Contextual Anger Regulation Therapy

A Mindfulness and Acceptance-Based Approach

Frank L. Gardner, Zella E. Moore

• Publisher: Routledge
• Year: 2013
• eBook ISBN: 9781135262792
• Topic: Psychology
• Subtopic: Mental Health in Psychology
• Index: Psychology

Anger is a natural human emotion that can serve important survival functions, but the excessive presence of anger and its associated negative outcomes—such as aggression and violence—can lead to significant interpersonal, intrapersonal, occupational, legal, familial, societal, and physical health problems. Unfortunately, clinical anger clients haven't historically been helped in truly sustainable ways, and loved ones and society at large are often left to simply watch as these individuals struggle to overcome their anger and the noxious behaviors that often emanate from this troubling condition.

Contextual Anger Regulation Therapy gives clinicians the power to change this. The book presents an exciting nine-module mindfulness and acceptance-based behavioral treatment program that has been effectively utilized in formal clinical settings with clinical anger clients, including those mandated for treatment following both non-domestic and domestic violence. Treatment success has not only been demonstrated in observable ways, including significant reductions in violence recidivism and marked improvements in quality of life; it has also been seen in scientific data both in the laboratory and with large numbers of mandated clinical anger clients.

1

Understanding Clinical Anger

Anger is in all of us, from the newborn child to the old and wise, and from the kindest person to the most vengeful tyrant. There’s no formula, prescription, or strategy to avoid the actual experience of this powerful emotional state. It is part of who we are, and the propensity for the emotion of anger will follow each of us to the end of our lives. Why? Because the emotion of anger is a natural human emotion that has its roots in the primary evolution-based motive of survival. Although emotion theorists do not agree on whether anger is a primary emotion or emanates secondarily from a more generalized distress state (Camras, 1992; Izard, 1991), they do agree that anger, like all human emotions, serves a variety of basic adaptive functions. From this evolutionary-based perspective, the emotion of anger serves as a signal of impending danger, and as such, organizes and triggers psychological and physiological processes related to goal-seeking and/or self-protection (Izard & Kobak, 1991; Saarni et al., 2006). Anger may also serve as a secondary emotion by functioning as an affective response to other emotional states. For instance, the emotion of fear, which may be experienced as unbearable by some, is frequently associated with strong feelings of uncontrollability and vulnerability, and can in turn serve as a discriminative stimulus for the secondary emotion of anger. This perspective is consistent with recent research, which has demonstrated that anger is in fact associated with both approach behavior (i.e. goal seeking), and avoidance/escape behavior (i.e. protective response to real or perceived threat-oriented behavior; Dettore, Pabian, & Gardner, 2010; Donahue et al., 2009). The capacity to effectively respond to both threatening and goal-related demands from the environment requires the awareness, understanding, and utilization of, and overt behavioral responses to, the subjective experience of anger.

Of course, the experience of anger can be conceptualized as falling on a continuum, upon which anger may range from mild irritation to extreme rage, and includes cognitive, subjective, and physiological elements. We support the conceptualization that emotion (i.e. anger), cognition, physiological responses, and subjective experience are all interacting entities, and should not be seen in a linear fashion in which cognition precedes subjective experience, which in turn precedes physiological responses. In addition, while anger has a clear adaptive function in its preparation of human beings to respond to external threat, it can also certainly pose significant problems, in that the associated action tendencies of anger (its behavioral expression) tend to have a negative impact on others and often result in substantial short- and long-term personal and interpersonal costs. Such expressions can include physical altercations, arguments, non-verbal displays of discontent, and aggression/violence, to name a few, and such costs can include relationship distress, occupational disruption, judicial action, and loneliness, among many others. Thus, since every human being will certainly feel the emotion of anger throughout their lifetime, the development of appropriate experience and expression of anger is necessary for optimal functioning and overall wellbeing. Of course, it is important to remember that when we talk about anger, we must always be cognizant of differentiating the healthy, normal, adaptive experiences and functions of anger from the dysfunctional, pathological, self, and interpersonal aspects of the experience and expression of anger. In this text, therefore, we refer to the dysfunctional/pathological variant of anger as clinical anger.

This introductory chapter begins the full discussion of clinical anger, its behavioral manifestations, and its remediation by beginning a dialogue on: (a) anger as a clinical problem; (b) diagnostic issues and status with regard to clinical anger; and (c) the theoretical models seeking to describe the relationship between anger and violence. Subsequently, we then present an historical perspective on the theory, research, and treatment of clinical anger so that readers can glean a full picture of where this interesting and important area of study has been, and appears to be progressing in the future.

Anger as a Unique Clinical Problem

Basic to the concept of clinical anger is the idea that excessive anger inevitably results in an individual being in a “fight or flight” mode too frequently. The consequence of this is the expenditure of substantial personal resources to functionally or dysfunctionally monitor and control the external environment, along with one’s own internal processes (i.e. cognitions, emotions, and physical sensations), and as a result, the individual all too often acts in an aggressive or violent manner toward friends, foes, or even benign individuals.

Yet while there are clear and present interpersonal costs, possibly the most fundamental long-term cost of clinical anger is its relationship to personal health-related problems, specifically the development of cardiovascular disease. Specifically, anger and hostility—the latter of which is most accurately thought of as a chronic angry ruminative process (Gardner & Moore, 2008), not unlike worry in anxiety (Borkovec, Alcaine, & Behar, 2004) and brooding/rumination in depression (Nolen-Hoeksema, 2000)— have been shown in the professional literature to be consistently related to the development of coronary heart disease (Smith & Ruiz, 2002; Suls & Bunde, 2005). Of particular importance have been several prospective studies that have supported the strong link between anger, hostility, and aggression, and the later development of cardiovascular disease (Smith et al., 2004; Williams et al., 2000). Traditionally, it has been postulated that the cardiovascular risk associated with anger, hostility, and aggressiveness is due to exaggerated cardiovascular and neuroendocrine responses to stressors (Williams, Barefoot, & Shekelle, 1985). On the other hand, more recent explanations have implicated increased peripheral inflammation in response to chronic hostility, which is a known risk factor for atherosclerosis and myocardial infarction (Ridker et al., 2000). While the precise pathogenesis of the relationship between anger and cardiovascular disease is not fully understood at this time, current empirical research strongly suggests that anger poses a substantial health risk, particularly for individuals in the middle stages of life. In fact, a fascinating recent meta-analysis by Mund and Mitte (2012) on more than 6,000 patients found that those who hold back/restrain the expression of anger experience greater likelihood of developing cardiovascular disease, hypertension, and cancer. Additionally, such individuals were found to live an average of two years less than those who adequately expressed the emotion of anger. These direct health consequences are certainly staggering.

In addition to negative personal health outcomes, the often noted dysfunctional behavioral component of anger, which is aggression and/or violent behavior, results in significant personal and societal costs in terms of judicial, correctional, and public health outcomes. For example, a study by Tafrate, Kassinove, and Dundin (2002) suggested that individuals identified as anger prone (that is, individuals identified as experiencing high levels of trait anger) are twice as likely to be arrested and three times as likely to have served time in the prison system than those scoring low on trait anger, with most of the offenses related to violent acts. In addition, it has been argued that anger is a mediator of domestic violence and substance abuse (Barbour et al., 1998). Consistent with this view, a recent meta-analysis by Norlander and Eckhardt (2005) suggested that elevated levels of anger and hostility are in fact distinguishing characteristics of male perpetrators of interpersonal violence.

Additionally, it is well accepted that a substantial number of motor vehicle accidents, costly in terms of personal wellbeing as well as medical and insurance costs, are related to angry/aggressive drivers (US Department of Transportation, 2005). Compared to low-anger motorists, high-anger motorists driving a similar number of miles have been shown to take significantly more driving risks such as speeding, passing unsafely, tailgating, frequently switching driving lanes, running stoplights, making illegal turns, and engaging in both verbal and physical aggression; and have more vehicular accidents (Deffenbacher et al., 2000, 2003). In another study of aggressive drivers, Deffenbacher et al. (2005) found that high-anger drivers were four times more likely to engage in aggressive driving behaviors, twice as likely to engage in high-risk driving behaviors, and were recipients of significantly more moving-violations than low-anger drivers.

Clinical anger in the workplace has also been found to be directly associated with negative occupational outcomes. For example, Carroll (2001) found that anger in the workplace is associated with reduced job performance and lower employee performance evaluations, which in turn culminate in reduced compensation and career advancement. In addition, they found that angry employees demonstrated lower organizational commitment and increased employee turnover, thus having a direct cost to individuals, and an indirect cost to organizations and society at large.

In summary, clinical anger and its related dysfunctional behavioral response of aggression and violence result in a variety of significant health, legal, interpersonal, and occupational outcomes affecting individuals, those close to them, and the world in which they live.

Clinical Anger and Psychological Comorbidities

In addition to being a significant problem in and of itself, clinical anger has also been shown to be associated with numerous other psychological disorders coming to the attention of the practicing psychologist. For example, Fava and Rosenbaum (1998) found that approximately one-third of depressed patients experienced “anger attacks,” defined as the sudden and intense experience of anger accompanied by significant autonomic arousal. Additional studies have found that 36% of patients meeting criteria for a Diagnostic and Statistical Manual of Mental Disorders-IV-TR (DSM-IV-TR; American Psychiatric Association (APA), 2000) diagnosis of major depressive disorder, 61% of patients meeting criteria for a diagnosis of bipolar II disorder (Benazzi, 2003), and 48% of patients meeting criteria for posttraumatic stress disorder (Murphy et al., 2004) reported substantial difficulties with anger that resulted in negative health, vocational, and occupational outcomes. Similarly, it has been found that measures of anger were significantly elevated, even when controlling for severity of PTSD symptoms, and were strongly related to occupational impairment, in combat-related PTSD cases (Frueh et al., 1998).

Anger has likewise been shown to negatively impact the effectiveness of otherwise empirically supported psychological treatments for other psychological disorders. For example, socially anxious patients demonstrated higher levels of experienced anger and demonstrated greater problematic expression of anger than non-anxious controls, and possibly most importantly for those who provide psychological care to anxious patients, elevated levels of anger were associated with premature termination from treatment and a generally less satisfactory response to cognitive behavioral treatment of social anxiety (Erwin et al., 2003). What we are seeing, then, is that while anger in its natural adaptive form is a necessary evolutionary emotional state, the dysfunctional experience and expression of this intense emotion is not only problematic in and of itself, but also co-occurs with other psychopathological conditions and further complicates the subsequent remediation of those conditions.

Diagnostic Issues and Status

Interestingly, although problematic anger has long been associated with dysfunctional behavior, relationship consequences, and negative health outcomes, the concept of an “anger disorder” is not currently recognized as a unique mental disorder by the DSM-5 (APA, 2013). The closest to an adult “anger disorder” currently found in the DSM is intermittent explosive disorder (IED). As a category, IED focuses on dysfunctional aggressive behavior, and is characterized by the following abbreviated criteria.

1. Episodes reflecting a failure to adequately resist verbally or physically aggressive impulses.
2. The level of aggressive behavior is clearly out of proportion to any precipitating psychosocial stressor.
3. The aggressive behavior cannot be better accounted for by another psychiatric disorder (i.e. antisocial personality disorder, borderline personality disorder, bipolar disorder).

A perusal of the criteria for IED leads to the unmistakable conclusion that this category of disorder is actually a disorder specific to violent and aggressive behavior, and the criteria do not even mention anger as a sign or symptom necessary for diagnosis.

There was some hope that the new DSM-5 (APA, 2013) would include an anger diagnosis. However, this has not been the case. The closest new diagnostic addition in the DSM-5 is a childhood classification known as disruptive mood dysregulation disorder (DMDD). This new diagnosis was born out of the notable increase in diagnoses of bipolar disorder (BD) in children and the need to better represent the developmental precursor to the adult disorder. While not actually seeking to represent clinically angry adult clientele, the DMDD criteria appear staggeringly appropriate for this population. To illustrate this, let’s review some of the specifics (although not an exhaustive list) of the DMDD criteria. First, the disorder requires that the individual engage in significant and recurrent verbal and/or behavioral “temper outbursts” that do not proportionally match the situation, which may include aggression toward other people or things. These eruptions in temper typically occur three or more times each week for at least a year. When not in the midst of a temper outburst, the individual’s mood is characterized as consistently angry or irritable, which is outwardly visible by others in the environment. Finally, but not exhaustively, the temper outbursts and between-episode anger and irritability should be observable in at least two settings.

Does this sound like the clinically angry client? It most certainly does! However, one catch is that this diagnosis is included in the new DSM as a childhood diagnosis, requiring a diagnosis after 6 years of age and before 18 years of age. In addition, the onset of the excessive temper outbursts must be prior to age 10.

Unfortunately, at present, individuals with clinical anger are classified under a multitude of psychiatric diagnoses even though these adult clients exhibit a similar symptom and behavior constellation as the DMDD disorder ostensibly established for children. While conceptualizing DMDD as a disorder that extends into adulthood in the form of clinical anger may appear warranted, at present we cannot utilize such a diagnosis with adult clientele.

Based on the ineffectiveness of the then-current DSM-IV-TR (APA, 2000) system to capture the clinical anger population, we decided it would be informative to conduct a study evaluating the utility of the then-proposed DSM-5 DMDD diagnosis as an adult diagnosis for clinical anger patients (Dettore, Kempel, & Gardner, 2010). We actually only needed to modify DMDD age-related criteria in order to allow an adult diagnosis to be given. Data were obtained via review of clinical and actuarial records gleaned from a sample of 86 court-mandated violent offenders undergoing treatment at a university-based anger treatment facility. The sample was 75% male, with a mean age of 32.14. Participants were self-identified as 60.5% African-American, 25.9% Caucasian, 11.1% Hispanic, and 2.4% as “other.” Thirty-two (32) different Axis I and Axis II DSM-IV-TR disorders were represented within the population, despite a predominant cohesive pattern of presenting pathology. Participants’ diagnoses included 26 Axis I diagnoses and 6 Axis II diagnoses. The primary DSM-IV-TR diagnoses for Axis I were: 13.5% major depressive disorder, 9.3% alcohol dependence, 6.8% dysthymic disorder, 5.9% posttraumatic stress disorder, 5.1% adjustment disorder, and approximately 59.4% cutting across all other Axis I disorders. Axis II diagnoses were: 6.8% antisocial personality disorder, 5.0% borderline personality disorder, 1.4% narcissistic personality disorder, and 20% personality disorder NOS (not otherwise specified). When DMDD was used as an alternative diagnosis, a whopping 49% of clients met criteria for the proposed diagnosis. With nearly half of the overall sample represented by this then-proposed DSM-5 disorder, DMDD accounted for a significantly greater proportion of this court-mandated adult clinical anger population than any other single diagnosis.

The fact is that no anger diagnosis exists in the DSM. However, this has not been due to a lack of effort. Given the absence of a unique diagnostic entity, Eckhardt and Deffenbacher (1995) long ago proposed a relatively simple new category for future iterations of the DSM, which would include three specific anger disorders: (a) adjustment disorder with angry mood (a disorder not unlike the old DSM-IV-TR adjustment disorder diagnosis, but with an emphasis on anger as a primary emotional manifestation); (b) situational anger disorder, which would share some features with IED but would focus more on situation-specificity of an angry response, and would be less dependent on aggressive behavior than IED; and (c) general anger disorder, which would be representative of high levels of trait anger and anger reactivity. These previously proposed disorders would be more focused on the experience of anger, although anger expression in the form of aggressive or violent behavior would certainly fall under their umbrellas. One can also readily see a relative similarity between this proposed anger diagnostic classification and the classification of anxiety disorders; adjustment disorder with anxious mood; simple phobia; and generalized anxiety disorder.

As an alternative diagnostic model, DiGiuseppe and Tafrate (2007) presented the most well-developed proposal for an anger disorder category in future DSM volumes. They have referred to their proposed anger disorder as anger regulation-expression disorder (ARED), and have suggested that individuals could meet criteria for this disorder via two distinct pathways. The first would be through subjective anger experiences as indicated by frequent, intense, and enduring angry affect, with two or more of the following being present either during or immediately following the anger experience: (a) physiological activation, (b) rumination, (c) cognitive distortions, (d) ineffective communication, (e) brooding/withdrawal, or (f) subjective distress. The second pathway would be through expressive patterns of behavior associated with the angry experience. These behavioral patterns must be out of proportion to the triggering stimulus, and at least one of the following must be consistently related to anger experiences: (a) aggressive/aversive verbalizations, (b) physical aggression toward people, (c) property destruction, (d) provocative/threatening bodily expression, or (e) various passive-aggressive behaviors including rumor spreading, secretly interfering with others’ tasks or property, or intentionally failing to meet other people’s expectations.

A diagnosis of ARED would require one of the above two pathways (experience or expressive), as well as evidence of consistent/repetitive damage to social or vocational relationships, and angry or expressive symptoms not better accounted for by another psychological disorder. Using the proposed ARED classification, clinicians would then be left with three choices based upon symptom presentation: (a) anger disorder, predominantly subjective (i.e. exp...

Table of contents

• Cover
• Half Title
• Title Page
• Copyright Page
• Table of Contents
• List of Tables and Figures
• Preface
• Acknowledgments
• 1. Understanding Clinical Anger
• 2. The Anger Avoidance Model (AAM)
• 3. Assessment and Case Conceptualization of Clinical Anger
• 4. Contextual Anger Regulation Therapy: Treatment Overview
• 5. Contextual Anger Regulation Therapy: Step-by-Step Treatment Description
• 6. Special Considerations
• 7. Case Study
• References
• Index