MEDIA APPEARANCE

Interview with Dr. Sepilian - Anger Management
The interview is held at a recording studio, with Dr. Vicken Sepilian wearing black scrubs sitting on the left and Anita Avedian, LMFT, wearing a navy dress and sitting to the right. Both Dr. Sepilian and Ms. Avedian are sitting behind a gold-colored table with the television centered behind them.

00:00:02 Dr. Vicken Sepilian
Good day, ladies and gentlemen, and welcome to Stay Healthy TV. I'm Dr. Vicken Sepilian, your host. Today in the studio, we're going to focus on some mental health issues. We have a very special guest, Ms. Anita Avedian, who is a licensed marriage and family therapist. Anita practices in Southern California. She has multiple locations, including Sherman Oaks, Tarzana, Glendale, and Hollywood, and she's the director of Anger Management 818. Anita, welcome to our program.

00:00:35 Anita Avedian
Thank you so much, Dr. Sepilian.

00:00:37 Dr. Vicken Sepilian
So mental health is a very, very you know, important topic that I think oftentimes gets overlooked in health educational programs. And before we start and we're going to talk about anger management today, I want you to tell us a little bit about your field. I mean, you're a licensed marriage and family therapist. What is a licensed marriage and family therapist? What are some of the common things or common conditions that you work with? And tell us a little bit about your typical day for you.

00:01:15 Anita Avedian
So the licensed marriage and family therapist is a license which allows us to provide psychotherapy services, individually, to couples, to groups, to adults, to children. We can specialize in different areas. So most therapists have certain specialties they like to focus on. Several of my specialties include anger management, social anxiety, and couples therapy; so , relationship issues. With your other question around this was my typical day, what my typical day would look like?

00:01:47 Dr. Vicken Sepilian
I know one of your specialties is actually anger management. So I mean typically, what are the type of conditions or issues that you work with that you specifically specialize?

00:02:00 Anita Avedian
So with anger management, you're asking or just in general? In general. So my personal client load is going to be half my practice; I actually work individually with clients who are struggling with anger, some of those are court ordered, some of them are coming in. They're executives at the workplace, and they want to improve, realizing that they keep experiencing loss of work or setbacks, and they're getting into trouble. And the other half come in voluntarily. So some are ordered by the workplace or court, some are coming in voluntarily. And then in terms of my clinical practice and I say clinical, I try to separate the therapy and the anger management because in the clinical aspect, I'm going to work more providing therapy services to either couples or the individuals who come to me either have social anxiety or some form of anxiety, and I also work a lot with mood disorders such as bipolar.

00:02:56 Dr. Vicken Sepilian
Right. So that's great to know. And today, in this episode at least, we're going to focus on anger management. And this is one of your specialties. As we said, Anita is the director of Anger Management 818 throughout Southern California. So what is anger?

00:03:14 Anita Avedian
Anger is the feeling. It's the emotion that we experience. And I know a lot of people aren't realizing this, but when you experience anger, a lot of times there's another feeling that comes up right before it. So we call anger, we treat anger as a secondary emotion because a lot of times we're going to be hurt and it's difficult to stay in that hurt place. So instead, we quickly get into the anger place to give us some energy and control of doing something about it. And so anger is a secondary emotion according to one school of thought, which is a school of thought I prefer to belong to. And so it's something that it's a protective emotion. So you'll see this especially in parents, their child gets hurt and they go into the school and they start yelling at the school principal. So it's a protective emotion. Don't harm my kids, and of course, of ourselves. But it's a signal to us when we start getting upset. How wonderful is it that there's something that signals to us that, you know what, something's wrong with this situation.. trust my instincts, trust whatever comes up for you. And using that signal, we get to channel through and properly deal with situations that arise one on one or in a group setting at the workplace you get to communicate what's really bothering you.

00:04:35 Dr. Vicken Sepilian
Right. That's an important aspect. Now, what's the difference between anger, aggression and rage?

00:04:44 Anita Avedian
Great Question.

00:04:45 Dr. Vicken Sepilian
You know, like you said, anger is a secondary emotion. What's the difference between aggression and rage?

00:04:52 Anita Avedian
So what's interesting is our program, anger management, should really be called aggression management, because aggression is the actual behavior, it's the act. So if I'm yelling, if I'm hitting, that's the aggression. But if I'm just feeling the anger, I haven't done anything wrong. I have not violated anybody. I haven't broken any rules or laws. So it's okay to be angry, not to be scared of that, but what do I do with my anger? So some people, if they're not channeling it properly, like we just discussed, that signal, we communicate. That's a proper way of dealing with it. But for those people who have trouble with channeling it properly, sometimes can aggressively take it out on people. Either put someone down, the road rage we'll see, office rage we'll see, and so that's the aggression. Now, rage, rage is really this tough concept to really pull together. But the way I look at rage is someone is aggressive, but ten times as much, it's out of control. They cannot control it. I usually like to ask my clients, if the cop was there, if the policeman was there and you knew you were going to get arrested for what you were doing, would you have stopped? Now, the person who has control over that and they knew, they would have stopped. There's aggression, there's an intention. The person who's raging, there's no control. So those are the people who you see, they're fighting back with the police or there's still the physical fighting going on. It's too much has passed. So we're going to see people who rage in the prison system, mostly because they've really gone out of their way, they've violated. Right. And with people who rage, we see more shame associated because it's not what they want to be doing. They get triggered and they act out like really badly. And then there's a lot of regret and shame. Not always.

00:06:47 Dr. Vicken Sepilian
Eventually.

00:06:47 Anita Avedian
Usually, yeah. Versus someone who's aggressive, you're going to see the aggressive person, they have an intention to harm. They have the intention to "I'll show him, I'll show her." And they have a plan on what they're going to do. So it's not an out of control behavior. They know what they're doing. Makes sense. And there is a fine line. Some people say, well, at what point would you call that rage?

00:07:12 Dr. Vicken Sepilian
Right.

00:07:12 Anita Avedian
And there's not enough research on that necessarily, but in all honesty, our program should be called aggression management and then I'd let people know. I ask, do you know why it's called anger management? Because the anger is okay. They say, well, what are people going to Google search, anger management or aggression management? Leave it to anger management.

00:07:32 Dr. Vicken Sepilian
You should start to correct the terminology and eventually have the search engines catch up.

00:07:39 Anita Avedian
That's right.

00:07:40 Dr. Vicken Sepilian
Batter's intervention. How is that different from anger management? Or perhaps I should use the correct lingo and say aggression management.

00:07:49 Anita Avedian
Oh, there we go. So great question, because a lot of people confuse what domestic violence is, which would involve batters intervention versus why people come to anger management. And the best way of knowing this is if there's domestic violence, think of domestic as a home. The violence that occurs within the home, husband to wife, partner to partner, partner to child, that's all considered domestic violence. And there's a different dynamic that occurs there that's not necessarily occurring with someone who has issues around anger. For example, we're going to see people come home and there's like the cycle of violence that reoccurs at the home, but that same person, the perpetrator at the home, is not an angry person at the workplace necessarily. They're holding it together there. They're very charming to society and their surroundings. But at home, you see all the anger come out there. Vice versa, if I have people who are coming to our program for anger management, these are not people who have necessarily ever been aggressive at the home place it's more at road rage or office rage or bar fight or things of that nature and not necessarily what goes on at home. So your biggest difference with domestic violence or batter's intervention (that's the treatment for domestic violence) and the anger management, is that one is at the home, one is outside the home. Some people need both, that does happen, but typically in our anger management program we don't see as many perpetrators or people who need batter's intervention and you also have judges who sometimes will court order someone to take anger management instead of batter's intervention. I don't know if it's because they're not sure of the difference, but if I had to guess if someone's ordered to do batter's intervention, it's an automatic 52-week program. Versus anger management, since there's no legislation, they can have just one session or ten sessions and not the rest. But that's your main difference. There's a whole different thing.

00:09:50 Dr. Vicken Sepilian
So what are some with anger, with chronic anger, what are some potential deleterious health effects?

00:10:00 Anita Avedian
I love that you're asking this question, and especially for men. I think what helps to know is that, and research has reflected this, after two hours of having an explosion, angry/anger episode, let's call it, a person is eight and a half more times likely to have a heart attack and three times more likely to have a stroke. And when people get to hear this, and this is really more you'll see this occurring with chronic anger. What happens is if you think about it, when we're getting angry, yeah, our blood is boiling, we're getting heated, there's chemicals getting released to the body, but how does the body pick up that energy? It takes the energy from the glucose getting released. So it needs the sugar, it needs the fat, and eventually when it keeps using all that sugar and fat, it starts to clog up the arteries and there you have your risk increasing with heart attacks and strokes,

00:10:52 Dr. Vicken Sepilian
Right. Indeed. In fact, spasm vasospasm, where the blood vessels may go into a spasm, could occur as well and these are all things that could ultimately contribute to a heart attack or a stroke, which have a similar mechanism at the end of the day. When a person is angry, what are some things that you would recommend to sort of calm themselves down? What are some tips?

00:11:21 Anita Avedian
Great. I usually love focusing on preventive tips, what they can do. Most of the clients who come through our program, we really focus on prevention such as communicating, which we'll talk about soon. But clients say just tell me what to do Anita, I'm about to blow up just tell me what to do and so here are my go-to suggestions in these situations. First, get out of that situation. If you're in the same room and you can't leave the home, try to leave that room, at the very least to another room because if that person who is upsetting you is still in front of you you're still activated, the chemicals are still being released in your body and you need that break away from that person. My preferred element around this is go outside, take a walk, because not only are you leaving the situation, you're walking and we know with walking you're in nature. You have the right left movement, which relaxes us, you have the breathing, which is relaxing us, you have endorphins being released if you're walking fast enough to relax us. There's a lot more benefit to be able to do something like that, but I get it not everyone's in the type of neighborhood that they were going to want to that's easily accessible to do and so at the very least, to be able to excuse yourself to be in another room. The other suggestion we typically will have is count, I know it's been said so many times, but count one to ten. And the reason for this is, if you think about it, we have our right hemisphere which regulates the emotion so when you're angry you're predominantly in your right hemisphere, and when you're counting you're predominantly in your left hemisphere. So you're almost distracting the left hemisphere to not be as angry. When you stop counting, the anger is going to come back, but temporarily, you're kind of calming yourself down as much as you can. The breathing exercises, I know a lot of people will say, take some deep breaths. I'll caution people around how to do the breathing because we have certain breathing we can do that will activate the sympathetic nervous system. Which is not what we're wanting, because anger is going to be in that in that sympathetic nervous system. What we do want is how do you relax the body with breathing so that you're activating the parasympathetic nervous system? And that is, you count in, if we had to count, count in 4 seconds, hold 4 seconds and then exhale 4 seconds. Or inhale 4 seconds, exhale 8 seconds.

00:13:45 Dr. Vicken Sepilian
(Takes deep breathe)

00:13:46 Anita Avedian
Is it only counting for us? No. (Laughs)

00:13:53 Anita Avedian
This is how easily this works.

00:13:54 Dr. Vicken Sepilian
I wasn't angry to begin with.

00:13:58 Anita Avedian
But yeah, that's an important one to know.

00:14:00 Dr. Vicken Sepilian
We're going to take a short break. We'll be back with Anita Avedian, who's a licensed marriage and family therapist, stay with us. [There is a 30-second advertisement in Armenian for Dr. Vicken Sepilian's fertility practice.]

00:14:46 Dr. Vicken Sepilian
Welcome back ladies and gentlemen to Stay Healthy TV, our guest today is Anita Avedian and we're talking about anger management. Anita, again, welcome to the program.

00:14:50 Anita Avedian
Thank you.

00:14:51 Dr. Vicken Sepilian
And now, understanding and setting boundaries is an important aspect of anger management. What can you say about that?

00:15:01 Anita Avedian
Good. Great. So with boundaries, we have so many different types of boundaries. We have the physical boundaries, emotional boundaries. So if someone is in my physical space, of course I'm going to start getting a little aggravated. And the reason why we want to set boundaries is not only to let people know, here's my comfort level and at this point I'm not that comfortable anymore. So we're trying to communicate to people what's comfortable for me and what's not comfortable for me. What we find in people who typically get angry are they're pretty generous people. They give a lot. People ask them for favors, they'll say, sure, no problem. People ask for money, they'll say, sure, no problem, but what happens is now there's some sort of expectation built where they've been there for this other person. And so that moment where they're asking you for the favor and you say no and they feel taken advantage of at that point or they've been wronged at that point, they may turn and blow up at the person. And so what we try to teach clients is, first of all identify what are your boundaries? Physical, emotional? Meaning if I share something with you and I ask you, please don't share with anybody else, otherwise you're not going to know not to share. Perhaps my financial boundaries. If I lend you money, my expectation is you're going to pay back. Well, not everyone agrees with that. Some people just say if you lend money, that means you've given it. And so we're just trying to communicate on what the understanding is and where my comfort zone is. And so I really try to get my clients to start to see that it's okay to say no. It's okay to not give them, not give others whatever they're asking for, or give, but don't expect anything in return. Just make the assumption that they may not be there for you when you're needing them.

00:16:51 Dr. Vicken Sepilian
Right. And that's important, I guess, to communicate what your boundaries are because it removes any type of a preconceived notion or an expectation that if and when not met, then could be a source of anger.

00:17:06 Anita Avedian
And I think what we start seeing, culturally speaking, is you know in different cultures, boundaries mean different things. If you and I grew up in a culture where it was okay for me to take food off your plate without asking you because that was our closeness growing up as siblings, let's say, then now I'm dating someone who that's a huge no no, but I'm feeling close and I tried to grab it. So now we're going to be in a conflict, so that's where it's important. Culturally, we have very different upbringings and it's important to let people in and let people know, here's my comfort level and here's not and please respect this.

00:17:42 Dr. Vicken Sepilian
Of course. Now, drinking and drugs, of course, oftentimes do play a role. You know. How does that impact anger?

00:17:52 Anita Avedian
When someone first comes to our anger management program, during our intake, we try to rule out if their anger is existing primarily when they're drinking or using. What I notice is if someone is passive and they don't typically express themselves and what's bothering them that same person, when they're drinking, this is when they start either getting into a rage fit almost, or they get aggressive and start yelling and taking everything out on that person. It's because they haven't been able to share much. So under the influence, their inhibitions are lowered and they're more impulsive, so they're more likely to speak up and how they're speaking up isn't in the best way possible. So what we start seeing is, okay, drinking or the drug use has become a problem because they're holding things in and then when they're using, they're letting everything out at that point. If there's a drinking or drug use problem, I tell them, you can learn all the skills here you want, but unless you start treating the alcohol consumption or the drug use, this is not going to be helpful because it's a skill based program. And so we try to rule that out and we try to get them into the right programs necessary. If they're court order, there's not much we can do outside of making recommendations to the courts that this is what we're also recommending.

00:19:12 Dr. Vicken Sepilian
But if you do see that where issues of anger or the emotions of anger begin to manifest themselves, whether if it's expressing, or aggression, or rage, then I suppose in one sense it at least gives you some information that you can work with.

00:19:37 Anita Avedian
Absolutely, and a good point that you're bringing up. So if that same person is able to start asserting themselves during times when they're sober and they're not under the influence, that may actually help them during the times when, let's say now they are drunk because they've kind of let it out in a healthy way, but they're still using. We kind of hope that that helps if a person is deciding to continue to drink and we'll see that sometimes happening. The other relationship I see with this is with marijuana use. I've noticed that the day after, if someone is a chronic marijuana user and the day that they're not using, sometimes they're like the angriest people I've seen when they're not using. And I don't mean social using and the next day, that's not what I'm talking about. And so I realized that sometimes these drugs or alcohol is what they're relying on to calm themselves down. So when you remove that substance and a person doesn't have the skill set to really identify and know what to do differently to calm themselves down, you'll start seeing them get into rage fits or become aggressive.

00:20:41 Dr. Vicken Sepilian
More aggressive, yeah. Now, how are some ways we could improve our communication when we are angry? You touched on they don't have the skill set or whatever, have you, but what are some of these skill sets?

00:20:57 Anita Avedian
One of my favorite worksheets that we talk about is assertive communication skills. For one, there's so many words, trigger words and phrases we have. For example, if I start saying you did this, you did that, I'm attacking you. Of course you're going to attack me back and of course that's going to become a conflict and it's going to escalate. We also ask why questions. Why did you do this? Why did you do that? Well, that's accusatory. Whoever I'm asking is going to attack me back and blame me or the conflict gets worse. And so what we recommend is when you do something specific, when you don't put away the glasses after you're done with them, right. It's very specific. It's not an attack on your character, but it's talking about a specific behavior that you're doing and how that impacts me. So, you know, I can get into that I feel bothered or I feel alone in this in the household chores, right. So I'm expressing how it's affecting me when you don't do a specific piece rather than attack on the character, so it's so important not to get into attacking on the character. You're lazy. No. it's to try and stay away from the judging and such. And we have an entire skill set, I won't go through all the details, but I think it's just as important to be aware of what not to use. Such as words such as "always", "never" those absolute words that we just try to make our statement more powerful when really what it's doing, it's negating what we're trying to say and so just be very specific. I would like for you to do this more, I don't like it when you do this, rather than you always do that or you never do that. So those are the big tips when it comes to certain communication.

00:22:37 Dr. Vicken Sepilian
And that's very very important. Now let me ask you, if somebody, if or when somebody is seeking for an anger management provider, what should they know? What questions should they ask? If you can give us some tips on that.

00:22:51 Anita Avedian
Of course, currently there is no legislation actually in any state in the United States, so my focus is trying to get legislation in California. But right now, anybody can teach anger management. So you don't need to go through any course, you don't need a degree. So it's a little bit scary of what's going on out there. So what I would ask, highly recommend for you to ask, is one, are they a clinician? Even though they don't have to be a clinician to offer the services, but if they are a clinician, it's an added benefit if they're also certified in anger management. So they have the skill set of what they're teaching you to help improve what you're there to work towards. Some people go to a certified anger management counselor and they're not necessarily clinician and they're great. So kind of look for both if you can, but at least go to someone who is at least certified and hopefully has been doing it for some time so they have some experience under their belt.

00:23:47 Dr. Vicken Sepilian
Right, of course, experience is always a plus. Now, when it comes to programs, I mean, we did touch on batter's intervention where it's a 52 week program. What's the typical anger management program and at least what do you recommend?

00:24:07 Anita Avedian
26 weeks, six months is my recommendation, and I'll say why. It takes three months for people to normally have that behavioral change. So all of a sudden they're incorporating all the skills we've been teaching and now it's become more natural, and we say six months because that's the amount of time it takes normally after trying to practice all the skills, that you're actually going to maintain it. Otherwise, if someone comes through a three-month program, there's a great chance a year later they're court ordered again or they're coming back again. And so we see that six month as a magic number, 1 hour once a week not to rush through it, because you need time to practice those skills. Is such a great number in terms of the term to incorporate the skill set and to learn. We also notice in that second or third month, a lot of times, clients will come to us and will say, "you know what, Anita? I was about to do dot dot dot, but I didn't I stopped myself." And really, part of this program is to have that cognitive behavioral approach to get people to have their prefrontal cortex to connect to the amygdala more quickly to stop themselves from otherwise acting out as to why they even got to the program.

00:25:17 Dr. Vicken Sepilian
Right, but that's great tips. Six month program. It takes about three months for us to even begin to change our habits and any other three months to maintain. Unfortunately, we're out of time. We have to close the program. But I also wanted to mention that Anita is a published author, has a book on anger management. If we can just show that, fundamentals.

00:25:45 Anita Avedian
This one's the teens book, I co-authored with Ingrid Caswell. This is the adult version and then we also have it translated in Armenian and it's called Anger Management Essentials. It's also been translated and published in Spanish, and the Hebrew version will be out in a few weeks from now.

00:26:03 Dr. Vicken Sepilian
Great. Thank you very much, Anita, and we'll have you back on our program very soon.

00:26:07 Anita Avedian
Thank you.

00:26:08 Dr. Vicken Sepilian
Thank you very much, ladies and gentlemen. We'll see you on the next episode. Until then, stay healthy.