Medical Examiner

Can We Have Compassion for the Angry?

If we recognize unregulated anger as the problem, we may be able to help people who are likely to become violent.

gun in hand.
The best predictor of future violence is past violence.


All humans are born with a powerful wired-in fight-or-flight response—anyone who has held a screaming infant can attest to its intensity. Anger is an essential biological reaction to perceived danger, a physiological shift that allows us to stop thinking and take immediate action, to act as if our life depends on it. It is generated by our evolutionary survival response to threat, and we all carry it. We are wired by nature for rage. It is the impulse that has insured our survival as a species: kill or be killed. It is primitive, and it is very strong.

If that crying baby is soothed and cared for, the fight-or-flight response will calm. This strengthens the pathways that regulate the response and allows the child to learn to control anger. If a baby learns instead that needs won’t be met, because caregivers are unpredictable or violent or abusive or absent, the brain wiring will develop to fit his life. Rather than learning to soothe itself, the brain will remain in a more or less constant state of fight or flight, and emotional responses will be unfettered and impulses out of control. Trauma later in life can also disrupt the brain’s ability to modulate the intensity of reactions.

An adult who is able to effectively regulate anger uses it to alert himself to a problem situation. Managed well, it is an extraordinarily effective warning system.  Unregulated, impulses are stronger, and thinking is less clear. The poorly regulated adult with enhanced reactivity, impulsivity, and a constant state of fight or flight sees in every interaction the potential for being harmed and the necessity to defend himself. The angrier he feels, the less clearly he will think. His reactions will often be out of proportion to the situation, and he will be prone to violence. Because he sees the world as a constant source of danger, he externalizes blame, to his spouse, children, neighbors, government, and “others” in race, nationality, religion, or culture. Angry, blaming, aggressive, and unable to modulate his emotions, he can become a danger to others.

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In the early hours of Sunday, June 12, a tragically familiar story unfolded. A lone shooter entered a gay bar in Orlando, Florida, one he had visited a dozen times before, and opened fire on patrons with a semi-automatic weapon. He murdered 49 people and injured dozens more. It was an act many would describe as both cowardly and horrifying, an act that defies not only logic, but human decency, and yet one we have seen played out over and over in recent years.

Mass murders with assault weapons are now occurring with a frequency of once every couple of months in the United States. Each time the same questions are raised. How could anyone do this? What could motivate them? Could this violence have been prevented? We search for an explanation to the inexplicable, but often, we are looking in the wrong places. Frighteningly, any of us is capable of this. All that sets the rest of us apart from a murderer is the ability to regulate our angry impulses.

The Florida shooter was a man whose weakness in managing his own emotions made him hostile and vicious and ultimately a killer. He had a history of violent spousal abuse and controlling behavior, his first wife ultimately having to escape him with help from her family. It is unclear at this point whether he also abused his second wife, but it appears that he restricted her movements and kept her from her family. A co-worker described the shooter as socially awkward and without friends, hostile to women, gays, Jews, Latinos, and black Americans. It appears to be his preoccupation with gay men that brought him to direct his rage at the LGBTQ bar, Pulse, on that Sunday morning.

There is always a kind of hope in these situations that mental illness will offer some explanation for this type of crime—surely, no one one sane could commit such an act. In the hours after the attack, as his first wife spoke out about how he had abused her and referred to him as “mentally unstable,” people grasped on to this label, concluding that of course anyone who could commit such an act must be mentally unwell.

To speak about mental health in this way reflects an inaccurate understanding of what mental illness is. We have been through this debate many times before. Over the span of a lifetime, the average American has a 47.4 percent chance of having some kind of mental disorder. The number of Americans who will go on to be violent in such a fashion is certainly extremely far from 1 in 2. Equating mental illness and an extreme propensity for violence is both inaccurate and damaging to how we perceive mental illness. The National Rifle Association has promoted the mental illness hypothesis for years, suggesting that if we had better mental health treatment, these mass killings could be stopped. It has even been suggested that we should ban people with a history of mental illness from buying weapons and that we should arm ourselves against them. The ban on weapons for dangerously violent people is an excellent suggestion but has been directed at the wrong group. Violent crimes committed by people with mental illness get a lot of attention. But they are rare enough that if all the violent crime perpetrated by those with mental illness were eliminated, 96 percent of violent crime would continue .

There is no form of mental illness that predicts murderous behavior. Violence is not a product of mental illness. Violent crimes are committed by violent people, people who are unable to manage their anger.

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Alternatively, prejudice has been suggested to be the driving force behind the murders. The killer had espoused racism toward at least a few minority groups and prejudice toward gays and women. But prejudiced thinking does not account for murder. In its basic, literal form prejudice is simply the process of making predictions with a lack of information. We all use this kind of thinking on a daily basis. We predict whether the bus will be on time because last time we had a bad experience with it. We predict that our husband will fall asleep at the play because that has happened before. We suspect those people speaking a different language will be unfriendly to us because we have heard that might be the case. It may be inaccurate, but in and of itself personal prejudice is not dangerous. It is only when prejudice becomes attached to fear and anger that it becomes a terrible thing.

There is evidence to suggest the killer may have been a closeted gay man. He frequented gay clubs, used gay dating apps, and according to one report, had a casual gay partner. His family believed homosexuals would be judged by God for their sinful lives. It has been speculated that it was because he was not liked and had difficulty finding a partner or, alternatively, because he had a partner who didn’t disclose his HIV status that he was driven to kill. Could something like this cause him to wildly lose control? There are many men in this world who do not openly disclose their sexuality. Sadly, there are many LGBTQ people rejected by their families. Yes, dating can be tough. And again, these are social issues that don’t create murderers.

The Orlando killer was also a Muslim so fingers have also been pointed at Islam as somehow explaining this tragedy. The fact that the killer was born and raised American has been overlooked, as has the fact that the correlation between being a Muslim and being involved in mass murder is zero. According to an FBI report looking at terrorist attacks in the U.S., only 6 percent of the attacks were perpetrated by Muslims.

Other reports suggest this man had been “radicalized” and had become sympathetic to terrorism and terrorist groups. But it is an error to assume that the terrorist agenda convinced the shooter to become violent. Rather the terrorist agenda created an outlet for the rage the Florida killer had already expressed in abuse of his spouses and diatribes against minority groups. Like the long-lived KKK, newer terrorist groups provide an outlet for threatened, angry men, but they are not the cause of this rage.

This was a very angry man. His anger was not a product of prejudice, homophobia, a bad marriage, or a religious affiliation. It is the reverse; his anger fed these problems. His violence was not caused by mental illness or by an affiliation with terrorism. His anger and violence were there for years, apparent in his prior actions. When they imploded, we looked for a reason but saw past the obvious.

There is a profile of the typical mass murderer, albeit not one particularly useful in identifying dangerous individuals. He is male, white, and single, divorced, or separated. He is also isolated, lacking in social support, and bears a grudge toward someone or something. He externalizes blame and sees himself as wronged. It is clear the first part of this profile—male, white, and single—is not the part that would best predict a violent killer. It is the second part,—lonely and isolated, blaming others for his problems, and most importantly, angry—that depicts a man likely to lose control.

This profile fits well with the one good predictor of future violence that we have: past violence. A felony domestic violence conviction is the single greatest predictor of future violent crime. Between 80 and 90 percent of murderers have prior police records in contrast to 15 percent of American adults overall. Domestic murders are preceded by prior domestic violence more than 90 percent of the time, and 46 percent of domestic murderers have had a restraining order against them in the past. Furthermore, the probability of violence increases in a linear pattern with the number of past violent acts.

Violent crimes are committed by people who lack the ability to regulate and modulate their response to perceived danger. This is not a hypothesis; it is a fact. The individual who lacks the essential skill of using more sophisticated reasoning, perspective-taking, and emotional stabilization to regulate his more primitive fear and aggressive impulses will fall into the pattern of aggressive overreaction again and again, often with escalating levels of violence.

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The allegation that the mental health community should be doing something to curb violent crime is a valid one. We have both not helped people to understand the perpetrators of senseless violence and done little to prevent the recent surge of violent acts. Everyone agrees there must be something wrong with a man who goes on a shooting rampage against strangers. While the field of mental health does not have a term or a diagnosis for people who have an unregulated fight-or-flight system, outside the psychiatric world there is a kind of consensus about them—we call them jerks (or worse). We avoid them, dislike them, feel no empathy for them. They spread their anger and aggression around indiscriminately, and others, their own sense of threat raised by the hostility, respond with avoidance. Or we respond in a way that feels warranted in the moment—by being a jerk back. Within the mental health community, these people are unfortunately treated much in the same way, as if they are not people with problems who need help, they are hostile troublemakers to be avoided.

But it is time that we acknowledge that there is something wrong with someone who cannot regulate his anger. It causes suffering, and it can be dangerous, even lethal. We need to recognize anger dysregulation and start treating people for it.

And we do know how to treat it. In recent years we have learned that the brain has a great deal of plasticity, or potential for growth, throughout our lifetimes. The areas of the brain involved in the excitation and the calming of the fight-or-flight response in particular have been shown to be capable of structural change in a matter of weeks when exercised. As brain science makes what is happening in emotionally unregulated brains more evident, we owe it to society and to unregulated individuals themselves to acknowledge this problem and provide help.

More than 1,000 studies have been published demonstrating the effect of mindfulness practice on mental health, and more recently, research has quantified the structural changes to the brain seen in those practicing mindfulness. The basic study, which has been replicated many times, utilizes an MRI brain scan to look at changes following an eight-week course on mindfulness practice. Subjects attend a weekly class, where they are given a recording and told to listen to it for 40 minutes a day. The findings have been quite impressive. At least eight areas of the brain are significantly affected. The amygdala, the fight-or-flight center of the brain, shrinks. The prefrontal cortex, an area that calms and regulates the amygdala, becomes thicker, and the connection between the two areas becomes stronger. The hippocampus, a region involved in learning, memory, and emotional regulation that is known to become smaller in people who experience chronic stress, increases in size with mindfulness. The anterior cingulate cortex, an area that when damaged causes aggression and impulsivity, shows greater levels of activity. The temporo-parietal junction, associated with perspective-taking, empathy, and compassion, also increases in size. Along with the structural changes to the brain, other changes include stress reduction and a decrease in anxiety, depression, and pain.

Engaging in mindfulness teaches us to observe our feelings without being driven to act on them. It helps us learn to use our angry fight-or-flight response as a signal and engages our higher reasoning brain to decide how to react to that signal.

The process of mindfulness is often described as nonjudgmentally bringing awareness to the present moment. One can be mindful about an infinite number of things, so there are many ways to approach it. Often instruction begins with exercises of breath and/or attention to what is happening in the present moment in the mind and body.

Here is an example:

Draw a deep breath through your nose taking a full 3 seconds to fill your lungs. Exhale very slowly through your mouth until you have completely emptied your lungs.

Repeat, slowly drawing breath in through your nose. Hold 2 seconds and blow the air out your mouth slowly.

One more time. Try closing your eyes this time.

Feel a little clearer? If not, try two more.

This breathing will calm vital functions like respiration and heartbeat. It will also send signals to your amygdala that tell it you are calm and that it can be too.

Short exercises like these three to five calming breaths can be done anywhere, anytime. Mindful meditation, like that done in the research studies, can be done in a class—find tips on instruction here. You can also find audio mindful meditations online, by mindfulness teachers like Ron Siegel, Tara Brach, and Jon Kabat-Zinn. Many mindfulness smartphone apps are also available—some good ones include Sounds True’s Moving With Mindfulness, Mindful Movements, Headspace, Sitting Still (for teens), and the Mindfulness Training App.

Mindfulness has been used with police officers, forensic psychiatric patients, cardiac patients, and preschoolers to name just a few.

Just as we need to name anger as the problem it is, we need to begin to teach mindfulness routinely. A good place to begin is with children in our schools, making it a standard part of our health curriculum. Our prehistoric ancestors living in the wild needed that powerful urge to act without thinking to keep them alive. Today, for the average American living in a highly technological world, to be able to recognize feelings of threat and anger, and to be able to act on them with foresight and planning, is far more advantageous. We must teach these skills to adults who lack them as well. A basic course should be mandatory when physical violence brings people in contact with the law. We should also consider following the NRA’s notion of banning weapons for those who are likely to endanger others with them; the people statistically most likely to use them in violence against others are those with a history of violence.

Anger is not a form of mental illness, and it is not something to be eradicated. In a well-regulated brain, it is very useful. But when poorly regulated, anger is a source of continuous discomfort to the individual and to others, and for certain individuals, it can become deadly.

Unmanaged anger has become a devastating issue in the U.S. Violent crime rates are climbing. Several mass killings occur each year, and the frequency is increasing. We recognize this but fail to see that we have a broader cultural problem of anger management. We continue to look for “others” who are responsible for the anger and suffering, the mentally ill, immigrant groups, religious groups, minority groups.

It is time we accept our anger epidemic as a cultural problem and address it broadly, in schools, in jails, and especially in our homes. We have the tools. We only need to recognize that anger always comes from within.