Anger management-psychologist-psychiatrist-therapist-training

1. Anger Management Can psychotherapy really work? J. Ryan Fuller, Ph.D. New York Behavioral Health Clinical Director

2. Anger: Definition © J. Ryan Fuller, 2016

3. What is Anger? © J. Ryan Fuller, 2016

4. Definition of Anger Anger is a negative, phenomenological (internal) feeling state, which is associated with  Cognitive and perceptual distortions  Subjective labeling  Physiological changes, and  Action tendencies to engage in socially constructed and reinforced behavioral scripts that often involve approach behaviors and loud verbal behaviors © J. Ryan Fuller, 2016

5. Dysfunctional Anger: Diagnosis © J. Ryan Fuller, 2016

6. When is anger a problem? © J. Ryan Fuller, 2016

7. Anger is common  Anger 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

8. Effects of Anger Maladaptive  Interpersonal conflict  Violence  Poor Driving  Inappropriate risk taking  Poor decision making  Health risks  Substance abuse Adaptive  Alerts goal blocked  Communicates feeling and perception of injustice  Deters threat  Prepares body for physical assault © J. Ryan Fuller, 2016

9. Proposed Anger Diagnoses 1. Generalized Anger without Aggression 2. Generalized Anger with Aggression 3. Situational Anger Disorder without Aggression 4. Situational Anger Disorder with Aggression 5. Adjustment Disorder with Angry Mood © J. Ryan Fuller, 2016

10. Should we change anger? © J. Ryan Fuller, 2016

11. Acceptance Based Conceptualization of Dysfunctional Anger © J. Ryan Fuller, 2016

12. DSM Diagnoses  Antisocial Personality Disorder  Borderline Personality Disorder  Conduct Disorder  Generalized Anxiety Disorder (GAD)  Intermittent Explosive Disorder  Major Depressive Disorder  Obsessive-Compulsive Disorder (OCD)  Narcissistic Personality Disorder  Oppositional Defiant Disorder  Panic Disorder  Paranoid Personality Disorder  Passive Aggressive Personality Disorder  Post-traumatic Stress Disorder (PTSD) © J. Ryan Fuller, 2016

13. How do we measure anger? © J. Ryan Fuller, 2016

14. Clinical Instruments STAXI-II (Spielberger, 1999)  Experience State Trait  Expression Anger- In Anger- Out Anger- Control ADS (DiGiuseppe & Tafrate, 2003)  Behavioral Domain  Arousal Domain  Motives Domain  Provocations  Cognitive © J. Ryan Fuller, 2016

15. Anger Component Model © J. Ryan Fuller, 2016

16. Componential Model of Anger  Trigger  Appraisal  Experience  Expression  Outcome © J. Ryan Fuller, 2016

17. Triggers © J. Ryan Fuller, 2016

18. Appraisals © J. Ryan Fuller, 2016

19. Experiences © J. Ryan Fuller, 2016

20. Expressions © J. Ryan Fuller, 2016

21. Outcomes © J. Ryan Fuller, 2016

22. Does anger management work, and for whom? © J. Ryan Fuller, 2016

23. Anger Treatment Research  Cognitive 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

24. What treatments work?  Cognitive Therapy  Relaxation  Skills Training  Combined  Exposure Based © J. Ryan Fuller, 2016

25. How well does treatment work? © J. Ryan Fuller, 2016

26. Treatment Efficacy Good 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

27. Treatment Efficacy (2) Good News  Change is large (effect sizes for most effective are around 1.00 for Cohen’s d)  Follow-up studies support maintenance Bad News  Most studies use volunteers  These 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

28. Anger: A Problem for Clinicians © J. Ryan Fuller, 2016

29. What are the general challenge and questions to implementing treatment? © J. Ryan Fuller, 2016

30. 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? © J. Ryan Fuller, 2016

31. Increase Motivation • Review negative facts • Values • Consequential thinking: short vs. long term • Catharsis © J. Ryan Fuller, 2016

32. 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

33. Values © J. Ryan Fuller, 2016

34. Values © J. Ryan Fuller, 2016

35. 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

36. 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

37. 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

38. 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 problem  Preparation: decision to change  Action: implementing change  Maintenance: already changed, own tx, relapse © J. Ryan Fuller, 2016

39. What does typical CBT anger management look like? © J. Ryan Fuller, 2016

40. Combined Treatment Example © J. Ryan Fuller, 2016

41. Outcome Research for Combined Anger Treatment © J. Ryan Fuller, 2016

42. Community Model Anger 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 population  Evaluate efficacy © J. Ryan Fuller, 2016

43. Goals  Who are we treating?  What is the treatment?  What are the outcomes of treatment? © J. Ryan Fuller, 2016

44. Population  Assessment of research participants  SCID 1 and 2  PDSQ  ADS  STAXI  BDI  Exclusionary Criteria  Actively psychotic  Group Inappropriate © J. Ryan Fuller, 2016

45. Treatment Measures  Anger Disorders Scale  State-Trait Anger Expression Inventory  Beck Depression Inventory  Idiosyncratic Anger Measures  Situation  Symptom  Behavior © J. Ryan Fuller, 2016

46. Recruitment and Fees  Recruitment  Advertised, Professional Referral, Self-Referral  Phone Interview  Fees and Compensation  $50 per session  $200 reimbursement for perfect attendance  $150 reimbursement for missing one session © J. Ryan Fuller, 2016

47. Screening  Criteria 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 Exclusion  Actively psychotic  Group Inappropriate © J. Ryan Fuller, 2016

48. Demographic Characteristics  Age:  45 years (11.95)  Gender Composition:  5 men and 7 women  Education:  16 years (2.54) © J. Ryan Fuller, 2016

49. Clinical Syndromes  Axis 1 Current (Past) Anxiety Disorder: 4/12 (9) Mood Disorder: 9/12 (8) Substance/Alcohol: 3/12 (7) © J. Ryan Fuller, 2016

50. Personality Disorders Axis 2 Frequency Passive Aggressive 7 Depressive 6 Obsessive Comp 5 Borderline 4 Narcissistic 4 Avoidant 4 Dependent 1 Histrionic 1 Paranoid 1 © J. Ryan Fuller, 2016

51. Treatment  Manual  Session 1-3 Overview and Model  Session 4-9 Skills Acquisition  Session 10-14 Exposure plus Coping  Session 15-16 Relapse Prevention  General  Organized by components  Flexible, but skill focused © J. Ryan Fuller, 2016

52. STAXI-II T-Scores Pre-treatment, Mid-treatment, & Post-treatment Changes 0 20 40 60 80 *Trait Anger ScaleTrait Temperament SubscaleTrait Reaction Subscale Pretreatment Midtreatment Posttreatment © J. Ryan Fuller, 2016

53. ANGER SITUATION Pre-treatment, Mid-treatment, & Post-treatment Changes 0 20 40 60 80 100 *Intensity (0- 100) Frequency (per month) Duration (minutes) Life Interference (0-100) Pretreatment Midtreatment Posttreatment © J. Ryan Fuller, 2016

54. ANGER SYMPTOM Pre-treatment, Mid-treatment, & Post-treatment Changes 0 10 20 30 40 50 60 70 *Intensity (0- 100) Frequency (per month) Duration (minutes) Life Interference (0-100) Pretreatment Midtreatment Posttreatment © J. Ryan Fuller, 2016

55. Anger Disorder Scale (ADS) Pre-treatment to Post-treatment Changes 0 20 40 60 80 Pretreatment * Posttreatment © J. Ryan Fuller, 2016

56. Beck Depression Inventory - II Total Score Pre-treatment to Post-treatment Changes 0 5 10 15 20 25 30 Pretreatment * Posttreatment © J. Ryan Fuller, 2016

57. Limitations  Sample size  Self-referred participant group that were highly motivated  No treatment control group  Independent coding of fidelity would be preferable  Self-report, rather than objective physiological/ behavioral measures  Administering treatment by one therapist © J. Ryan Fuller, 2016

58. Implications  Many 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

59. Skill Details © J. Ryan Fuller, 2016

60. What are the client skills?  Self-monitoring  Consequential Thinking & Time Projection  Problem Solving  Assertiveness Training  Cognitive Rehearsal & Disputation  Relaxation  Response Prevention © J. Ryan Fuller, 2016

61. Cognitive Rehearsal & Disputation © J. Ryan Fuller, 2016

62. Cognitions  Negative vs. Positive  Expectancies  Attribution  Specific vs. Global  Stable vs. Unstable  Internal vs. External  Cognitive Triad  Self  World  Future  Irrational vs. Rational © J. Ryan Fuller, 2016

63. Cognitive-Behavioral Therapy (CBT)  What is it?  Learning Theory  Functional Assessment  Clinical Model (ABC)  Techniques © J. Ryan Fuller, 2016

64. Cognitive-Behavioral Therapies (Continued)  Behavioral Therapies  Cognitive 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

65. CBT: Behaviorist Model  Antecedent  Behavior  Consequence © J. Ryan Fuller, 2016

66. CBT – what are the strategies? CBT attempts to change behaviors by modifying:  Antecedents/Cues  Beliefs, Emotions, Stressors  Processes  Acceptance/Willingness/HFT/Distress Tolerance  Consequences  Reinforcers / Punishers / Modeling © J. Ryan Fuller, 2016

67. ABC Model © J. Ryan Fuller, 2016

68. Activating Events © J. Ryan Fuller, 2016

69. Beliefs © J. Ryan Fuller, 2016

70. Consequences © J. Ryan Fuller, 2016

71. Yerkes-Dodson © J. Ryan Fuller, 2016

72. Cognitive Behavioral Model A B  Ce  Cb

73. CBT: Cognitive  Cognitive Model  A = Activating Events  B = Beliefs  C = Consequences © J. Ryan Fuller, 2016

74. Emotional Education  Alexithymia  Shared vocabulary for communication  Utilization of the ABC Model © J. Ryan Fuller, 2016

75. Model of Emotions © J. Ryan Fuller, 2016

76. Cognitive Behavioral Therapy (CBT) General Strategies  Regulate emotions  Tolerate frustration (distress)  Pursue goals © J. Ryan Fuller, 2016

77. Dysfunctional Thoughts Maladaptive Cognitions  He can’t do that to me  I won’t be a doormat  They had it coming  F- him!  He’s such an $%^&! –hole!  It is the only thing he understands! © J. Ryan Fuller, 2016

79. Irrational Beliefs (IB)  Demandingness  Low-frustration Tolearnce (LFT)  Awfulizing  Global Evaluation of Worth © J. Ryan Fuller, 2016

80. ABC Cognitive Anger Chain  Let’s imagine a few:  A1 = [Fill in the blank]  B1 = [Fill in the blank]  C1 = [Fill in the blank] © J. Ryan Fuller, 2016

81. Cognitive Therapies Intervening at the Inference or Belief What 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

82. 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

83. 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

84. 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

85. Cognitive Emphasis: Global Evaluation • Behavior vs. Person • Attributions • Intent • Concept of Self: Spiritual © J. Ryan Fuller, 2016

86. 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

87. Secondary Disturbance A1 B1 C1 Poor work performance by new younger boss---> I might lose my job The economy is terrible. I must be an idiot. Panic A2 B2 C2 Panic 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 C3 Inappropriate 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

88. Secondary Coping A1 B1 C1 Poor 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 C2 Concern 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. Concern Frustration Drafts a written action plan proposing ways to address negative bullets in his evaluation. © J. Ryan Fuller, 2016

90. Problem Solving: A Misplaced Fundamental Definitions  Problem: a situation that presents difficulty  Problem 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

91. Problem Solving Examples 1. Difficult situation at work with client, vendor, employer, employee 2. I am getting into arguments with my spouse 3. How to furnish a new room 4. My diet plan is not producing the results I want 5. I can’t find a job or appropriate romantic partner © J. Ryan Fuller, 2016

92. 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

93. Problem Solving: Step 1 General Orientation a. Normalize- assume that situation is a normal part of life b. Acknowledgement- that it is possible others have coped with something similar c. Inhibit- halt the tendency to respond with initial impulse © J. Ryan Fuller, 2016

94. Problem Solving: Step 2 Define problem a. Operationalize- define all aspects of the issue in concrete (observable and measurable) ways b. Dissect- reclassify parts into smaller more manageable elements © J. Ryan Fuller, 2016

95. Problem Solving: Step 3 Generation of Alternatives a. Brainstorming i. Criticism omitted ii. Welcome novelty and divergence iii. Encourage quantity of ideas iv. Improvement and integration of suggested ideas © J. Ryan Fuller, 2016

96. Problem Solving: Step 4 Decision making Temporal 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

97. Problem Solving: Step 5 Verification & Assessment Test-Operate-Test-Exit (TOTE; Miller, Galanter & Pribram, 1960) Was the implemented plan effective? 1. Yes→ Exit 2. No→ Go back to step 4 © J. Ryan Fuller, 2016

99. Assertiveness  Definition  What is it not?  Aggressive  Passive  Definition #1  Assertiveness: proper expression of any emotion other than anxiety toward another person- Joseph Wolpe (1973) © J. Ryan Fuller, 2016

101. Assertiveness Two Critical Components in definition  The communication of feelings, desires, wants, and preferences  The acceptance of another person’s right of refusal and recognition he/she may also agree but not act congruently © J. Ryan Fuller, 2016

102. Assertive Communication Four Communication Statements  When. . . . . . . . . . (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

103. Assertive Acceptance My 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

106. © 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.

107. © 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?

108. © 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!

109. © 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.