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Transcript of Anger management-psychologist-psychiatrist-therapist-training
Anger Management
Can psychotherapy really work?J. Ryan Fuller, Ph.D.
New York Behavioral HealthClinical Director
© J. Ryan Fuller, 2016
Anger: Definition
© J. Ryan Fuller, 2016
What is Anger?
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Dysfunctional Anger: Diagnosis
© J. Ryan Fuller, 2016
When is anger a problem?
© J. Ryan Fuller, 2016
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)
© J. Ryan Fuller, 2016
Effects of AngerMaladaptiveInterpersonal conflictViolencePoor DrivingInappropriate risk takingPoor decision makingHealth risksSubstance abuse
AdaptiveAlerts goal blockedCommunicates feeling and perception of
injusticeDeters threatPrepares body for physical assault
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Should we change anger?
© J. Ryan Fuller, 2016
Acceptance Based Conceptualization of Dysfunctional Anger
© J. Ryan Fuller, 2016
DSM DiagnosesAntisocial Personality DisorderBorderline Personality DisorderConduct DisorderGeneralized Anxiety Disorder
(GAD) Intermittent Explosive DisorderMajor Depressive DisorderObsessive-Compulsive Disorder
(OCD)
Narcissistic Personality DisorderOppositional Defiant DisorderPanic DisorderParanoid Personality DisorderPassive Aggressive Personality
DisorderPost-traumatic Stress Disorder
(PTSD)
© J. Ryan Fuller, 2016
How do we measure anger?
© J. Ryan Fuller, 2016
Clinical InstrumentsSTAXI-II (Spielberger, 1999)
Experience
StateTrait
Expression
Anger- InAnger- OutAnger- Control
ADS (DiGiuseppe & Tafrate, 2003)
Behavioral DomainArousal DomainMotives DomainProvocationsCognitive
© J. Ryan Fuller, 2016
Anger Component Model
© J. Ryan Fuller, 2016
Componential Model of Anger
TriggerAppraisalExperienceExpressionOutcome
© J. Ryan Fuller, 2016
Triggers
© J. Ryan Fuller, 2016
Appraisals
© J. Ryan Fuller, 2016
Experiences
© J. Ryan Fuller, 2016
Expressions
© J. Ryan Fuller, 2016
Outcomes
© J. Ryan Fuller, 2016
Does anger management work, and
for whom?
© J. Ryan Fuller, 2016
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).
© J. Ryan Fuller, 2016
What treatments work?Cognitive TherapyRelaxationSkills TrainingCombinedExposure Based
© J. Ryan Fuller, 2016
How well does treatment work?
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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)
© J. Ryan Fuller, 2016
Anger: A Problem for Clinicians
© J. Ryan Fuller, 2016
What are the general challenge and questions to
implementing treatment?
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
© J. Ryan Fuller, 2016
Values
© J. Ryan Fuller, 2016
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?
© J. Ryan Fuller, 2016
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)
© J. Ryan Fuller, 2016
© J. Ryan Fuller, 2016
Clinical Focus with Angry Clients
Do you validate anger?
Which part?
Cognitions, feelings, expressions
Important for therapeutic alliance and maybe your safety.
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
What does typical CBT anger management
look like?
© J. Ryan Fuller, 2016
Combined Treatment Example
© J. Ryan Fuller, 2016
Outcome Research for Combined Anger
Treatment
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
GoalsWho are we treating?
What is the treatment?
What are the outcomes of treatment?
© J. Ryan Fuller, 2016
Population
Assessment of research participantsSCID 1 and 2PDSQADSSTAXIBDI
Exclusionary CriteriaActively psychoticGroup Inappropriate
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Demographic Characteristics
Age:45 years (11.95)
Gender Composition: 5 men and 7 women
Education:16 years (2.54)
© J. Ryan Fuller, 2016
Clinical SyndromesAxis 1 Current (Past)
Anxiety Disorder: 4/12 (9)Mood Disorder: 9/12 (8)Substance/Alcohol: 3/12 (7)
© J. Ryan Fuller, 2016
Personality Disorders Axis 2 FrequencyPassive Aggressive 7Depressive 6Obsessive Comp 5Borderline 4Narcissistic 4Avoidant 4Dependent 1Histrionic 1Paranoid 1
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
ANGER SITUATIONPre-treatment, Mid-treatment, & Post-
treatment Changes
*Intensity (0-100)
Frequency (per month)
Duration (minutes)
Life Inter-ference (0-
100)
0102030405060708090
Pretreatment
Midtreatment
Posttreatment
© J. Ryan Fuller, 2016
ANGER SYMPTOMPre-treatment, Mid-treatment, & Post-
treatment Changes
*Intensity (0-100)
Frequency (per month)
Duration (minutes)
Life Inter-ference (0-
100)
010203040506070
Pretreatment
Midtreatment
Posttreatment
© J. Ryan Fuller, 2016
Anger Disorder Scale (ADS)Pre-treatment to Post-treatment Changes
Pretreatment * Post-treatment
0
20
40
60
80
© J. Ryan Fuller, 2016
Beck Depression Inventory - II
Total Score Pre-treatment to Post-treatment Changes
Pretreatment * Post-treatment
05
1015202530
© J. Ryan Fuller, 2016
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Skill Details
© J. Ryan Fuller, 2016
What are the client skills?
Self-monitoringConsequential Thinking & Time ProjectionProblem SolvingAssertiveness TrainingCognitive Rehearsal & DisputationRelaxationResponse Prevention
© J. Ryan Fuller, 2016
Cognitive Rehearsal & Disputation
© J. Ryan Fuller, 2016
CognitionsNegative vs. PositiveExpectanciesAttribution
Specific vs. Global Stable vs. Unstable Internal vs. External
Cognitive Triad Self World Future
Irrational vs. Rational
© J. Ryan Fuller, 2016
Cognitive-Behavioral Therapy (CBT)
What is it?Learning TheoryFunctional AssessmentClinical Model (ABC)Techniques
© J. Ryan Fuller, 2016
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)
© J. Ryan Fuller, 2016
CBT: Behaviorist ModelAntecedentBehaviorConsequence
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
ABC Model
© J. Ryan Fuller, 2016
Activating Events
© J. Ryan Fuller, 2016
Beliefs
© J. Ryan Fuller, 2016
Consequences
© J. Ryan Fuller, 2016
Yerkes-Dodson
Cognitive Behavioral Model
A B Ce Cb
© J. Ryan Fuller, 2016
CBT: CognitiveCognitive Model
A = Activating EventsB = BeliefsC = Consequences
© J. Ryan Fuller, 2016
Emotional EducationAlexithymiaShared vocabulary for communicationUtilization of the ABC Model
© J. Ryan Fuller, 2016
Model of Emotions
© J. Ryan Fuller, 2016
Cognitive Behavioral Therapy (CBT)
General StrategiesRegulate emotionsTolerate frustration (distress)Pursue goals
© J. Ryan Fuller, 2016
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!
© J. Ryan Fuller, 2016
Cognitive Therapy (CT)
Automatic ThoughtsAssumptionsCore Beliefs
© J. Ryan Fuller, 2016
Irrational Beliefs (IB)Demandingness Low-frustration Tolearnce (LFT)AwfulizingGlobal Evaluation of Worth
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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?
© J. Ryan Fuller, 2016
Cognitive Interventions• Similar to those for depression and
anxiety
• Cognitive restructuring?• Rehearsal • Disputing
• Emphasis• Demands on others• Global evaluation of worth
© J. Ryan Fuller, 2016
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?
© J. Ryan Fuller, 2016
Cognitive Emphasis: Global Evaluation
• Behavior vs. Person
• Attributions
• Intent
• Concept of Self: Spiritual
© J. Ryan Fuller, 2016
© J. Ryan Fuller, 2016
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]
© J. Ryan Fuller, 2016
Secondary DisturbanceA1 B1 C1Poor work performance by new younger boss---> I might lose my job
The economy is terrible.
I must be an idiot.
Panic
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!
Anger
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.
Shame
Starts drinking more than usual, and considers quitting.
© J. Ryan Fuller, 2016
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.
© J. Ryan Fuller, 2016
Problem Solving
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Problem Solving: An Empirical Approach
Goldfried and Davison (1976)1. General Orientation
2. Define problem
3. Generation of Alternatives
4. Decision making
5. Verification
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Problem Solving: Step 2
Define problem
a. Operationalize- define all aspects of the issue in concrete (observable and
measurable) waysb. Dissect- reclassify parts into smaller
more manageable elements
© J. Ryan Fuller, 2016
Problem Solving: Step 3
Generation of Alternativesa. Brainstormingi. Criticism omitted ii. Welcome novelty and divergence iii. Encourage quantity of ideasiv. Improvement and integration of suggested ideas
© J. Ryan Fuller, 2016
Problem Solving: Step 4
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?
© J. Ryan Fuller, 2016
Problem Solving: Step 5
Verification & AssessmentTest-Operate-Test-Exit
(TOTE; Miller, Galanter & Pribram, 1960)
Was the implemented plan effective?1. Yes→ Exit2. No→ Go back to step 4
© J. Ryan Fuller, 2016
Assertiveness
© J. Ryan Fuller, 2016
AssertivenessDefinitionWhat is it not?
AggressivePassive
Definition #1Assertiveness: proper expression of any emotion
other than anxiety toward another person- Joseph Wolpe (1973)
© J. Ryan Fuller, 2016
Assertiveness: GoalsImprove interpersonal environment
Enhance self-efficacy
Emote
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
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)
© J. Ryan Fuller, 2016
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
© J. Ryan Fuller, 2016
Forgiveness
© J. Ryan Fuller, 2016
Experiential Exercises
© J. Ryan Fuller, 2016
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.
© J. Ryan Fuller, 2016
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?
© J. Ryan Fuller, 2016
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!
© J. Ryan Fuller, 2016
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.
© J. Ryan Fuller, 2016
Anger Managemen
t