For Shanghai's expats the pace of life, marital problems and alcohol abuse are the most common causes of anger problems. Photos: CFP

By Thomas McKinley

The irascible foreigner has become a stereotype in Shanghai. We have all seen them - shouting in broken Chinese at the taxi driver or shop owner, gesticulating wildly, walking off in a huff and generally making a scene. Onlookers, whether Chinese or expat, are apt to shrug their shoulders, perhaps chuckle, and dismiss the incident as one of someone simply having a bad day. It is no secret that everyone loses their temper once in a while.

However for some this behavior may not be occasional, but chronic. Their personality may have become defined by their anger; and for some their automatic response to conflict, confusion and disappointment is sheer rage.

Dr Paul Wang, a licensed clinical psychologist at the Shanghai United Family hospital and Chair of the Taiwan Psychology Network, told the Global Times about a patient he once had, whose anger was controlling his life. "The patient had a severe alcohol problem and frequent outbursts of anger, to the extent of demolishing furniture at home, as well as a loss of interest in activities that he formerly viewed as pleasurable," Wang told the Global Times.

The condition of being in a "cycle of anger" has been studied by the psychological community in an effort to deduce where these behavioral patterns change and how to assist patients in extricating themselves. The practice has become known as anger management (which became a household word in the US in the late 90s).

In Shanghai several medical and counseling facilities also offer the service. According to practitioners, Shanghai offers its own unique set of circumstances that can arouse anger in expats regardless of their age or gender.

Unhealthy anger

As for defining what constitutes an anger disorder Dr Wang said, "Anger is a completely normal, usually healthy, human emotion. Anger can be a good thing. It can give you a way to express feelings, for example, or motivate you to find solutions to problems. But when it gets out of control and turns destructive, it can lead to problems - problems at work, in your personal relationships, and in the overall quality of your life. Increased blood pressure and other physical changes associated with anger make it difficult to think straight and can harm your physical and mental health."

Counseling Coordinator at the Community Center Shanghai, Carrie Jones, added, "There is no specific 'diagnosis' for someone with an anger problem, but it really has to do with how much your anger is affecting and interfering with your daily life."

While many individuals may have latent anger issues before they come to Shanghai, doctors believe that Shanghai does have a tendency to exacerbate anger conditions. According to Dr Wang, there is an extensive list of general qualities about Shanghai that seem to intensify one's chance of having an anger issue. These include the obvious problems generally associated with big cities, such as traffic, pollution, and population density, but also several other issues, including weather, the lack of access to nature and language difficulties.

"A lot of cases are related to culture shock," said Jones. Dr Wang identifies four stages of culture shock, beginning with the "Excitement" or "honeymoon" stage when one first arrives in a new locale. This is followed by "Withdrawal," in which one finds the new culture frustrating, and then "Adjustment" and finally "Enthusiasm." "The Withdrawal phase is where people begin to dislike the culture and react negatively, feel anxious, and begin to criticize, mock and show animosity towards other people," he said.

Temper town

However, there are also causes of anger conditions that seem peculiarly indigenous to Shanghai itself: the frenetic pace of life, marital discord, and the abuse of alcohol. Shanghai's rapid development, and the consequent high expectations that global headquarters have of their Shanghai offices, help contribute to the stress felt by foreign executives working here. "Some of the jobs here involve a large number of business trips as well as many late night conference calls," Jones said. This creates more mental and physical fatigue, which can lead to heightened stress levels. Such problems also have an effect on spousal relations. "Expatriate fathers are often very busy and travel a lot and mothers often feel the pressure and stress of being a 'single mom' during the father's absence," said Dr Wang. 

Work also increases stress because of the different style of doing business in China. "For foreigners, working in China can be difficult, because of the guanxi system. It is very confusing and time-consuming, and can make foreigners very angry," said Dr Helena Guo, clinical director at Psychcn, a firm that trains counselors.

This Eastern approach to doing business also often involves an abundance of work-related dinners and drinking sessions which eventually create marital problems, most notably fidelity issues. For foreign workers here, especially males, there are many opportunities to meet young members of the opposite sex. "Extramarital affairs are a huge problem here in Shanghai," Dr Guo said. Dr Wang stated that "marital conflicts between expatriate parents are common here, and some stem from infidelity." A large proportion of anger cases seem to be marriage-related, whereas, according to Dr Wang, single men's anger issues are usually linked to depression. "Most married male anger patients who come in for therapy do so at the behest of their wives," he added.

Another sector of the expatriate population that experiences anger issues is children. In most cases, children who come overseas have had little choice in the relocation decision and find themselves having to recreate the sense of familiarity and belonging that they have striven for in their hometowns. "Anger can be caused by acculturation difficulties. Adolescents and children can have trouble adjusting to Chinese culture and the expatriate culture here, while also fighting to retain their own cultural identity. They may have difficulties learning to interact with people from other cultures. This can lead to a feeling of isolation," said Dr Wang. Jones also has extensive experience in children's cases. "We tend to catch anger cases early here in children, as they are often part of a larger issue, say cultural transition. A lot of it is due to a loss of control," Jones told the Global Times.

Calming clients

In the cases that doctors shared with the Global Times, there are recurring themes of anger resulting from a loss of communication, feelings of abandonment, and work-related stress. Dr Wang related a case in which a 45-year-old executive manager, originally from Sweden, had anger issues and an alcohol problem. The patient was brought in for therapy by his wife, who threatened to divorce him if he did not receive treatment. The main causes of the problem were threefold. First, the patient had difficulty acclimatizing to Chinese culture and found himself bereft of the friendships he had established in Sweden. Second, the patient felt "abandoned" by head office and was receiving little support, while having to reach intense deadlines with a staff he did not know how to manage. Lastly, the patient's family were going through problems individually: the mother felt like a "single mom," and the children were having trouble adjusting to an Americanized education system. 

Jones related another case which also involved marital strife and, interestingly, alcohol abuse. A "trailing spouse" - one who follows their spouse when the latter is transferred to China - was caught in a cycle of anger. Marriage counseling had not been helpful, and her husband had gone back to the US for alcohol treatment, which was taking longer than expected. "Her outbursts were verbal but also repressed, and her health was suffering," Jones said. The patient - or "client," as they are referred to at Community Center Shanghai - was also feeling like a single mother, with two sons in international schools in the city. "There is a lot of 'comparing' within the expat bubble, and this puts further pressure on parents," Dr Wang added.

Another case described by Jones involves a child who was suffering from anger issues. A 10-year-old boy, originally from a small town in the US, began to have verbal outbursts as well as physical altercations in school. On top of his difficulty adjusting to Shanghai, he was also experiencing the typical problems of a boy his age, including sibling rivalry. "He was very bitter," Jones said.

Nearly all anger cases involve a lack of communication, and one of the central aspects of therapy is to help patients verbalize their feelings to someone who is there to listen. In Dr Wang's case, he began by providing "psycho-education on culture shock stages and validating the difficulties of being an expatriate family in Shanghai," and later moved on to helping the patient understand the triggers to his "maladaptive coping" - referring to the patient's alcohol abuse. The coping skills that were prescribed were intended to help the patient manage stress, and included participating in more group activities, whether sports-related or just social. In addition to this, Dr Wang's therapy focused on helping the patient increase communication at home. "My goal was to assist the patient and his wife in developing a stronger relationship by helping them support each other," he said.

Communication played a critical role in both of Jones' cases. The trailing spouse was able to express her feelings to a listener at the counseling center, and then felt enabled to talk to her eldest son about the father's alcoholism. Later, she found support through an online Alcoholics Anonymous type network. At the same time, Jones' treatment helped the client find a physical outlet to help vent some of the pent-up frustration, and simply involved exercise and getting closer to nature.

For the situation involving the 10-year-old boy, the counseling involved playing role-playing games to help him with adapting to the new culture and dealing with the hostility with his siblings. He began to respond well to this, and Jones helped him to learn new vocabulary through which to better verbalize his feelings. "We taught him how to keep things in perspective," Jones said.

Passive anger

While the cases above are less psychological than emotional, and generally employ cognitive-behavioral therapy, there are cases of chronic anger that are more related to one's psychological condition. Dr Guo described a case in which a patient dealt with her anger towards her boss in a passive-aggressive manner - avoiding acrimonious outbursts while taking out her anger in a variety of more subtle ways. In this case, it involved the patient adding urine to her boss's coffee each morning. When the patient finally sought help, Dr Guo was able to diagnose her problem as having taken root in the distant past. "The boss reminded the patient of an uncle in her past, who had sexually abused her. This was a case of trauma, and she needed to release," Dr Guo said. "Most things that annoy us in life remind us of something from our past," she added.

If one wishes to approach a friend, colleague, or family member, doctors recommend that it be done gently. "Avoid direct confrontation, but provide active listening and empathy. Then refer them to a professional," Dr Wang said. Jones added, "Think about your personal safety, but suggest that therapy may be helpful. Don't expect them to take it onboard immediately." Dr Guo suggested that it is best done "by someone close to them, or someone at work with a level of authority."

Most cases end positively, with patients learning how to vent their anger less explosively and more clearly and constructively. "It is important to help them realize the stress they are under and to help them make better decisions on balancing work and life," Wang said. Nevertheless, there are occasional cases where some patients find that their emotions simply are not up to handling life in China, and where the only solution to their anger situation is to leave. "If that is the case, we help them to come to that conclusion on their own," Jones said.