Anger Treatment And Its Special Challenges
By Raymond W. Novaco, Ph.D.
NCP Clinical Quarterly 6(3): Summer 1996
Problems of anger and aggression are on the forefront of our attention as citizens and clinicians. Uncontrolled anger, being too easily transformed into destructive aggression, beckons for therapeutic intervention to improve self-regulation, particularly in a societal context where external inhibitory forces have been weakened. The treatment of anger, however, presents a number of special challenges to clinicians and to health care institutions, as the delivery of "anger management" services is less than straightforward.
As is well known to this readership, anger has been found in epidemiological, clinical, and empirical reports to be a prominent symptom of traumatic exposure. For persons with PTSD, anger and aggression have wide-ranging impact on their personal well-being, their families, their work settings, and society at large. The treatment of anger, nevertheless, remains a relatively neglected topic in clinical research, especially with seriously disturbed patients. Vietnam combat veterans with PTSD most certainly fall in that latter category. Recent studies (1,2) show the heightened anger associated with Vietnam combat PTSD patients and call attention to the importance of anger control skills. These patients are not only treatment resistant, they are additionally problematic because of their readiness to become angry during therapy and towards the therapist.
The intractability of human aggression is rooted in its instrumentality; and just as aggression is inevitably acquired, so too is anger learned for its adaptive functions (3). Thus, proposals of "anger management" might be viewed disparagingly as strategies to stifle the individual human personality or to constrain the will to determine one's own destiny. As an energizer of aggressive behavior, anger may have value in the context of combat, although strong arousal can impair the processing of complex information. However, outside of combat, episodes of anger and aggression are problematic for military organizations, and, in civilian life, a disposition to react quickly and intensely with anger and aggression is inappropriate. Anger is indeed a prominent concern for Vietnam veterans seeking clinical services (4).
Angry people are often fiercely resistant to anger treatment. Because anger can mobilize one's psychological resources, energizing behaviors that take corrective action, we need our capacity for anger as a survival mechanism. In an increasingly bureaucratized world that diminishes the significance of the individual, anger is a psychological fortification for a sense of worth. Anger provides for personal resilience. It is a guardian of self-esteem, it potentiates the ability to redress grievances, and it can boost determination to overcome obstacles to happiness and aspirations.
Anger, thus, is a Janus-faced character in psychosocial images. Clients may very well be attached to those psychosocial images of anger as energizing, empowering, justifying, signifying, rectifying, and relieving, but they can nonetheless be helped to see its dysfunctional, counterproductive effects, without a hard-sell on the contrasting social metaphors of anger as eruptive, destructive, unbridled, savage, venomous, burning, or consuming. Achieving this, however, hinges on the therapeutic relationship, and there are a number of refractory impediments to that.
The Challenging Task Of Treating Angry Clients
Unique difficulties arise in the treatment of anger that can thwart or derail the therapeutic process. Because anger is an activator of aggressive behavior, because it is a manifestation of intolerance for frustration, and because it has instrumental value as part of a learned style of coping with aversive events, there are some common obstacles and concerns for therapists.
A prevalent concern is personal danger. Needless to say, it is unsettling for therapists and counselors to work with persons who have explosive tendencies. In cases where there has been a history of violent behavior, the clinician's concern is easily aroused by the client's expressions of anger and by descriptions of anger experiences accompanied by aggressive impulses. It is imperative that the therapist be at ease with client anger, expressed in narrative accounts and as experienced in the therapy room or on the ward. Precautions for personal safety should always be in place, particularly in conjunction with treating mentally disordered patients who have been previously violent.
While on the one hand, anger imparts a sense of mastery, on the other, it can signify that one is out of control. When it attains levels of intense arousal, it can be profoundly troubling to the person having the anger experience. In this regard, the client needs the therapist to provide a sense of control and in many ways to serve as a role model for how to handle anger experiences (modeling of anger control coping skills is, in fact, and explicit part of the my treatment procedure). Because the experience of strong anger and its implied loss of control can be anxiety-engendering for the client, it is imperative that the therapist not be unduly alarmed by exposure to anger. First, the admixture of fear might even intensify rage reactions. Secondly, the troubled individual might well wonder whether it is safe or the least bit useful to be revealing matters of deep personal significance to someone who becomes unsettled upon hearing the disclosures.
Some clients having anger problems may even test the therapist's acceptance of them by describing angry feelings, hostile fantasies, and violent behavior. Issues of trust often take the form of anger reactions, hence the need for composure on the part of the therapist is imperative. Also, when clients sense that their psychological realities alarm the therapist, the helping process is undermined. Treatment of angry clients requires the mastery of anxiety about assaultive risk. This requires sharpened awareness, safe arrangement of physical surroundings, training in personal protection, and a security response to crisis.
A second difficulty in doing treatment with persons who are prone to provocation is that they are inherently impatient. Being in treatment often involves ambivalence, and some clients will have poorly defined or unrealistic goals for the course of therapy. They may thus become frustrated when desired treatment effects are not quickly forthcoming. As their impatience mounts, they may become inclined to disengage from therapy, the impulse for which may be activated by relatively minor events in their regular life or in conjunction with receiving treatment. Because angry people, by their own long-standing behavior, have raised the probability of exposure to aversive events, the therapist should be prepared for such occasions of client frustration and demoralization. It is imperative that the clinician exercise good coping skills when faced with client expressions of frustration, viewing this as a manifestation of the clinical problem and to not "take it personally." Rather than making undue personal attributions about the client's reactions, the therapist can utilize the manifest crisis as an opportunity to teach anger coping skills. Instead of merely providing reassurance and attempting redirection, the client's frustration and impatience can be engaged and explored. The client thereby be taught how to communicate about anger and how to deal with conflict.
Given the impatient disposition of clients with anger problems, it is advantageous for a treatment program to be clearly defined and structured, so as to minimize the frustration that can result from vague expectations regarding treatment. Moreover, the proneness to frustration and impatience that are intrinsic to the problem constellation also dictates that treatment studies be thoughtfully designed with control group conditions that do not activate anger responses.
A third and very important complication in treating angry, aggressive people is that this action emotion complex has instrumental value in dealing with aversive situations. Anger has a potentiating function, imparting a sense of mastery or control. One can overcome constraints and dispatch unwanted others by becoming angry and acting aggressively. Persons who are so disposed are reluctant to relinquish this sense of effectiveness. The propensity for anger reflects a combative orientation in responding to situations of threat and hardship, which, as an over-generalized response, is clearly problematic; one does not, however, easily surrender this learned style of coping with stressful life demands.
If the clinician's presentation of "anger control" therapy suggests to the client that he will be robbed of his power, the leverage for treatment is easily undermined. Clients need to understand that learning anger control skills will mean that they will become more powerful rather than less powerful. The stress inoculation approach indeed provides new coping strategies for handling provocation in an adaptive manner. To some extent this involves skills in interpersonal communication and assertiveness, but many problems entailing anger cannot be resolved so straightforwardly. Hence, anger control must be approached in a preventive mode and in an arousal-regulatory mode, as well as by enhancing overt behavioral skills. Clients must learn to ask themselves, not "What should I do when I get angry," but "How can I not get angry in the first place; and, if I do get angry, how can I keep the anger at a moderate level of intensity?" They can be helped to see that, whatever it is that they want to accomplish of a lasting nature, anger does not increase its likelihood of attainment. The dysfunctionality of anger is the keystone for therapeutic change.
A fourth impediment to treatment is that clients with problems of anger and aggression have deficiencies in cognitive and social skills and in economic resources. This is particularly the case for persons institutionalized for mental disorder, developmental disabilities, or criminal behavior. Often of low socio-economic status, they have few resources to overcome their anger difficulties. Beyond the ordinary inertia impeding change, they can develop a hopelessness about ever being different. For cognitive-behavioral treatments like mine, institutionalized people inevitably need help in elementary matters (e.g. identifying emotion, differentiating types and degrees of emotion, and recording of self-observation) that are at the foundation of self-regulatory procedures such as self-monitoring; they will need help with self-disclosure and coming to terms with the costs of anger. If treatment is done in a group format, they will need added assistance in social interaction.
Anger Treatment And PTSD
Given the far-ranging negative impact of anger problems, the dearth of research on treatment for PTSD patients is lamentable. However, a recent study (5,6) conducted with Vietnam combat veterans in Hawaii having severe PTSD and severe anger offers an optimistic note for the efficacy of anger treatment. The project utilized the stress inoculation approach to anger treatment, based on a cognitive-behavioral intervention that has been demonstrated to be effective in numerous studies involving experimental, multiple baseline, and case study designs, conducted with a wide range of clinical populations (7,8).
The core components of the treatment consist of (a) cognitive modification techniques (attentional focus strategies, cognitive restructuring, problem-solving skills, and self-instruction); (b) arousal reduction procedures, primarily relaxation counter-conditioning but also breathing regulation and imagery exercises; and (c) behavioral skills for dealing with provoking situations, modeled and rehearsed with the therapist. The "stress inoculation" approach is designed as a three-phased procedure of cognitive preparation, skill acquisition, and application training, first developed by Meichenbaum for problems of anxiety and then extended by myself to anger disorders (8,9).
The "inoculation" concept is a medical metaphor, and the treatment approach involves exposing the client to graduated dosages of a stressor that challenge but do not overwhelm coping resources. The client is taught a variety of cognitive modification, arousal reduction, and behavioral skills, which are then applied to conditions of provocation (stressor) exposure in a graduated, hierarchical procedure. Provocation is simulated in the therapeutic context by imagination and role play of anger incidents from the life of the client, as directed by the therapist, in either an individual or group therapy format. This is a graduated exposure to provocation based on a hierarchy of anger incidents produced by the collaborative work of client and therapist. This graduated, hierarchical exposure, done in conjunction with the teaching of coping skills (cognitive, somatic, and behavioral) is the basis for the "inoculation" metaphor.
The anger control therapy involves interventions in the cognitive, somatic, behavioral, and environmental domains, thus being congruent with a model for anger assessment (10). The client is helped to restructure cognitions, to regulate arousal, to engage in problem-solving action, and to makes changes in the environmental fields within which anger experiences occur. The treatment aims to promote anger self-regulation, developing coping skills by means of an approach that emphasizes collaboration with the client.
Recently, a controlled treatment trial was conducted through the Hawaii VA, in collaboration with Drs. Claude Chemtob, Roger Hamada, and Doug Gross (5,6). This was an experimental analysis of the stress inoculation anger therapy, understood to be a treatment adjunct to routine psychological and medical care. Our experimental design involved the anger treatment, being evaluated against a routine clinical care control condition, which consisted of an amalgam of treatments. The patients in the study had severe PTSD and severe anger. Compared to the control treatment condition, we obtained significant anger treatment group effects on multiple measures of anger reactions and anger control at post-treatment, and the significant differences in anger control were maintained at 18-month follow-up. By showing that such severely angry patients can increase their anger regulatory abilities, our findings are indeed encouraging for continued work with this population having great needs for clinical care.
References
1. Chemtob, C.M., Hamada, R.S., Roitblat, H.L., & Muraoka, M. (1994). Anger, anger control, and impulsivity in combat-related post-traumatic stress disorder. Journal of Consulting and Clinical Psychology, 62, 827-832.
2. Lasko, N.B., Gurvits, T. V., Kuhne, A.A., Orr, S.P., & Pitman, R.K. (1994). Aggression and its correlates in Vietnam veterans with and without post-traumatic stress disorder. Comprehensive Psychiatry, 35, 373-381.
3. Novaco, R.W. (1976). The functions and regulation of the arousal of anger. American Journal of Psychiatry, 133, 1124-1128.
4. Scurfield, R.M., Corker, T.M., & Gongla, P.A. (1984). Three post-Vietnam "rap/therapy" groups: An analysis. Group, 8, 3-21.
5. Chemtob, C.M., Novaco, R.W., Hamada, R.S., Gross, D.M., & Smith, G. (in press). Anger regulatory deficits in combat-related post-traumatic stress disorder. Journal of Traumatic Stress.
6. Chemtob, C.M., Novaco, R.W., Hamada, R.S., & Gross, D.M. (in press). Cognitive-behavioral treatment for severe anger in post-traumatic stress disorder. Journal of Consulting and Clinical Psychology.
7. Novaco, R.W. (1975). Anger control: The development and evaluation of an experimental treatment. Lexington: D. C. Heath.
8. Novaco, R.W. (1994). Clinical problems of anger and its assessment and regulation through a stress coping skills approach. In W. O'Donohue & L. Krasner (Eds.), Handbook of psychological skills training: Clinical techniques and applications. Boston: Allyn & Bacon.
9. Meichenbaum, D. (1985). Stress inoculation training. New York: Pergamon Press.
10. Novaco, R.W. (1994). Anger as a risk factor for violence among the mentally disordered. In J. Monahan & H. Steadman (Eds.), Violence and mental disorder: Developments in risk assessment. Chicago: University of Chicago Press.
|
