Ray DiGiuseppe Describes New
Treatment for Anger at NJ-ACT Workshop
by Lynn Mollick
“Anger is the forgotten emotion in the mental health field,” asserted Raymond DiGiuseppe to an audience of 50 at NJ-ACT’s eighth Master Clinician’s Workshop on Saturday, March 8. Ray described the phenomenology of anger, effective treatment techniques, and outcome research. He began his presentation with two key assertions:
1) “I must express my anger” and “I can’t tolerate feeling angry” are two cognitions that are highly correlated with aggressive acts. Treatment should always address these cognitions. Contrary to popular belief in contemporary American culture, it isn’t necessary to express anger.
2) “More than any other emotion, anger is easily displaced.” Once anger is aroused, it readily becomes attached to other stimuli. Therapists should work with the most recent, proximal stimulus, the one foremost in the patient’s mind, before addressing the distal stimulus.
Interviewing Techniques
Interviewing anger patients requires a special style because these patients do not answer questions about their problem in a thoughtful, informative way. Clinicians will learn more if they ask close-ended questions that require yes or no answers instead of the open-ended questions that are effective with anxious and depressed patients. For example, the question “do you slap/push/curse/hit?” will yield more useful information than “tell me about your anger problem.”
Anger patients often minimize their provocative behavior. For example, they may say that they slapped someone, when actually they hit so hard their victim had to be taken to a hospital. It is always important to ask, “does your spouse/significant other think you have an anger problem?”
Developing a strong therapeutic alliance early in treatment is crucial. However, angry patients’ blaming, condemning, and self-righteous attitudes often make it difficult for therapists to experience and express empathy. Ray’s advice: Express empathy even if you don’t feel it. Acknowledge the provocation experienced by your patient, even when you believe the patient’s response is out of proportion. This strategy helps to prevent patients from feeling misunderstood and angrily terminating therapy prematurely.
Angry patients want the people around them to change, a goal that is incompatible with psychotherapy. At the beginning of treatment, we should accept whatever goal our patients suggest, even if the goal is not psychological.
Anger Episode Record
It is essential to focus anger patients on the long term negative consequences of their outbursts, instead of the short term benefits. We should discuss these consequences in terms of the patient’s stated goals – for example to preserve their marriage or limit legal action against them – in order to help the patient anticipate the costs and downgrade the benefits of their angry behavior. Teaching patients to consider the consequences of their anger is a pivotal component of treatment because it moves patients from trying to change others to trying to change themselves.
Managing Physiological Arousal & Skill Training
Anger creates immediate, high physiological arousal. Using relaxation training early in treatment to lower arousal helps anger patients attend to constructive cognitions and behaviors. Coping self-statements can help patients remain calm in high risk situations. Learning to inhibit angry responses with self-instructional training prevents patients from performing further self-destructive acts.
Anger patients frequently have no adaptive script for dealing with conflict situations. Assertion training with role-playing of adaptive behaviors and calming self-instructions is an important component of anger management treatment. Exposure is essential. Role playing is especially effective, but imaginal exposure is also useful. Therapists should help patients identify role models who experience angry emotions but cope with them adaptively. This technique enhances motivation and helps the patient generate new responses to problem situations.
Cognition & Schema Change
To avoid rupturing the therapeutic alliance, therapists should use caution and tact when encouraging angry patients to modify their dysfunctional cognitions. Cognitions that increase anger include demandingness attributions of hostility, external attributions of blame, perceived disrespect and unfairness, and thoughts of retribution and revenge.
Demandingness refers to the expectation that others should behave as the patient wishes them to behave. Therapists can side with the desire – wanting anything is OK – but we must challenge the expectation. Patients will be unable to behave constructively until they lower their expectations for achieving whatever they desire.
A simple calculation can be helpful: Ask the patient to think of something someone close to them does that makes them angry. For example, a patient’s spouse might leave the milk on the counter every morning. Ask the patient to compute how many times this has happened in the course of the marriage. If the patient has been married for 13 years, and the spouse leaves the milk out every day of the working week, that is 13 years X 5 days a week X 52 weeks per year, or 3,380 times. Then ask the patient why they’re surprised each morning when they see the milk on the counter. Repeated many times, this exercise helps patients change their unrealistic expectations. Referring back to the patient’s goals, the therapist can add, “It doesn’t matter that it isn’t right. If you accept the situation, you will be able to achieve your goal.”
Forgiveness
In teaching forgiveness, patients should not attempt or be asked to accept the admonition “forgive and forget.” Since people seldom forget transgressions against them, they must make a conscious effort to forgive or accept what has happened to them. Remind patients that forgiveness and acceptance don’t mean reconciliation or approval, and the world is not fair.
Research on Efficacy of Anger Treatments
The efficacy of cognitive-behavioral treatment for anger is firmly established. To date five meta-analytic studies have reported effect sizes around 1.0. Most of the treatments studied employed a multi-modal approach – usually relaxation training, cognitive restructuring, conflict resolution training, and exposure with response prevention (learning new responses to anger triggers).
Significantly, improvement has been found on a variety of dependent variables: physiological measures, spouse and family assessments, and self-report. Additional improvement has often occurred between post-treatment assessment and long term follow-up. Furthermore, treatment is effective for every age group and for men and women equally. The only limitation of these data is that they reflect treatment of volunteers. In real life, anger patients are often coerced into treatment.
A Nosology of Anger Problems
DSM-IV notes only one anger problem, Intermittent Explosive Disorder, a problem of impulsivity. Ray believes that there are different kinds of anger problems and each requires a specific treatment. He proposed the following nosological system:
1) Pervasive Anger Disorder – These are the ruminators whose persistent bitterness and resentfulness dominates their emotional experience. There are two sub-types:
1a) Deliberate - individuals who are very controlled and vengeful. Examples include terrorists, planful serial rapists and murderers. Their treatment should emphasize forgiveness and cognitive restructuring.
1b) Indirect- individuals who are very controlled and sneaky about expressing their anger. They commit passive-aggressive acts. Examples include gossips, disgruntled employees, and failing students who commit petty acts of vandalism or thievery. Their treatment should emphasize assertion training, exposure, forgiveness, and cognitive restructuring.
2) Impulsive Aggressive Disorder – These are individuals with high, pervasive anger and resentment who do not control their emotions. They do not plan their revenge, so the targets of their anger are often unrelated to the original source. Examples include: impulsive rapists and murderers, passion murderers.
Impulsivity is a problem for these individuals. They should be treated with self-instructional training and development of consequential thinking skills.
3) Overcontrolled Anger Disorder – These are individuals who experience anger, but do not ruminate or express their anger directly. They are demanding and condemning of others. In treatment they require assertion training and cognitive restructuring.
4) Suppressed Anger Disorder – These are individuals who have no inkling that they’re angry. They are often dragged into marital therapy by their spouses or treated by cardiologists when they become ill. Often they are depressed. Gestalt techniques help these individuals to figure out what they’re angry about.
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