Anger and The Monster Within Us

David A. Perna, PhD 
Licensed Psychologist
Lecturer in Psychiatry
Harvard Medical School

---

“And if thou gaze long into an abyss, the abyss will also gaze into thee”
​-Nietzsche

For those who are interested in working with angry patients the journey is fascinating. However, from a countertransference perspective one needs to be cautious and should follow the advice that Nietzsche offers in Beyond Good and Evil:

“He who fights with monsters should be careful lest he thereby become a monster”

“And if thou gaze long into an abyss, the abyss will also gaze into thee”
​
Let me be clear, the monster is not the patient, it is the anger and rage that he or she harbors. In his comments Nietzsche is referring to the extent that one can become tainted and reactive when interacting with such challenging behaviors over time. It is often all to easy to focus on the client’s overreactions and extreme rages and lose sight of the clinician's own clinical shortcomings and tendencies to be blind to his/her own hurtful behavior and countertransference blindspots.

---

Arc de Triomphe interior,
​statue- “La Marseillaise”
Credit: David A. Perna (2014)

In working with angry patients one is constantly challenged to address one’s own temper and tendency to lash out in a sadistic/hurtful manner. Boundaries that seem to be so clear when one is in training under clinical supervision can at times become blurred later in a clinician's career during an intense treatment experience. The risk is the likelihood that the clinician can start to treat the patient with the same sense of  venom and distrust that the patient experiences in his/her daily interactions. This is the slippery slope that prompts one to lose clinical perspective as the abyss grabs a hold and pulls the clinician downward..

One of Marsha Linehan's greatest contributions to the field of contemporary  psychology has been her ability humanize the the treatment of patients diagnosed with Borderline Personality Disorder. This population has always been identified by treaters and members of the general population as angry and furious. Prior treatment approaches encouraged sadistic reactions to borderline patients who struggled with mood regulation skill challenges, rage, and a long history of interpersonal instability with significant others.

Linehan's "Eastern Philosophical" approach to treatment posited that the therapist was at fault if the patient did not progress, thereby prompting the therapist to think of ways to change his/her approach rather than simply rebuking the patient as being lazy or slothful. This humanistic approach ushered in a much healthier era in treating Borderline patients by helping them develop skills in an incremental manner that is at times slow, and yet with time-steady and incrementally effective.

So in following Nietzsche's lead, the clinician should always question him/herself when the interaction with the patient becomes intense. Anger and rage focused back towards the patient and family should always be considered as unhealthy and connected to the pull of the abyss. There have been so many clinicians who have rationalized these hurtful approaches as appropriate and needed in light of the patients acting out, but the truth is that they represent an unhealthy countertransference response to a vulnerable group of patients.

---