Cognitive-Behavioral Conceptualization and Treatment of Anger

doi:10.1016/j.cbpra.2009.12.004

Cognitive and Behavioral Practice

Volume 18, Issue 2, May 2011, Pages 212-221

https://doi.org/10.1016/j.cbpra.2009.12.004 Get rights and content

Abstract

Anger is conceptualized within a broad cognitive-behavioral (CBT) framework emphasizing triggering events; the person's pre-anger state, including temporary conditions and more enduring cognitive and familial/cultural processes; primary and secondary appraisal processes; the anger experience/response (cognitive, emotional, and physiological components); anger-related behavioral/expressive components; and anger-related outcomes and consequences. Functional/adaptive and dysfunctional/maladaptive anger are briefly discussed along with assessment strategies. Several change-oriented CBT interventions for clients who identify anger as a personal problem and seek therapy for anger reduction are outlined. Many angry clients, however, are not at a change-oriented stage of readiness. For such clients, strategies for increasing readiness and attending to the therapeutic alliance with angry clients are outlined. These principles and strategies are then applied to the case study.

Section snippets

A Working Model of Anger

Anger is a natural part of the human experience. The human nervous system is hard-wired for the experience of anger, and most emotion theorists consider anger one of the basic human emotions. Temperament, neurological, hormonal, and other physiological processes certainly contribute to the experience and expression of anger. Nonetheless, anger arises from the converging interaction of (a) one or more triggering events, (b) the person's pre-anger state consisting of both momentary states and

Application to the Case Study

The client, Mr. P (Santanello, 2011), is not a good candidate for change-oriented CBT interventions. In prior therapy, he failed at a relaxation intervention and did not see the relevance of that intervention. He does not conceptualize anger as a personal problem or seek help for it. Motivation for therapy appears low and not self-directed; he is in therapy primarily to reduce pressure from others. However, it would be important to clarify why he is coming for therapy now, because there may be

Acknowledgement

This manuscript was supported, in part, by Grant R49/CCR811509 from the Centers for Disease Control. Its contents are solely the responsibility of the author and do not necessarily represent the official views of the Centers for Disease Control and Prevention.

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In addition, anger is a problem area that may be associated with less perceived stigma than PTSD, anxiety or depression and hence assessing for anger in military contexts may be more likely to generate accurate self-reporting. The translation and implementation implications of these findings indicate the need to ensure that anger assessment is routinely included in clinical assessment and measurement approaches and that clinicians are cognisant of, and trained in treatment approaches with the existing evidence base now being used and tested with active and ex-serving veteran populations (Cash et al., 2018; Deffenbacher, 2011; Morland et al., 2010). The current study has a number of strengths, such as the large sample size, the inclusion of both veterans and military personnel in the one study sample, and the use of established measures.
Problem anger is increasingly identified as an important issue, and may be associated with suicidality and violence. This study investigates the relationship between problem anger, suicidality, and violence amongst veterans and military personnel.
Cross-sectional survey data from n = 12,806 military personnel and veterans were subject to analyses. These considered the weighted prevalence of problem anger, while further analyses of veterans (n = 4326) considered risk factors and co-occurrence with other psychiatric conditions. Path analyses examined inter-relationships involving anger, violence and suicidality.
There were 30.7% of veterans and 16.4% of military personnel that reported past month problem anger, while 14.9% of veterans and 7.4% of military personnel reported physical violence. There were higher levels of suicidality among veterans (30.3%), than military personnel (14.3%). Logistic regression models indicated that PTSD was the strongest risk factor for problem anger (PCL-5, OR = 21.68), while there were small but substantial increases in anger rates associated with depression (OR = 15.62) and alcohol dependence (OR = 6.55). Path models indicated that problem anger had an influence on suicide attempts, occurring primarily through suicidal ideation, and an influence on violence. Influences of problem anger on suicidal ideation and violence remained significant when controlling for co-occurring mental health problems.
Problem anger, violence, and suicidality are common and inter-related issues among military personnel and veterans. Problem anger is a unique correlate of suicidality, supporting the need for anger to be included as part of violence and suicide risk assessment, and clinician training.
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In the present report from the Rhode Island Methods to Improve Diagnostic Assessment and Services (MIDAS) project, we describe the development and validation of the Clinically Useful Anger Outcome Scale (CUANGOS). Current anger measures vary in their psychometric quality, clinical utility, and clinically relevant content coverage, and no one scale addresses all three of these key considerations. We aimed to develop a brief, clinically useful anger scale that (a) assesses clinically relevant aspects of anger, (b) performs well across different patient populations, and (c) is brief, accessible, and easy to use in routine clinical practice either as a stand-alone measure or as part of an assessment battery. Analyses included data from 2710 psychiatric outpatients and 1397 partial hospitalization patients. We used data from randomly drawn subsamples to select items with good psychometric properties and sufficient distinction from measurements of other emotional dysfunction, resulting in a 5-item scale. In reliability and validity analyses using the remaining participants, CUANGOS scores showed high internal consistency and appropriate test-retest reliability, as well as excellent discriminant validity from measurements of depression and anxiety. CUANGOS scores converged strongly with clinician ratings of subjective and overt anger and differentiated across all or almost all levels of clinician-rated anger severity. CUANGOS scores were also significantly higher in patients with anger-related disorders versus patients with other psychiatric disorders. Results provide promising evidence for the CUANGOS as a reliable and valid measurement of anger in clinical populations. Moreover, the CUANGOS is brief and feasible to incorporate into routine clinical practice.
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Anger is a normal human emotion that manifests in a spectrum of expression from frustration and irritability to fury and rage Deffenbacher (2011).
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To develop and test an Arabic version of the Dimensions of Anger Reactions 5 (DAR-5) scale, a five-question scale to screen for anger distress and problematic anger in adults and adolescents.
DAR-5 was translated into Arabic, then back translated into English, and finally rechecked for accuracy. Participants were 1641 Syrian adults, (621 males and 1020 females) and 784 Syrian adolescents (355 males and 429 females) aged between 14 and 16 years old. Only Arabic speaking participants were included. Measures included the DAR-5 Arabic version (DAR-5-A) for both samples, the Depression Anxiety Stress Scale-21 (DASS-21) for the adults, and the Children Revised Impact of Events Scale-8 for the adolescents.
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View full text

Cognitive-Behavioral Conceptualization and Treatment of Anger

Abstract

Section snippets

A Working Model of Anger

Application to the Case Study

Acknowledgement

Personality and Individual Differences

Behaviour Research and Therapy

Clinical Psychology Review

Behavior Therapy

Cognitive and Behavioral Practice

Cognitive therapy and the emotional disorders

On information and regulation of anger and aggression: A cognitive-neoassociationistic analysis

American Psychologist

Cognitive behavioral treatment for severe anger in posttraumatic stress disorder

Journal of Consulting and Clinical Psychology

Anger and depression management: Psychoeducational skills training for women caregivers of a relative with dementia

Gerontologist

A partial component analysis of Beck's cognitive therapy for the treatment of general anger

Journal of Cognitive Psychotherapy

Anger disorders

Evidence of effective treatment of anger-related disorders

The Driving Anger Expression Inventory: A validity study with community college student drivers

Journal of Psychopathology and Behavioral Assessment

Overcoming situational anger and general anger: Therapist protocol

Evaluation of two cognitive-behavioral approaches to general anger reduction

Cognitive Therapy and Research

Lowering state anger, aggression, and risky behavior in high anger drivers

A comparison of cognitive restructuring and systematic desensitization techniques for anger reduction with an inmate population

Anger treatment for adults: A meta-analytic review

Clinical Psychology: Science and Practice