Transcript Anger As A Disorder: Moving Beyond DSM-IV-TR

A Comprehensive
Treatment Program for
Anger Disorders
Raymond DiGiuseppe, Ph.D., D.Sc., ABPP
St. John's University
and
The Albert Ellis Institute
March, 2012
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Seneca On Anger
We are here to encounter the most
outrageous, brutal, dangerous, and
intractable of all passions; the most loathsome
and unmannerly; nay, the most ridiculous
too; and the subduing of this monster will do
a great deal toward the establishment of
human peace (Seneca, On Anger, 40-50 AD)
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Seneca On Anger
“My purpose is to picture the cruelty of anger which
not only vents its fury on a man here and there but
renders in pieces whole nations.”
(Seneca, On Anger 40-50 AD)
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LOS ANGELES (October 26, 2010) — According to a
new study by the Josephson Institute of Ethics on
High School Students
I hit a person because I was angry at least once within the past 12
months.
Type of School
Boys Girls Overall
Public Schools
57% 48%
53%
Religious Private schools
57% 38%
47%
Non religious private schools
44% 35%
40%
All Schools combined
56% 47%
52%
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Anger on the Web March 16, 2013
An online Google™ search at the time this
manual goes to print for the terms “anger
management” produced more than 80
Million hits
“anger management treatment” produced more
than 28,100,000 hits
and “children” produced links to more than
28,100,000 pages devoted to this topic.
A search for the terms “anger” and
“adolescents” in Google™ resulted in more
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than 1,720,000 pages.
Anger and “children” produced links to more
than 28,100,000 pages devoted to this topic.
A search for the terms “anger” and
“adolescents” in Google™ resulted in more
than 1,720,000 pages.
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Problems Studying Clinical Anger

1.
2.
3.
4.
We know much less about anger as a clinical problem
than we know about other emotional disorders:
We have less literature to inform us.
People question anger’s status as a basic human
emotion. Clinicians often see it as secondary to
depression and anxiety.
Definitional confusion exists among anger and related
terms.
We have questions about how is anger learned.
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5.
6.
7.
8.
9.
Can anger be dysfunctional?
No diagnostic categories exist for anger
problems in DSM IV, 5.
We have little treatment outcome
research to guide practice.
Confusion exists about the elements of
the anger experience. What elements
make up anger?
How should treatment proceed?
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Less Literature to Inform Us
A much larger literature exits about
depression and anxiety compared
with anger for:
1. Diagnosis
2. Assessment
3. Treatment
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Figure 1.1: Psyc Info References for Diagnosis
350
300
# of References
250
200
150
100
50
0
1971-75
1976-80
1981-85
1986-90
1991-95
1996-00
2001-04
Years
Depression
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Anxiety
Anger
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PsycInfo References for Assessm ent
300
250
# of References
200
150
100
50
0
1971-75
1976-80
1981-85
1986-90
1991-95
1996-00
2001-04
Years
Depression
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Anxiety
Anger
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G. Stanley Hall, 1899
“The psychological literature contains no comprehensive
memoir on this very important and interesting subject.
Most textbooks treat it either very briefly or not at all, or
enumerate it with fear, love, etc., as one of the feelings,
sentiments or emotions which are discussed collectively.
Where it is especially studied, it is either in an abstract,
speculative way, as in ethical works, or descriptively as in
books on expression or anthropology or with reference to
its place in some scheme or tabulation of the feelings, …or
its expressions are treated in the way of literary
characterizations as in novels, poetry, epics, etc., or finally
its morbid and perhaps hospital forms are described in
treatises on insanity.”
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This state of affairs is true for other
emotions also.
1. Disgust
2. Envy
3. Jealousy
Since Freud we have limited the study of
dysfunctional emotions to depression &
Anxiety
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Is Anger a
Secondary
Emotion
or a Basic
Emotion?
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
The majority of theorists and researchers in the
Psychology of emotions consider anger one of
the basic emotions.
 These include: Arnold, Darwin, Ekman, Friesen
and Ellsworth, Gray, Izard, James, McDougall,
Oatley and Johnson Laird, Panksepp, Plutchik,
Tomkins. Watson.
 Frijda, Mowrer, and Weiner and Graham do not.
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Thus, most scientists studying emotions
disagree with commonly held position of
clinicians that anger is a secondary
emotion.
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Anger is Not Well Defined
Rothenberg (1971) noted more than 38 years ago said
that,
“...almost invariably, anger has not been considered
an independent topic worthy of investigation ...
[which] has not only deprived anger of its rightful
importance in the understanding of human behavior,
but has also led to a morass of confused definitions,
misconceptions, and simplistic theories.” (p. 86)
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Definitions
Anger: an internal, mental, subjective feeling state
with associated cognitions and physiological arousal
patterns.
2. Aggression: overt behavior enacted with the intent to
do harm or injury to a person or object.
3. Hostility:
A personality trait evidenced by cross-situational
patterns of anger with verbal or behavioral
aggression.
An attitude of resentment, suspiciousness, and
bitterness (Buss & Perry, 1992), and the desire to get
revenge (Mikulincer, 1998).
1.
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Irritability: increased sensitivity to environmental
stimulation that causes physiological arousal and
tension without cognitive mediation, that results
in a lowered threshold to anger.
AFFECTIVE AROUSAL without COGNITION
There is a lack of agreement on irritability items.
5. Hate: long-lasting predisposition to dwell on the
transgressions committed by a person held in
general disdain and condemned for their
transgressions or traits.
COGNITION without AFFECTIVE AROUSAL
4.
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 Most
tests of anger do not agree on
what constructs or components of
anger and aggression to measures.
 How WORD files of tests
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How is Anger Learned?




Theorists frequently comment that animals &
people learn anger through classical and operant
conditioning.
Pavlov listed anger as one of the responses that
could be learned by classical conditioning.
Literature searches of classical conditioning terms
uncovered only three references about anger.
Two were with fish. One acknowledged extensive
research leading to the null hypothesis.
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How is Anger Learned?

People easily learn to fear an angry face or voice.

No evidence has emerged that people learn to feel
angry through classical conditioning.

Anger seems to be an approach, not an escape
emotion.

Experiential avoidance does not seem to be a
mechanism of disturbance or treatment.
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How is Anger Learned?

Anger produces neural activity in the
left frontal lobe with approach emotions, such
as joy.
 It does not activate activity in the right frontal
lobe as do other negative emotions which
produce an escape gradient.
 Treatment should be based on reinforcement
models of anger and aggression
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Is Anger A Clinical Problem?

As many clients seek mental health services for anger
as do for depression and anxiety (Posternak & Zimmerman, 2002).
 Clinicians claim they see as many angry clients as
anxious clients (Lochman, DiGiuseppe, & Fuller, 2005).
 Anger can be as dysfunctional as any emotional excess.
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Can Anger Be Dysfunctional?
“Certain wise men have claimed that anger is temporary
madness. For it is equally devoid of self-control,
forgetful of decency, unmindful of ties, persistent and
diligent in whatever it begins, closed to reason and
counsel, excited by trifle causes, unfit to discern the
right and true -the very counterpart of a ruin that is
shattered in pieces where it overwhelms. But you have
only to behold the aspect of those possessed by anger to
know that they are insane. Seneca On Anger - 50 AD
(Basore, 1958, p. 107).”
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Dysfunctional Anger - Brevis Furor
“Whereof it is that anger is called Brevis Furor, a short
madness, because it differs not from madness but in time.
Saving that herein it is far worse, in that he who is possessed
with madness is necessarily, willy, nilly, subject to that fury:
but this passion is entered into wittingly and willingly.
Madness is the evil of punishment, but anger is the evil of sin
also; madness as it were thrusts reason from its imperial
throne, but anger abuseth reason by forcing it with all violence
to be a slave to passion. For Anger is a disease of the mind.
From “A Treatise of Anger” by John Downame, 1608, cited in
Hunter and Macalpine, 1963, p. 55).”
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Anger In Classical Philosophy
• Anger was always considered a major part of
human suffering since the classic Greek &
Roman philosophers.
• Anger ceased to be considered a clinical
problem at the beginning of the 20th Century.
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•
Rabbi Moshe Chaim Luzzatto
Mesilas Yesharim (The Path of
the Just)
Rabbi Moshe Chaim Luzzatto
(1707 - 1746, 26 Iyar 5506),
also known by the Hebrew
acronym RaMHaL, was a
prominent Italian Jewish rabbi,
kabbalist, and philosopher.
Born in Padua, he received
classical Jewish and Italian
educations, showing a
predilection for literature at a
very early age. He attended the
University of Padua and with
his vast knowledge in religious
lore, the arts, and science, he
quickly became the dominant
figure in that group.
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"V'hasair Kaas Meeleebecha" ("And you shall
remove anger from your heart" from the verse
in Ecclesiastes Chapter 11)
•
Whoever has a brain in his head needs to run from
this evil attribute [of anger] as he [would] run from
a fire. For [the person] is clearly aware that due to
this evil attribute [of anger], in the future, on The
Day of Judgment, he will definitely emerge [with a
verdict of] guilty. [The person should be aware that
he would emerge guilty on The Day of Judgment
due to his attribute of anger, for it] is known that
one who has a majority of demerits, falls in the
category of [those who are] evil.
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Early 20th Century

Kraeplin, and then Freud, made anger part of
depression.
 They were referring to bipolar disorder and mania
does have a strong anger component.
 Since Kraeplin & Freud, clinicians have seen
anger as part of depression.
 Is this what they intended? Freud recognized the
thought patterns of narcissistic entitlement which
arose anger.
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Anger and Depression
•
Anger and depression are part of the social
dominance system (Stevens & Price, 1996 Evolutionary Psychiatry).
•
Anger is the expression of dominance.
•
Depression is the expression of submission.
•
Thus, they are opposite ends of the
dominance/submission social display system.
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Anger and Depression
• For people who experience both anger and
depression, we suspect a sequential
relationship.
• They get depressed about their anger
episodes, or when they realize they cannot
intimidate others into compliance.
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Anger in the DSM-IV-TR
• No anger disorders exist in the DSM-IV.
• ICD-10 has an Explosive Personality Disorder.
• Many depressive (mood) disorders and anxiety
disorders exist.
• Intermittent Explosive Disorder is the most used
diagnosis for anger problems. It does not define
angry clients.
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Should we have an anger
disorder diagnosis?
Or at least a taxonomy of angry
and aggressive clients?
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How Clinicians Diagnosis Anger Clients
• We asked clinicians to diagnosis case studies of angry and
anxious clients (Lochman, DiGiuseppe, & Fuller, 2006).
• For the anger cases, the most common Axis I diagnosis
was Intermittent Explosive Disorder.
• Next most common is Organic Brain Syndrome.
• Clinicians had low agreement for diagnosis of the anger
cases.
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Diagnosing Anger
•
80% used an Axis II diagnosis when
allowed 2 diagnoses.
• Clinicians over-pathologized anger
clients.
• Clinicians saw the diagnosis of an anger
disorder as unrelated to the development of
a treatment plan.
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 Wakefield's
& DSM’s Definition of
a Disorder is that it involves a
response both harmful and
dysfunctional.
 Can
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anger be a harmful dysfunction?
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Anger has been dysfunctional in:
•
•
•
•
•
•
•
War - aggressors more frequently lose.
Terrorism – most often fails to reach political goals.
Torture – most often fails to get information.
Rape – often fails to gain satisfaction.
Murder – almost always regretted by offender.
Road Rage – causes unsafe and dangerous behaviors.
Illness – associated with many forms of illness.
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Anger is harmful in that:






Anger harms interpersonal relationships.
Anger impedes sexual functioning.
Effects on marital relations.
Negatively effects goal attainment.
Anger leads to medication noncompliance.
Anger is the component of Expressed Emotion that
leads to relapse of serious mental illness.
 Anger increases involvement in the Criminal Justice
System.
 Anger interferes with judgment.
 Anger slow the healing of wounds.
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Opposition to an Anger Disorder
1. An anger disorder will hold people less culpable for
antisocial/aggressive behavior.
2. DSM has too many disorders already. What if other
fields of medicine adopted this.
3. Anger is covered by other diagnoses.
Is this true?
4. Anger can be functional. – So, are all emotions.
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Anger In Psychiatric Outpatients
(McDermut, Fuller, DiGiuseppe, Zimmerman, & Chelminski, 2009)

Complete Structured Interviews to all outpatients
o Axis I – SCID; Axis II – SIDP-IV; N = 1774
o Best anger item is Borderline Symptom 8. This has ten
questions that ask:
o Anger intensity, frequency, duration, Anger expression, type
of triggers, Rated on scale of 0 to 3, Score of 2 or 3 indicated
one has the symptom.
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Do most anger patients meet
criteria for In Borderline PD
 Since
this symptom is part of the BPD
module, does BPD account for anger in
psychiatric outpatients?
 NO.
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If the comorbidity of anger
symptoms with any others disorder
is very high, we do not need a new
anger disorder to explain anger
problems.
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Overlap of Anger and PD Diagnoses

Highest Kappa is anger symptoms and BPD =
.33
 Kappa between anger symptoms and other PDs
ranged from .01 to .13.
 These are low and suggest that anger
symptoms do not overlap much with
Personality Disorders other than BPD.
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Mean Personality Disorder Traits By
Level of Anger
3.00
Borderline
Depressive
Mean No. of Traits
2.50
2.00
Obsessive
Avoidant
Self-Defeat
Antisocial
1. 5 0
1. 0 0
Negativistic
Narcissistic
Paranoid
Dependent
Schizotypal
Histrionic
Schizoid
0.50
0.00
Low
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Medium
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Level of Anger
High
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
Anger is often considered to be an impulse
disorder, like IED, or part of mania.
 Do these disorders account for those with anger
symptoms?
 No. The Kappa coefficients of these Dx and
anger is les than .1
 Do anxiety and mood or depressive disorders
account for anger symptoms?
 NO – These relationship are small about .2.
 Anger is more comorbid with anxiety than
depression.
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Anger and Emotional Disorders
• The most common comorbid Anxiety
Disorders are those with possible anger
symptoms such as GAD or PTSD.
• It is Social Phobia.
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Diagnostic Criteria for Anger-Aggression/
Expression Disorder
Either (1) or (2)
1. Significant angry affect as indicated by frequent, intense, or enduring anger episodes
that have persisted for at least six-months. Two more of the following characteristics
are present during or immediately following anger experiences:
a) Physical activation (e.g., increased heart rate, rapid breathing, muscle tension, stomach
related symptoms, headaches)
b) Rumination that interferes with concentration, task performance, problem-solving, or
decision-making.
c) Cognitive distortions (e.g., biased attributions regarding the intentions of others;
inflexible demanding view of others unwanted behaviors, code of conduct, or typical
inconveniences; low tolerance for discordant events; condemnation or global rating of
others who engage in perceived transgressions).
d) Ineffective communication .
e) Brooding or withdrawal.
f) Subjective distress (e.g., awareness of negative consequences associated with anger
episodes, anger experiences perceived as negative, additional negative feelings such
as guilt, shame, or regret follow anger episodes)
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Diagnostic Criteria for Anger-Aggression/
Expression Disorder
2. A marked pattern of aggressive/expressive behaviors associated with anger episodes.
Expressive patterns are out of proportion to the triggering event. However, anger
experiences need not be frequent, of high intensity, or of long duration. At least one of
the following expressive patterns is consistently related to anger experiences:
a) Direct Aggression/Expression
 Aversive verbalizations (e.g., yelling, screaming, arguing nosily, criticizing,
using sarcasm, insulting)
 Physical aggression toward people (e.g., pushing, shoving, hitting, kicking,
throwing objects)
 Destruction of property
 Provocative bodily expression (negative gesticulation, menacing or
threatening movements, physical obstruction of others)
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Diagnostic Criteria for Anger-Aggression/
Expression Disorder
b) Indirect Aggression/Expression
 Intentionally failing to meet obligations or live up to others’
expectations
 Covertly sabotaging (e.g., secretly destroying property, interfering
with task completion, creating problems for others)
 Disrupting or negatively influencing others’ social network (e.g.,
spreading rumors, gossiping; defamation, excluding others from
important activities).
B. There is evidence of regular damage to social or vocational relationships due to
the anger episodes or expressive patterns.
C. The angry or expressive symptoms are not better accounted for by another
mental disorder (e.g., Substance Use disorder, Bipolar Disorder, Schizophrenia, or
a personality disorder) or medical condition.
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Diagnostic Criteria for Anger-Aggression/
Expression Disorder
Sub - types:
 Anger Disorder, Predominately Subjective
Type
 Anger Disorder, Predominately Expressive
Type
 Anger Disorder, Combined Type
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Research on Anger Treatments

We completed a meta-analytic review of anger
treatments
 DiGiuseppe, R., & Tafrate, R. (2003). Anger
treatments for adults: A meta- analytic review.
Clinical Psychology: Science and Practice, 10 (1)
70-84.
 Several conclusions emerge from these reviews
that direct successful treatment of anger
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Research on Anger Treatments

First, optimism is justified.
 Successful treatments for anger exist with adults,
adolescents, and children.
 Anger treatments appear to work Researchers
have applied treatments to college students
selected for high anger, volunteered angry men,
outpatients, spouse abusers, prison inmates,
special education populations, and people with
medical problems, such as hypertension or
medical risk factors like type A behavior.
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Research on Anger Treatments

Treatments are equally successful for all
age groups and all populations.
 Anger treatments are equally effective for
men and women.
 However, this enthusiasm is tempered by
one limitation of the anger outcome
research.
 Most studies used volunteers.
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Research on Anger Treatments

Many practitioners treat angry clients whom
courts, employers or spouses have coerced into
treatment (“You should get help or I am leveling
you”).
 The research participants used to date may not
represent the clients who actually present for
treatment. This may mean that actual clients have
less of a desire for change than the volunteers.
We will return to this point later.
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Research on Anger Treatments


Second, the change is of a large magnitude.
The upward range of effect sizes is less than the
upward range of effect sizes reported in metaanalytic reviews of treatments for anxiety and
depression.
 The upward range of effect sizes for Cohen's d
statistic in anger treatments is 1.00.
 The upward range of the effect sizes in treatment
studies of depression > than 3.00 and for anxiety,
more than 2.00.
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Research on Anger Treatments

As Norcross & Kobayashi (1999) lamented,
we cannot treat anger as successfully as we
do other emotional problems. We still need
new creative interventions.
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Research on Anger Treatments

Third, treatment effects appear to last.
 We analyzed the effect sizes of all the
anger outcome studies that included follow
up measurements (DiGiuseppe, & Tafrate,
2003).
 Most studies held the gains accomplished
at post tests or and some even improved
more at follow up.
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Research on Anger Treatments

Studies that maintained their effectiveness
at follow up used interventions that
incorporated multiple interventions. Arnold
Lazarus' (1988) notion that multi-modal
treatment produces the most long lasting
change appears to apply to anger.
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Research on Anger Treatments

Fourth, anger outcome studies reveal change on
different types of dependent measures, not only
self reports of anger.
 Researchers have reported large magnitudes of
change on physiological measures, self and other
reports of positive and assertive behaviors, and
with self and significant others' ratings of
aggressive behavior.
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Research on Anger Treatments

This last finding may be the most important.
Spouses and other family members see
changes from our interventions.
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Research on Anger Treatments

Sukholdolsky & Kassinove's (1998)
reported little change on measures
completed by peers of children and
adolescents.
 Two interpretations of these results are
possible.
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Research on Anger Treatments

Perhaps peers represent the most valid measure of
behavior, and people really do not change. This
seems unlikely since parents, teachers, and
unbiased observers all large report large changes
in these studies.
 Perhaps peers stigmatize angry people, and peers
retain their stereotype of angry people, despite
changes made in therapy.
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Research on Anger Treatments

Fifth, symptom and treatment-modality
matching has not been supported.
 Clinicians often try to match an
intervention to the client's primary
symptoms. This comes from the generally
accepted notion that the treatment
modalities will effect their corresponding
outcome measures.
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Research on Anger Treatments

Sixth, 80% of all published and non
published research studies employed group
therapy.
 We would speculate that the majority of
practitioners treating anger problems work
in correctional facilities, substance
programs, hospitals, residential centers and
schools and regularly employ a group
format.
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Research on Anger Treatments

Our meta analytic review indicated that the
group therapy format had significantly
lower effect sizes than individual therapy
intervention on measures of aggression.
 Group and individual anger interventions
are equally effective on measures of anger,
assertion and physiology.
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Group Therapy?

Do not allow reinforcement of antisocial
attitudes and behaviors.
 Be careful of personal feedback among
members. It could lead to personal attacks.
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Research on Anger Treatments

Seventh, studies that use of treatment manuals and
integrity checks to ensure that therapists follow
the manual both produced higher effect sizes than
ones who did not use manuals or integrity checks.
 This finding, again, occurred only for measures of
aggression. If one want to reduce aggressive
behavior use treatment manuals and monitoring of
the therapists.
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Research on Anger Treatments

Finally, most of the empirical literature (forty-five
for adults and forty for children and adolescents),
tested either behavioral, cognitive, or cognitive
behavioral therapies.
 Two studies evaluated mindful meditation, which
could be considered a Buddhist intervention.
 One study included Yalom's process oriented or
experiential group therapy.
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Research on Anger Treatments





The most widely supported anger treatments
included :
a) relaxation training.
b) cognitive restructuring as proposed by Beck,
Ellis, Nezu, and Seligman.
c) exposure -learning new response to anger
triggers.
d) rehearsal of new positive behaviors to resolve
conflict.
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Research on Anger Treatments

Adherents of other theoretical orientations have
abstained from empirical corroboration of their
effectiveness with anger.
 We found no psychodynamic, family systems,
gestalt, or client-centered research studies upon
which to draw.
 The absence of so many theoretical orientations
from the outcome research literature has resulted
in a limited view of anger.
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Managing Physiological Arousal
Anger causes immediate and high
physiological arousal.
Lowering the bodily tension before focusing
on other aspects of the treatment will help the
client to attend to the interventions, and is
likely to reduce the potential for aggression.
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An Iatrogenic Treatment?

Since Freud people have believed that the
symbolic expression of will reduce the
anger and aggression based on the hydraulic
drive theory.
 Every ten years or so an experimental
psychologists tests this theory because of
the wide spread use by practitioners
New York Association of School
Psychologists
Some of them are.
Leonard
Berkowitz, Ph.D. in
the 1950s
Alan Bandura, Ph.D.
In the 1960s & 70s
New York Association of School
Psychologists
Brad Bushman,
Ph.D. Presently
WHAT IS MISSING IN
OUR UNDERSTANDING
OF ANGER?
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Good Assessment
Instruments that include a
Comprehensive List of
Characteristics of Anger and
Aggression
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Clinically Relevant Domains of
any Emotion
 Powers
and Dalglish (2008) identified five
domains of all emotions that are relevant for
clinical assessment and intervention. These
included:
1. Triggers / Eliciting Stimuli
2. Thoughts / Cognitions
3. Emotional Experience
4. Motives
5. Behaviors
New York Association of School
Psychologists
Characteristics of Anger

Because anger has received so little attention in
the scientific literature, reviewing some aspects of
anger that differentiate it from other emotions
may be helpful.
 This may provide some insights into aspect of
anger that therapists could target in interventions
that have not already been included in the existing
anger outcome literature.
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Anger Assessment

Since people think anger is not a problem, they
may not store all of the information together.
Open-ended questions may not be as helpful as is
usually the case as in other disorders.

If you use a psychometric instrument, total scale
scores may be in the normal range yet the person
may experience a clinical problem with some
aspects of anger. Total anger scores may not be as
informative.
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Assess Anger as a Normal Trait
or Psychopathology

Most other tests do not agree or say whether
they are measuring anger as a NORMALLY
distributed personality trait
Or
As a form of Psychopathology or Clinical
Problem.
• This decision influences the types of
subscales, the items and the distribution of
the scales.
New York Association of School
Psychologists
Our Anger measures are based on a
theoretical model of ARED that identifies
the ways anger can be a disturbance. This
model was based on 15 years of
experience by the authors researching
disturbed anger and clinical experiences
treating angry clients.
New York Association of School
Psychologists
Anger Disorder Scale &
Anger Regulation and Expression Scale
Structured Interview for Anger Disorders
 Multi-dimensional nature: 5 Domains and 15-18
Subscales.
 Each factor or sub-scale has implications for treatment
and represents an aspect of anger observed in clients.
 The number of sub-scales reflects our beliefs
concerning what a clinician should know to plan
effective treatment.
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Behavior Domain






Anger elicits more behavioral reaction than any other
emotions (Deffenbacher (1997; Deffenbacher et al., 1996).
Most anger scales have Anger-out and Anger-in.
Some split anger-out in to Verbal and physical aggression.
Deffenbacher developed an anger expression inventory a
combination of cluster and exploratory factor analyses of the
items revealed 14 separate anger expression modes.
Tangney, Wagner et al (1996) identified four additional
means of anger expression.
So which should we include and which to leave out?
New York Association of School
Psychologists
Factor Name
Description
In the ADS
&ARES
Anger control
All responses that attempt to control one’s
behavior.
Not present
Direct expression of anger
Clear, direct, and assertive expression of how
one feels.
Not present - Low base rate in
disturbed groups
Reciprocal communication
Problem solving with the target to resolve the
conflict.
Not present - Low base rate in
disturbed groups
Thinking before responding
Cognitively reflecting on the consequences of
anger expression before engaging in any
activity.
Not Present - Low base rate in
disturbed groups
Time-out
Removing oneself from the conflict until he or
she calms down.
Not Present - Low base rate in
disturbed groups
Physical assaults on people
Striking out at the target of one’s anger by
hitting, slapping, pushing, or punching people.
Overt Aggression/ Expression:
Physical aggression subscale
Physical assault on objects or
Symbolic Anger
Throws, slams, hits, or bangs things.
Overt Aggression/ Expression:
Physical aggression subscale
New York Association of School
Psychologists
Factor Name
Negative Verbal Anger
Expression
Dirty Looks
Body Language
Anger In/ Suppression
Anger In/ Critical
Description
In the ADS
&ARES
This factor represents one or
three separate factors.
a) Noisy arguing.
b) Verbal assault.
c) Verbal Put Downs.
Making facial expressions that
communicate anger or
contempt.
Making bodily gestures that
communicate anger or
contempt.
Experiences anger, but keeps it
in or avoids expressing anger,
or avoids people.
Overt Aggression/ Expression:
Verbal Expression subscale
Experiences critical thoughts
of others or negative opinions
of others without expressing
them.
Not Present All attempts to get
items just loaded with Angerin Suppression
New York Association of School
Psychologists
Not Present – Cannot be
assessed with self report .
Not Present - Cannot be
assessed with self report .
Anger-In
Factor Name
Diffusion/ distraction
Passive aggression
Relational victimization or
Socially isolate the target
Covert Aggression
Description
In the ADS &
ARES
Releasing the anger tension
through an avoidance activity
that distracts one from the
anger without facing the
problem e.g. dinking,
driving fast
Behavior that either fails to
help, or fails to complete
assigned or agreed upon
tasks that blocks the goals of
the target of one’s anger.
Encourage, cajole, or bully
other persons to socially
isolate the target of one’s
anger.
The secretive destruction of
another persons’ property
Not Present – Low base rate
on self report for clinical
groups of youth.
New York Association of School
Psychologists
Subversion: Passive
Aggression subscale
Subversion: Relational
Aggression Subscale
Covert Aggression
Anger Disorder Scale
Arousal Domain
1. Duration of Axis I Problem
2. Episode Length
3. Physiological reactivity
Cognitive Domain
1. Rumination
2. Impulsivity
3. Suspiciousness (attributions for hostile intention)
4. Resentment
Provocations
1. Hurt / Social Rejection – other specific provocations do
not distinguish normal and clinical samples
2. Scope of anger provocations
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Anger Disorder Scale
Motives Domain
1. Coercion
2. Revenge
3. Tension Reduction (Experiential Avoidance).
This did not make it into out Youth scale. It
weakened CFA and failed to discriminate normal
and clinical samples.
Constructive resolution was mentioned by Averill
and did not make it into the scale.
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Missing Components of Anger
Treatments
Addressing the Low
Desire for Change
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 People
feel little desire to change or control
their experience of anger. The only emotion
that people wish to change less is joy (Scherer
& Wallbott, 1994).
 Angry clients do not come for treatment, they
come for supervision. They want consult with
us to change the people who anger them.
 Angry clients often have difficulty forming an
alliance with therapists because therapist and
client fail to agree on the goals of therapy.
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Motivational Enhancement
Interventions

External attributions for blame and justification because
one has been hurt are two of the cognitive hallmarks of
anger.
 When you ask someone to change they often take it as
an indication that you are siding with the enemy.
 Clients arrive for treatment in a pre-contemplative stage
of change and the agreement on the goals of treatment
(part 0 of the therapeutic alliance) is often fragile.
 Starting at the Action level of Change may disrupt the
therapeutic alliance.
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“the causes and motives of anger,
are chiefly three. First, to be too
sensible of hurt; for no man is
angry, that feels not himself hurt;
and therefore tender and delicate
persons must needs be of angry;
they have so many things to
trouble them, which more robust
natures have little sense of. The
next is, the apprehension and
construction of the injury offered,
to be, in the circumstances
thereof, full of contempt: for
contempt is that, which putteth an
edge upon anger, as much or
more than the hurt itself”.
Francis Bacon (1561-1626)
(Francis Bacon The Essays Of Anger, 1601)
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Aspects of Anger That Block the
Therapeutic Alliance

Emotional responsibility and other blame.

Cathartic expression

Short term reinforcement

Self- righteousness leads one to believe that
justice and God are on his or her side.

Other condemnation
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Motivation for Change

The most frequently used and researched
interventions are designed to target those in the
action stage of change.
 Perhaps this explains why anger treatments fail to
attain the large effect sizes as treatments for anxiety
and depression.
 Anger treatment can learn much from studies of
addictions treatment - Stages of change in the
Trans - theoretical Model of Procaska & DeClemente
(1983).
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Empathy

No one likes to hug a porcupine. People
usually fail to elicit empathy form others
when they experience anger (Palfai & Hart,
1997).

Because psychotherapists are people, we
can fail to experience empathy for angry
clients.
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Transgression to Retaliation
Ratio Process

The client reveals anger and a hostile
response toward the instigator.
 The client’s retaliation is more offensive
than the initiator's original transgression.
 Clients usually fail to perceive their
retaliation as excessive and usually perceive
themselves as justified.
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Transgression to Retaliation
Ratio Process

The client perceives retaliation as justified and the
client demonstrates no desire to change his or her anger
and feels no remorse for the vengeful act.

This upsets the therapist, who perceives the lack of
motivation and remorse.

The therapist tries to give the client insight into the
desirability of change based on the fact that the client’s
revenge was out of proportion to the initiator's act.
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Motivation for Change
People will rate their anger as positive if they
accomplish their angry motives, even if the motives
are destructive or selfish (Luttinger, 2007).
We can beginning this stage by asking them which
motive they want to accomplish.
They might not be aware of their motive.
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Motivation for Change

Motivational Interviewing (Miller and Rollnick 2002)
has not been tried with anger.

This procedure involvers reinforcing talk of
change and not responding (extinguishing
talk of not changing) and might be an
effective treatment for anger.
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Motivation for Change

We have use a variation of decisional
balance technique.

First used by Benjamin Franklin and by
Janis and Mann (1977) to make
decisions.
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“my way is to divide half a sheet of paper by a line
into two columns; writing over the one Pro, and
over the other Con. Then, during three or four
days of consideration, I put down under the
different heads short hints of the different
motives, that at different times occur to me, for or
against the measure.
When I have thus got them all together in one
view, I endeavor to estimate their respective
weights; and where I find two, one on each side,
that seem equal, I strike them both out. If I find a
reason pro equal to some two reasons con, I strike
out the three . . . and thus proceeding I find at
length where the balance lies; and if, after a day
or two of further consideration, nothing new that
is of importance occurs on either side, I come to a
determination accordingly.
And, though the weight of reasons cannot be taken
with the precision of algebraic quantities, yet
when each is thus considered, separately and
comparatively, and the whole lies before me, I
think I can judge better, and am less liable to
make a rash step, and in fact I have found great
advantage from this kind of equation."
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Motivational Enhancement
1) Assess the client's goals. The therapist needs to clearly
assess whether the clients have as their goal the reason for
referral. Failure to closely attend to the issue of agreement
on the therapeutic goals will clearly lead to an alliance
rupture. Which motive do they want to accomplish?
2) Agree on goal to explore only. If the client does not wish
to change the reason for referral, seek an agreement on the
session’s focus on reviewing the functionality and
adaptiveness of their behavior or their motives.
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Motivational Enhancement
3) Explore the consequences of the emotion. The therapists
can lead the clients through Socratic dialogue through an
analysis of the consequences of their behavior. Clients are
likely to focus on the immediate consequences of their
behavior rather than the longer term social consequences.
4) Explore alternative scripts. Once the client agrees that it is
in his/her best interest to change their EMOTION, they
still can be thwarted because they may not know what to
replace it with. They may have a limited scheme or scripts
to apply to the situation or alternative scripts may be
considered socially inappropriate to the individual's status
in their group.
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The Motivational Syllogism

The present script is dysfunctional.

There is an alternative script which is better.

There are therapeutic tasks which can help me change
from the dysfunctional script to the new script.

Therefore, it is best to engage in the therapeutic tasks.

Repeat the steps of the motivational syllogism each
time the client presents a new anger episode or when
you change to a new therapeutic task.
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Focus on the Consequences

This strategy could also be conceptualized as
based on research on problem solving
interventions of D'Zurilla & Nezu, specifically
consequential thinking.

It helps build the therapeutic alliance by
strengthening agreement on the goals of
therapy.
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Anger Episode Record

Have client complete the Anger Episode
Record (AER).

Either between sessions or in session for
most recent or dramatic anger episode.

Have them complete the AER out as often
as possible or whenever they get angry.
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Anger Episode Record

Fill in box for activating event.

Rate the degree of endorsement of various
cognitions.

Rate the degree of physiological responses.

Rate behaviors in which they engaged.
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Anger Episode Record

Rate the consequences of the anger.
 This is done as a memory prompt.
 Write in the actual consequences in the four
boxes.
– Short term negative consequences.
– Long term negative consequences.
– Short term positive consequences.
– Long term positive consequences.
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Anger Episode Record
No one ever puts anything in the long term
positive box.
Then ask clients to rate the helpfulness of their
anger from 0-100.
Ask why they assigned such a high value to the
helpfulness rating.
This reveals selective abstraction or arbitrary
inference errors in the weights they give to
outcomes.
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Anger Episode Record

Discuss the reasons they assign different
weights to the outcomes .
 Discuss the cost of the consequences and
their relation to their goal.
 Then ask the client to re-rate helpfulness of
their anger on the 0-100 scales.
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REVENGE
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Revenge in has always been an important
Common theme in Western Literature.
It Starts with play Orestes by Aeschylus
Goes to Sophocles’ Ajax
Homer’s Iliad is all about revenge.
If you want to learn about Revenge go to
the Classics or English Departments not
Psychology
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Revenge Tragedies
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Hamlet
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Revenge in Opera
Verdi’s Opera Rigoletto.
Enrico Caruso as the evil
Duke of Mantua, target
of Rigoletto’s revenge.
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Revenge tends to
prolong conflict
as in the Star
Wars series.
The rebels’ attack
leads to the
REVENGE OF
THE SITH
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And The
EMPIRE
STRIKES
BACK
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That leads to THE
RETURN (or
REVENGE) OF
THE JEDI
Revenge causes a
circular worsening
spiral of aggression
even with the
religious Jedi.
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 More
recent movies
have glorified
revenge.
 Could
this have a
negative impact on
our society?
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Revenge
Thoughts of revenge leads to increased
activity in the reinforcement centers of the
brain.
Revenge is Positively Reinforcing.
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THE BIG REINFORCERS
Sex
Drugs
Rock
‘n’ Roll
 and Revenge
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Revenge to Forgiveness

This forgiveness literature suggests that people
have difficulty forgiving because of some
common myths like “forgive and forget”
 People have difficulty forgetting. If they cannot
forget, well may be they have not forgiven.
 Forgiveness occurs even when remembering
those trespasses against you is human,
(conditioning to negative stimuli is never forgotten
-LeDoux, 1996).
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Forgiveness
 Forgiveness
is also a conscious decision and
does not gradually come over you.
 Only recently have the forgiveness
researchers added measures of anger to their
studies and so far the results have been
successful (International Forgiveness
Institute, 1998).
 Thus, most treatments for anger have left out
forgiveness, which is often part of religious
or spiritual institutions.
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Forgiveness Interventions

The incorporation of forgiveness
interventions may add to the cognitive
component of anger treatment.
 Several successful outcome studies have
appeared teaching forgiveness and these
interventions could be added to anger
control treatments.
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Forgiveness

In most religious and legal models of
forgiveness the transgressor must:
– Acknowledge their wrong doing.
– Make repartition for the damage they caused.
– Make resolution to amend their behavior. (Go
forth and sin no more.)
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Forgiveness

What if the transgressor refuses to do these
things.
 Some people can forgive. But is this a
reasonable expectation for clients.
 Consider the Shooting in an Amish School
House in Lancaster, PA in October 2006.
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Forgiveness

http://www.cnn.com/2006/US/10/02/amish.
shooting/
 The community forgave the shooter.
 This is an unusual event that has its own
Wikipedia entry.
 Can many people do this.
 Should we try acceptance (a.k.a. Ellis)
before forgiveness.
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Satiation Treatment - Basis for Revenge
Interventions
Knight Dunlap 1903 - 1949
Dunlap, Knight (1949). Habits:
their making and unmaking.
Oxford, England: Liveright.
March, 2012
Ayllon, T. (1963). Intensive treatment
of psychotic behaviour by stimulus
satiation and food reinforcement.
Behaviour Research and Therapy,
1(1), 53- 61.
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Satiation Treatment for Revenge

Have the client imagine delivering revenge
to the target of their anger.
 Exaggerate the behaviors and extend the
time of the imagery – similar to the
procedure in FLOODING.
 DO this for several sessions until the client
reports no desire to get revenge or they are
bored with the imagery.
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Satiation Treatment for Revenge

Should we do this with people who have
actually engaged in aggressive behavior?
 Will it increase their potential for
aggression?
 Case studies so far.
 Single subject research on this topic.
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Coercion is
a Motive
in Anger
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Instrumental vs. Affect Aggression

Is operant, instrumental aggression devoid of
affect?
 Is affect aggression always impulsive?
 The answer is No to both questions.
 This theoretical distinction has outlived its
usefulness.
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Coercion as a Motive

The instrumental versus affective
aggression distinction suggests these are
independent or different types of aggression
 Bushman & Anderson (2001) have
challenged this and we agree.
 Many angry adult and children clients
scored high on our Coercion subscale.
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Coercion

Coercion is another positively reinforcing
motive in the experience of anger.
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Tension Reduction

Proposed by Averill, Tangeny and others
 We included it in all of our measures. It has
always been a weak subscale.
 It is the most frequently endorsed motive
for adolescents.
 It does not discriminate between normal and
clinical groups.
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Tension Reduction

Experiential avoidance represents the motive to
escape an emotional experience.
 It has become a central mechanism proposed to
explain psychopathology in modern behavior therapy.
 The anger avoidance model proposed that
experiential avoidance could explain aggression in
clinical populations (Gardner and Moore, 2008).
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Tension Reduction

Accordingly, angry clients engage in
aggressive behaviors, which result in ending
an anger-provoking episode.
 In addition, they can engage in rumination
which distracts them from involvement in
the here and now and then to avoiding their
anger.
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Tension Reduction

We used data from five samples, resulting
in 4787 participants from normative and
clinical sample, adults, and children and
adolescents, US and Canadian samples, we
assessed motives assessed across four
formats, and assessed self-report aggression
across five formats. (Lopes and Digiuseppe, 2010).
 But people endorse Tension Reduction
more than any other motive.
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Tension Reduction

Most predictions involving Tension Reduction
failed to attain significance. It was often
negatively related to aggression or related to
anger-in.
 Revenge and Coercion emerged as strong
motives in predicting multiple forms of
aggression when angry.
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Tension Reduction

Positive reinforcement of anger appears
more prevalent than negative reinforcement
proposed by the anger avoidance model in
understanding aggression.
 We propose that treatment models may
work best if they work at removing or
countering the reinforcing values of these
two motives. (DiGiuseppe, Luttinger, Unger, Lopes,
Tafrate, & Ahmed, 2009)
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Anger to Aggression

For many clients continued aggression can
lead to serious consequences such as felony
arrest, job loss, separation, CPS reports.
 Clinicians worry about this and try to assess
dangerousness.
 This does not lead to a treatment plan and
results in the therapist wanting to end
therapy.
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Anger to Aggression
Target Aggression First.
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Anger and Aggression

Anger usually precede aggression
 Anger and Anxiety lead to more sever
Aggression
 Most people perform 6.5 aggressive acts per
episode.
 The most Common aggressive act is Verbal
aggression either alone or in concert with other
forms of aggression.
 We do not know the exact relations between and
aggression.
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Anger and Aggression

Aggression and anger are not the same thing and you
cannot define anger by aggressive behavior.
 When angered, more men than women and more
Americans than Russians want or desire to hit a
person or thing.
 Only about 11% of anger episodes result in actual
hitting a person or object. Americans and men (14%
vs. 8%) are more likely to hit. These differences are
significant, but not large. Actual physical aggression
as a response to anger is uncommon.
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Anger and Aggression

Verbal reactions are the most frequent response people
desire to make when angered (Kassinove, Sukhodolsky,
Tsytsarev & Solovyova 1997).

The most frequent responses to anger include yelling and
arguing, making sarcastic remarks, complaining and
resolving the problem.
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Anger and Aggression

Several studies that have reported similar
results concerning the percentage of anger
episodes that result in aggression (Averill, 1983;
Luttinger, 2006; Kassinove, Sukhodolsky, Tsytsarev & Solovyova,
.
 However, no studies have appeared to date
that have examined the relationship between
anger and aggression in clinical
populations.
1997; Vaughn, 1996)
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Anger and Aggression

Clients will react with aggression in a small
percentage of their anger episodes.

Clinical experience suggests even the most
aggressive clients behave aggressively in only a
small percentage of anger episodes.
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Three Models Describing
Anger to Aggression

The Parfait Model

Discriminative Stimulus Model

Cognitive Triggers
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Parfait Model

The person maintains the belief that they can only bear so
much frustration, or discomfort. Each frustration
experience adds another level to the parfait. Eventually, as
the frustrations mount, the parfait glass and the person
erupts with aggression.
– general parfait model - frustrations in all areas of life mount
up and are added. Once they have had their limit they explode
although the last frustration occurred in an area separate from the
others. (I can’t take any more stress.
– category specific parfait models – clients will lose their
temper in one area because they have experienced frustration in
many others. (I can’t take any more of your grief.)
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Discriminative Stimulus Model

Some clients believe they can control their
anger in most situations, but become angry
and aggressive in response to a specific
discriminative stimulus.
 When the anger-target speaks with a certain
tone or uses a particular gesture that the
client believes is intolerable, does she or he
retaliate with anger?
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Cognitive Triggers & Controls

Lopes and DiGiuseppe (2012) have identifies a five
factor scale that predicts actual aggression in
retrospective analysis.
– I must let my anger out and show the transgressor how I
–
–
–
–
feel (also found by Leis , 2006).
Desire for revenge and not getting caught or receive
retaliation.
Thinking of consequences and having moral constraints on
aggression. This is complicated.
Can’t take or stand the situation any more.
Value aggression to preserve a persona or public image.
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VA Perry Point, MD
156
Cognitive Triggers & Controls





I must let my anger out and show the transgressor how
I feel (Leis , 2006).
Desire for revenge and not getting caught or receive
retaliation.
Thinking of consequences and having moral
constraints on aggression.
Can’t take or stand the situation any more.
Value aggression to preserve a persona or public
image.
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Anger to Aggression

Impulsivity is a strong predictor of aggression.

Anger-in also leads to aggression.

The impulsivity to aggression path is partly
mediated by physiological arousal.

The anger-in to aggression is mediated by
rumination and revenge.
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Rumination as a
Cognitive
Process
In Anger
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Impulsivity & Rumination
• Anger states tend to last longer than most affective
states (Scherer & Wallbott, 1994).
• Rumination has been associated with depression.
• Affective anger is supposed to be impulsive.
• We found Anger Impulsivity and Anger Rumination
are strongly correlated in adults, adolescents &
children.
• They cannot be separated as separate scales in
adolescents.
• Most people ruminate before they aggress.
• Very few people are impulsive without ruminating.
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Impulsivity and Rumination
 Most
angry clients have rumination and
anger-in besides anger-out.
 Treating their impulsivity will not help
totally
 Self-control is like a muscle and it tires
(Baumeister, 2003).
 Reducing rumination will lead to less
aggressive incidences.
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Impulsivity and Rumination
 For
adolescents Rumination and Impulsivity
items are very highly correlated and cannot
be separated.
 Either poor self-control influences both
cognitive and behavioral processes. or;
 These processes become more independent
and separate as one matures.
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Cognitive Triggers & Controls

Anger does not always lead to aggression. Perhaps it
does do 10% of the time.

We have very little research on what distinguishes
an angry-non aggressive episode from an angryaggressive episode.

Lopes and DiGiuseppe (in preparation) have identified a
four factor scale that predicts actual aggression in
retrospective analysis.
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Cognitive Triggers & Controls





I must let my anger out and show the transgressor how
I feel (Leis , 2006).
Desire for revenge and not getting caught or receive
retaliation.
Thinking of consequences and having moral
constraints on aggression.
Can’t take or stand the situation any more.
Value aggression to preserve a persona or public
image.
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Anger to Aggression

Impulsivity is a strong predictor of aggression.

Anger-in also leads to aggression.

The impulsivity to aggression path is partly
mediated by physiological arousal.

The anger-in to aggression is mediated by
rumination and revenge.
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Managing Physiological Arousal

Include one of these interventions in every
case:
– Relaxation training
– Meditation
– Yoga
Teach the client to associate the sensation of anger
or the trigger to the relaxation response.
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Cognitive Models and
Interventions
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Self Esteem?

Anger is believed to result from low self
esteem?
 Research does not support this.
 Low Self esteem leads to depression.
 How can low self-esteem lead to both
depression and anger?
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Self Esteem?







Low-self esteem is commonly thought to lead to anger and
aggression.
Anger results from perceived threats to high, unstable self esteem
(Baumeister, Smart & Boden, 1996).
It is not necessarily high self- esteem, but narcissism that leads to
anger and aggression.
Narcissism involves passionate desire to think well of oneself.
Not all people with high self-esteem are narcissistic, but
narcissists appear to have high self-esteem.
Threats to self-esteem in narcissists results in increased anger and
aggression (Bushman & Baumeister, 1998).
Teaching self-esteem does not necessarily lead to narcissism, but
it could.
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Self Esteem?





Anger includes a greater experience of power or potency
than the eliciting threat (MacKinnon & Keating, 1989).
Anger is associated with self-efficacy.
Roseman (1984): when people experience anger they
believe, “...aversive events are not necessary or
uncontrollable.”
Fridja (1986) noted that, “Anger implies hope.”
Several authors note that anger triggers problem solving
activities to overcome obstacles to goal attainment.
(Averill, 1982; Mikulincer, 1998; Scherer, 1984).
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Self Esteem?

Circumplex models of emotions suggest that anger
is a high energy activation, negative emotion, as
opposed to sadness, which is a low energy
activation, negative emotion (Larsen & Diener,
1992; Russell, 1980).
 Anger is the perception of an injustice or grievance
against oneself (Tedeschi & Nesler, 1993).
 The perceptions of an other's blameworthiness
(Clore & Ortony, 1991;1993) not self blame.
 No studies exist relating to building self esteem and
reducing anger.
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Self Esteem In Anger

We see some clients
with low self-esteem
who are angry.
 Is this low self esteem
related to a comorbid
problem?
 Could it lower their
threshold for ego
threats?
March, 2012

Shanahan, Jones, &
Thomas-Peter, (2011)
found angry inmates
did endorse irrational
beleifs about self
downing and shame.
They point out that all
the high self-esteem
has been done on non
clinicla smaple.
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Cognitions and Anger

Hostile Automatic Thoughts.
 Evaluations of those thoughts.
 Demanding thoughts may be the key.
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Challenging Schemas

Demands or schemas are cognitive
expectancies about reality.
 Expectancy - reality - discrepancy leads to
emotional arousal.
 Assimilate - keep the schema intact.
 Accommodate - change the schema.
 Anger results from Assimilation
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Challenging Core Schema

Not all schema accommodations lead to
anger.
 The most problematic is the schema
concerning the existence of things we want.
 We confuse what we want with the reality
of what is.
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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.
 Multiple 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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Challenging Core Schema

Demands are schemas about the reality of
preferences or desires.
 Thus, we are two cognitions here.
 The desire that something occurs.
 The expectancy that it will.
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Challenging Core Schema

First, teach the client the distinction
between the preference/desire and the
schema/expectancy that something will or
must occur.
 Second, posit or reinforce the
preference/demand.
 Third, challenge the schema/expectancy/
demand that the preference must occur
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Challenging Core Schema

Fourth, develop a rational replacement idea.
 Just because I want X to happen does not
mean that it must.
 This realization is often followed by
problem solving to attain X or cope with no
X.
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Learning New Responses

Assertion versus aggressive response
 Angry clients often have long periods of
unassertive behavior, with ruminative
resentful thoughts followed by explosive,
aggressive outburst.
 They need to learn to act assertively early in
the sequences of events.
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Anger In and Anger Out
•
Are Anger In and Anger Out orthogonal
constructs?
•
Not True
•
These constructs are related the more you
hold anger in the more you are aggressive.
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Anger - In

Anger-In is supposed to be orthogonal to AngerOut.
 We found that for each sample and for the ADS
and the STAXI-2, Anger-In correlated
significantly with Anger-Out (STAXI-2) and with
the ADS Verbal and Physical Aggression.
 Perhaps the relation between anger and aggression
is continuous.
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Assertiveness Training

Anger is more verbally expressive than any
emotion except joy (Scherer & Wallbott,
1994).

Anger causes the strongest paralinguistic
changes in one’s voice than any other
emotion (Scherer & Wallbott, 1994).
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Assertiveness Training

Angry clients will want to say something.
 Problems Solve the appropriate response.
 Rehearse, Feedback, coach.

Angry clients will have intonations of anger
even if they know the assertive response.
 “Giving tone”
March, 2012
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Displaced or Redirected
Aggression is a well
documented phenomenon
We do not acknowledge it in
CBT interventions for anger or
aggression
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Displaced/Redirected Aggression
 Animals
that have an opportunity to attack
another animal after they are shocked have less
damage to their stress system than animals who
do not have this opportunity (Barash, 2007).
 If
so, does this make redirected aggression
negatively reinforcing?
A
growing literature on displaced aggression in
humans exists.
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March, 2012
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Displaced/Redirected Aggression
 Robins and Novaco (1999) is the one
exception here and he identifies two types of
triggers for anger:
Proximal – the immediate trigger
Distal - the upsetting thing in the past
The Proximal triggers are often trivial
events.
March, 2012
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Displaced/Redirected Aggression
Anger
is a symptom of PTSD
As
time passes from the trauma
the potential for anger
increases.
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Displaced/Redirected Aggression
Perhaps
we need to teach coping
with the proximal stimuli first and
then teach the skills of coping with
anger associated with the distal
causes?
We have no real protocols for this.
March, 2012
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Anger-In and Resentment

Resentment has long been a construct assessed
in anger scales (Buss & Durkee, 1957).
 Anger clients are resentful of past bad
treatment.
 About half of our angry clients report histories
of abuse or neglect.
 They have a strong desire for retributive
justice.
 They have lower threshold for anger.
March, 2012
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Exposure Treatments
Conceptualizing Exposure as an Intervention
for Clients With Anger Problems

Evidence for classical conditioning of anger
and exposure based emotional processing.
No evidence for emotional processing.

Evidence for instrumental conditioning.

Instrumental conditioning wins
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




Exposure interventions are used to treat anxiety disorders.
Prolonged exposure to the anxiety-eliciting stimuli is
necessary for “emotional processing” and successful
treatment to occur.
Following an operant model, the image of the anger
triggering stimuli would not be held for a prolonged
period.
It would be followed by an image of a new incompatible
response to anger.
Research with one session, analogue treatments found
these type of exposure imagery interventions are equally
effective. (Reich & DiGiuseppe, 2009).
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Exposure Treatments

Exposure based on classical conditioning
would
– Have maximum arousal experienced
– Hold the exposure of the image to sustain
arousal for a long time until there is a reduction
in arousal.
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Exposure Treatments

Exposure based on instrumental
conditioning would:
– Have new, different or incompatible emotional
response paired with the trigger/stimulus that
had aroused anger.
– Reinforce that new response
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Exposure Treatments

Types of exposure.
 Imaginal
 video
 role play
 role play with coach
 and eventually in vivo
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Reasons Exposure May Have
Been Neglected for Anger

Concerns about clients harming the
practitioners?
 Concerns about the intervention causing
harm to the client?
 Concerns about damaging the therapeutic
relationship?
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Repairing Damaged Relationships
Step 4. Make a searching and fearless moral inventory of
ourselves.
Step 8. Made a list of all persons we had harmed, and
became willing to make amends to them all.
Step 9. Made direct amends to such people wherever
possible, except when to do so would injure them or
others.
Step 10. Continued to take personal inventory and when
we were wrong promptly admitted it.
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Repairing Damaged Relationships
Significant others in the client’s life have
learned to fear the client’s anger.
 Changes in the client’s anger will not result
in immediate reductions in this fear.
 Love and affection may have been
extinguished.
 Positive rebuilding is not always possible.

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Contact Ray DiGiuseppe
[email protected]
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