Death/Dying Understanding Displaced Anger in Dying Patients

In my experience, it's very common in a person that is going through this experience. Their life is coming to an end for them to get impatient. They may get impatient with a caregiver, they may get news they don't want, and they may get upset with the doctor or the person delivering the news. They may be more, or say more than average, irritable with their family members. That circumstance is something I think we observe. What is your suggestion for how we help them in that circumstance?

Well, I think you're actually understating it. I mean, there's flat out displaced anger on a regular basis as a feature that happens in probably half of patients lives that are dying. And usually it's not that direct. They get the news and they get angry at the doctor. Usually they get the news and they get angry at their wife or their husband. And so it's very important for counselors to understand. Displaced anger is something that we're on the lookout for now. When we see it, we understand that. Well, it's pretty hard to just say, you know what? I'm really pissed off that I'm dying. I'm furious that I'm dying. That's the real emotion. I'm furious that I'm out of control. I'm furious that I don't have my life. And I'm mirroring that right now just so people can really, as this is being watched, that people can hear. That's the real emotion. And who wouldn't feel the natural fury if they had access to those kinds of feelings? It's a perfectly natural feeling and one that would go on a lot for someone that loved life and their life that they know is being limited and taken away. Because that's so hard to experience. It needs to evoke a compassion that, well, of course, therefore, it's going to be partially displaced. But then as clinicians, in a certain way, we're looking and saying, is there a chance this person could handle a version of the truth? And if the answer is a little bit, we might say something along the lines of, you know, your wife really is doing the best she can. We might not talk about the anger directly, but we might just support the person that's being criticized or the caregiver. Really, they really are doing the best they can. You know, it must really be hard for you not to be, you know, frustrated or angry. And we probably would do it in a slightly understated way to give them a chance to come forward. Now, if we have a great relationship, which is probably 20% of the time where we can be that direct. We probably would want to. We would definitely want to come forward and say, hey, I bet you're really pissed off about your situation. Do you want to talk about it directly? But 80% of the time we're going to be in that inching scenario. Or maybe in this case, if it's really hurting other people, we might be going a few inches forward and saying something along the lines of it seems like you're really having a hard time. We'll let them know the general mood is coming across, but we won't really hit them harder than go. Then they give us a few more inches. We take a foot or two.

That brings me to the next issue, which is the family. And particularly when I'm going to visit client patient that's in a position where maybe they're at home or maybe they're in the hospital and other family members are there. And I'm noticing the displaced anger and I'm around these people. What type of interaction in this family unit is helpful?

Well, this is a situation where if you're oriented as a counselor, which some are, some aren't. As a family counselor, you'd handle it one way. If you're an individual counselor, you'd handle it another way. As a family counselor, you're going to want to be able to be timely, talk to somebody outside the room, be able to help them understand the nature of displaced anger, support them not to take it so personally if they aren't. Ask them how they're doing with it. They might have their own emotional states that they're dealing with that have beyond even what's going on, let alone the situation. So basically, if we're individual counselors, then our function really will just stay with the individual at hand. The, the optimal situation when you're dealing with a family is to have a family counselor. There's no question, because then you're dealing with a whole gestalt and you have a much better opportunity to leave the individual patient you're dealing with in the direction of finishing unfinished business, exploring the possibility of finishing unfinished business and partitioning out an individual outside the door and being able to have the private conversations.

Many times I'm a counselor with somebody in the circumstances that's at home, and I'm observing this displaced anger and I'm watching it. And of course I want to be the most effective I can be in that family and help them effectively help and be as loving as they can be with this person who may be expressing a lot of anger. Over something that has nothing to do with them. How can I be the most effective?

I think it's very important that the counselor recognize that they're really an overall coach or they're really available to as many people as possible. So it's very critical that they realize that they can't deal with everything publicly and that they're going to pull people off or catch somebody outside in the hall, and that that's part of the function as a counselor if you have enough of a rapport with the family members. And again, that's an intuitive assessment because a family member might think you're completely presumptuous to go and talk to somebody that you don't have a counseling relationship with. So you need to assess, which has to do with eye contact, which has to do with how long you've known the client, which has to do with whether the person gives you the respect in the conversation, whether in the interactions. You've really been clearly a key focus in the exchange in the room while the family's been there, and that they kind of know the history with you. If you have that relationship, then you want to pull somebody outside and talk with them privately. But the key thing is that everyone needs to understand the concept of displaced anger. And everyone needs to understand, if possible, that that's natural, it's normal, and you can't always directly confront it, because many people can't handle the reality of the fact that they're enraged, that they're out of control, and that they're dying, and that you will do your best to be the one to try to deal with it, which will relieve the family of that kind of responsibility. And then in your direct relationship with the patient, with your client, you would certainly explain to them at some point that you know this is a normal phenomenon, and you'll do your best to try to lean into that. And if the client is not receptive to it, then your limit is drawn. Now, we're not talking about psychotic proportions where somebody's really going off the deep end. In that case, you really might have to stand and say, you know, John, there's probably a lot of good reasons why you're angry in addition to being angry at the doctor, and you're probably going to need to do that if it's really getting extreme. So all those are sort of intuitive clinical assessments.

As a family counselor, one of the most commonplace things is, especially if it's a husband and wife, a parent, a child, one person is just fervently attached to the life of the person that's dying, and they simply don't know how to let go. And it can come at a time when that not often, but rare time happens when the person that's dying is even accepted their situation. How do we help family members let go?

Well, the first thing is that we'll make our best efforts, but this is really one of the hardest situations, and we can work at it from two angles if we have the ear of both the husband and the wife.

Let's say.

If you have a husband, let's say that's dying and that's your patient, and they're clear, they're ready to go, they actually want to die. Which in my experience, when someone has really reached a stage of acceptance, that's where they are. That's actually a good thing, it's not a bad thing. They're ready, they faced it. Their daily life is either pain or it's. It's over. They've said their goodbyes, they said their I love yous and one more, one more, one more. It's too many. So when they're in that situation, it's actually really something to be praised or, let's say, appreciated. And so let's just say you have a wife that really wants him to stay around. So you have the chance as a counselor to go to your client and say, do you want me to support you? I'm kind of noticing that you seem to really be asking for the morphine to be increased, and you don't seem to be getting a response, or you seem to be saying directly to me, and I hear you even saying it to your wife that you really would like to go, and she doesn't seem to want to let you go. And how is that affecting you? So you're really opening up the conversation so that he has a real chance to talk about what he's experiencing. Do you want my support? Is really the question to ask. Do you want to either talk to me about how you can talk to her, or would you like me to make an attempt to say to her what you're experiencing? And I think that's really what our responsibility is as a counselor, is to give the dying person the choice as to whether or not they want to advocate for themselves or they would like us to advocate for them.