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Think about the last time a patient yelled at you in anger.  How did you react?  The last time this happened to me I immediately went on the defensive despite years of training in serious illness communication skills.  Afterwards, I thought there must be a better way.

Well on today’s podcast we invite two of our favorite palliative care psychiatrists, Dani Chammas and Keri Brenner, to teach us about going beyond simple communication skills like naming the emotion when interacting with the angry patient (see our podcast on avoiding the uncanny valley for a deeper dive into the dangers of becoming too rote and scripted).  As Keri put it in the podcast, we must go beyond “a hammer and a nail” philosophy to approaching anger by developing a toolkit for anger that is vast and varied. 

Dani and Kery present three steps for interacting with an angry patient: 

  1. Look within: What is this anger bringing up in me? How is this anger making me feel, think, and react?
  2. Ask why: What is underneath the anger for this particular patient? Creating a “formulation” for the patient
  3. Act mindfully: Decide what can we do, and how we can respond therapeutically (and no there is no mnemonic for this step)

Here are some other great references we discussed in the podcast:

And for those interested in other podcast we did with Dani and Keri, check out the following:



Eric: Welcome to the GeriPal podcast. This is Eric Widera.

Alex: This is Alex Smith.

Eric: And Alex, I know these faces.

Alex: We are so happy to welcome back to the GeriPal podcast, Dani Chammas, who’s an outpatient palliative care doctor at UCSF. She’s a psychiatrist and palliative care physician. Welcome back to the GeriPal podcast, Dani.

Dani: Thank you.

Alex: And we’re delighted to welcome back to the GeriPal podcast, Keri Brenner, who is also a psychiatrist and palliative care doctor and clinical associate professor at Stanford. Welcome back to GeriPal.

Keri: Great to be here.

Eric: All right, we’re going to get on the topic of anger. I’m really excited about this because clinically this happened to me, somebody was very angry at something we were talking about. And I felt like I could have done a better job clinically in responding to their anger instead of becoming my usual defensiveness. But before we get on the topic, I think somebody has a song request. Is that you Dani?

Dani: It is me. The song request is Firework by Katy Perry.

Eric: Why firework from Katie Perry?

Dani: Actually, there is a story behind this song. When I was a psychiatry resident on the inpatient psych unit, there was one specific patient who was angry. He was livid, being held against his will. And he was saying just the most uncomfortably insulting things to my attending. And finally my attending, you guys might know him, said to the patient, “Why do you feel the need to do this?” And the patient looked him right in the eyes in unexpectedly burst into Katy Perry, “Baby, I’m a firework.” The [inaudible 00:01:39] and everything. It took all myself to not into devolve laughter with a patient.

Eric: I was not expecting that’s where the story was going to go right there. [laughter]

Alex: Not at all.

Dani: It’s true.

Keri: It has deeper meaning though.

Dani: I probably should have picked something else.

Alex: Here’s a little bit. Do you ever feel lack a plastic bag drifting through the wind, wanting to start again? Do you ever feel so paper thin, like a house of cards, one blow from caving in? And do you ever feel already buried deep, six feet onto screams, but no one seems to hear a thing? Do you know that there’s, there’s still a chance for you because there’s a spark in you. You just got to ignite the light and see it shine just own the night like the 4th of July. Because baby, you are a firework. Come on show him what you worth. Make them go oh, oh, oh, as you shoot across the, sky.

Eric: I have to do some non-verbal communication to get Alex to stop singing that song because I know he loves it. I can tell.

Dani: Yeah. It just reminds you when you’re feeling paper thin, buried, overwhelmed, there’s still that authentic self, that firework within to connect and elevate the moment.

Eric: Yeah. I also know-

Alex: That’s deep analysis of Katy Perry.

Dani: It is.

Eric: Alex probably hates the fact he loves singing Katy Perry. [laughter]

Alex: It is rather painful, but-

Eric: But you love it.

Alex: It’s fun to sing.

Dani: I will admit, I gave Alex two song choices and he was like, “Let’s go with Katy Perry.”

Alex: And I almost chose the other, which was from Oscar the Grouch from Sesame Street.

Dani: Oscar the Grouch.

Alex: And the creator of Sesame Street died recently. And so that was a reason to potentially show it, to sing that song. But I couldn’t resist the Katy Perry. Terrible. Okay. We have to go from laughter to anger here. Shifting emotions. Damn it, Eric.

Eric: Yeah. Alex’s voice is very strong right now. So I’m trying to calm down a little bit. Calm down. We just love having both of you on this podcast.

Keri: Thank you.

Eric: And part of this, when we were thinking we just wanted you back on and trying to think of things that we can talk about together, anger came up. And I’m wondering, why did this bubble to the top of topics to discuss today?

Dani: Yeah, good question. I would say… And we all love people being angry at us, not. Managing anger is hard, it’s really hard. And I think in palliative care, we just feel so equipped for emotions like sadness, disbelief, shock. The majority of us feel really comfortable with those, but a lot of us don’t feel comfortable in the presence of anger. And yet, it’s everywhere. It’s super prevalent in palliative care. It’s all around us. And I would also argue that we have so little training in anger. Eric, you, I think, run a fellowship program. Do you still run a fellowship program?

Eric: I do not run the fellowship program. I’m just a psych director for the palliative care fellowship.

Dani: I’ll take it. Okay. Well, when you did, how many didactic hours did you have dedicated to anger?

Eric: Zero.

Dani: Zero.

Eric: Zero.

Dani: Yeah, it’s everywhere. And yet we don’t ever talk about how to manage it.

Keri: And Dani and I, we came to come to this topic through the lens of our training as psychiatrists and psychotherapists. And so we’re trying to think about what are the most relevant insights from that world of psychotherapy that we can apply to this topic? What are some high yield techniques that can be integrated into our everyday palliative care practice, so when we see a patient tomorrow or next week, we feel more equipped at the interface of anger?

Alex: And when we’re talking about anger here, are we talking about anger in the context of caring for a patient and we start to feel angry? Is it anger in our personal lives? Is it anger at our colleagues with whom we work in teams? I remember [inaudible 00:06:16] said, “You say you’ve worked in teams. Show me your scars.”

Keri: That’s true. That’s true. There’s anger in so many different contexts in our life. Today we’re going to zoom in on the angry patient. So when we encounter anger clinically, when we’re in an encounter with a patient and their family, what are perhaps three steps, and we have the three step model for how we can look within ourselves and respond.

Alex: Okay, so we’re talking about a patient who’s angry.

Eric: All right. Step one, I’m going to just guess the steps. This is my usual. Step one, get incredibly defensive.

Dani: Always.

Eric: Step two, match their anger. And step three, try to leave the room real fast.

Dani: I don’t even know what we’re doing here, Keri. We have no use.

Keri: But we do have a disclaimer.

Eric: I can’t believe they didn’t want me to be program director anymore.

Dani: But listen, I have to… Yeah, we do have to acknowledge anger is a massive topic. So Keri and I can only hope that the psychiatric giants and psychology giants who came before us and wrote textbooks about this can forgive us for the fact that we’re going to try to distill it into three steps. Because shame on us, Keri.

Eric: Three steps. Okay, I’m looking forward to this. So let’s jump into it. Let’s say you have somebody.

Alex: Or do you have a case?

Eric: Oh yeah.

Keri: We definitely have a case.

Eric: Give us a case.

Keri: Dani, are we going to bring up the one, it actually pertains to both of you, from Dani’s …

Dani: Why don’t you tell them what step one is, just one and then …

Eric: The time we made Danny really angry. [laughter]

Keri: So step one, when encountering anger with a patient is look within, look within. What is this anger bringing up in me? How is this patient’s anger making me feel, think, react. So go ahead, Dani.

Dani: Okay, so for our first case, I do, I have a confession to make because I have kept this a secret from you, from everybody for over a decade about a case that I experienced when I was training at the VA with you all. But one time, very early in my training, I walked into the room of a patient at the VA who was really sick and also really upset. And I was about two steps into the room. I had barely introduced myself, and he started to yell, like, “Oh, great, this is what they think is going to help? They sent me a cheerleader. They sent me an effing 12-year-old cheerleader.” And I remember, two seconds in the room and my whole insides were clenched. He didn’t know me. He was just randomly throwing darts because he was angry. But he actually totally inadvertently hit something very raw for me. I was a young woman. I was a trainee. I was trying so hard to make you guys believe that I was competent to do a good job here.

And I share the confession, not because this is a case of anger handled really well. And while I was in the hospital, I never actually got over, like you were talking about, Eric, my defensiveness, the sting to my ego and my character and my worth, enough to get to the place of thinking about how I could be a good doctor for him. I didn’t look within, as Keri was saying. Because we all want to be good doctors, but what does that mean? Is it that we’re never hurt, we’re never upset, we’re endlessly empathetic? I don’t think so.

Keri: Yeah, Dani I-

Alex: Tell us some more about what look within means, because I could look within and say, “Oh, now I’m pissed. This person has questioned my identity.” Right?

Dani: Now I’m pissed. But I love actually the way you’re doing it, now I’m pissed. Why am I pissed? Because this question person has questioned my identity. Why is that hard for me? Really look within.

Keri: And this can feel so taboo within medicine and palliative care to have this when we look within and to encounter those negative feelings we might have within ourselves. Because there’s this tacit expectation in our field to either feel good and empathic and warm and fuzzy, or perhaps to be devoid of any feelings and just bury them. I remember in my fellowship the first time I felt anger, and it was in the context of a patient who was actively dying. And I just felt so guilty experiencing this anger amid within me when I was with a patient in their final hours.

Eric: We all have the inner voice. When you’re doing the look within step, are there things that you’re asking yourself?

Keri: Definitely, yes.

Eric: What are those things that go through Keri’s mind?

Keri: When I have a look within, I start with these check-in questions with myself and with my learners. Am I experiencing any emotions that are different or peculiar? I normally don’t feel bored or impatient. So if I notice that, then I know something’s off. Or are my thoughts different about this patient? Am I deviating from my normal practice patterns? Is my behavior variant in the way I’m responding to this patient? Those are all clues of something happening when I’m looking within. And there’s a psycho jargon term for this.

Dani: No clues. Yeah, don’t give it to them because they’re …

Eric: Countertransference. That’s the only… Did I get it?

Dani: You got it!

Eric: That’s like my extent of derm knowledge is steroids.

Dani: Yeah. But it’s an exciting concept, I see the excitement in your eyes and I hope it’s not just because you got it right.

Eric: No, it’s hundred percent because I got it right. Luck of the draw.

Keri: We’re talking about countertransference, which encompasses all those emotions, reactions, associations that we experience when we’re with a patient. What feelings do we have toward the patient and toward their families? And countertransference is everywhere. It’s in all human interactions. But in palliative care, it’s particularly intense because things just get dialed up when we’re in these crucible life or death moments with patients. So what otherwise might have been subdued, gets amplified in our work.

Eric: Yeah. So for example, after an encounter, we’re recognizing the next day we really don’t want to, “Maybe we should not see that patient today. Maybe we don’t want to see them. Maybe we’ll go on to something else. Maybe we’ll just send the med student to see them.” Being mindful that we may be changing our behavior based on that encounter that we had.

Keri: Exactly. And just some points about countertransference, it can be negative, like we’re talking about, or it can be positive. I had a patient last week where I felt inspired and uplifted. But I had another case last week where I felt hopeless and exacerbated. It can also be universal or personal. I’m thinking about your case, Dani, of the VA patient, where I imagine any one of us would’ve felt irritated and stressed in that room to some degree. That’s universal countertransference. Everyone would get it, feel really devoid in that case. But there was something personal too in your counter transference, maybe because you were a trainee where you had a specific sensitivity to that patient, what he was saying to you, where you had a unique reaction.

Eric: I also wonder, thinking about our own medical school training, at least mine, is that there wasn’t a lot of normalizing emotions in our med school. So we were trained to be like Androids, you’re not going to respond. You’re going to minimize bias. You’re going to have a clean slate with every patient. Without recognizing that we are humans, it’s normal to feel emotions. And I think the problem is when we do feel anger, we feel then bad about ourselves that we’re having this emotion, or sadness. Yeah. So thoughts on that?

Dani: I mean, if you’ll indulge me, maybe I can tell you, this totally goes with that. Part two of my confession case is that I distinctly remember, just like you’re talking about, that the one piece of relief I had in that case was that I was alone in the room, that nobody, not Alex, not Eric, not any colleague witnessed me being belittled because then I didn’t have to share any of it with any of you guys. I just kept it all in. And it’s so interesting to think now at this point in my career, how differently I would’ve experienced that. At this point in my career, gosh, I would’ve loved to have somebody in the room room. I might have felt flattered that the guy thought I was young. And I would’ve walked out of that room and I a hundred percent would’ve called Keri and said, “Keri, after preschool drop off, I need to talk about how incredibly inept this patient just made me feel today.” But that’s because I’ve evolved At that point, I was in this medical culture that you’re talking about that wants us to not be vulnerable, wants us to not share how we feel.

Keri: And I’m happy you brought this up, Dani and Eric, because it’s such a gift that we have to offer to create this space for one another to process together, through IDT, through friend peer groups, case supervision with colleagues. And that is a place where we can gain this ability to look within in a way where it’s all data and we can have a nonjudgmental presence toward these types of reactions that we have with patients.

Dani: Totally. And we can’t really… I can’t more strongly say what a gift this is to trainees. Because it’s not enough in this culture to just say that it’s okay to look at your countertransference. When I’m in touch with any notable countertransference, I purposely make a point of verbally sharing it so that I can show them that it’s okay.

Alex: Can I go back to a point of clarification? That we’re talking about clinical encounters with patients who are angry that in turn make us angry.

Dani: That in turn make us any number of things.

Alex: Any number of things.

Dani: Because being angry, might make us ashamed, might make us defensive, might make us any number of things.

Eric: Bored, thinking about-

Dani: Feel helpless.

Eric: Yeah. Yeah. And that’s all normal, right?

Keri: It’s all normal, and it’s all data that can better inform our practice.

Dani: Yeah. I am way more suspicious of the clinician who just is completely unaware or unwilling to look at these negative feelings, they’re all normal, than the clinician who’s willing to just own them and look at them. And if I [inaudible 00:16:56] sure we make the teaching point, because Alex, you started talking about how it can come out in our behaviors.

Alex: Yeah.

Dani: Bonus questions.

Keri: And I think that is first-

Dani: Oh, do you know the psychological term for that? When our countertransference comes out in our behaviors?

Eric: I was going to say, any future questions, I’m just going to repeat the word countertransference. That’s all I know. I’m going to turn this one to Alex. Alex?

Dani: All right, we reached the limit. We reached the limit. Alex, you can turn it to Keri if you need to phone a friend.

Alex: Reaction formation.

Keri: Oh wow, you’re into this. You’re deep into-

Dani: No, I love it. [laughter]

Keri: Alex, we will talk about reaction formation a little later if we have time.

Dani: We’ll make a note to do it. Yeah.

Keri: So enactment, enactment.

Eric: Wait, what was that?

Keri: Enactment.

Eric: Enactment?

Alex: Okay.

Keri: Yes.

Alex: Never heard that before.

Eric: Never heard of it.

Keri: What we can’t acknowledge within ourselves or say in words, it’ll come out in behaviors. We’ll act it out. It’ll come out in these deviant behaviors, just like you mentioned earlier, where maybe we stave off seeing that patient, send the medical student instead or delay that visit till the end of the day. These reactions that we have with patients, if we can’t acknowledge them or verbalize them, might come out in our care, either conspicuously or maybe in a camouflaged kind of way.

Dani: Yeah. And it’s not always avoidance with anger. I recently had an angry patient and I had the opposite enactment. I was so concerned about wanting this guy to like me that I let our visits run over a bunch. I started bending over backwards. Not my normal clinical practice. Definitely a deviation. But it’s just interesting how differently it can be enacted if we haven’t taken the time to look at what’s getting triggered inside of us.

Keri: Yeah. We can either over-treat or under-treat. It’s just so interesting the myriad of ways that this can present in our behavior when we neglect to just look within. I had this curmudgeon patient last month with cirrhosis, and I just kept punting seeing him till later in the day ,and suddenly it’s 5:00 PM and I’m just dragging my feet to get to his room.

Eric: So I guess there’s one thing that… So you’re looking within, you’re acknowledging kind of how you’re feeling, asking questions, why am I feeling this way? What do you do next?

Dani: This is a nice way to lead to step two. Yeah.

Eric: Step two. I was told there are three steps.

Dani: Yes. There are three steps. So step one, we’ve looked within, just like you said. If we’re feeling something different, if we’re acting differently. So step two is ask why. What is underneath this for the patient? What’s the why behind this anger? And it’s actually really hard to do step two if we haven’t done step one. We get stuck on our own feelings too much to get into it.

Eric: So am I asking the patient why?

Dani: No.

Eric: Or am I thinking about why?

Keri: We ask ourselves why.

Eric: What is that?

Dani: We’re asking in our minds why.

Eric: This is asking in our mind.

Dani: Why are you so angry? No. We ask why in our minds. We use all the data we have from what they’ve said, from input from our interdisciplinary team, from our own feelings. We use all the data we have to really reflect on this question, why, why are they so angry? And I know you said countertransference is the limit, but I have to ask, if you can channel my first podcast from four years ago, in the cobwebs of your mind, do you in any way remember the word for this why behind a person’s behaviors?

Eric: Not hypothesis, but-

Dani: Oh, you’re so close.

Eric: I’m so close. It is your…

Alex: Holding space?

Dani: Partial credit for Eric, zero credit for Alex. [inaudible 00:20:49].

Eric: It is something like hypothesis. It is a synonym to hypothesis.

Dani: You’re really breaking my heart here. Keri, give it to them.

Keri: Formulations.

Eric: Formulations.

Alex: Ah, formulations. It’s coming back now.

Eric: Yeah, it is coming back now. You’re making a formulation as to why, as you’re creating a hypothesis of why.

Keri: Exactly. So I know that formulation also sounds like probably psycho jargon, but it’s actually a fairly simple concept. A formulation is the why beneath a patient’s thoughts, emotions, or behaviors. It’s asking ourselves, why is this patient thinking, feeling, or acting in this way? So you’re exactly right. It’s a hypothesis. It’s a theory for understanding the patient’s psychology of what’s happening beneath the surface that’s driving what we’re seeing in the room.

Eric: So I can also imagine that’s the importance of step one, because you have to also acknowledge your own emotions. Because this step seems like it requires a fair amount of empathy too. You got to put yourself into the patient’s shoes.

Dani: Yes. Which again, and that first case I shared, I never got there. I didn’t even tread towards formulation because I was stuck. But there’s so many different formulations that could be behind an angry patient. There’s no way we could name them all. But maybe, if you guys are game, the four of us can kind of brainstorm together a bit of a differential for anger. What are some of the common formulations at play when we see anger in palliative care. So I don’t know if you guys want to kick us off. Is there anything that comes to your mind when you think about this differential …

Alex: Yeah, I’m angry that I have this disease. Why me? Why is this happening to me? This is not fair.

Dani: Totally. Almost anger that’s part of their normal grieving process. And like you’re saying, it’s a real deep existential anger. We don’t think of people as linearly going through the stages of grief anymore, but we understand that anger is an important piece of that for people. Oh yeah.

Keri: And that reminds me of the benefits of anger too. That when we see anger in this way that you’re describing Alex, of this normative grieving process, that is often a patient working things through, perhaps this unbearable injustice that absolutely needs to be processed, that eventually has a catharsis to it, where they’re able to vent what was seemingly intolerable.

Dani: Not all anger is bad. I agree with that. So what else?

Eric: You could have been the sixth person to walk in that morning with a cheery disposition coming in and he just maybe got some bad news with the last four visits.

Dani: Yeah, so the way you presented was triggering to them.

Eric: Yeah, or just not even anything by you. In a hospital in the morning, six people wake him up, they got a blood draw, they got everything else. It has nothing to do with you. Because it didn’t have anything to do with you. You just walked into the room.

Speaker 6: Innocently. And I think of that, Eric, as I often frame that as righteous anger. There’s so many elements of a patient that’s hospitalized or going through our medical system. And we know there’s so many elements of the system that are just broken. Those patient cases where even a patient falls through the crack or an error occurs. And righteous anger is something that’s real. If they got bad news or they were woken up five times before we came in, it’s legitimized.

Dani: But the other… There’s another on the differential that I think could be at play in what Eric’s describing as well, which is displacement. Patient sort of has anger for one thing and they displace it onto another target, either because it’s a more tolerable target or a more concrete target. I had a woman recently who was so enraged in my clinic about this very small discrepancy over her steroid dosing. But really underneath it was that she was enraged at a world where her husband was dying and nothing felt in her control. But she couldn’t express that enraged at the world. So it came out in this steroid dosing dramatic saga that we went through.

Alex: You mentioned steroid dosing, and I can’t help but say that there are also… It could be a side effect of a medication. Steroids, for example, could cause psychosis, could make a person feel very strong emotions they wouldn’t ordinarily feel. They may express that as anger directed toward you.

Keri: Yeah. I think that’s a really insightful point is always thinking about organic causes. What medications are the patient on? What disease processes do they have? And also the whole potential psychiatric diagnoses. So we know that irritability is a potential manifestation of a mood disorder, of depression or anxiety. So when we see things like anger and irritability, I always encourage my trainees to keep an anxiety, depression, medication lists top of mind. Maybe it’s delirium that’s been undiagnosed. So always having those in our differential.

Dani: Totally. What else?

Eric: He could just be a sexist. I was going to say a different word, but I’d have to bleep it out. But it could have been about you. It could be like, “I don’t want to work with young women doctors.”

Keri: Yes. That makes me think about transference. So we just talked about countertransference earlier, but transference is what is the patient’s emotions, reactions when they’re with you? What does that bring up for them? And I had this case when I was a resident where my attending literally walked into the room and immediately she was just kicked out before she even said anything. And later we discovered that apparently her appearance and her dress reminded the family of their aunt who was totally loathed by the family. So it had nothing to do with my attending. It was this intense transference or perhaps these biases that they carried with them when in that encounter.

Eric: Well, it’s really interesting. The last case of anger that I ineptly dealt with was we were delivering in some ways good but bad news, that somebody was graduating from hospice. And the anger was… I was the one delivering the bad news, but the anger was very much directed at a social worker on our service who’s female. And even afterwards, the next day, the anger was still directed at this person that they delivered this bad news, when in truth, I was the person who was the bad cop. And I wonder how we think about microaggressions and biases and sexism and racism when it comes to this step.

Dani: Yeah.

Keri: Well, and once again, that displacement where for some there’s those biases and those isms, and then also [inaudible] directed toward her rather than to the proper target.

Dani: Something made it more comfortable to put on her than you. We don’t know what, but something. Was it a bias? Was it a loyalty to you? They couldn’t displease you in a way to make you feel like they didn’t like you. Some reason in their psyche made that easier.

Keri: And obviously we have to protect our members of our team, call out things that are egregious and also process them with one another too to create that collegiality that we all deserve.

Alex: Yeah. I think one of the times that I’ve felt most angry was when I was taking care of a patient who was planning to go home with hospice, and his wife came in and just read the riot act to our brand new fellow in July, and was just tearing them down, tearing something in them. And I got so angry because I was feeling protective of this new fellow, vulnerable, just starting. And here’s an incredibly angry family member. I’ll say that I did not follow your steps. I reacted angrily and I yelled back at the family member and I said, “Just because we put on these white coats doesn’t mean you can say whatever you want to us. We still deserve some basic human respect in our interactions. And we are going to leave the room now and we’ll try again another time and hope that we can react more civilly.”

Dani: Is yelling a part of your normal practice, Alex?

Alex: And then I left the room and I said to the fellow, “This is not what I want to teach you. This is not the way that you should react to anger.” However, in that case, we went back in the next day and they behaved much more civilly toward us. The caregiver apologized. And I think what it did is it placed some boundaries around her behavior .and she needed that containment vessel, even though it was probably more strongly worded and emoted than I would’ve liked to have come out.

Dani: Absolutely. And if I could, I think we should talk about boundaries, but if I could slow us down to get to step two, because you’ve done a brilliant job describing and describing how it played out. But what was beneath it, Alex? Do you have a theory? Why was she so angry?

Alex: She was angry because this is a situation she lost control of. And she couldn’t control her husband’s illness the way it was heading towards his death. And so she put that anger on our inability to get a hospice bed into her house the moment she wanted it delivered, the hour she wanted it delivered before they got home.

Dani: Totally. So it’s another displacement case. We see that a lot because they’re the sources of anger in this existential space of palliative care, it’s really hard to put them where they should go. So displacement, I think we see a lot more than other fields.

Eric: I have another example, though.

Dani: Yeah, go.

Eric: So another example, Bruce Banner, the Hulk, remember the first Marvel movie? I’m always angry. That’s how he maintained control and didn’t become the Hulk. And that’s the funny part. But there are people who are characterologically… Or maybe it’s not characterological, maybe it’s a defense mechanism. I think about people who are marginally housed who come in and it’s a protective mechanism on the street. They’re prickly, right? That’s their first reaction because it helps them to survive dangerous encounters.

Dani: Some people’s personality constructs, and I liked how you were kind of getting at personality disorder, but then you were like maybe it’s a defense, but they’re really related. A personality disorder is a constellation of someone’s coping and defenses that comes out sort of maladaptively in the world.

Keri: And there’s a great paper about that, James Groves wrote it in the New England Journal in the 1970s, called The Hateful Patient. And one of the personalities that he described in that paper was about self-destructive deniers, so those patients that just evoke malice. And they are coming in and leaving AMA and always angry. And that’s a whole different approach with that kind of a presentation. There are a few others. Dani, do you want to mention a couple others…

Dani: On the differential?

Keri: Yeah.

Dani: Have you guys talked much in your careers about this idea of anger being a secondary emotion?

Eric: No.

Dani: No. All right. So for a lot of people, we think of anger as being a secondary emotion, that there’s some primary emotion underneath, either sadness, inadequacy, guilt, fear, that for whatever reason for some people is so intolerable to feel that they get out of having to feel it by slipping into anger. And they feel so scared that they get angry, they feel so guilty, that’s uncomfortable, that they get angry. And so sometimes I think when we’re looking at anger, what we’re seeing is the… It’s the secondary emotion manifesting from a different emotion underneath.

Keri: And I had a case like this, Dani, last year where I delivered the prognosis that the patient had likely weeks to short months. And the wife immediately just started yelling at me. She looked at me and she said, “You just don’t get it. No one gets it. Just get out.” And she was so angry. And my intuition was telling me that she really didn’t intend to kick us out. I’ve been fired before, but I could just sense that this was something different, beneath her vehemence, there was something else. So I ended up, I just sat there in silence beside her, non-defensively. It was probably about two minutes. It felt like an eternity. And suddenly she just started weeping. She leaned over into me and just wept and wept. And it was like this blazing fire of rage suddenly just started to crackle into tears.

Alex: Yeah. Grief.

Eric: So this is the plot line of what was that Pixar movie about the different emotions?

Dani: Inside Out?

Eric: Inside Out.

Alex: Oh, yeah.

Eric: This is the plot line of Inside Out.

Dani: Yeah. Oh my goodness. This is too funny.

Eric: The life of the teenager, which I guess is the life of everybody.

Dani: It’s in all of us. And I think we talked, I’m actually going to indulge Alex, or no, it was Eric. No, it was Alex, I think it was Alex, you brought up reaction formation. But we talked about displacement, but I would say a lot of our defense mechanisms come out as anger. Projection can come out as anger. Transference we talked about coming out as anger. Reaction formation can come out as anger.

Keri: Alex, I think the best example of reaction formation that I feel like we all see frequently is the son who comes in from the East Coast, parachutes in irate, saying, “You need to do everything. This is such horrible care here. You need to make him full code. You need to do everything,” who’s been estranged for years, comes in. And the reaction formation part of that is that son is probably harboring some kind of unconscious guilt, maybe from the estrangement of his dad for years, maybe it’s because he’s desired his father to be dead. So that unconscious guilt is so unacceptable that it manifests as the opposite, by being so irate saying, “You need to do everything to keep him alive.”

Eric: When I was in New York, it was always the daughter from California.

Keri: Yes. And now that I’m in California, it’s the East Coast son.

Dani: And then projection we mentioned, I would say that patients, sometimes as a defense, they unconsciously take unwanted emotions or traits that they don’t like about themselves and they attribute it to someone else. Just this week, I had a patient in clinic, she was yelling, I have the nicest front desk staff in the world, but she was yelling at me, “The front desk staff in your office is hostile and irritable.” And it was obvious to me that she was struggling with those emotions. She had actually projected them on a lot of different targets in prior visits, but she didn’t want to own that she felt hostile and irritable. So she was projecting it on them. Gosh, we should do a whole ‘nother talk on defense mechanisms because we’re going to get lost in this rabbit hole if we keep going.

Eric: So I’ve got a question.

Keri: It does remind me, Dani, of that scapegoating phenomenon, when you’re talking about projection, where you see anger getting projected onto another person or a team, saying, “Oh, it’s the physical therapist’s fault or the oncologist is culpable.” And I think we’re all vulnerable to that, not just patients and families, but teams as well.

Dani: Totally.

Eric: So I got a question. So I remember this from last time when you were doing formulations, because I asked, what if you get it wrong? And here, Alex came up with a formulation of why the patient may be acting, but you don’t know. They have a experience that you will never have had. You can make a guess, but there’s also a reasonable chance you are completely wrong.

Dani: Totally. Formulations are fluid. I wish they were just a diagnosis. It doesn’t work like that. It’s a fluid hypothesis. And like we talked about last time, you are constantly integrating data. So the task is not to have it right. The task is to have a compass. And that compass is sort of leading you through what you think is going on. But as new data comes in, maybe you name what you think is going on and it totally shuts them down. And when new data comes in, you just adjust the compass as you’re going. But it’s the void of having taken the time to think through it or have a compass at all, that’s where I think we get in trouble.

Alex: So is the step three to articulate your formulation, to test out your hypothesis, so to speak?

Dani: No, it is not.

Alex: No? You don’t say to the son from the East Coast, are you angry because you just haven’t participated in your father’s care at all for years, and you feel guilty about that and now you’re yelling at me?

Dani: You’re mad at yourself, aren’t you?

Alex: That doesn’t go over well?

Eric: Are you angry? I don’t think you’re angry at the front desk staff, I think you’re angry at yourself. Should I say that?

Dani: Well, listen, we’re going to get into step three in a second, but I will say that… And we’re going back into formulation, but the crystallizing point of step three, which we’ll get to, is that there isn’t one right way to deal with it. You use the formulation as a compass. So in some cases, with some patients, verbalizing what they’re angry about is going to be incredibly therapeutic. And in some cases, with some patients, verbalizing what they’re angry about is going to have a bed pan thrown at your head. And so this is why we have to go through steps one and two before we can get to that step three about how do we be therapeutic?

And I will also say that when we’re formulating, we’re taking in a lot of data, but one of the really big pieces of data that we’re taking in is our countertransference. Because we will have a different kind of countertransference to different formulations. They’ll evoke something differently in us. I recently had this patient in clinic who, for complicated reasons that I won’t go into, our outpatient clinic had to put limits on his frequency of visits with me. And he was livid. And I was aware in the room that at the appointment when he was mad at the system, I could have sat with that forever. It wasn’t comfortable, but it was fine for me. But when he looked me in the eyes and he said, “You really hurt me. You let me down,” that was very hard for me.

Keri: And Dani, if you think about the two steps that we’ve just gone through, step one, looking within, what did that bring up for you? What was your countertransference?

Dani: You’re putting me on the spot to enact what we’re we’re teaching here. Okay, so step one, looking within, I felt terrible. I’m a huge people pleaser. So it tapped into this uncomfortable thought for me of, “Am I bad? Am I cold? Did I harm him?” And kind of like Alex talked about, I felt this urge to… Or maybe it was Eric. It was Eric. I felt this urge to defend myself. I felt defensive.

Keri: And then step two, asking why. So what do you think was happening beneath the surface? What was your formulation there?

Dani: Yeah, we’ve talked a bit about personality structures, but this patient had a really traumatic history in his past. And I think limiting the visits really triggered a deep sense of abandonment in him from a provider that he felt attached to. Which is also the beauty of formulation. Because not only do we better understand how to be therapeutic, which I promise we’ll get to in step three, but it helps us have empathy. It helps us like the patient if we get where they’re coming from. In this case, it’s only because I had an understanding of the formulation that I could hold onto and anchor to, that instead of getting defensive and explaining just why we were putting the limits, I was able to say to him, “It’s okay that you’re mad at me. It really hurts to feel let down by somebody you trust.”

Eric: So that was your step three.

Dani: That was my step three.

Eric: All right. We’re coming the top of the hour. How did you get there? What is step three?

Speaker 6: Step three is acting mindfully. So act mindfully.

Dani: So based on step one and two, what can we do? How can I be therapeutic? And one thing that’s interesting about anger, Alex brought it up earlier, is that we have to keep our needs and the needs of the patient in mind. So in terms of our needs, where do we draw the lines? Alex, you started talking about boundaries with that case earlier, giving boundaries. Alex and Eric, are you guys okay with people throwing things at your face?

Alex: No. That would be a boundary that they should not cross.

Dani: No, right? Are you okay with them insulting your nursing staff?

Alex: No.

Eric: No.

Dani: Are you okay with them raising their voices at you?

Alex: Oh yeah.

Eric: Yeah.

Alex: To some extent.

Dani: All of our boundaries are different. So we have to remember that we are humans too. We have personal limits on what kind of behavior we’re okay with. We have to cultivate in ourselves an ability to metabolizing or appropriately. But if we set that all aside, we can start to think about how am I going to be therapeutic for this anger? And I wish I could give you a pneumonic. I wish there was one way, but there isn’t.

Eric: So forget all these three steps, you got the nurse pneumonic, just name the anger and we’re done. Right?

Keri: Well, I think that in terms of naming… Well, first of all, beyond the pneumonics, our toolkit for anger needs to be vast and varied. We have to really expand our style and our ranges of responses. It’s not just a hammer and a nail for communication technique.

Eric: Just not say to everybody, “It sounds like you’re angry.”

Keri: Exactly. Exactly. And I actually relish… When I think about the words to use with anger, I relish this concept that I learned from Vicki Jackson who taught me that words have levels of potency, just like medications. And we can titrate words the same way that we titrate morphine. So saying something like, “This must be irritating,” is a one milligram dose, but saying, “This must be enraging,” is a hundred milligram dose. And we can augment or attenuate our dosing to match what a patient needs to feel heard and understood.

Alex: Oh, I love that analogy.

Keri: This reminds me of a case where I needed to administer a bunch of thousand milligram words. I’d love to share.

Eric: Yeah.

Dani: Go for it.

Keri: So it was this 55 year old man, he had laryngeal cancer and he had a total laryngectomy. So he literally couldn’t speak anymore. And we received this consult to assist with goals of care. And the team said that he was belligerent and bitter. Those are the words they used, that he would fire teams, kick them out of the room, or teams would just flee out of frustration. And I remember the first time that I witnessed this. My first visit, there was an occupational therapist in the room before me, and the patient was so infuriated, he was writing ferociously on his clipboard. And the OT person was just trying to say all these niceties to calm him. And he literally took the clipboard and he just threw it across the room. And the occupational therapist just bolted. So my formulation about him was he was voiceless. He literally felt unheard. He was totally alone with his anger. He had no way of releasing that fury within him, and no one was acknowledging the magnitude of his rage that was just boiling within.

Eric: Yeah. And the sheer amount of suffering he must be going through.

Dani: So then step three, for us, Keri, act mindfully. How did you become his voice or vocalize his anger? How did you use that compass to be there for him?

Keri: He was writing on this clipboard all of these vulgarities. He got another clipboard, started writing all these vulgarities, all this profanity. And I just started saying whatever he was writing out loud. And then I realized I needed to embody it more deeply for him to really hear it in the intonation of my voice. So I literally just started proclaiming all of these expletives with intensity. And after about 10 minutes, he just started writing more calmly, and suddenly he’s started-

Eric: So you literally became his voice?

Keri: Yes. He just started, then, all of a sudden jotting down thoughts about his new grandson and his financial struggles. And then about 10 minutes later, he just scribbles, “When will you be back again?” And a couple visits later, we really were able to pierce to the heart of his goals of care more meaningfully.

Dani: And for anybody who’s listening who knows Keri, you’re probably cracking up right now because this technique of screaming expletives in the room is definitely outside of Keri Brenner regular operating [inaudible 00:46:13]. I would pay money to hear Keri use vulgar language.

Keri: I had to get out the power tools.

Dani: But it underscored that idea, Keri, that your choice to lean in and match his anger so intensely, it’s not what you do for all anger. It was specific to his formulation, that he was voiceless.

Keri: Yes.

Dani: It could instead been, like we were talking about, if it had been a wife who had a lot of sadness underneath, we might have validated the anger, “Oh yeah, this system can be really infuriating.” But then we would’ve leaned in elsewhere. Maybe we would’ve said, “And it’s totally petrifying to have someone we love be so sick.” There’s not one pneumonic. I hate pneumonics.

Eric: I’m just thinking about me and Alex throughout this whole exercise, these three steps. So we’re always jumping, give me the third step, give the third step. But it’s really step one and step two, it seems like, are incredibly critical in that order before you can even think about step three.

Keri: I do think, though, us focusing on this third step can be empowering because it’s sometimes nice to just think of a whole potpourri of approaches to consider when you’re facing anger.

Eric: Yeah.

Keri: I don’t know if we want to brainstorm some of those.

Eric: Yeah, can we just quickly, because we’re running into the top of the hour, but what are some of those things that come to your mind? I have my toolbox now. What are some things that you can give us?

Dani: Yeah. I would say one domain in this bucket is thinking about if you want more or less people in the room. So do you guys find it easier with anger to have more people in the room, like joint visits, or less people, downsizing the meeting?

Eric: I feel like less is usually…

Dani: I tricked you, I tricked you. It’s [inaudible] formulation.

Eric: Oh, [inaudible] formulation.

Keri: I think it’s both. So we see, just like you’re saying, Eric, less people, sometimes downsizing the family meeting so patients don’t feel like they’re on trial and they feel less confronted is good. But sometimes, like with that patient with laryngeal cancer I just mentioned, I partnered up and did joint visits with my social worker with him. Or if a family feels unseen or unheard, getting all the specialists together so they feel more validated.

Eric: That’s a great point.

Alex: That’s true. When they see that all of these, every team member is here, we’ve got the primary team, the palliative care team, got the oncologist here, boy, they are taking some incredible time to think and put their heads together and be here all for us.

Keri: Or if they’re angry about mixed messages, bringing everyone together so they can hear the unified message and the consolidation of the case, that can be really consoling.

Eric: Other things in the toolbox?

Dani: Other things on the toolbox. More time or less time, I’m not going to try to trick you again on this.

Eric: It depends.

Dani: It depends. Keri, do you want to talk about that a little?

Keri: Yeah, I think that more time or less time is important. Another one is our body language, so having a non-confrontational stance. I notice sometimes in family meetings I’ll sit down and it’s like all the doctors and clinicians on one side and the family on the other side of the table. And it feels like Sharks versus Jets in West Side Story. So I try to make my posturing more aligned with a family, where actually my body shows I’m their ally and I’m accompanying them. And when I’m one on one, I carry a portable chair with me just to sit with a non-intimidating presence, to be more fully present right with the family and with the patient. So those non-confrontational stances. But other moments, you might need a stronger stance. If a family dynamic is really dysregulated or a patient needs containment, you might need to show that you are more powerful and competent in your posturing.

Dani: Totally.

Keri: I think the other final points are about, with posturing, just to think about am I crossing my arms signaling I’m closed off? Or am I actually standing with a more open stance of acceptance? My eye contact, am I using less eye contact? Which actually sometimes when the anger escalates, decreasing the eye contact can be a lot less threatening to people. But sometimes you need more eye contact when you need to let them know you’re really listening and receiving anything that they have to share.

Eric: That reminds me of touch. You got to be… Sometimes it’s helpful, sometimes it’s not.

Dani: Totally. And one thing that we talked about a little bit, but I’ll put it on this list in your toolkit, is am I going to lean into this anger, am I going to join them in anger or am I going to try to be a super calm pacifying presence? Or am I going to lean into something else if I think something else is under it? There isn’t a right answer, that’s why there’s no pneumonic. But that’s one domain to be thinking about when you want to be therapeutic for anger. Any other others come to mind?

Eric: Any others?

Dani: I mean, like a million others. But I think the key being, and it’s like you said, Eric, if you’re tapped into one and two, you’ll have a place from which to think through what is going to help out here. And I think slow it down, slow down is the piece of advice.

Eric: And if I remember from your last one, if you get it wrong, you can always change. So if step three you formulated wrong, it’s about a process. It’s really about… This is not 1, 2, 3, you’re done. This is about constantly going through kind of how you’re feeling inside, what you think is going on with patient, how you …

Keri: Yeah, and we talked about that last time too, about it’s not about perfection, it’s about. Connection. And so it’s not about getting it perfect, it’s about staying connected. In this instance, staying connected within ourselves by looking within, staying connected with a patient and their experience by asking why.

Dani: I can’t help right now, but think of my husband every morning getting my kids out the door. And one of them always forgets their shoes and he’s immediately so angry. And I’m always thinking, “Slow it down, slow it down. You’re going to get them out the door better if we take a moment.” But it’s hard. Anger revs us up. We want to get away from it. It is hard to slow down in the face of something that is intense. And so it really is a practice that we have to cultivate. How do I tolerate sitting with anger? And also, we might not have time to go to there today, but how do I process this anger? Because I’ve let someone’s anger come in and I’m going home to a family and a life, and Dani told me to sit there and tolerate it, but how do I then process it so I’m not carrying it forever?

Eric: Well, maybe that will be the next podcast, right? And we also did-

Alex: In an ongoing series.

Eric: And we’re going to have links to all of our past podcasts, including Using Our Emotional PPE, which was a great podcast. So we’ll have links to that on the show notes. But one way you can do it is just sing a nice song, right? That’s one way to process?

Alex: An empowering song?

Eric: An empowering song?

Dani: Blast it in the car, right?

Alex: All right, here’s a little bit more. You don’t have to feel like a of waste of time. You’re original, cannot be replaced. If you only knew what the future hurls, after a hurricane comes a rainbow. Maybe your reasons why all the doors are closed, so you could open one that leads you to the perfect road. Like a lightning bolt, your heart will blow. And when it’s time, you’ll know you just got to ignite the light and let it shine. Just own the night like the 4th of July. ‘Cause baby, you’re a firework. Come on show them what you’re worth. Make them go oh, oh, oh, as you shoot across the sky.

Eric: I always wondered why Alex had a Katy Perry poster on his wall, but now I get.

Dani: She helps him process anger.

Eric: Keri, Dani, thank you for joining us on this podcast. We love having you on.

Keri: Thanks, it was so much fun.

Dani: Thank you.

Eric: And thanks to all of our listeners. Hope you enjoyed the podcast and thanks for your support.

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