a comprehensive treatment program for anger disorders

A Comprehensive Treatment Program for Anger Disorders

Raymond DiGiuseppe, Ph.D., D.Sc., ABPPSt. John's University

andThe Albert Ellis Institute

March, 2012 1Villanova University

Seneca On AngerWe 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)


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)


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 SchoolBoys 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%

Villanova UniversityMarch, 2012 4

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 than 1,720,000 pages.Villanova UniversityMarch, 2012 5

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.

March, 2012 Villanova University 6

Problems Studying Clinical Anger

We know much less about anger as a clinical problem than we know about other emotional disorders:

1. We have less literature to inform us.2. People question anger’s status as a basic human

emotion. Clinicians often see it as secondary to depression and anxiety.

3. Definitional confusion exists among anger and related terms.

4. We have questions about how is anger learned.

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7Villanova University

5. Can anger be dysfunctional?6. No diagnostic categories exist for anger

problems in DSM IV, 5.7. We have little treatment outcome

research to guide practice.8. Confusion exists about the elements of

the anger experience. What elements make up anger?

9. How should treatment proceed?


Less Literature to Inform Us

A much larger literature exits about depression and anxiety compared with anger for:1. Diagnosis2. Assessment3. Treatment


Figure 1.1: Psyc Info References for Diagnosis

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1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-04

Years

# of

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Depression Anxiety Anger


PsycInfo References for Assessment

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150

200

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1971-75 1976-80 1981-85 1986-90 1991-95 1996-00 2001-04

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Depression Anxiety Anger


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.”


This state of affairs is true for other emotions also.

1. Disgust2. Envy3. JealousySince Freud we have limited the study of

dysfunctional emotions to depression & Anxiety


March, 2012 14

Is Anger a Secondary Emotion or a BasicEmotion?

Villanova University

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.


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)

March, 2012 Villanova University

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Definitions1. 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).


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4. 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


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.


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.


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).”


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).”


March, 2012 27

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.


Rabbi Moshe Chaim LuzzattoMesilas 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.


"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.


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.

Early 20th Century


• 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.

March, 201231

Anger and Depression


March, 2012 32

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.


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 anger be a harmful dysfunction?


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.


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 = 1774o 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.


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

0. 00

0. 50

1. 00

1. 50

2. 00

2. 50

3. 00

Low Medium High

Mea

n No

. of T

raits

Level of Anger

Depressive Borderline

AvoidantSelf-DefeatAntisocialNegativisticNarcissistic

Obsessive

ParanoidDependentSchizotypalSchizoidHistrionic


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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.


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)



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)



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.



Sub - types: Anger Disorder, Predominately Subjective Type Anger Disorder, Predominately Expressive

Type Anger Disorder, Combined Type


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



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.



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.



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.



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 meta- analytic 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.



As Norcross & Kobayashi (1999) lamented, we cannot treat anger as successfully as we do other emotional problems. We still need new creative interventions.



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.



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.



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.



This last finding may be the most important. Spouses and other family members see changes from our interventions.



Sukholdolsky & Kassinove's (1998) reported little change on measures completed by peers of children and adolescents.

Two interpretations of these results are possible.



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.



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.


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.



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.


Group Therapy?

Do not allow reinforcement of antisocial attitudes and behaviors.

Be careful of personal feedback among members. It could lead to personal attacks.



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.



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.



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.



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.


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.


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

Brad Bushman, Ph.D. Presently

Villanova University 75

WHAT IS MISSING INOUR UNDERSTANDING

OF ANGER?

March, 2012

Good Assessment Instruments that include a Comprehensive List of Characteristics of Anger and Aggression


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 Stimuli2. Thoughts / Cognitions3. Emotional Experience4. Motives5. 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.


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.


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

OrAs a form of Psychopathology or Clinical

Problem.• This decision influences the types of

subscales, the items and the distribution of the scales.


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 ScaleStructured 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.


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?


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


Factor Name Description In the ADS &ARES

Negative Verbal Anger Expression

This factor represents one or three separate factors. a) Noisy arguing. b) Verbal assault. c) Verbal Put Downs.

Overt Aggression/ Expression:Verbal Expression subscale

Dirty Looks Making facial expressions that communicate anger or contempt.

Not Present – Cannot be assessed with self report .

Body Language Making bodily gestures that communicate anger or contempt.

Not Present - Cannot be assessed with self report .

Anger In/ Suppression Experiences anger, but keeps it in or avoids expressing anger, or avoids people.

Anger-In

Anger In/ Critical Experiences critical thoughts of others or negative opinions of others without expressing them.

Not Present All attempts to get items just loaded with Anger-in Suppression



Factor Name Description In the ADS & ARES

Diffusion/ distraction Releasing the anger tension through an avoidance activity that distracts one from the anger without facing the problem e.g. dinking, driving fast

Not Present – Low base rate on self report for clinical groups of youth.

Passive aggression 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.

Subversion: Passive Aggression subscale

Relational victimization or Socially isolate the target

Encourage, cajole, or bully other persons to socially isolate the target of one’s anger.

Subversion: Relational Aggression Subscale

Covert Aggression The secretive destruction of another persons’ property

Covert Aggression

Anger Disorder ScaleArousal Domain1. Duration of Axis I Problem2. Episode Length3. Physiological reactivityCognitive Domain4. Rumination5. Impulsivity6. Suspiciousness (attributions for hostile intention)7. ResentmentProvocations8. Hurt / Social Rejection – other specific provocations do

not distinguish normal and clinical samples9. Scope of anger provocations


Anger Disorder Scale

Motives Domain

1. Coercion2. Revenge3. 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.


Missing Components of Anger Treatments

Addressing the Low Desire for Change


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.



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.

March, 2012


Francis Bacon (1561-1626)

“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 The Essays Of Anger, 1601)

March, 2012

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


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).


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.


Transgression to RetaliationRatio 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.


Transgression to RetaliationRatio 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.


Motivation for ChangePeople 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.


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.


Motivation for ChangeWe have use a variation of decisional

balance technique.

First used by Benjamin Franklin and by Janis and Mann (1977) to make decisions.


“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."


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.


Motivational Enhancement3) 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.


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.


Focus on the ConsequencesThis 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.


Anger Episode RecordHave 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.


Anger Episode RecordFill 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.


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.


Anger Episode RecordNo 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.


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.


REVENGE


Revenge in has always been an important Common theme in Western Literature.

It Starts with play Orestes by AeschylusGoes 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 PsychologyMarch, 2012 Villanova University 112

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Revenge Tragedies


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Hamlet


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Revenge in OperaVerdi’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 SITHMarch, 2012 Villanova University

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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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RevengeThoughts of revenge leads to increased activity in the reinforcement centers of the brain.

Revenge is Positively Reinforcing.


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THE BIG REINFORCERSSexDrugsRock ‘n’ Roll and Revenge


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).


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.


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.


ForgivenessIn 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.)


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.


Forgivenesshttp://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.


http://www.cnn.com/2006/US/10/02/amish.shooting/

http://www.cnn.com/2006/US/10/02/amish.shooting/

Satiation Treatment - Basis for Revenge Interventions


Knight Dunlap 1903 - 1949Dunlap, Knight (1949). Habits: their making and unmaking. Oxford, England: Liveright.

Ayllon, T. (1963). Intensive treatment of psychotic behaviour by stimulus satiation and food reinforcement. Behaviour Research and Therapy, 1(1), 53- 61.

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.


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.


Coercion is a Motivein 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.


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.


Coercion

Coercion is another positively reinforcing motive in the experience of anger.


Tension ReductionProposed by Averill, Tangeny and othersWe 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.


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).


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.


Tension ReductionWe 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.


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.


Tension ReductionPositive 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)


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.


Anger to Aggression

Target Aggression First.


Anger and AggressionAnger usually precede aggressionAnger 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.March, 2012 148Villanova University

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.


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.


Anger and AggressionSeveral studies that have reported similar

results concerning the percentage of anger episodes that result in aggression (Averill, 1983; Luttinger, 2006; Kassinove, Sukhodolsky, Tsytsarev & Solovyova,

1997; Vaughn, 1996). However, no studies have appeared to date

that have examined the relationship between anger and aggression in clinical populations.


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.


Three Models DescribingAnger to Aggression

The Parfait Model

Discriminative Stimulus Model

Cognitive Triggers


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.)


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?


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.

October, 2010 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.


Anger to AggressionImpulsivity 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.


Rumination as aCognitive ProcessIn Anger


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.


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.


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.


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 angry-aggressive episode.

Lopes and DiGiuseppe (in preparation) have identified a four factor scale that predicts actual aggression in retrospective analysis.


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.


Anger to AggressionImpulsivity 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.


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.


Cognitive Models and Interventions


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?


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.


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).


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.


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?


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.

Cognitions and Anger

Hostile Automatic Thoughts.Evaluations of those thoughts.Demanding thoughts may be the key.


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


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.


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 ExperimentThese 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!


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.



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.


Challenging Core SchemaFirst, 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



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.


Learning New Responses

Assertion versus aggressive responseAngry 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.


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.


Anger - In

Anger-In is supposed to be orthogonal to Anger-Out.

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.


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).


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”



Displaced or Redirected Aggression is a well

documented phenomenon

We do not acknowledge it in CBT interventions for

anger or aggressionMarch, 2012


Displaced/Redirected AggressionAnimals 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.

March, 2012

Villanova University 193March, 2012


Displaced/Redirected Aggression Robins and Novaco (1999) is the one

exception here and he identifies two types of triggers for anger:Proximal – the immediate triggerDistal - the upsetting thing in the past

The Proximal triggers are often trivial events.

March, 2012


Displaced/Redirected Aggression

Anger is a symptom of PTSD

As time passes from the trauma the potential for anger increases.

March, 2012


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

Anger-In and ResentmentResentment 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.


Exposure TreatmentsConceptualizing 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).


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.


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


Exposure Treatments

Types of exposure. Imaginal video role play role play with coach and eventually in vivo


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?


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.


Repairing Damaged RelationshipsSignificant 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.



Contact Ray [email protected]

March, 2012

a comprehensive treatment program for anger disorders

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