Working with clients with anger

problems
SW 8350
Marla K. Ruhana, LMSW
School of Social Work

Anger throughout history

Come not between the dragon and his wrath
(Shakespeare, King Lear (1.1.123)

Numerous references to anger in literature and religious texts (the Bible,

the Quran, the Talmud, Bhagavadgita).
Catholicism: Anger is one of the seven cardinal sins.
Buddhism: Anger is one of the three poisons, greed and ignorance the
other ones.
The Gita states that lust, greed and anger are the three doorways to hell.
Islam: Anger is one of the evil whispers of Shaytaan.
Jewish scholars views on anger
The Vilna Gaon (Elijah ben Shlomo Zalman Kramer) declared that anger is one
of the two traits that actually prevent a person from serving God (lust is the other
one).
Maimodines, referred to anger as a bad trait and anyone who becomes
angry is as if he worships idols...his wisdom departs from him.

But is all anger expression necessatily negative or harmful???

General Observations on Anger

What makes one angry?

Generally, it is the perception of receiving unfair or unjust treatment.

But, there is more to it

Anger can alert us that an injustice has been committed and take
appropriate action to correct it.
A universal emotion found across all cultures an nationalities.
The expression of anger is shaped by
Cultural display rules

Collectivistic vs. Individualistic cultures/societies

Gender role socialization

There are no differences in the frequency of anger expression for men and women.
The difference is in the manner of expression.

What do we know?

Limitations of anger research:

Limited studies around gender, ethnic/racial minorities, culture.

Mostly focused on undergraduate student populations & group tx.

Anger Definitions
Anger:
A negative phenomenological feeling state associated with specific
cognitive and perceptual distortions and deficiencies (e.g. misappraisals,
errors, attributions of blame, injustice, preventability, intentionality),
subjective labeling, physiological changes, and action tendencies to
engage in socially constructed and reinforced organized behavioral scripts
(Casanova & Sudholdolsky, 1995, p.7).

Trait anger:
A disposition to perceive a wide-range of situations as annoying or
frustrating and the tendency to react to such situations with high elevations
of anger (Spielberger, 1999).

State anger:
The intensity of anger reactions to specific situations (Spielberger, 1999).

Anger (emotion), hostility (attitude), aggression (behavior).

DSM and Anger

No diagnoses in DSM for anger problems
Some diagnoses have anger/irritability as a diagnostic
criteria or associated feature:

Intermittent Explosive Disorder (aggressiveness)

Borderline Personality Disorder
Antisocial Personality Disorder (irritability/aggressiveness)
Paranoid Personality Disorders
Obsessive-Compulsive Personality Disorder
Narcissistic Personality Disorders
Mania or Hypomania (irritable mood)
Posttraumatic Stress Disorder
Generalized Anxiety Disorder (irritability)
Oppositional Defiant Disorder
Conduct Disorder (hostility)

Anger & Violence

Anger disturbances are risk factors for IPV and
characterize IPV perpetrators (Anderson & Bushman, 2002; Eckhardt, Babour,
& Davison, 1998; Eckhardt & Jamison, 2002; Eckhardt, Jamison, & Watts, 2002; Eckhardt,
Norlander, & Deffenbacher, 2004; Eckhardt, Samper, & Murphy, 2008; Landenberger & Lipsey, 2005;
Lundeberg, Stith, Penn, & Ward, 2004; Norlander & Eckhardt, 2005; Schumacher, Feldbau-Kohn,
Slep, & Hayman, 2001).

Parental abuse (Dix, 1991).

Aggressive driving, road rage (Galovski & Blanchard, 2001; Mizzell, 1997).
The cost of violence in the USA
50,000 deaths and 2.5 million injuries
$72 billion (Corso, 2007).

Not all aggression is fueled by anger and not all anger

results in aggression.

Anger & Health

Health & behavioral consequences of anger.
Self-cutting (Abu-Madini & Rahim, 2001; Matsumoto et al., 2004).

Bulimia (Meyer et al., 2005).

Alcohol and/or drug use, (Brady & Sonne, 1999; DeMoja Spielberger, 1997 ).
Hypertension (Webb & Beckstead, 2005).
Cardiovscular disease & myocardial infarction (Bongard, alAbsi & Lovallo,
1997; Miguel-Tobal, Casado, Cano-Vindel, & Spielberger, 1997; Suarez & Williams, 1989;
Warren-Findlow, 2006; Williams, 2010; Yuen & Kuiper, 1991).

Arteriosclerosis (Williams, 2010).

Exacerbation of pain (Fernandez & Turk, 1995; Fernandez & Kerns, 2008).
Cancer (Andersen, Farrar, & Golden-Kreutz, 1998).
Obesity, (Robert & Reither, 2004; Wamala, Wolk, & Orth-Gomer, 1997).

The cognitive basis of anger (Gonzlez-Prendes, 2008)

Loss of or threat to a valued object.

Externalization of blame.

Rigid & absolute rules or demands.

Personalization.

Attribution of responsibility for the causes and solutions of problems.

The direction of blame may engender either anger or depression.

Demandingness.

Self (i.e. loss of respect), loved one, objects, values/principles.

Egocentric perspective.
Paranoid perspective

Devaluing or dehumanizing the transgressor

The more dehumanizing the label the higher the probability of

aggression (Beck, 1999)

The Path of Anger (Gonzlez-Prendes, 2008)

Anger Treatment
Aim is not to get rid of anger but channel it to healthy expressions.
Healthy vs. unhealthy anger.
Anger experience
No difference between genders

Anger expression
Socially constructed according to gender role and culture.

Rule out closed-head injury & organic brain syndrome

Mode
Therapy or Didactic? Individual or Group?

Therapeutic relationship a key factor

Anger & paranoia: implications for treatment.

One size does not fit all

Gender and culture sensitive treatments.

Ownership of emotions
Increase responsibility for ones anger.

Anger Treatment
Build a sound therapeutic alliance.
Cognitive components:

Identify, evaluate and reframe anger-inducing beliefs.

Increase responsibility for ones emotions and behaviors.
Increase awareness of anger triggers & cues
Cognitive, behavioral, somatic/physiological.

Upsetness Scale
A visual representation of anger as an emotion that runs along a continuum
including mild & severe and healthy & unhealthy expressions.
Increases awareness of emotional alternatives to anger.

Behavioral components:

Help expand breadth & depth of emotional expression.

Skills building (i.e. assertive communication, conflict resolution, etc.).
Relaxation (i.e., breathing, mindfulness, etc.).
Thought stopping.
Time-out.
Imaginal exposure.

Gonzlez-Prendes, 2008

Men & Anger

Make up the majority of cases reporting to anger treatment.
Gender-role socialization patterns - men
Aggression is often normalized from an early age in boys.
Makes it more acceptable to express anger through aggression.

Messages promote a doer, provider, fixer role.

No room for vulnerability
When feeling threatened or vulnerable the emotional response is often anger.

Anger treatment
Increased awareness of gender-role socialization messages.
Increase scope and range of emotional expression.
Develop list of emotions (positive and negative) expand vocabulary.
Take time to identify emotions in others
Listen to the emotional content of the message empathic listening
Identify and verbalize emotions in self.

Increase ability to communicate emotions other than anger.

Anger & Women

Gender role socialization messages tell women that the direct
expression of anger is not appropriate
Covert and overt negative messages.

Early on women see anger as a threat to relationships.

Thus anger anxiety, guilt.

Consequently, women learn to divert their anger

Anger diversion (Cox & St. Clair, 2005; Cox, Van Velsor & Hulgus, 2004):

Anger containment restraint (bite your tongue)

Anger segmentation - dissociation
Anger internalization - denial
Anger externalization blame, aggression toward less powerful targets, other
pathologies.

Powerlessness: a defining factor in womens anger.

Minority women & women in positions of dependence.

Suggested steps to diffuse anger

Stay calm

Do not get caught up in the other persons anger.

Do not take it personally.
Do not become defensive.
Do not be judgmental.
Slow down your breathing.
Maintain a normal tone of voice.

If possible isolate the angry person

Do not ignore safety issues.
Be careful if there is any concern for violence.
There is always the danger of escalation.
Have an escape route if necessary.

Has the individual made any explicit threats?

Do have a pre-determined plan of action for these types of situations.

Suggested steps to diffuse anger

Listen
Let the other person talk about what is upsetting.
Avoid reassurances such as everything will be okay.

Do not interrupt.
Let him/her know that you are listening
Listen to the information and the underlying emotions.
Use reflective statements; Reflect the other persons content or
emotions.
Use acknowledgements (e.g. nod your head, minimal sounds, etc.).

Acknowledge the importance of what they are saying.

Do not minimize .
Ask for additional information; clarification.
Use I messages.

Tactfully set limits as to what behaviors are acceptable.

How would you handle shouting, swearing, threats?

Stay focused on the current issue and what you can do to

diffuse the situation.

Suggested steps to diffuse anger

Be mindful of your body language
Maintain an open posture
Arms by your side.
If seated, both feet on the ground.
Maintain eye contact, but do not stare.

Let the person know that you understand and seek a

solution

Reflect feelings.
Summarize what he/she has told you.
Ask for a proposed resolution.
Ask for permission to offer suggestions.
May I suggest.

Avoid the shoulds.