, right? Right. And I think my working definition of rage, just for conversation, is that rage equals anger plus helplessness plus entitlement. Mm-hmm. So if I just feel angry, but I feel powerful or empowered in that anger, I'm not going to rage out, because the classic line is we don't go to war with countries we can negotiate with, right? Right, right. So if I'm angry at my partner, but I feel like we can have a calm conversation and my history says that my anger will be heard and recognized and I know how to manage it, and his history says that anger is safe and conflict is okay, then we're both going to be able to have the conversation through anger, right? I know that it won't be conflictual or uncomfortable, but we'll both feel empowered through it, and we'll both keep our empathy, right? Yeah. But if I don't feel that, right, and if not, I'm sure it's his fault. I'm just joking. But for whatever reason, I don't feel empowered, so I feel both angry and helpless, right? So I feel like something in my boundary has been violated, but I also feel helpless to do anything about it. Then I think there's a sense of panic. There's a sense that this has to be handled right now. It's a threat to my integrity, almost. So if I get cut off in traffic, right, I mean, there's nothing more helpless than getting cut off in traffic. And if I'm angry, but I can't go in and go after the other car. I can't plead with them. I don't know what their history is in conflict, but I certainly can't call them and have a calm discussion. Rage may kick in. Now, in my opinion, anger's goal is to set a boundary. Rage's goal is to hurt the other. And that's where I think the entitlement piece comes in, right? It's like, I feel entitled to be able to hurt you. Do you think that there's ever a place where that's appropriate? Of course, right? If, great example. This was several, several years ago. I'm walking with a friend kind of down a dark alley on the way to have a cocktail for happy hour. And behind me, I hear somebody running up on me. And I guessed, and I think I was correct, that their intention was to rock, right? I turned around very quickly and lunged at them and made a really loud, aggressive noise. That was a rageful behavior, right? The person had their hand in their pocket, I assume it was a gun, and ran off. I think that was an incredible use of my rage. I felt angry, but I felt helpless to do anything other than to attack. And I felt entitled to do that because I thought, thought, and I think correctly assumed, that they were there to rob me. And you know what? I feel entitled to defend myself. Right. And so I'm not even here to say, and I don't think you are either, that rage is always bad. In the same way, sadness is not always bad. And without anxiety, we walk into traffic. Right. Right? Like each of these are maybe important emotions, but my argument is, and maybe this is a discussion for this podcast, maybe it's for the next one, of when does rage become, when does it hit that loss of functioning characteristic? Right. Yeah. Right. And I think that makes so much sense. And I think putting rage in context is necessary to then identify when is it a problem. Mm-hmm. What would you think? Do you agree or disagree with the definition of rage equaling anger plus helplessness plus entitlement? Yeah. I think that when you took your definition and put it on, like the traffic example, I thought, oh my God, that's exactly what it is. Right? Like suddenly somebody has impinged upon your safety and there is just nothing you can do about it because your options are going and trying to like rage at them, like hunt them down, right? Like there's just no avenue to say, hey, I think you cut me off. Can we agree that you cut me off and you won't do it again? Right? Right. Like that just doesn't happen. So yeah, I think that's a, yeah, I completely agree with that definition. And that's actually what made me think. I can think of a few moments in our history just as a world where it's like rage made total sense from a portion of society. Right? For sure. Right? Yes. But I think about, I mean, why do you think that we diagnose sadness, we diagnose anxiety, but we don't diagnose rage? You know, when we started, I was saying that there's this moment when rage feels, fun isn't the right word, but basically it's clear. Right? Like you know what you're doing, you've hit like this moment when you don't, you're not navigating between what I'm feeling, what the other person is feeling, where my integrity is, what are the consequences. You just have this moment of moving forward. That sounds very masculine, doesn't it? Like it sounds like there's this masculinity of I'm protecting, I'm saving, I'm acting in accordance with this felt sense of fight in my body. Uh huh. Right? Right. You know, you and I have talked a lot about sort of having a gender model of femininity, toxic femininity, masculinity, toxic masculinity that, you know, may be coming up in a podcast soon enough if people are interested. But what I hear you saying is one of the reasons that it may not be diagnosed is that it sort of represents this sort of patriarchal idea of what masculinity should be. Well, depression doesn't, right? Depression is not profitable, it's not protective. Like anxiety also doesn't. Anxiety almost flies in the face of the ideals of traditional masculinity in many ways. Rage is almost harnessable. We almost see it on the football field. I think that's right. Like we almost kind of, it's almost synonymous or we can use it in some ways in society, I guess is what I'm trying to say. Yeah, not only can we use it, but it's also exemplified. Uh huh. Right? Yeah. But yes and no, right? Because I think about being aggressive is different than being rageful, right? And that aggressiveness, people tend to hold onto their ego strength. But it's interesting, I think almost any therapist out here has been working for more than three minutes, has either worked with clients who have their own rage or certainly worked with clients who are working through their parents' rage. Uh huh. Right? And I think about a client I had forever ago who said, you know, my father never hit me, but he looked at me as if he could kill me. And so even the behavior of rage, even though the behavior of rage didn't come out, the emotion of rage was scary enough to this man to have a big shame response, right? Uh huh. And so like, again, you know, if rage encourages entitlement or entitlement is necessary for rage, like it's a really hard thing to tell people you're not entitled. Oh, yeah. Right? Yeah. It's so fascinating because ever since I started thinking about this over the past couple of years, I just have been asking, you know, you and I teach a lot of classes, we supervise, we see a lot of clients, and I've just been asking people, both in my personal life and, you know, I'm a hoot to have a happy hour, right? And like, hey, why do you think we don't diagnose rage? And it really kind of looks at me, right? But I've asked so many, like, training therapists, like, why do we not diagnose rage? And they always just look at me like, I never thought about it, right? Which is kind of an enormous thing to say when we look at all the gun violence going on right now and all of the kids who are losing to school shootings, you know, all of these things. And, like, I'm not saying depression isn't a horrible thing in our society, but depression isn't walking into schools and killing our children. Yeah. That's rage. Yeah. So this fact that we're not diagnosing this and treating it as a mental health condition it is, but the other piece of this is, to go back to what I was saying, is that, like, I think most of us who have parents who've raged out would say that while we both were afraid of our parents, we also realized that they were really fragile in their rage, that it was about a loss of control versus more control. Right. And even though in the rage you feel really powerful, the outside image is that, you know, how many of our clients we say, like, you know, my dad would rage out, but I also felt really protective of him because at the same time I was afraid of him, I knew he was almost afraid of himself. Yeah. Right? Yeah. And so it's just fascinating that this has both the strength and the fragility all at the same time. How fascinating, right? Like, that there's almost a protection at times from the person who is the focus of the rage, right? Mm-hmm. Like, there's something where they are saying, and we see this in, like you said, intimate partner violence all the time, where there's some level of the partner ends up taking responsibility, the abuse partner ends up taking responsibility initially for the rage from the abuser, right? Yeah. And feeling protective of the person who's hurting them. Right. Because they see this fragility in the rage, right? Yeah. And so it's just a fascinating thing that, you know, and you're much younger than I am, and so I can remember a time when there actually was a research idea in the DSM. I don't know, it was probably the DSM-1, you know, like the before Christ DSM. But, no, I think it was like three or four, that was Bowderer Syndrome. Mm-hmm. Right? Mm-hmm. And... Wow. Right? Yeah. And yet, we have no diagnosis for somebody with ongoing rage, even though that came out as a potential diagnosis in the, what, 90s? Early 2000s. And yet, we have no diagnosis for that. That's an interesting thing, right? Because you were saying earlier that one of the problems with not having a diagnosis for this is that then we don't have a treatment plan, and we don't have resources, and we don't have training modules for this, right? So when we risk acknowledging this with our clients, we're also risking a huge moment of just, I don't know what to do with this client. Right. Right? And then not even I don't know what to do, but I don't know who to turn to to support me through this, right? And I can't even say it's a mental illness. And so, as we're saying, it's fascinating to me that there was better syndrome, right? Mm-hmm. Because if we look at the diagnosis as actually a supportive mechanism where then we can develop training, and then we can, you know, identify protocols for support in that. Like, I think it's, I was thinking that one of the reasons that we don't have this diagnosis is because coming to therapy and saying something along the lines of, I really, really love my spouse, but sometimes I just want to punch him in the face, and I'm so worried about it, right? Mm-hmm. Like, coming in and saying every so often I have these thoughts of violence that take over, right? Right. And I think that's something where that has to be one of the hardest things to come in and tell somebody and risk coming in and tell somebody. Well, and as a couples therapist, I see this occasionally in clients where there'll be rage, and somebody comes in with their head hung saying, like, yeah, I did it. I lost control. I don't know what to do. And, you know, and this isn't somebody who, you know, in the intimate partner violence community, this isn't what we would call the intimate terrorist who's more like sociopathic and trying to control and manipulate. This is more situational couple violence where somebody just cannot manage their rage, right? Yeah. And it's a real shame, but I tell you what, it's a toxic trait, and it's a dangerous trait, right? And when I give them this, you know, whenever I have somebody who deals with rage, I give them my definition, right, of rage equals anger plus helplessness plus entitlement. And many times we'll look at the entitlement pieces and we'll say, like, well, I mean, it's not a conscious thing. And my question is, well, how many times have you punched your boss, right? And very seldomly, not never, but very seldomly has the rage come out there. So even though it doesn't feel controlled, there is a level of control in that I feel entitled. And then my question, you know, then this forms a line of questioning of, like, why would you feel entitled? Where did you learn it was okay, you know, literally to punch down? Right. Yeah. And so it's a really interesting thing. And I think about, and I think this would have to be a separate podcast, but just to give a couple of ideas, when would rage just be rage, and when would rage be diagnosable for you? It's an interesting thought that, like, I'm thinking about this in two ways. I think you made an important distinction that I just wanted to highlight for a second, that there is a distinction between the antisocial, sociopathic rage, right? And I think we are trying to find this space where it's not just every so often I'm enraged when it's appropriate, so I can connect to my rage and enact it in a way that is appropriate in my life. But we're also not talking about this covert sadistic, I went to terrorize somebody. That's a great point, right? Because if you look at most of these school shooters, they didn't follow the sociopathic ladder up. They didn't set fires as a kid and torture animals. They didn't, you know, commit crimes looking, like, wanting to see the fear. They didn't follow the sociopathic train, right? They were more ODD, if anything, before 18. So that's a great point, because if it already fits under the sociopathic diagnosis, that's not really what we're talking about. Right, exactly. And so I think that to answer your question, though, that distinction between, you know, when is it a diagnosable thing versus when is it appropriate, like, in some ways I totally get, like, getting cut off in traffic and feeling enraged about that. And I kind of have to take a minute to calm myself down, because, you know, that wouldn't serve me in any way. But I'm able to take a slight moment and say, oh, this actually isn't functioning for me. Uh-huh. Versus when it feels like something – I might have to think about this, but my thoughts are going to something that I feel right to feel entitled to and something where it feels my options are just severely narrowed. So I feel entitled to safety in my home. If that feels like it's violated, my options feel narrowed to violence in some way to protect myself. Like, I don't know what I would do. Like, yell and scream and tell the dogs to get on my butt. But, I mean, like, there's something in that space where I feel entitled to something that I agree to in my integrity. Uh-huh. And then I feel like my options are limited in some way. That feels like where rage would feel not diagnosable and appropriate to me. Okay. You mean diagnosable and not appropriate. Not diagnosable, yes. Yeah. Yeah. Yeah. I mean, I think about – for some reason, what I keep thinking about is alcohol in this. Oh, why? Well, I think because I retain the right to go have a glass of wine with my friends. Right. And yet some of my clients can't go do that. Why? Because they have a problem with alcohol. Okay. Right? And, you know, if I have a second glass of wine, I still feel okay about that. But I tell you what, if my partner said to me, like, hey, I think you have a problem, or all of a sudden it was interfering with work, or all of a sudden – like, I'd be thinking about whether or not I could have the glass of wine. Okay. Right? And with rage, it's sort of – it seems to follow the same trajectory. Like, is it – you know, there's a classic line in the alcoholic community saying, do you have warts? Like, with alcohol comes repeated trouble. Right. Right? Right. And, like, with your rage, does it have repeated trouble? Right? Like, so have you raged out – I'll give you an example. One of my first gigs forever ago in the Stone Ages was to work in patients – to work in the ER doing intake in a hospital. Okay. And there would be very often some 20-year-old on a Friday or Saturday night, some 20-year-old who had punched a hole through the wall. Okay. And just so you know, if you go and – if you've punched a hole through the wall and you go to the ER and say, like, oh, something fell in my hand, it's a different break. Everybody knows. Right? And so they would call me in, and the standard response that I would have is I'd go in and say to this kid, usually male, and say, hey, so you got mad and punched a hole in the wall. And he'd say, yep. And I'd say, well, does it hurt when you do that? And he's like, yep. I'm like, are you going to do it again? He's like, nope. And my standard response was, well, next time we'll have a longer conversation. Okay. Because anybody can do it once. But if you've punched a hole in the wall, had to go to the ER, get it casted, blah, blah, blah, blah, blah, and you do it again. Yeah. I think we're closer to saying you may have a problem with rage. Yeah, yeah. And so, you know, if you do struggle with rage, then is it more like alcoholism in that you have to just be careful about it throughout your life in a way that others don't? Okay. Right? Or at least until you get more emotional regulation. Okay. Right? And so, you know, because, I mean, some people may be able to yell and scream in traffic, and it's really not that big of a deal. And other people can't fuel that fire without it becoming super destructive. That makes so much sense. Right? Yeah. So, I mean, you know, my hope for this podcast is not that we come up with any decisions, because, you know, my hope is there are people who are doing research on this, although I haven't heard of any, and my hope is that, you know, there are people with more degrees than I do, than I have, that are researching this. Right. But I want to open it up for discussion, and what do you think we'll see in the comments section on this? You know, I keep thinking about, you know, one of the things that we love to talk about in the therapy world is chicken or the egg. Right? And what has led to the rage being something where I punched a hole in the wall, I learned from my mistake, I won't do it again. Right? And so, two, I don't have the ability to learn from the behavior. Right? Yeah. I don't have the ability to learn from the consequence. And so, I'm curious what people would say about the lack of ability to regulate or learn from the rage. Is it, you know, nature-nurture? Like, what's resulting in this distress? Yeah, and to me, it's very similar. Again, I keep trying to make this parallel to substance abuse. It's like, you know, most of us, maybe not, but most people I know have had a really bad experience with alcohol, gone too far, either thrown up or woke up the next day feeling horrible and said, oh, you know what, I probably shouldn't do this. Right. And other people wake up and say, wow, that was a really hard night, and I need a hair of the dog. Right. And start drinking again. And I wonder if it's a similar dysregulation, compulsive behavior. Yeah. And I think there have been some people on and off who've asked if you could be addicted to rage in the same way you're addicted to other substances. Right. And, you know, in the same way that there's this argument you could be addicted to sugar or like whatever that is. Right. Right. And, yeah, I mean, maybe that's something people will comment on as far as like what they see and how they see it, if it's nature or nurture. Right. Yeah. And so, final thoughts on this? Man, this brings up more thoughts and there are more questions than it does answers for me. Right. My final thoughts are I'm leaving this podcast feeling like I have more questions than answers. But, you know, as a podcaster, that's sort of what we call job security. Right. Yeah. All right. Well, thanks, everybody, for listening. Feel free to comment and pass it along to anybody else who you think is working with some of the same population. I'm afraid to share, like, and subscribe, Chris. It's real simple. Sorry. I'm working on that. Bye.