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Anger Management
Can psychotherapy really work?J. Ryan Fuller, Ph.D.
New York Behavioral HealthClinical Director
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© J. Ryan Fuller, 2016
Anger: Definition
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What is Anger?
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Definition of AngerAnger is a negative, phenomenological (internal)
feeling state, which is associated withCognitive and perceptual distortionsSubjective labelingPhysiological changes, andAction tendencies to engage in socially
constructed and reinforced behavioral scripts that often involve approach behaviors and loud verbal behaviors
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Dysfunctional Anger: Diagnosis
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When is anger a problem?
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Anger is commonAnger is a basic emotion (Plutchik, 1980) Anger is frequently experienced even by
normative samples (Tafrate, Kassinove, & Dundin, 2002)
Anger is a clinical problem (Lachmund, DiGiuseppe, & Fuller, 2005)
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Effects of AngerMaladaptiveInterpersonal conflictViolencePoor DrivingInappropriate risk takingPoor decision makingHealth risksSubstance abuse
AdaptiveAlerts goal blockedCommunicates feeling and perception of
injusticeDeters threatPrepares body for physical assault
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Proposed Anger Diagnoses
1. Generalized Anger without Aggression2. Generalized Anger with Aggression3. Situational Anger Disorder without Aggression4. Situational Anger Disorder with Aggression5. Adjustment Disorder with Angry Mood
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Should we change anger?
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Acceptance Based Conceptualization of Dysfunctional Anger
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DSM DiagnosesAntisocial Personality DisorderBorderline Personality DisorderConduct DisorderGeneralized Anxiety Disorder
(GAD) Intermittent Explosive DisorderMajor Depressive DisorderObsessive-Compulsive Disorder
(OCD)
Narcissistic Personality DisorderOppositional Defiant DisorderPanic DisorderParanoid Personality DisorderPassive Aggressive Personality
DisorderPost-traumatic Stress Disorder
(PTSD)
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How do we measure anger?
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Clinical InstrumentsSTAXI-II (Spielberger, 1999)
Experience
StateTrait
Expression
Anger- InAnger- OutAnger- Control
ADS (DiGiuseppe & Tafrate, 2003)
Behavioral DomainArousal DomainMotives DomainProvocationsCognitive
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Anger Component Model
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Componential Model of Anger
TriggerAppraisalExperienceExpressionOutcome
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Triggers
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Appraisals
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Experiences
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Expressions
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Outcomes
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Does anger management work, and
for whom?
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Anger Treatment ResearchCognitive Restructuring, Skills Training, and
Relaxation. Angry Undergraduates (Deffenbacher et.al,
1986). Veterans with PTSD (Novaco et.al., 1997). Outpatients (Fuller, et. al 2010)
Exposure may be a useful treatment (Tafrate & Kassinove, 1998; McVey, 2000).
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What treatments work?Cognitive TherapyRelaxationSkills TrainingCombinedExposure Based
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How well does treatment work?
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Treatment EfficacyGood News
Many treatments influence change in many different types of clients: college students, outpatients, prison inmates, and spouse abusers
Equally effective regardless of age and gender
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Treatment Efficacy (2)Good NewsChange is large (effect sizes for most effective are
around 1.00 for Cohen’s d)Follow-up studies support maintenanceBad News Most studies use volunteersThese effect sizes are smaller than those found for
anxiety and depression treatment- socially sanctioned, adaptive at times, less attention (DiGiuseppe & Tafrate 2003)
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Anger: A Problem for Clinicians
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What are the general challenge and questions to
implementing treatment?
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Questions about Angry Outpatients
How do I establish a therapeutic alliance with an angry client?
How do I establish a therapeutic alliance with violent client?
How do I cultivate, enhance, and maintain motivation for change with angry clients?
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Increase Motivation
• Review negative facts• Values• Consequential thinking: short vs. long term• Catharsis
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Review negative facts
It’s really not that bad- anger is normal and manly.
• Interpersonal conflicts• Medical problems• Negative Evaluations by others• Car accidents• Substance abuse
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Values
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Values
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Consequential Thinking: Short vs. Long Term
How else can I get them to do what I want? It works!
• What are the long-term costs?
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Catharsis“I have to get it out. It is not healthy
to keep it in.”
Venting or “unbottling”• Leads to increases in anger feelings (Ebbesen,
1975)• Leads to increases in aggression (Bushman, Baumeister, and Stack (1999)
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Clinical Focus with Angry Clients
Do you validate anger?
Which part?
Cognitions, feelings, expressions
Important for therapeutic alliance and maybe your safety.
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Clinical Focus with Angry Clients (2)
Keep the Stages of Change Model in mind (Prochaska & DiClemente (1983).
Precontemplative: no intention of change, unaware problem or sees the problem
Contemplative: thinking about the problemPreparation: decision to changeAction: implementing changeMaintenance: already changed, own tx, relapse
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What does typical CBT anger management
look like?
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Combined Treatment Example
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Outcome Research for Combined Anger
Treatment
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Community ModelAnger groups have run for years, but never
systematically studied
Goals of the study Describe population, Clearly define the treatment, Assess viability of fee-for-service
treatment research in anger populationEvaluate efficacy
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GoalsWho are we treating?
What is the treatment?
What are the outcomes of treatment?
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Population
Assessment of research participantsSCID 1 and 2PDSQADSSTAXIBDI
Exclusionary CriteriaActively psychoticGroup Inappropriate
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Treatment MeasuresAnger Disorders ScaleState-Trait Anger Expression InventoryBeck Depression InventoryIdiosyncratic Anger Measures
SituationSymptomBehavior
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Recruitment and FeesRecruitment
Advertised, Professional Referral, Self-ReferralPhone Interview
Fees and Compensation$50 per session$200 reimbursement for perfect attendance$150 reimbursement for missing one session
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ScreeningCriteria for Inclusion
Self-identified as having anger problems and requested treatment.
Significantly disturbed by anger as measured by the STAXI-II, the idiosyncratic anger forms, & the clinical interview.
Criteria for ExclusionActively psychoticGroup Inappropriate
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Demographic Characteristics
Age:45 years (11.95)
Gender Composition: 5 men and 7 women
Education:16 years (2.54)
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Clinical SyndromesAxis 1 Current (Past)
Anxiety Disorder: 4/12 (9)Mood Disorder: 9/12 (8)Substance/Alcohol: 3/12 (7)
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Personality Disorders Axis 2 FrequencyPassive Aggressive 7Depressive 6Obsessive Comp 5Borderline 4Narcissistic 4Avoidant 4Dependent 1Histrionic 1Paranoid 1
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TreatmentManual
Session 1-3 Overview and ModelSession 4-9 Skills AcquisitionSession 10-14 Exposure plus CopingSession 15-16 Relapse
PreventionGeneral
Organized by componentsFlexible, but skill focused
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STAXI-II T-ScoresPre-treatment, Mid-treatment, & Post-
treatment Changes
*Trait Anger Scale
Trait Tem-perament Subscale
Trait Reaction Subscale
010203040506070
Pretreatment
Midtreatment
Posttreatment
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ANGER SITUATIONPre-treatment, Mid-treatment, & Post-
treatment Changes
*Intensity (0-100)
Frequency (per month)
Duration (minutes)
Life Inter-ference (0-
100)
0102030405060708090
Pretreatment
Midtreatment
Posttreatment
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ANGER SYMPTOMPre-treatment, Mid-treatment, & Post-
treatment Changes
*Intensity (0-100)
Frequency (per month)
Duration (minutes)
Life Inter-ference (0-
100)
010203040506070
Pretreatment
Midtreatment
Posttreatment
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Anger Disorder Scale (ADS)Pre-treatment to Post-treatment Changes
Pretreatment * Post-treatment
0
20
40
60
80
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Beck Depression Inventory - II
Total Score Pre-treatment to Post-treatment Changes
Pretreatment * Post-treatment
05
1015202530
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LimitationsSample sizeSelf-referred participant group that were highly
motivatedNo treatment control groupIndependent coding of fidelity would be
preferableSelf-report, rather than objective physiological/
behavioral measuresAdministering treatment by one therapist
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ImplicationsMany suffering from anger problems seek anger
treatment
Slightly different demographic sample also appear to benefit from CBT based treatment
High levels of comorbidities between anger and other disorders in outpatient samples
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Skill Details
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What are the client skills?
Self-monitoringConsequential Thinking & Time ProjectionProblem SolvingAssertiveness TrainingCognitive Rehearsal & DisputationRelaxationResponse Prevention
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Cognitive Rehearsal & Disputation
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CognitionsNegative vs. PositiveExpectanciesAttribution
Specific vs. Global Stable vs. Unstable Internal vs. External
Cognitive Triad Self World Future
Irrational vs. Rational
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Cognitive-Behavioral Therapy (CBT)
What is it?Learning TheoryFunctional AssessmentClinical Model (ABC)Techniques
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Cognitive-Behavioral Therapies (Continued)
Behavioral TherapiesCognitive Therapy (CT)Rational Emotive Behavior Therapy (REBT)Problem Solving Dialectical Behavior Therapy (DBT)Acceptance and Commitment Therapy (ACT)Functional Analytic Psychotherapy (FAP)
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CBT: Behaviorist ModelAntecedentBehaviorConsequence
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CBT – what are the strategies?
CBT attempts to change behaviors by modifying:Antecedents/Cues
Beliefs, Emotions, StressorsProcesses
Acceptance/Willingness/HFT/Distress ToleranceConsequences
Reinforcers / Punishers / Modeling
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ABC Model
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Activating Events
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Beliefs
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Consequences
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Yerkes-Dodson
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Cognitive Behavioral Model
A B Ce Cb
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CBT: CognitiveCognitive Model
A = Activating EventsB = BeliefsC = Consequences
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Emotional EducationAlexithymiaShared vocabulary for communicationUtilization of the ABC Model
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Model of Emotions
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Cognitive Behavioral Therapy (CBT)
General StrategiesRegulate emotionsTolerate frustration (distress)Pursue goals
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Dysfunctional ThoughtsMaladaptive Cognitions
He can’t do that to me I won’t be a doormatThey had it comingF- him!He’s such an $%^&! –hole! It is the only thing he understands!
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Cognitive Therapy (CT)
Automatic ThoughtsAssumptionsCore Beliefs
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Irrational Beliefs (IB)Demandingness Low-frustration Tolearnce (LFT)AwfulizingGlobal Evaluation of Worth
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ABC Cognitive Anger Chain
Let’s imagine a few:A1 = [Fill in the blank]B1 = [Fill in the blank]C1 = [Fill in the blank]
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Cognitive TherapiesIntervening at the Inference or BeliefWhat are common cognitions?• Hostile attribution or intent
• Controllable/Preventable
• Automatic thought with themes of lack of respect, injustice, inequity
• Dichotomous thinking
• Demandingness of others
• Low-frustration tolerance
• Global Evaluation of Others’ Worth
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Primary Cognition• Is the bully suffering from low self-esteem?• Does he/she really think little of himself and his
abilities?• Low self-esteem is associated with depression• High temporally unstable self-esteem results in
anger when threatened (Baumeister, Smart, Boden 1996)
• What personality dimension will you see?
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Cognitive Interventions• Similar to those for depression and
anxiety
• Cognitive restructuring?• Rehearsal • Disputing
• Emphasis• Demands on others• Global evaluation of worth
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Cognitive Emphasis: Demandingness
• Disappointment is infrequent without expectations
• Demands or schemas are cognitive expectations about reality
• Discrepancies between expectation and reality lead to anger
• What is the first response of the high trait anger person?
• Has this person always behaved this way?
• What are the chances tonight?
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Cognitive Emphasis: Global Evaluation
• Behavior vs. Person
• Attributions
• Intent
• Concept of Self: Spiritual
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ABC Cognitive Anger Chain
Let’s imagine a few here for anger- and then do a chain.A1 = [Fill in the blank]B1 = [Fill in the blank]C1 = [Fill in the blank]
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Secondary DisturbanceA1 B1 C1Poor work performance by new younger boss---> I might lose my job
The economy is terrible.
I must be an idiot.
Panic
A2 B2 C2Panic about losing job. It is my new bosses fault.
I can’t tolerate this.If he respected me I wouldn’t have to feel this way. This isn’t fair, I’ve been here 15 years.He is a snot nosed rich who was given this job!
Anger
Sends a hostile threatening email to the boss, and carbon copies coworkers.
A3 B3 C3Inappropriate email.
I shouldn’t have done that.This situation is really awful!I really am a loser and outcast, and now everyone knows it.
Shame
Starts drinking more than usual, and considers quitting.
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Secondary CopingA1 B1 C1Poor work performance by new younger boss---> I might lose my job
The economy is really bad.
I made a really big mistake, and now it is a good idea to follow that misstep, with some good steps.
Concern
A2 B2 C2Concern about job. I can tolerate this even
though it is incredibly uncomfortable. It is really hard being in this spot. I have been in tough spots before, and gotten out. I can go and address the issues in my evaluation, and my new boss.
ConcernFrustration
Drafts a written action plan proposing ways to address negative bullets in his evaluation.
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Problem Solving
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Problem Solving:A Misplaced
Fundamental Definitions Problem: a situation that presents difficultyProblem Solving: a structured strategy that
elicits a multitude of responses that contains steps to maximize the likelihood of implementing a viable one
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Problem Solving Examples
1.Difficult situation at work with client, vendor, employer, employee
2. I am getting into arguments with my spouse3.How to furnish a new room4.My diet plan is not producing the results I want5. I can’t find a job or appropriate romantic partner
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Problem Solving: An Empirical Approach
Goldfried and Davison (1976)1. General Orientation
2. Define problem
3. Generation of Alternatives
4. Decision making
5. Verification
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Problem Solving: Step 1
General Orientation
a. Normalize- assume that situation is a normal part of lifeb. Acknowledgement- that it is possible others have coped with something similarc. Inhibit- halt the tendency to respond with initial impulse
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Problem Solving: Step 2
Define problem
a. Operationalize- define all aspects of the issue in concrete (observable and
measurable) waysb. Dissect- reclassify parts into smaller
more manageable elements
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Problem Solving: Step 3
Generation of Alternativesa. Brainstormingi. Criticism omitted ii. Welcome novelty and divergence iii. Encourage quantity of ideasiv. Improvement and integration of suggested ideas
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Problem Solving: Step 4
Decision makingTemporal Consequential Thinking (TCT)
i. What is the probability it will achieve the desired result?
ii. If it does work what are the likely advantages in the immediate, near, mid, and long-term future?
iii. What are the likely disadvantages in the immediate, near, mid, and long-term future?
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Problem Solving: Step 5
Verification & AssessmentTest-Operate-Test-Exit
(TOTE; Miller, Galanter & Pribram, 1960)
Was the implemented plan effective?1. Yes→ Exit2. No→ Go back to step 4
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Assertiveness
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AssertivenessDefinitionWhat is it not?
AggressivePassive
Definition #1Assertiveness: proper expression of any emotion
other than anxiety toward another person- Joseph Wolpe (1973)
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Assertiveness: GoalsImprove interpersonal environment
Enhance self-efficacy
Emote
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AssertivenessTwo Critical Components in definitionThe communication of feelings, desires, wants,
and preferencesThe acceptance of another person’s right of
refusal and recognition he/she may also agree but not act congruently
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Assertive Communication
Four Communication StatementsWhen. . . . . . . . . . (Specific Behavior and Context)I feel. . . . . . . .(Specific Emotional State, this is
ONE word, not a metaphor or simile)Because. . . . (What I tell myself that causes the
emotion, not about him/her)What I would appreciate/like. . . . . . . .(Specific
request of other person)
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Assertive AcceptanceMy Communication Rights I have a right to tell someone what I am feeling.
I have a right to ask for what I want.
After communicating Assertive Acceptance Statements
Recognition others may not give us what we want I recognize that I may not get what I want even when
someone says I will.Other people have a right to ignore my requests, deny my
requests, promise to grant my request and then not fulfill the commitment And/Or become emotionally upset
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Forgiveness
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Experiential Exercises
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Thought Experiment•Imagine someone who you love and have known for a long time, a parent, mate, a sibling child, friend.•Is there something that they do regularly that really angers you?•Imagine that person engaging in that act.
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Thought Experiment
• Have you ever had these thoughts
while angry with this person?
• I cannot believe that he or she did it
again.
• How could he or she do it again?
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Thought Experiment•These cognitive responses show shock.•Count how frequently the person has done the act.•Multiply by how much time you know them.•They have done the act you are angry at hundreds of times, yet you cannot believe they have done it again!
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Thought Experiment•My spouse leaves the milk out on the counter every morning before work.
•How often? About 5 times per week.
•How long? We have been married for 13 years.
•She has done it 5 x 52 x 13 = 3,380 times.
•So, why are you still surprised.
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Anger Managemen
t