anger management-psychologist-psychiatrist-therapist-training

Anger Management

Can psychotherapy really work?J. Ryan Fuller, Ph.D.

New York Behavioral HealthClinical Director

Anger: Definition

What is Anger?

Definition of AngerAnger is a negative, phenomenological (internal)

feeling state, which is associated withCognitive and perceptual distortionsSubjective labelingPhysiological changes, andAction tendencies to engage in socially

constructed and reinforced behavioral scripts that often involve approach behaviors and loud verbal behaviors

Dysfunctional Anger: Diagnosis

When is anger a problem?

Anger is commonAnger is a basic emotion (Plutchik, 1980) Anger is frequently experienced even by

normative samples (Tafrate, Kassinove, & Dundin, 2002)

Anger is a clinical problem (Lachmund, DiGiuseppe, & Fuller, 2005)

Effects of AngerMaladaptiveInterpersonal conflictViolencePoor DrivingInappropriate risk takingPoor decision makingHealth risksSubstance abuse

AdaptiveAlerts goal blockedCommunicates feeling and perception of

injusticeDeters threatPrepares body for physical assault

Proposed Anger Diagnoses

1. Generalized Anger without Aggression2. Generalized Anger with Aggression3. Situational Anger Disorder without Aggression4. Situational Anger Disorder with Aggression5. Adjustment Disorder with Angry Mood

Should we change anger?

Acceptance Based Conceptualization of Dysfunctional Anger

DSM DiagnosesAntisocial Personality DisorderBorderline Personality DisorderConduct DisorderGeneralized Anxiety Disorder

(GAD) Intermittent Explosive DisorderMajor Depressive DisorderObsessive-Compulsive Disorder

Narcissistic Personality DisorderOppositional Defiant DisorderPanic DisorderParanoid Personality DisorderPassive Aggressive Personality

DisorderPost-traumatic Stress Disorder

(PTSD)

How do we measure anger?

Clinical InstrumentsSTAXI-II (Spielberger, 1999)

Experience

StateTrait

Expression

Anger- InAnger- OutAnger- Control

ADS (DiGiuseppe & Tafrate, 2003)

Behavioral DomainArousal DomainMotives DomainProvocationsCognitive

Anger Component Model

Componential Model of Anger

TriggerAppraisalExperienceExpressionOutcome

Triggers

Appraisals

Experiences

Expressions

Outcomes

Does anger management work, and

for whom?

Anger Treatment ResearchCognitive Restructuring, Skills Training, and

Relaxation. Angry Undergraduates (Deffenbacher et.al,

1986). Veterans with PTSD (Novaco et.al., 1997). Outpatients (Fuller, et. al 2010)

Exposure may be a useful treatment (Tafrate & Kassinove, 1998; McVey, 2000).

What treatments work?Cognitive TherapyRelaxationSkills TrainingCombinedExposure Based

How well does treatment work?

Treatment EfficacyGood News

Many treatments influence change in many different types of clients: college students, outpatients, prison inmates, and spouse abusers

Equally effective regardless of age and gender

Treatment Efficacy (2)Good NewsChange is large (effect sizes for most effective are

around 1.00 for Cohen’s d)Follow-up studies support maintenanceBad News Most studies use volunteersThese effect sizes are smaller than those found for

anxiety and depression treatment- socially sanctioned, adaptive at times, less attention (DiGiuseppe & Tafrate 2003)

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 problemPreparation: decision to changeAction: implementing changeMaintenance: already changed, own tx, relapse

What does typical CBT anger management

look like?

Combined Treatment Example

Outcome Research for Combined Anger

Treatment

Community ModelAnger groups have run for years, but never

systematically studied

Goals of the study Describe population, Clearly define the treatment, Assess viability of fee-for-service

treatment research in anger populationEvaluate efficacy

GoalsWho are we treating?

What is the treatment?

What are the outcomes of treatment?

Population

Assessment of research participantsSCID 1 and 2PDSQADSSTAXIBDI

Exclusionary CriteriaActively psychoticGroup Inappropriate

Treatment MeasuresAnger Disorders ScaleState-Trait Anger Expression InventoryBeck Depression InventoryIdiosyncratic Anger Measures

SituationSymptomBehavior

Recruitment and FeesRecruitment

Advertised, Professional Referral, Self-ReferralPhone Interview

Fees and Compensation$50 per session$200 reimbursement for perfect attendance$150 reimbursement for missing one session

ScreeningCriteria for Inclusion

Self-identified as having anger problems and requested treatment.

Significantly disturbed by anger as measured by the STAXI-II, the idiosyncratic anger forms, & the clinical interview.

Criteria for ExclusionActively psychoticGroup Inappropriate

Demographic Characteristics

Age:45 years (11.95)

Gender Composition: 5 men and 7 women

Education:16 years (2.54)

Clinical SyndromesAxis 1 Current (Past)

Anxiety Disorder: 4/12 (9)Mood Disorder: 9/12 (8)Substance/Alcohol: 3/12 (7)

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

TreatmentManual

Session 1-3 Overview and ModelSession 4-9 Skills AcquisitionSession 10-14 Exposure plus CopingSession 15-16 Relapse

PreventionGeneral

Organized by componentsFlexible, but skill focused

STAXI-II T-ScoresPre-treatment, Mid-treatment, & Post-

treatment Changes

*Trait Anger Scale

Trait Tem-perament Subscale

Trait Reaction Subscale

010203040506070

Pretreatment

Midtreatment

Posttreatment

ANGER SITUATIONPre-treatment, Mid-treatment, & Post-

treatment Changes

*Intensity (0-100)

Frequency (per month)

Duration (minutes)

Life Inter-ference (0-

0102030405060708090

Pretreatment

Midtreatment

Posttreatment

ANGER SYMPTOMPre-treatment, Mid-treatment, & Post-

treatment Changes

*Intensity (0-100)

Frequency (per month)

Duration (minutes)

Life Inter-ference (0-

010203040506070

Pretreatment

Midtreatment

Posttreatment

Anger Disorder Scale (ADS)Pre-treatment to Post-treatment Changes

Pretreatment * Post-treatment

Beck Depression Inventory - II

Total Score Pre-treatment to Post-treatment Changes

Pretreatment * Post-treatment

1015202530

LimitationsSample sizeSelf-referred participant group that were highly

motivatedNo treatment control groupIndependent coding of fidelity would be

preferableSelf-report, rather than objective physiological/

behavioral measuresAdministering treatment by one therapist

ImplicationsMany suffering from anger problems seek anger

treatment

Slightly different demographic sample also appear to benefit from CBT based treatment

High levels of comorbidities between anger and other disorders in outpatient samples

Skill Details

What are the client skills?

Self-monitoringConsequential Thinking & Time ProjectionProblem SolvingAssertiveness TrainingCognitive Rehearsal & DisputationRelaxationResponse Prevention

Cognitive Rehearsal & Disputation

CognitionsNegative vs. PositiveExpectanciesAttribution

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 TheoryFunctional AssessmentClinical Model (ABC)Techniques

Cognitive-Behavioral Therapies (Continued)

Behavioral TherapiesCognitive Therapy (CT)Rational Emotive Behavior Therapy (REBT)Problem Solving Dialectical Behavior Therapy (DBT)Acceptance and Commitment Therapy (ACT)Functional Analytic Psychotherapy (FAP)

CBT: Behaviorist ModelAntecedentBehaviorConsequence

CBT – what are the strategies?

CBT attempts to change behaviors by modifying:Antecedents/Cues

Beliefs, Emotions, StressorsProcesses

Acceptance/Willingness/HFT/Distress ToleranceConsequences

Reinforcers / Punishers / Modeling

ABC Model

Activating Events

Beliefs

Consequences

Yerkes-Dodson

Cognitive Behavioral Model

A B Ce Cb

CBT: CognitiveCognitive Model

A = Activating EventsB = BeliefsC = Consequences

Emotional EducationAlexithymiaShared vocabulary for communicationUtilization of the ABC Model

Model of Emotions

Cognitive Behavioral Therapy (CBT)

General StrategiesRegulate emotionsTolerate frustration (distress)Pursue goals

Dysfunctional ThoughtsMaladaptive Cognitions

He can’t do that to me I won’t be a doormatThey had it comingF- him!He’s such an $%^&! –hole! It is the only thing he understands!

Cognitive Therapy (CT)

Automatic ThoughtsAssumptionsCore Beliefs

Irrational Beliefs (IB)Demandingness Low-frustration Tolearnce (LFT)AwfulizingGlobal 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 TherapiesIntervening at the Inference or BeliefWhat are common cognitions?• Hostile attribution or intent

• Controllable/Preventable

• Automatic thought with themes of lack of respect, injustice, inequity

• Dichotomous thinking

• Demandingness of others

• Low-frustration tolerance

• Global Evaluation of Others’ Worth

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 DisturbanceA1 B1 C1Poor work performance by new younger boss---> I might lose my job

The economy is terrible.

I must be an idiot.

A2 B2 C2Panic about losing job. It is my new bosses fault.

I can’t tolerate this.If he respected me I wouldn’t have to feel this way. This isn’t fair, I’ve been here 15 years.He is a snot nosed rich who was given this job!

Sends a hostile threatening email to the boss, and carbon copies coworkers.

A3 B3 C3Inappropriate email.

I shouldn’t have done that.This situation is really awful!I really am a loser and outcast, and now everyone knows it.

Starts drinking more than usual, and considers quitting.

Secondary CopingA1 B1 C1Poor work performance by new younger boss---> I might lose my job

The economy is really bad.

I made a really big mistake, and now it is a good idea to follow that misstep, with some good steps.

Concern

A2 B2 C2Concern about job. I can tolerate this even

though it is incredibly uncomfortable. It is really hard being in this spot. I have been in tough spots before, and gotten out. I can go and address the issues in my evaluation, and my new boss.

ConcernFrustration

Drafts a written action plan proposing ways to address negative bullets in his evaluation.

Problem Solving

Problem Solving:A Misplaced

Fundamental Definitions Problem: a situation that presents difficultyProblem Solving: a structured strategy that

elicits a multitude of responses that contains steps to maximize the likelihood of implementing a viable one

Problem Solving Examples

1.Difficult situation at work with client, vendor, employer, employee

2. I am getting into arguments with my spouse3.How to furnish a new room4.My diet plan is not producing the results I want5. I can’t find a job or appropriate romantic partner

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 lifeb. Acknowledgement- that it is possible others have coped with something similarc. Inhibit- halt the tendency to respond with initial impulse

Define problem

a. Operationalize- define all aspects of the issue in concrete (observable and

measurable) waysb. Dissect- reclassify parts into smaller

more manageable elements

Generation of Alternativesa. Brainstormingi. Criticism omitted ii. Welcome novelty and divergence iii. Encourage quantity of ideasiv. Improvement and integration of suggested ideas

Decision makingTemporal Consequential Thinking (TCT)

i. What is the probability it will achieve the desired result?

ii. If it does work what are the likely advantages in the immediate, near, mid, and long-term future?

iii. What are the likely disadvantages in the immediate, near, mid, and long-term future?

Verification & AssessmentTest-Operate-Test-Exit

(TOTE; Miller, Galanter & Pribram, 1960)

Was the implemented plan effective?1. Yes→ Exit2. No→ Go back to step 4

Assertiveness

AssertivenessDefinitionWhat is it not?

AggressivePassive

Definition #1Assertiveness: proper expression of any emotion

other than anxiety toward another person- Joseph Wolpe (1973)

Assertiveness: GoalsImprove interpersonal environment

Enhance self-efficacy

AssertivenessTwo Critical Components in definitionThe communication of feelings, desires, wants,

and preferencesThe acceptance of another person’s right of

refusal and recognition he/she may also agree but not act congruently

Assertive Communication

Four Communication StatementsWhen. . . . . . . . . . (Specific Behavior and Context)I feel. . . . . . . .(Specific Emotional State, this is

ONE word, not a metaphor or simile)Because. . . . (What I tell myself that causes the

emotion, not about him/her)What I would appreciate/like. . . . . . . .(Specific

request of other person)

Assertive AcceptanceMy Communication Rights I have a right to tell someone what I am feeling.

I have a right to ask for what I want.

After communicating Assertive Acceptance Statements

Recognition others may not give us what we want I recognize that I may not get what I want even when

someone says I will.Other people have a right to ignore my requests, deny my

requests, promise to grant my request and then not fulfill the commitment And/Or become emotionally upset

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.

Anger Managemen

anger management-psychologist-psychiatrist-therapist-training

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