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August 1999
Volume 63 |
Number 8
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WHAT'S NEW IN ...
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| ... Stress Management:
Calming the Lion |
Jessie A. Leak, M.D.
"I have learned through bitter experience the one supreme
lesson: to conserve my anger, and as heat conserved can be transmitted
into energy, even so our anger controlled can be transformed
into a power which can change the world."
- Mohandas Gandhi
Fifteen years ago when you asked physicians what they considered
to be their greatest daily challenge, more than likely you might
hear about caseloads, call schedules, difficult patients or, at
worst, paperwork. In today's world, things are not so definable.
Physicians have a gnawing sense of baseline stress, shaped in
part by less controllable entities: issues of compliance, antitrust
considerations, corporate America in white coats; a sense that
nothing has prepared us for the realities of patient care into
the next century. Many physicians ask, how do we identify ourselves,
if not by what we do?
In the most basic sense, then, we have a set-up for a
state of disequilibrium, the ubiquitous condition known
as stress: any mental or physical tension or strain (Webster).
Clearly, humans do exceed their adaptive steady-state capability
as Selye hypothesizes when he describes the insidiously destructive
result of cumulative internal resource depletion: stress. His
General Adaptation Syndrome theory allows us to understand the
unique nature of each individual's stress response.
But Why Am I So Angry?
The experience of stress implies a sense of either real
or perceived loss of control. Implicit in this sensation is fear:
fear of fear, fear of boredom, fear of change. Change is work.
What we want is less work (less stress). The result of this circular
view is more exhaustion and malaise. A vicious cycle develops
and our malaise turns into a fear of change. By implication then,
we "fail to thrive," perhaps both professionally and/or personally.
Our stasis and our fears feed into boredom and reinforce our perception
that we are dealing with a hostile environment, one over which
we have no control. We are locked in an angry battle with ourselves
that we have no hope of winning unless we understand why we are
angry (fearful) and then subsequently make choices to turn our
anger into opportunity.
Why Does Controlling My Anger Matter So Much?
Unfortunately, our conditioning as physicians compels
us to limit our range of displayed emotions to: competence, goodwill,
empathy and maybe joy (on holidays). Emotions such as fear, hope
or shame are not allowed; they portray weakness. Therefore, when
a negative emotion is evoked, most often our fear, envy, jealousy,
contempt or displeasure, it is manifested as anger. We may use
anger as a survival skill in our baseline hostile environment
to regain power, to control or to simply distance ourselves from
our own fears.
Unfortunately, an angry physician, because of an implied
position of power, is frequently perceived in a different "frame":
aggression. Aggression, by its very nature is a behavior, rather
than an emotion, which requires a response from the other individual:
avoidance. Experientially then, just when we crave restoration
of control and must communicate these needs to those around us,
we drive away the very individuals who may want to help us. Hence,
to regain control, at least in the short term, we must control
our anger.
Developing a Sense of Purpose
Perhaps the first step to controlling anger is agreeing
to the experience with a sense of purpose. Anger, viscerally experienced,
can be a signal from our minds to wake up and take notice. Something
may need immediate attention. The potential for learning and making
positive changes may be right there. We need simply to grasp the
opportunity with a sense of purpose and discovery.
We can choose to refocus our anger and learn something
about ourselves. It has an energy and an aliveness that, if directed,
is one of the most powerful of all emotions. The key to the process
is to not fear anger. Like pain, it is a sensation that lets us
know that we are alive and fully experiencing the process of living.
Perhaps one should "Consider how much more you often suffer from
your anger and grief, than from those very things for which you
are angry and grieved." (Marcus Antonius)
Where Do I Go From Here?
So, you have made the decision to acknowledge your anger,
to use its "aliveness" to energetically make conscious positive
changes, and then you go back to work at the hospital. Suddenly,
you are on the receiving end of someone else's wrath. What do
you do?
Simply having the skill set to reframe what we perceive
as aggression into what may be someone else's emotional pain allows
us not only to step back and see the other person, but to gain
instant control in a potentially volatile situation. The bonus
that we receive is perhaps a little insight about how others may
see us in a similar situation! This can be quite an "ah-hah."
Practical Tools for Diffusing Anger
The reality of learning anger management is practice.
However, having a set of practical tools at your disposal never
hurts.
- Do not personalize. Chances are that the person yelling
at you is having a bad day or a bad life. The issue is not
about you even if you are being blamed. Constantly remind
yourself not to escalate your responses with the angered
individual.
- Do not ever try to rationalize with an angry individual.
They simply cannot hear you. It is likely that
you remind them of someone with whom they have poor communication,
e.g., spouse, friend, sibling.
- Do not ever get into a shouting match with
someone in front of an audience, e.g., a co-worker. Quietly
work to get a short-term "fix" and take the individual aside
later and try to resolve the situation when their anger has
decreased. Remember that your audience will only remember
that you stooped to the same level of immaturity as your aggressor,
not that you were right.
- If you cannot resolve the issue, figure out what the
"chain of command" is and start working your way up. Remember
though, it is always best to pick your battles. The person
who accesses the "chain" repeatedly is likely to get rapidly
diminishing returns.
- Do not ever send or forward verbal or written complaints
when you are very angry. It is very likely that not only
have you not had time to consider the "downside" of this action,
but that you are likely incapable of rationality when you
are angry. There will most likely be quieter and more effective
means to evoke change other than biting "incident reports."
The caveat is to avoid complaints unless you have a suggestion
for change or an opportunity to improve the situation.
- When all else fails, "kill 'em with kindness." If
you have a chronic problem with an individual, your best recourse
is to deal with them with kindness and cordiality. It is very
difficult as well as socially unacceptable for them to be
rude or hostile to someone who exhibits unfailing courtesy.
The rest of the staff will greatly appreciate your efforts
and can be your greatest ally if the other individual does
cross the line.
During my stress management work with physician groups, it has
become readily apparent that anger and its management is one of
the single most pervasive and insidious issues in the group dynamic.
As physicians, our abilities to problem-solve seem to be inadequate
when dealing with the raw emotions and behaviors of anger and
aggression. It is essential to recognize this challenge and to
take pre-emptive measures, both in our personal and our professional
lives.
There are no easy or right answers to the dilemma of anger,
either your own or someone else's. All one can do is to understand
that anger is a natural part of living with emotion. When you
feel propelled toward the depths of anger, heed the advice of
Thomas Jefferson who wrote, "When angry, count 10 before you speak;
if very angry, count a hundred."
Jessie A. Leak, M.D., is Associate Professor,
Department of Anesthesiology and Department of Symptom Control
and Palliative Care, M.D. Anderson Cancer Center, Houston, Texas.
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