Assessment and Treatment of Anger as a Clinical Problem
Despite the fact that no official diagnostic category exists for an anger disorder in the Diagnostic and Statistical Manual of Mental Disorders, fourth edition, text revision (DSM IV-TR; American Psychiatric Association, 2000), clinicians report seeing as many angry clients as they do clients with depression and anxiety problems (Lachmund, DiGiuseppe, & Fuller, 2005; Posternak & Zimmerman, 2002). The failure to have a diagnostic model to understand anger seems to lead clinicians to overdiagnose clients presenting with anger problems and to categorize clients with disorders such as personality disorders or organic brain syndrome when no symptoms appear to support these disorders. It is possible that the presence of anger elicits the clinician’s fear of aggression that leads to choosing more pathological diagnoses than can be supported. The first rule of practice is not to overdiagnose and present a more pessimistic impression of the client than is warranted. DiGiuseppe and Tafrate (2007) have proposed criteria for an anger regulation and expression disorder with three subtypes. These include a predominately subjective type, which represents holding one’s anger in with few aggressive outbursts; a predominately expressive type, which represents a person who may have average degrees of trait anger but who explodes with aggression when he or she experiences anger; and a combined type.
(p. 211) Eckhardt, Norlander, and Deffenbacher (2004) noted that anger assessment instruments fail to present a unified model of anger as a clinical problem. They differ widely on which characteristics of anger they sample to include. Thus, the choice of which assessment instrument to use can result in very different information about a client. Many scales lack clear theoretical foundations and fail to specify how they define anger and which characteristics of anger they are sampling and why. The characteristics and purpose of many anger scales are unspecified. Many scales fail to specify whether they assess anger as a basic emotion/personality trait that is normally distributed or as a form of psychopathology or clinical problem. Clinicians should carefully select anger instruments that have a clear definition of anger as a clinical problem, and sample widely among the characteristics of anger such as anger triggers, cognitions, phenomenology, motives, and behaviors. The scale should have good psychometric characteristics, and the items should have been developed to be appropriate for diverse cultural and age groups.
Because anger is a multivariate construct, clinicians should use instruments that include many dimensions of anger. In such scales, the reliance on total scores of the psychometric instrument could be deceiving. Total scale scores could be in the normal range while the client has significant problems on several components of anger such as resentment, rumination, or revenge. Some clients can have average trait anger, but when they get angry they are vicious and sarcastic. Others could have modest elevations of a trait or total anger scale and an external expression of anger yet experience serious anger-in with brooding and rumination.
Several reviews of anger treatments have appeared (DiGiuseppe & Tafrate, 2007). Most of the empirical literature supports the effectiveness of cognitive-behavioral interventions. The most widely supported anger treatments included (a) relaxation training; (b) cognitive restructuring as proposed by Beck’s cognitive therapy, Ellis’s rational emotive behavior therapy, Nezu and Nezu’s social problem solving therapy, and the Seligman reattribution model; (c) exposure interventions where clients learn new response to anger triggers; and (d) rehearsal of new positive behaviors to resolve conflict. Limited research supports mindfulness meditation, a Buddhist intervention, and Yalom’s process-oriented or experiential group therapy. No outcome studies exist to draw upon to evaluate the effectiveness of therapies based on other theoretical orientations.
Anger treatments are equally effective for all populations that have been studied. Most of the research studies report that change is of a large magnitude. However, the magnitude of change is less than for anxiety and depressive disorders. Most likely, we cannot treat anger as successfully as we do other emotional problems, and we still need new creative interventions.
Several important topics have been left out of understanding of anger and the assessment and treatment models, and the field could increase its effectiveness if these topics were incorporated into clinical practice. These topics influence the therapeutic alliance with angry clients, and clinicians should attend to them carefully.
One characteristic of anger that permeates all areas of clinical practice is the desire for change. Humans all over the globe have little desire to change or control their experience of anger. The only emotion that people are less likely to want to change is joy (Scherer & Wallbott, 1994). This feature of anger poses the greatest problem for practitioners. Angry clients do not come for therapy; they come for supervision. They want us to consult with them about how to change the people who anger them. People in general evaluate the consequence of their anger as trivial and not harmful to their targets or victims. They see themselves as victims and believe that their reactions are justified and reasonable (Pinker, 2011).
Because angry clients often do not see their anger as a target for change, they might not store the information about their anger together. Their lack of insight on the damage they have done to others and to their interpersonal relations often leads angry clients to fail to develop a self-schema concerning their angry reactions. As a result, open-ended questions often fail to access important information about the frequency, intensity, and triggers of their anger or about the behavioral reactions that their anger sets in motion. Because of (p. 212) these assessment problems, clinicians could use some type of more structured assessment. This could take the form of more structured interview questions or self-report inventories, and interviews with significant others.
Angry clients often arrive for treatment in a precontemplative stage of change, and the agreement on the goal to change their anger is at best ambivalent. Most of the empirically based interventions for anger rely on action-stage interventions and begin with the assumption that the client wants to change. Perhaps clinicians had best assume that the client’s goal to change his or her anger is weak, fragile, or absent. Therapy could start with motivational enhancement interventions that strengthen the desire to change before going on to other interventions. Several characteristics of anger suggest topics to explore during the motivational enhancement work. External attributions for blame and justification because one has been hurt are two of the cognitive hallmarks of anger. Failure to take responsibility for one’s emotions is another. Motivational enhancement interventions appear to be the first line of interventions (DiGiuseppe & Tafrate, 2007).
Because angry clients believe that their anger was justified and that they are victims of another person’s transgression, active interventions can easily have the result of the client feeling invalidated. Sometimes angry clients can accuse the therapist of siding with their enemies. It is important to validate the angry client’s sense of being a victim and focusing on the existential choice of how he or she will respond to an unfair or unjust world. Therapists can easily become trapped into pointing out that the client’s retaliation was much more severe than the transgression against them. Clients usually fail to perceive their retaliation as excessive and usually perceive themselves as justified. People will rate their anger as positive if they accomplish their angry motives, even if the motives are destructive or selfish. A discussion of the relative levels of retaliation interaction is likely to lead to invalidation and a rupture in the therapeutic alliance. It is best to acknowledge that the client perceives his or her self as a victim and focus on the different reactions the client can chose to react to the transgression, as well as the benefits of each. This approach is less threatening and less invalidating than challenging the client’s exaggerated thoughts about the antagonist who triggered the anger.
Another characteristic of anger that could threaten the therapeutic alliance concerns empathy. People usually fail to elicit empathy from others when they experience anger (Palfai & Hart, 1997). No one likes to hug a porcupine. Because psychotherapists are people too, they often fail to experience empathy for and can have difficulty expressing empathy toward their angry clients. One can identify and reflect the angry client’s desires and feelings without approving of them.
Angry clients often want to express their anger and believe that it is good and healthy for them to do so. Overwhelming evidence contradicts this common assumption (Olatunji, Lohr, & Bushman, 2007). Cathartic expression only reinforces the person’s probability of having an anger response to a trigger associated with the episodes. Clinicians should discourage cathartic expression and help clients develop and practice new calm responses to their anger triggers.
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. Eighty percent of all published and nonpublished 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 review of anger treatments (see DiGiuseppe & Tafrate, 2007) 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. However, aggression is an important dependent variable. What is it about group therapy that facilitates less change for aggression? A number of angry clients starting an anger management group at one time can easily reinforce each other for antisocial and aggressive attitudes. Clinicians should take strong efforts to avoid and interfere (p. 213) with social reinforcement of antisocial attitudes and behaviors such as these.
Revenge is a strong motive often associated with anger. Interestingly, the psychological community has rarely included revenge in content sampled in anger assessment instruments or in the empirically supported treatments for anger. The scientific research shows that revenge is a strong component of anger and the presence of this motive predicts aggressive behaviors. Revenge appears to be very reinforcing and areas of the brain associated with reward are active when people contemplate it. This suggests that the reinforcement of revenge plays an important role in the regulation of anger. No consensus has emerged on how to intervene to reduce someone’s desire for revenge. Clinicians can use models of intervention designed for other positively reinforcing behaviors such as drug and alcohol abuse. Recently there has been an interest in forgiveness as a form of therapy to counteract revenge. A growing literature appears to support the effectiveness of forgiveness interventions.
Anger has long been thought to be an impulsive emotion. However, impulsivity does lead to an increase in impulsive behavior, and anger episodes last longer than all other emotion episodes (Scherer & Wallbott, 1994) in all cultures that have been studied. This suggests that anger involves a good deal of rumination. Also, anger rumination is very highly correlated with anger impulsivity. Perhaps that rumination about transgressions leads to anger and the desire for revenge. As the rumination persists, a person’s self-control to inhibit his or her aggressive impulses is taxed and the self-control is depleted, leading to the phenomenology of an uncontrollable response (DiGiuseppe & Tafrate, 2007). Perhaps more interventions could focus on the rumination of angry clients rather than their impulsivity.
It is helpful to distinguish between two types of anger triggers (Robins & Novaco, 1999). The first are immediate or proximal stimuli that trigger immediate experiences of anger. Most clients report being very much aware of the immediate proximal cues to their anger, and therapy usually starts with teaching clients new cognitive-behavioral responses to such cues. However, many if not most angry clients have distal issues about which they are angry. Usually there are some resentments over past events about which the client ruminates. These distal or past resentments set the stage for the way clients interpret their world. The client may have resentment about specific and discrete abuse experiences, a history of ongoing abuse, or he or she may be an “injustice collector,” who can recount a litany of ways he or she has been cheated by the world. The anger triggered by distal experiences seems to lower the clients’ threshold for anger episodes and makes them more sensitive to proximal triggers. Clients often deny that their proximal triggered anger episodes have anything to do with the distal issues. They often do not wish to work on the anger and resentment associated with the distant issue. However, after they have learned some coping strategies to better cope with the proximal issues, they become more open to exploring the anger that seethes from these distal resentments. Clinical experience suggests that more than half of those clients presenting with anger problems have such resentments. Most therapy manuals used in therapeutic outcome studies focus on teaching new reactions to the proximal stimuli and fail to focus on the distal resentments.
Anger-in and anger-out are often considered orthogonal, independent aspects of anger. However, this does not seem to be the case. Anger-in scores seem to have an accelerating exponential effect on anger-out scores. Thus, the more a person holds his or her anger in, the higher the probability that a person will express his or her anger with some type of outwardly expressed aggression. When angry clients experience anger-in, they are annoyed by another person’s behavior and make no mention of it. They sometimes engage in mind reading and think that the other person should know how they feel and what they do not like and fix it. They usually fail to assertively speak up. Therefore, the conflict goes unresolved. Angry clients are often very unassertive. They fail to speak up about an unpleasant event. After a long period of mind reading and no resolution, their anger and frustration increases and their urge to aggress grows. Then they explode. Teaching assertiveness is an important component of anger treatment. This provides the client a new (p. 214) skill to negotiate conflict. A problem, however, is that the angry client can demand that his or her assertiveness obliges the other person to comply; and of course no such guarantees of compliance exist. Angry clients can often learn assertiveness and say the word correctly. Anger is one of the most paralinguistically expressive emotions. Although their words may be mannerly, clients may still communicate anger in their tone or gesture. It is important that these aspects of communication receive adequate attention in the rehearsal of assertive responses.
References and Readings
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DiGiuseppe, R., & Tafrate, R. (2007). Understanding anger disorders. New York: Oxford University Press.Find this resource:
Eckhardt, C., Norlander, B., & Deffenbacher, J. (2004). The assessment of anger and hostility: A critical review. Aggression and Violent Behavior, 9(1), 17–43.Find this resource:
Lachmund, E., DiGiuseppe, R., & Fuller, J. R. (2005). Clinicians’ diagnosis of a case with anger problems. Journal of Psychiatric Research, 39(4), 439–447.Find this resource:
Olatunji, B. O., Lohr, J. M., & Bushman, B. J. (2007). The pseudopsychology of venting in the treatment of anger: Implications and alternatives for mental health practice. In T. A. Cavell & K. T. Malcolm (Eds.), Anger, aggression and interventions for interpersonal violence (pp. 119–141). Mahwah, NJ: Erlbaum.Find this resource:
Palfai, T. P., & Hart, K. E. (1997). Anger coping styles and perceived social support. Journal of Social Psychology, 137, 405–411.Find this resource:
Pinker, S. (2011). The better angels of our nature. New York: Viking.Find this resource:
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Robins, S., & Novaco, R. (1999). A systems conceptualization and treatment of anger. Journal of Clinical Psychology, 55, 325–337.Find this resource:
Scherer, K. R., & Wallbott, H. G. (1994). Evidence for the universality and cultural variation of differential emotional response patterns. Journal of Personality and Social Psychology, 67(1), 55–65.Find this resource: