Anger management-psychologist-psychiatrist-therapist-training

Anger Management
Can psychotherapy really work?
J. Ryan Fuller, Ph.D.
New York Behavioral Health
Clinical Director

Anger: Definition
© J. Ryan Fuller, 2016

What is Anger?

Definition of Anger
Anger is a negative, phenomenological (internal) feeling
state, which is associated with
 Cognitive and perceptual distortions
 Subjective labeling
 Physiological changes, and
 Action tendencies to engage in socially constructed and
reinforced behavioral scripts that often involve approach
behaviors and loud verbal behaviors

Dysfunctional Anger:
Diagnosis

When is anger a problem?

Anger is common
 Anger 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)

Effects of Anger
Maladaptive
 Interpersonal conflict
 Violence
 Poor Driving
 Inappropriate risk taking
 Poor decision making
 Health risks
 Substance abuse
Adaptive
 Alerts goal blocked
 Communicates feeling and
perception of injustice
 Deters threat
 Prepares body for physical
assault

Proposed Anger Diagnoses
1. Generalized Anger without Aggression
2. Generalized Anger with Aggression
3. Situational Anger Disorder without Aggression
4. Situational Anger Disorder with Aggression
5. Adjustment Disorder with Angry Mood

Should we change anger?

Acceptance Based
Conceptualization of
Dysfunctional Anger

DSM Diagnoses
 Antisocial Personality Disorder
 Borderline Personality Disorder
 Conduct Disorder
 Generalized Anxiety Disorder (GAD)
 Intermittent Explosive Disorder
 Major Depressive Disorder
 Obsessive-Compulsive Disorder (OCD)
 Narcissistic Personality Disorder
 Oppositional Defiant Disorder
 Panic Disorder
 Paranoid Personality Disorder
 Passive Aggressive Personality
Disorder
 Post-traumatic Stress Disorder
(PTSD)

How do we measure anger?

Clinical Instruments
STAXI-II (Spielberger, 1999)
 Experience
State
Trait
 Expression
Anger- In
Anger- Out
Anger- Control
ADS (DiGiuseppe & Tafrate, 2003)
 Behavioral Domain
 Arousal Domain
 Motives Domain
 Provocations
 Cognitive

Anger Component Model

Componential Model of
Anger
 Trigger
 Appraisal
 Experience
 Expression
 Outcome

Triggers

Appraisals

Experiences

Expressions

Outcomes

Does anger management
work, and for whom?

Anger Treatment Research
 Cognitive 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).

What treatments work?
 Cognitive Therapy
 Relaxation
 Skills Training
 Combined
 Exposure Based

How well does
treatment work?

Treatment Efficacy
Good 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

Treatment Efficacy (2)
Good News
 Change is large (effect sizes for most effective are
around 1.00 for Cohen’s d)
 Follow-up studies support maintenance
Bad News
 Most studies use volunteers
 These effect sizes are smaller than those found for
anxiety and depression treatment- socially sanctioned,
adaptive at times, less attention (DiGiuseppe & Tafrate
2003)

Anger: A Problem for
Clinicians

What are the general
challenge and questions to
implementing treatment?

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?

Increase Motivation
• Review negative facts
• Values
• Consequential thinking: short vs. long term
• Catharsis

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

Values

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?

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)

Clinical Focus with Angry
Clients
 Do you validate anger?
 Which part?
 Cognitions, feelings, expressions
 Important for therapeutic alliance and maybe your
safety.

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 problem
 Preparation: decision to change
 Action: implementing change
 Maintenance: already changed, own tx, relapse

What does typical CBT
anger management look
like?

Combined Treatment
Example

Outcome Research for
Combined Anger Treatment

Community Model
Anger 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 population
 Evaluate efficacy

Goals
 Who are we treating?
 What is the treatment?
 What are the outcomes of treatment?

Population
 Assessment of research participants
 SCID 1 and 2
 PDSQ
 ADS
 STAXI
 BDI
 Exclusionary Criteria
 Actively psychotic
 Group Inappropriate

Treatment Measures
 Anger Disorders Scale
 State-Trait Anger Expression Inventory
 Beck Depression Inventory
 Idiosyncratic Anger Measures
 Situation
 Symptom
 Behavior

Recruitment and Fees
 Recruitment
 Advertised, Professional Referral, Self-Referral
 Phone Interview
 Fees and Compensation
 $50 per session
 $200 reimbursement for perfect attendance
 $150 reimbursement for missing one session

Screening
 Criteria 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 Exclusion
 Actively psychotic
 Group Inappropriate

Demographic
Characteristics
 Age:
 45 years (11.95)
 Gender Composition:
 5 men and 7 women
 Education:
 16 years (2.54)

Clinical Syndromes
 Axis 1 Current (Past)
Anxiety Disorder: 4/12 (9)
Mood Disorder: 9/12 (8)
Substance/Alcohol: 3/12 (7)

Personality Disorders
Axis 2 Frequency
Passive Aggressive 7
Depressive 6
Obsessive Comp 5
Borderline 4
Narcissistic 4
Avoidant 4
Dependent 1
Histrionic 1
Paranoid 1

Treatment
 Manual
 Session 1-3 Overview and Model
 Session 4-9 Skills Acquisition
 Session 10-14 Exposure plus Coping
 Session 15-16 Relapse Prevention
 General
 Organized by components
 Flexible, but skill focused

STAXI-II T-Scores
Pre-treatment, Mid-treatment, & Post-treatment
Changes
0
20
40
60
80
*Trait Anger ScaleTrait Temperament SubscaleTrait Reaction Subscale
Pretreatment
Midtreatment
Posttreatment

ANGER SITUATION
Changes
0
20
40
60
80
100
*Intensity (0-
100)
Frequency
(per month)
Duration
(minutes)
Life
Interference
(0-100)
Pretreatment
Midtreatment
Posttreatment

ANGER SYMPTOM
Changes
0
10
20
30
40
50
60
70
*Intensity (0-
100)
Frequency
(per month)
Duration
(minutes)
Life
Interference
(0-100)
Pretreatment
Midtreatment
Posttreatment

Anger Disorder Scale (ADS)
Pre-treatment to Post-treatment Changes
0
20
40
60
80
Pretreatment * Posttreatment

Beck Depression Inventory - II
Total Score
Pre-treatment to Post-treatment Changes
0
5
10
15
20
25
30
Pretreatment * Posttreatment

Limitations
 Sample size
 Self-referred participant group that were highly motivated
 No treatment control group
 Independent coding of fidelity would be preferable
 Self-report, rather than objective physiological/ behavioral
measures
 Administering treatment by one therapist

Implications
 Many 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

Skill Details

What are the client skills?
 Self-monitoring
 Consequential Thinking & Time Projection
 Problem Solving
 Assertiveness Training
 Cognitive Rehearsal & Disputation
 Relaxation
 Response Prevention

Cognitive Rehearsal &
Disputation

Cognitions
 Negative vs. Positive
 Expectancies
 Attribution
 Specific vs. Global
 Stable vs. Unstable
 Internal vs. External
 Cognitive Triad
 Self
 World
 Future
 Irrational vs. Rational

Cognitive-Behavioral
Therapy (CBT)
 What is it?
 Learning Theory
 Functional Assessment
 Clinical Model (ABC)
 Techniques

Cognitive-Behavioral
Therapies (Continued)
 Behavioral Therapies
 Cognitive Therapy (CT)
 Rational Emotive Behavior Therapy (REBT)
 Problem Solving
 Dialectical Behavior Therapy (DBT)
 Acceptance and Commitment Therapy (ACT)
 Functional Analytic Psychotherapy (FAP)

CBT: Behaviorist Model
 Antecedent
 Behavior
 Consequence

CBT – what are the
strategies?
CBT attempts to change behaviors by modifying:
 Antecedents/Cues
 Beliefs, Emotions, Stressors
 Processes
 Acceptance/Willingness/HFT/Distress Tolerance
 Consequences
 Reinforcers / Punishers / Modeling

ABC Model

Activating Events

Beliefs

Consequences

Yerkes-Dodson

Cognitive Behavioral
Model
A B  Ce  Cb

CBT: Cognitive
 Cognitive Model
 A = Activating Events
 B = Beliefs
 C = Consequences

Emotional Education
 Alexithymia
 Shared vocabulary for communication
 Utilization of the ABC Model

Model of Emotions

Cognitive Behavioral
Therapy (CBT)
General Strategies
 Regulate emotions
 Tolerate frustration (distress)
 Pursue goals

Dysfunctional Thoughts
Maladaptive Cognitions
 He can’t do that to me
 I won’t be a doormat
 They had it coming
 F- him!
 He’s such an $%^&! –hole!
 It is the only thing he understands!

Cognitive Therapy (CT)
 Automatic Thoughts
 Assumptions
 Core Beliefs

Irrational Beliefs (IB)
 Demandingness
 Low-frustration Tolearnce (LFT)
 Awfulizing
 Global Evaluation of Worth

ABC Cognitive Anger Chain
 Let’s imagine a few:
 A1 = [Fill in the blank]
 B1 = [Fill in the blank]
 C1 = [Fill in the blank]

Cognitive Therapies
Intervening at the Inference or Belief
What 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

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?

Cognitive Interventions
• Similar to those for depression and anxiety
• Cognitive restructuring?
• Rehearsal
• Disputing
• Emphasis
• Demands on others
• Global evaluation of worth

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?

Cognitive Emphasis: Global
Evaluation
• Behavior vs. Person
• Attributions
• Intent
• Concept of Self: Spiritual

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]

Secondary Disturbance
A1 B1 C1
Poor work
performance by
new younger
boss---> I might
lose my job
The economy is
terrible.
I must be an idiot.
Panic
A2 B2 C2
Panic 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 C3
Inappropriate
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.

Secondary Coping
A1 B1 C1
Poor 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 C2
Concern 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.
Concern
Frustration
Drafts a written action plan
proposing ways to address
negative bullets in his
evaluation.

Problem Solving

Problem Solving:
A Misplaced Fundamental
Definitions
 Problem: a situation that presents difficulty
 Problem Solving: a structured strategy that elicits a
multitude of responses that contains steps to maximize
the likelihood of implementing a viable one

Problem Solving
Examples
1. Difficult situation at work with client, vendor, employer,
employee
2. I am getting into arguments with my spouse
3. How to furnish a new room
4. My diet plan is not producing the results I want
5. I can’t find a job or appropriate romantic partner

Problem Solving:
An Empirical Approach
Goldfried and Davison (1976)
1. General Orientation
2. Define problem
3. Generation of Alternatives
4. Decision making
5. Verification

Problem Solving: Step 1
General Orientation
a. Normalize- assume that situation is a normal part
of life
b. Acknowledgement- that it is possible others have
coped with something similar
c. Inhibit- halt the tendency to respond with initial
impulse

Define problem
a. Operationalize- define all aspects of the
issue in concrete (observable and measurable)
ways
b. Dissect- reclassify parts into smaller more
manageable elements

Generation of Alternatives
a. Brainstorming
i. Criticism omitted
ii. Welcome novelty and divergence
iii. Encourage quantity of ideas
iv. Improvement and integration of
suggested ideas

Decision making
Temporal 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?

Verification & Assessment
Test-Operate-Test-Exit
(TOTE; Miller, Galanter & Pribram, 1960)
Was the implemented plan effective?
1. Yes→ Exit
2. No→ Go back to step 4

Assertiveness

Assertiveness
 Definition
 What is it not?
 Aggressive
 Passive
 Definition #1
 Assertiveness: proper expression of any emotion other
than anxiety toward another person- Joseph Wolpe
(1973)

Assertiveness: Goals
 Improve interpersonal environment
 Enhance self-efficacy
 Emote

Assertiveness
Two Critical Components in definition
 The communication of feelings, desires, wants, and
preferences
 The acceptance of another person’s right of refusal
and recognition he/she may also agree but not act
congruently

Assertive Communication
Four Communication Statements
 When. . . . . . . . . . (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)

Assertive Acceptance
My 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

Forgiveness

Experiential Exercises

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.

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?

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!

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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