Anger

Course Objectives:

Describe Anger Management Techniques.

Identify common ways of expressing anger.

Assess a clients level of anger and danger.

Anger Defined

There are many different views from which to consider the construct of anger. Dahlen and Deffenbacher (2001) identify three main ingredients to anger. First, there is an anger-eliciting stimulus, typically an easily-identifiable external source (e.g., somebody did something to me) or internal source (e.g., emotional wounds). Second, there is a pre-anger state, which includes one's cognitive, emotional, and physical state at the time of provocation; one's enduring psychological characteristics; and one's cultural messages about anger and about expressing anger. Third, there is one's appraisal of the anger-eliciting stimulus and one's ability to cope with the stimulus. All three of these ingredients interact to create a state of being angry.

Dahlen and Deffenbacher (2001) also identify four related domains in which anger exists. First, in the emotional and experiential domain, anger is a feeling state ranging in intensity from mild annoyance to rage and fury. Second, in the physiological domain, anger is associated with adrenal release, increased muscle tension, and activation of the sympathetic nervous system.

Third, in the cognitive domain, anger is associated with biased information processing. Fourth, in the behavior domain, anger can be either functional (e.g., being assertive, setting limits) or dysfunctional (e.g., being aggressive, withdrawing, using alcohol and drugs, etc.).

Rhoades (n.d.) provides additional ways to understand anger. What is the source and expression of the anger? Is it intense and situation-specific or chronic and generalized? What is the extent of the anger? Does it easily and quickly evolve into deep feelings of resentment? Is it coupled with intense aggression or explosiveness? Has it become uncontrollable? What is the anger hiding? Is it a cover-up for fear, being used as a shield to keep other people at a distance so they are unable to see one's insecurities and weaknesses?

Expressing Anger

Everybody experiences anger and everybody expresses anger. It is a natural and healthy human emotion when managed effectively. But it can be a source of various physical, mental, emotional, social, or legal problems when not managed effectively. It is often a problem in one of these areas that brings a client in for counseling, either on a voluntary or a mandated basis. As a counselor, there are numerous and varied options for intervention. And there are numerous and varied aspects to consider before selecting an appropriate intervention.

The expression of anger can take many forms. Some common means of expressing anger include venting, resisting, seeking revenge, expressing dislike, avoiding the source of anger, and seeking help (Marion, 1997). However, in many cultures, people are taught that while expressing anxiety, depression or other emotions is acceptable, expressing anger is not (Controlling anger before it controls you, n.d.). As a result, many people never learn how to handle their own or others' anger effectively or to channel it constructively.

Gorkin (2000) distinguishes between the intention and the usefulness of anger expressions. In terms of intention, the expression of anger can be purposeful or spontaneous. The purposeful expression of anger is intentional, has a significant degree of consideration or calculation, and yields a high degree of self-control. The spontaneous expression of anger is immediate, has little premeditation, and yields little to moderate self-control.

In terms of usefulness, the expression of anger can be constructive or destructive. Constructive expression of anger affirms and acknowledges one's integrity and boundaries without intention to threaten another person. Destructive expression of anger defensively projects and rigidly fortifies one's vulnerable identity and boundaries. These distinctions provide for four basic expressions of anger. Purposeful and constructive expression leads to assertion. Purposeful and destructive expression leads to hostility. Spontaneous and constructive expression leads to passion and suffering. And spontaneous and destructive expression leads to rage, violence, screaming, and hitting. With respect to rage, one can be outraged, by a seemingly clear and external (sometimes criminal) target, or one can be "in-raged" (Gorkin, 2000), by a reaction tostill unresolved internal hurts and humiliations (vs. actual, immediate stimulus-and-response provocation).

Although much of the work in anger management focuses on helping people understand what triggers their anger and on learning a healthier response, or expression, of that anger, the debate continues regarding the healthiest ways to express anger. Interestingly, some sources (e.g., Schwartz, 1990) indicate that repressing anger can be adaptive for coping with certain emotions. Other sources (e.g., Controlling anger before it controls you, n.d.) document that suppressing anger can lead to headaches, hypertension, high blood pressure, depression, emotional disturbances, gastrointestinal disorders, respiratory disorders, skin disorders, genitourinary disorders, arthritis, disabilities of the nervous system, circulatory disorders, and even suicide. It is important to learn to identify whether or not a client's reactions to and expressions of anger are a problem.

Assessment

How does a client know when his or her anger is more of a problem than a help? Few formal assessments exist to quantifiably measure the level of one's anger. However, there are numerous qualitative indicators to review with clients to understand the extent of their concerns about their anger and anger management strategies.

* Is the anger chronic, long-lasting, too intense, or too frequent (Rhoades, n.d.)?
* Does the anger disrupt the client's thinking, affect the client's relationships (Rhoades, n.d.), or affect the client's school or work performance?
* Does the client exhibit frequent loss of temper at slight provocations,
passive-aggressive behavior, a cynical or hostile personality, chronic irritability and grumpiness?
* Has the client begun to display low self-esteem, sulking, or brooding?
* Is the client withdrawing socially from family and friends?
* Is the client getting physically sick or doing damage to one's own or others' bodies or property?
* Is the client experiencing physical symptoms such as increased heart rate, increased blood pressure, or increased adrenaline flow (Controlling anger before it controls you, n.d.)?

Although some of these symptoms may be indicative of other issues, they are also often related to unresolved anger. The bottom line is that when a person becomes a victim to his or her anger, the anger is a problem.

Managing Anger

According to Wellness Reproductions (1991), there are three main methods of dealing with anger. First, there is "stuffing" one's anger, a process in which a person may or may not admit his or her anger to self or others and in which one avoids direct confrontations. A person may stuff his or her anger out of fear of hurting someone, fear of rejection, fear of damaging relationships or fear of losing control. Often, a person who stuffs anger is unable to cope with strong, intense emotions and thinks that anger is inappropriate orunacceptable. Stuffing one's anger typically results in impaired relationships and compromised physical and mental health. CEU

Second, there is escalating one's anger, a process in which a person provokes blame and shame. The purpose is to demonstrate power and strength while avoiding the expression of underlying emotions. A person who escalates his or her anger is often afraid of getting close to other people and lacks effective communication skills. Escalating one's anger typically yields short-term results, impaired relationships, and compromised physical and mental health. Sometimes, escalating one's anger also leads to physical destruction of property or to abusive situations, thus adding the potential for legal ramifications.

Third, there is managing one's anger, a process in which a person is open, honest, and direct and in which one mobilizes oneself in a positive direction. The focus is on the specific behavior that triggered the anger and on the present (past issues are not brought into the current issue). A person who manages his or her anger avoids black and white thinking (e.g., never, always, etc.), uses effective communication skills to share feelings and needs, checks for possible compromises, and assesses what is at stake by choosing to stay angry versus dealing with the anger. Managing one's anger results in an increased energy level, effective communication skills, strengthened relationships, improved physical and mental health, and boosted self-esteem.

It is this process of managing one's anger that is the primary goal of counseling people to effectively deal with anger. The goal is not to eliminate anger. Anger is a natural and healthy emotion. After a client acknowledges he or she is angry, a counselor can help the client learn how to reduce the emotional and physiological arousal that anger causes and learn to control its effects on people and the environment. To be more effective, practitioners should attempt to understand the extent and expression of the anger, the specific problems resulting from the anger, the function the anger serves, the underlying source of the anger, and the domain the problems occur in (e.g. emotional, physiological, or cognitive) before choosing interventions for the client.

Strategies and Skills

Many different strategies and skills for anger management intervention have been tried and tested. Some of the most empirically supported interventions are cognitive-behavioral interventions including relaxation coping skills, cognitive interventions, behavioral coping and social skills training, and problem-solving skills training.

According to Dahlen and Deffenbacher (2001), relaxation coping skills target both the emotional and physiological arousal associated with anger with the intent being to lower the anger arousal. In contrast to targeting arousal, cognitive interventions target biases in information processing and cognitive appraisals. They help to identify distorted patterns of thinking, develop more reality-based and less anger-engendering cognitions, and free up problem-solving and coping resources.

Behavioral coping and social skills training target the actual expression of anger (vs. reducing anger arousal). Specific skills training that has been empirically supported includes direct coping skills (e.g., interpersonal communication, negotiation, feedback), related coping skills (e.g., parenting, budgeting and financial planning, assertive communication), and inductive social skills training (e.g., clients identify and explore effective behaviors for coping with anger) (Dahlen and Deffenbacher, 2001).

Problem-solving skills training is useful when there are no behavioral skill deficits (e.g., poor social skills) but there is a lack of general problem-solving skills with which to assess situations and to choose various coping skills. A basic problem-solving methodology is to identify the problem, generate alternative solutions, consider theconsequences of each solution, select an effective and appropriate response, and evaluate the outcomes of implementing the specific response (Skiba & McKelvey, 2000). CEU

Additional strategies that have been found to be useful in managing anger effectively include avoiding situations that make one angry, changing environments, focusing on something positive, engaging in substitute positive activities, and improving communication and social skills. Humor has also been found to be helpful when it is used constructively to help face problems; sarcastic humor is just another form of unhealthy anger expression (Controlling anger before it controls you, n.d.).

Structured Programs

In addition to the strategies and skills highlighted above, there are numerous structured and pre-packaged programs for helping people learn to manage their anger more effectively. These programs vary in intended audience, theoretical basis, teaching method, and actual skills and techniques used.

Additional Considerations

Cultural Impact of Client's Natural Environment. Howells and Day (2002) highlight the importance of understanding the culture a client returns to upon leaving a counseling or training session. Will the culture support the behavior changes and thinking processes that the client has been learning? In some cases (e.g., the gang a client hangs out with, incarcerated clients, institutionalized clients), the culture the client lives in day-to-day will not necessarily support the kinds of changes a client may be trying to make. 

Indeed, daily survival may be based on vastly different modes of operation than a client may be practicing in counseling. It is important to clarify which culture is in charge of the client's daily life (e.g., the family and its subcultures? the street corner and friends? the neighborhood? the school and teachers?) and how it may affect a client's success in learning to manage anger more effectively.

Another consideration is the adequate transfer of skills learned in counseling to one's natural environment. This could be the classroom, the workplace, or even one's home. Besley (1999) conducted an experiment on transferring skills to the classroom environment of a student client.

According to Besley (1999), change begins at a teachable moment, and four conditions are necessary for change: 1) the person is in an environment where he or she feelssafe, 2) the person is supported and encouraged during the change process, 3) theenvironment is relevant to the person, and 4) the person is involved and has some degree of control in the change process.

In a school setting, when a counselor has been working with a student individually to develop more effective anger management skills, there still remains the issue of encouraging the student to use the new skills outside the counseling sessions (e.g., in the classroom, in the cafeteria, on the playground). One proven way to do this is to have the counselor sit in the classroom (or cafeteria or playground) with the student and be available to coach the student right at the moment(s) he or she becomes angry (Besley, 1999). The counselor can then coach the student's cognitive processes and help the student cope with impulsivity and, at the same time, model effective and useful skills for the other students and even the teacher.

Readiness for Anger Management Intervention

The best anger management training delivered by the most qualified counselor will be ineffective if the client is not ready for anger management training. According to Howells & Day (2003), there are several different things that can impact readiness for anger management.

Sometimes there are a complex array of factors presenting with the anger problem. People with certain mental and personality disorders may also have an anger management problem. Or anger management and control may be a symptom of a serious mental or personality disorder.

Existing client inferences about their anger "problem" can impact their readiness. Some clients may view anger as an appropriate response to many situations. Some clients may believe that catharsis is the best approach (expressing anger is considered better than controlling it) or that angry responses get results (in reality, although angry outbursts sometimes generate desired short- term results, they rarely result in long-term change). Attitudes of self-righteousness, low personal responsibility, blaming others, and condemning others also reduce readiness. For some clients, anger may not even be considered a problem. In fact, anger may be adaptive in certain settings for the client: it may bring with it many social benefits such as perceptions of higher status, strength, and competence. Unfortunately, these types of beliefs and perceptions can be difficult to uncover and assess.

The client's skill level also impacts readiness for effective treatment. People need certain cognitive processes with which to think about consequences and choices in order to improve anger management skills. Sometimes a person's impulsive nature will interfere with the application of such cognitive processes. Other issues that impact a client's readiness are difficulty judging the intent of others, underestimating one's own reaction to anger-provoking situations, wanting to blame conflict on others, an inability to distinguish one's feelings, and poor social and problem-solving skills.

Finally, the client's beliefs about treatment impact readiness. Even in coerced or mandatory treatment, if the client concurs with the need for treatment and perceives the treatment as likely to be helpful in meeting his or her goals, then coercion is not as big an issue. However, if the client believes the treatment is not likely to fulfill his or her personal goals, then coercion could definitely impact readiness.

How does a counselor positively influence the readiness variables? Counselors can explore the personal goals of the client and help the client become aware of any discrepancies between the actual social consequences of their anger expression and the pursuit of their personal goals. Counselors can work to incorporate the client's goals and treatment plan into the values and goals of the existing informal culture of the client.

Counselors can also help clients build appropriate interpersonal and cognitive skills and develop an appropriate vocabulary for communicating triggers, thoughts, emotions, and behaviors.

Variables that Influence Effective Treatment

In studies on the effect of anger management interventions with student populations, Skiba and McKelvey (2000) found three variables to have the most influence. First, the length of treatment: typically, more sessions yield stronger initial outcomes and booster sessions (e.g., annually) improve long-term outcomes. Second, proper framing: the more the training is made relevant to the student and the environments in which he or she lives on a daily basis, the stronger the initial outcomes. Finally, supplemental interventions (e.g., utilizing weekly goals, utilizing components of Aggression Replacement Training) help improve initial outcomes. Although these factors were studied specifically in reference to student populations, they are likely applicable to other client bases as well.

Anger. Everybody experiences it and everybody expresses it. Some people manage their anger in healthy ways. Other people are managed by their anger in unhealthy ways. Although there are many skills, strategies, and structured programs known to help people improve how they deal with anger, there are many factors to consider when selecting an effective intervention. In addition to understanding the expression, function, source, and resulting problems of a client's anger, practitioners can also attempt to understand the client's cultural needs with respect to dealing with the problem, the ability of the client to transfer new skills to their daily environments, and the client's readiness and skill level for dealing with the problem. Only then can the practitioner choose an intervention that will be truly effective for the client.

Structured Programs and Interventions 

Numerous structured programs exist for helping clients learn to manage their anger more effectively. These programs vary in intended audience, theoretical basis, teaching method, and actual skills and techniques used. A review of several structured programs follows. It is important to remember that prior to selecting an intervention, one must assess the expression, function, source, and resulting problems of a client's anger (see Anger Management 1: An Overview for Counselors). In addition, one must consider the client's cultural needs, the ability of the client to transfer new skills to their daily environments, and the client's readiness and skill level for dealing with the problem in order to select interventions that will be effective.

Children's Programs

"25 Ways to Help Children Control Their Anger"

"25 Ways to Help Children Control Their Anger," developed by Lawrence E. Shapiro of Childswork/Childsplay, is geared toward children and is designed to be used with individuals. It is based on cognitive behavioral theory and focuses on relaxation, recognition of feelings and emotions, and awareness of behavioral triggers (Jahnke, 1998).

"The Anger Control Kit"

"The Anger Control Kit," developed by Lawrence E. Shapiro of Childswork/Childsplay, is geared toward children. It covers six modalities: affective, behavioral, cognitive, developmental, educational, and social. It is composed of 38 techniques and focuses on teaching self-regulation, expression of feelings, stress management, and peer mediation skills (Jahnke, 1998).

"How I Learned to Control My Temper"

"How I Learned to Control My Temper," developed by Debbie Pincus of Childswork/Childsplay, is geared toward children and is designed to be used with individuals. It is based on cognitive behavioral theory and utilizes worksheets to help children recognize feelings and emotions, control their temper, be assertive, and develop empathy (Jahnke, 1998).

"Aggression Replacement Training (ART)"

"Aggression Replacement Training (ART)," developed by A.P. Goldstein and B. Glick (1987), geared toward adolescents, is unique in its design because it has a behavioral component (structured learning), an affective component (anger control training), and a cognitive component (moral reasoning). The Anger Control Training (ACT) component is based on the earlier work of Novaco (cognitive preparation, skill acquisition, application training) and Feindler (triggers, cues, reminders, reducers, self-evaluation). CEU

The objectives are to teach adolescents to understand what causes them to feel angry and act aggressively and then to teach techniques they can use to reduce their anger and aggression. Often adolescents feel they do not have a choice in many situations: they feel their only choice is aggression. The goal of training is to give them skills necessary to make a choice.

The general format of the Anger Control Training involves modeling by trainers, role playing by trainees, and feedback. The ABC model provides the foundation of the anger control training. A is the trigger (what triggered the problem), B is the behavioral response (what one did in response to A), and C is the consequences (to oneself and to the other person). Since it is important to know one is angry before one uses self-control to reduce anger or to impact one's reaction, adolescents also learn about triggers (both external and internal), cues (physical signs that let one know he/she is angry) and anger reducers (e.g., deep breathing, backward counting, pleasant imagery).

The program teaches adolescents to choose their response in a conflict situation and to think ahead about short- and long-term consequences, internal and external consequences, and social consequences of their potential actions. The program makes use of self-evaluation in which an adolescent judges for himself how well he has handled a conflict, self-rewards himself based on handling a situation well, and coaches himself based on how he could have handled it better.

The program also addresses the concept of an Angry Behavior Cycle in which participants are encouraged to consider what they might be doing to make others angry versus just dealing with what others do to make them angry. Finally, since the Anger Control Training (ACT) teaches what not to do (be aggressive) and how not to do it (anger control technique), ART includes a component of learning what to do in place of being aggressive. This behavioral component of learning and using new behaviors is incorporated through structured learning skills.

ACE Model

Taylor (as cited in Besley, 1999) developed a cognitive anger management approach for adolescents that focuses on the boundaries of angry situations, the consequences that could develop from certain choices, and appropriate positive responses. The positive response model is known as ACE and it provides three responses for any given situation. A is for adapt: when one cannot change the circumstances, one can choose to accept the situation and change one's behavior. C is for confront in a productive and calm manner. E is for escape: for varied reasons, there are times when one cannot adapt nor confront the situation, so one must retreat physically or emotionally. It is important to learn how to identify an angry situation as needing an A or C or E response and then consider consequences that might occur with each response. Finally, it is important to focus on one's own responses to the problem versus on the intent of others.

"The Anger Coping Program"

"The Anger Coping Program," developed by Jonh E. Lochman, Susanne Dunn and Bonnie Klimes-Dougan is geared toward aggressive adolescents and is designed to be utilized in groups. It is based on Dodge's model of perceiving and deciding how to react to problematic social situations. It is composed of 18 sessions with a focus on physiological awareness, perspective taking, social problem solving, and self-instruction to inhibit impulsive responding (Jahnke, 1998).

"Anger Control Training for Adolescents in Residential Treatment" 

"Anger Control Training for Adolescents in Residential Treatment," developed by R.F. Dangel, J.P. Descher, and R.R. Rasp, is geared toward adolescent groups. It is based on cognitive behavioral theory and is composed of 6 sessions with a focus on thought stopping and relaxation (Jahnke, 1998).

"Anger Control Training for Children and Teens"

"Anger Control Training for Children and Teens," developed by Dr. John F. Taylor, is geared toward both children and adolescents; it is designed to be used individually or in groups. It is based on cognitive theory and focuses on defining, expressing, and managing anger. It is available from Mar*co Products, Inc. (Jahnke, 1998).

"Anger Management for Youth: Stemming Aggression and Violence"

"Anger Management for Youth: Stemming Aggression and Violence," developed by Dr. Leona Eggert, is geared toward high school students and is designed to be utilized in groups. It is based on cognitive behavioral theory and focuses on linking thoughts, feelings, and behavior; discovering consequences of angry outbursts; and thought stopping (Jahnke, 1998).

"ThinkFirst Curriculum"

The "ThinkFirst Curriculum," developed by Dr. James Larson and Dr. Judith McBride of  the University of Wisconsin-Whitewater, is geared toward aggressive adolescent and high school students; it is designed to be utilized in groups. It is based on cognitive behavioral theory and focuses on the ABC model, physiological cues, direct and indirect provocations, assertion techniques, problem solving, and self-evaluation (Jahnke, 1998).

Adult Programs

"Rethink"

The "Rethink" curriculum, developed by R.J. Fetsch and C.J. Schultz in conjunction with Colorado State University Cooperative Extension, Family and Consumer Sciences (Fetsch & Schultz, & Wahler, 1999), is designed for parents and teens and is unique in that it incorporates information about normal childhood development issues and about normal parenting issues. The objectives are to increase participants' knowledge about parenting, child development, and anger management; assist participants in improving attitudes about parenting and anger management; assist participants in making positive behavioral changes; increase participants' anger control levels; decrease participants' unrealistic expectations of their children; and decrease participants' family conflict, anger, and violence. The program is built around the following concepts:

*R = RECOGNIZE anger in yourself and others
*E = EMPATHIZE with the other person
*T = THINK about the situation differently
*H = HEAR what is being said
*I = INTEGRATE respect and love when expressing anger
*N = NOTICE your body's reactions to anger
*K = KEEP your attention on the present problem

"The Anger Workbook"

"The Anger Workbook," developed by Dr. Less Carter and Dr. Frank Minirth, is geared toward high school and adult individuals but it can be incorporated into a group format. It is based on cognitive theory and is composed of 13 steps that focus on self-reflection, understanding how emotions feed anger, and identifying learned patterns of relating, thinking and behaving that influence anger. It is available from Thomas Nelson Publishers (ISBN # 0-0-8407-4574-5) (Jahnke, 1998).

"Anger Management Program"

The "Anger Management Program," developed by Linda Panaccione, LISW, is geared toward adolescents and adults and can be utilized in individual work or in group work. It is based on cognitive behavioral theory and is composed on 10 steps with a focus on recognizing triggers and determining replacement behavior (Jahnke, 1998).

Intermittent Explosive Disorder

Intermittent explosive disorder (IED) is a disorder characterized by impulsive acts of aggression, as contrasted with planned violent or aggressive acts. The aggressive episodes may take the form of "spells" or "attacks," with symptoms beginning minutes to hours before the actual acting-out. DSM-IV-TR classifies IED under the general heading of "Impulse-Control Disorders Not Elsewhere Classified." Other names for IED include rage attacks, anger attacks, and episodic dyscontrol.

Intermittent explosive disorder was originally described by the eminent French psychiatrist Esquirol as a "partial insanity" related to senseless impulsive acts. Esquirol termed this disorder monomanies instinctives, or instinctual monomanias. These apparently unmotivated acts were thought to result from instinctual or involuntary impulses, or from impulses related to ideological obsessions.

People with intermittent explosive disorder have a problem with controlling their temper. In addition, their violent behavior is out of proportion to the incident or event that triggered the outburst. Impulsive acts of aggression, however, are not unique to intermittent explosive disorder. Impulsive aggression can be present in many psychological and nonpsychological disorders. The diagnosis of intermittent explosive disorder (IED) is essentially a diagnosis of exclusion, which means that it is given only after other disorders have been ruled out as causes of impulsive aggression.

Patients diagnosed with IED usually feel a sense of arousal or tension before an outburst, and relief of tension after the aggressive act. Patients with IED believe that their aggressive behaviors are justified; however, they feel genuinely upset, regretful, remorseful, bewildered or embarrassed by their impulsive and aggressive behavior.

Causes and symptoms

Causes

Recent findings suggest that IED may result from abnormalities in the areas of the brain that regulate behavioral arousal and inhibition. Research indicates that impulsive aggression is related to abnormal brain mechanisms in a system that inhibits motor (muscular movement) activity, called the serotoninergic system. This system is directed by a neurotransmitter called serotonin, which regulates behavioral inhibition (control of behavior). Some studies have correlated IED with abnormalities on both sides of the front portion of the brain. These localized areas in the front of the brain appear to be involved in information processing and controlling movement, both of which are unbalanced in persons diagnosed with IED. Studies using positron emission tomography (PET) scanning have found lower levels of brain glucose (sugar) metabolism in patients who act in impulsively aggressive ways.

Another study based on data from electroencephalograms (EEGs) of 326 children and adolescents treated in a psychiatric clinic found that 46% of the youths who manifested explosive behavior had unusual high-amplitude brain wave forms. The researchers concluded that a significant subgroup of people with IED may be predisposed to explosive behavior by an inborn characteristic of their central nervous system. In sum, there is a substantial amount of convincing evidence that IED has biological causes, at least in some people diagnosed with the disorder.

Other clinicians attribute IED to cognitive distortions. According to cognitive therapists, persons with IED have a set of strongly negative beliefs about other people, often resulting from harsh punishments inflicted by the parents. The child grows up believing that others "have it in for him" and that violence is the best way to restore damaged self-esteem. He or she may also have observed one or both parents, older siblings, or other relatives acting out in explosively violent ways. In short, people who develop IED have learned, usually in their family of origin, to believe that certain acts or attitudes on the part of other people "justify" aggressive attacks on them.

Although gender roles are not a "cause" of IED to the same extent as biological and familial factors, they are regarded by some researchers as helping to explain why most people diagnosed with IED are males. According to this theory, men have greater permission from society to act violently and impulsively than women do. They therefore have less reason to control their aggressive impulses. Women who act explosively, on the other hand, would be considered unfeminine as well as unfriendly or dangerous.

Symptoms

IED is characterized by violent behaviors that are impulsive as well as assaultive. One example involved a man who felt insulted by another customer in a neighborhood bar during a conversation that had lasted for several minutes. Instead of finding out whether the other customer intended his remark to be insulting, or answering the "insult" verbally, the man impulsively punched the other customer in the mouth. Within a few minutes, however, he felt ashamed of his violent act. As this example indicates, the urge to commit the impulsive aggressive act may occur from minutes to hours before the "acting out" and is characterized by the buildup of tension. After the outburst, the IED patient experiences a sense of relief from the tension. While many patients with IED blame someone else for causing their violent outbursts, they also express remorse and guilt for their actions.

Demographics

IED is apparently a rare disorder. Most studies, however, indicate that it occurs more frequently in males. The most common age of onset is the period from late childhood through the early 20s. The onset of the disorder is frequently abrupt, with no warning period. Patients with IED are often diagnosed with at least one other disorder—particularly personality disorders, substance abuse (especially alcohol abuse) disorders, and neurological disorders.

Diagnosis

As mentioned, IED is essentially a diagnosis of exclusion. Patients who are eventually diagnosed with IED may come to the attention of a psychiatrist or other mental health professional by several different routes. Some patients with IED, often adult males who have assaulted their wives and are trying to save their marriages, are aware that their outbursts are not normal and seek treatment to control them. Younger males with IED are more likely to be referred for diagnosis and treatment by school authorities or the juvenile justice system, or brought to the doctor by concerned parents.

A therapist who is evaluating a patient for IED would first take a complete psychiatric history. Depending on the contents of the patient's history, the doctor would give the patient a physical examination to rule out head trauma, epilepsy, and other general medical conditions that may cause violent behavior. If the patient appears to be intoxicated by a drug of abuse or suffering symptoms of withdrawal, the doctor may order a toxicology screen of the patient's blood or urine. Specific substances that are known to be associated with violent outbursts include phencyclidine (PCP or "angel dust"), alcohol, and cocaine. The doctor will also give the patient a mental status examination and a test to screen for neurological damage. If necessary, a neurologist may be consulted and imaging studies performed of the patient's brain.

If the physical findings and laboratory test results are normal, the doctor may evaluate the patient for personality disorders, usually by administering diagnostic questionnaires. The patient may be given a diagnosis of antisocial or borderline personality disorder in addition to a diagnosis of IED.

Myths About Anger

Myth #1: Anger Is Inherited. One misconception or myth about anger is that the way people

Anger is inherited and cannot be changed. Evidence from research studies, however, indicates that people are not born with set and specific ways of expressing anger. Rather, these studies show that the expression of anger is learned behavior and that more appropriate ways of expressing anger can also be learned.

Myth #2: Anger Automatically Leads to Aggression. A related myth involves the misconception that the only effective way to express anger is through aggression. There are other more constructive and assertive ways, however, to express anger.

Effective anger management involves controlling the escalation of anger by learning assertiveness skills, changing negative and hostile “self-talk,” challenging irrational beliefs, and employing a variety of behavioral strategies. 

Myth #3: You Must Be Aggressive To Get What You Want. Many people confuse assertiveness with aggression. The goal of aggression is to dominate, intimidate, harm, or injure another person—to win at any cost. Conversely, the goal of assertiveness is to express feelings of anger in a way that is respectful of other people. Expressing yourself in an assertive manner does not blame or threaten other people and minimizes the chance of emotional harm.

Myth #4: Venting Anger Is Always Desirable. For many years, there was a popular belief that the  aggressive expression of anger, such as screaming or beating on pillows, was therapeutic and healthy. Research studies have found, however, that people who vent their anger aggressively simply get better at being angry. In other words, venting anger in an aggressive manner reinforces aggressive behavior.

Anger Is a Habit

Anger can become a routine, familiar, and predictable response to a variety of situations. When anger is displayed frequently and aggressively, it can become a maladaptive habit. A habit, by definition, means performing behaviors automatically, over and over again, without thinking.T he frequent and aggressive expression of anger can be viewed as a maladaptive habit because it results in negative consequences.

Events That Trigger Anger 

When you get angry, it is because you have encountered an event in your life that has provoked your anger. Many times, specific events touch on sensitive areas. These sensitive areas or “red flags” usually refer to long-standing issues that can easily lead to anger. In addition to events that you experience in the here and now, you may also recall an event from your past that made you angry. Just thinking about these past events may make you angry now. Here are examples of events or issues that can trigger anger:

Long waits to see your doctor

Traffic congestion

Crowded buses

A friend joking about a sensitive topic

A friend not paying back money owed to you

Being wrongly accused

Having to clean up someone else’s mess

Having an untidy roommate

Having a neighbor who plays the stereo too loud

Being placed on hold for long periods of time while on the telephone

Being given wrong directions

Rumors being spread about your relapse that are not true

Having money or property stolen from you.CEU

Timeouts

The timeout is a basic anger management strategy that should be in everyone’s anger control plan. A timeout can be used formally or informally. In its simplest form, it means taking a few deep breaths and thinking instead of reacting. It may also mean leaving the situation that is causing the escalation or simply stopping the discussion that is provoking your anger.

The formal use of a timeout involves our relationships with other people. These relationships may involve family members, friends, and coworkers. The formal use of a timeout involves having an agreement, or a prearranged plan, by which any of the parties involved can call a timeout and to which all parties have agreed in advance. The person calling the timeout can leave the situation, if necessary. It is agreed, however, that he or she will return to either finish the discussion or postpone it, depending on whether the parties involved feel they can successfully resolve the issue.

A timeout is important because it can be used effectively in the heat of the moment. Even if a person’s anger is escalating quickly as measured on the anger meter, he or she can prevent reaching 10 by taking a timeout and leaving the situation. A timeout is also effective when used with other strategies. For example, you can take a timeout and go for a walk. You can also take a timeout and call a trusted friend or family member or write in your journal. These other strategies help you calm down during your timeout period.

The Aggression Cycle 

An episode of anger can be viewed as consisting of three phases: escalation, explosion, and phase is characterized by cues that indicate anger is building. As you may recall, cues are warning signs, or responses, to anger-provoking events. If the escalation phase is allowed to continue, the explosion phase will follow. The explosion phase is marked by an uncontrollable discharge of anger that is displayed as verbal or physical aggression. The post explosion phase is characterized by the negative consequences that result from the verbal or physical aggression displayed during the explosion phase. These consequences may include going to jail, making restitution, being terminated from a job, being discharged from a drug treatment or social service program, losing family and loved ones, or feelings of guilt, shame, and regret.

The Aggression Cycle and the Anger Meter

Notice that the escalation and explosion phases of the aggression cycle correspond to levels or points on the anger meter. The points on the anger meter below 10 represent the escalation hase, the building up of anger. The explosion phase, on the other hand, corresponds to a 10on the anger meter. A 10 on the anger meter represents when you lose control and express anger through verbal or physical aggression that leads to negative consequences.

One of the primary objectives of anger management treatment is to prevent reaching the explosion phase. This is accomplished by using the anger meter to monitor changing levels of  anger, attending to the cues or warning signs that indicate anger is building, and using the appropriate strategies from your anger control plans to stop the escalation of anger. If the explosion phase is prevented, the post explosion phase will not occur and the aggression cycle will be broken.

The A-B-C-D Model

The A-B-C-D Model (see next page) is consistent with the way some people conceptualize anger management treatment. In this model, “A” stands for an activating event. The activating event is the “event” or red-flag event. “B” represents our beliefs about the activating event. It is not the events themselves that produce feelings such as anger; it is our interpretations and beliefs about the events. “C” stands for the emotional consequences. These are the feelings experienced as a result of interpretations and beliefs concerning the event. “D” stands for dispute.

This part of the model involves identifying any irrational beliefs and disputing them with more rational or realistic ways of looking at the activating event. The idea is to replace self-statements that lead to, or escalate, anger with ideas that allow you to have a more realistic and accurate interpretation of the event.

Thought stopping

A second approach to controlling our anger is called “thought stopping.” Thought stopping is an alternative to the A-B-C-D Model. In this approach, you simply tell yourself through a series of self-commands to stop thinking the thoughts that are making you angry. For example, you might tell yourself, “I need to stop thinking these thoughts. I will only get into trouble if I keep thinking this way,” or “Don’t buy into this situation,” or “Don’t go there.” In other words, instead of trying to dispute your thoughts and beliefs as outlined in the A-B-C-D Model above, the goal is to stop your current pattern of angry thoughts before they lead to an escalation of anger anda loss of control.

Aggression is behavior that is intended to cause harm to another person or damage to property. This behavior can include verbal abuse, threats, or violent acts. Often, the first reaction when another person has violated your rights is to fight back or retaliate. The basic message of aggression is that my feelings, thoughts, and beliefs are very important and your feelings, thoughts, and beliefs are unimportant and inconsequential.

One alternative to aggressive behavior is to act passively or in a nonassertive manner. This behavior is undesirable because you allow your rights to be violated. You may resent the person who violated your rights, and you may also be angry with yourself for not standing up for your rights. The basic message of passivity is that your feelings, thoughts, and beliefs are very important but my feelings, thoughts, and beliefs are unimportant and inconsequential.

From an anger management perspective, the best way to deal with a person who has violated your rights is to act assertively. Acting assertively involves standing up for your rights in such away that is respectful of other people. The basic message of assertiveness is that my feelings, thoughts, and beliefs are important and your feelings, thoughts, and beliefs are equally important.

By acting assertively, you can express your feelings, thoughts, and beliefs to the person

who violated your rights without suffering the negative consequences associated with aggression or the devaluation of yourself associated with passivity or non-assertion.

It is important to emphasize that assertive, aggressive, and passive responses are learned

behaviors;  they are not innate, unchangeable traits. By practicing the Conflict Resolution

Model, you can learn to develop assertive responses that will allow you to manage interpersonal conflicts in a more effective way.

Conflict Resolution Model

The Conflict Resolution Model is one method you can use to act assertively. It involves five

steps that can easily be memorized.

1) Identifying the Problem. This step involves identifying the specific problem that is causing

the conflict (e.g., a friend’s not being on time when you come to pick him or her up).

2) Identifying the Feelings. In this step, you identify the feelings associated with the conflict

(e.g., frustration, hurt, or annoyance).

3) Identifying the Specific Impact. This step involves identifying the specific impact or outcome of the problem that is causing the conflict (e.g., being late for the meeting that you and your friend plan to attend).

4) Deciding Whether To Resolve the Conflict. This step involves deciding whether to resolve

the conflict or let it go. In other words, is the conflict important enough to bring up?

5) Addressing and Resolving the Conflict. In this step, you set up a time to address the conflict, describe how you perceive it, express your feelings about it, and discuss how it can be resolved. CEU

Anger and the Family

For many of us, the interactions we had with our parents have strongly influenced our behaviors, thoughts, feelings, and attitudes as adults. With regard to anger and its expression, these feelings and behaviors were usually modeled for us by our parents or parental figures. The following series of questions concerns the interactions you had with your parents and the families that you grew up in. Discussing family issues can sometimes bring up uncomfortable feelings.

That's the hope of a research project headed by Dr. Rachel Lampert, associate professor of cardiology and electrophysiology at Yale University. It's based on a phenomenon called T-wave alternans, and it's getting attention in the cardiology community.

The T-wave is the last bump in the electrocardiogram (ECG), which records the electrical activity of the heart as it beats. T-wave alternans is a wide variation in the height or regularity of that bump. A number of studies have linked T-wave alternans to the risk of a potentially fatal heart arrhythmia that can be prevented by implanting a defibrillator, which delivers jolts to keep the heart beating regularly.

T-wave alternans can be detected by a physical stress test. A report by Lampert in the March 3 issue of the Journal of the American College of Cardiology on 62 people with implanted defibrillators widened that finding by having them take a mental stress test, something as simple as remembering a recent situation in which they were angered or aggravated.

Over the next three years, 16 percent of the participants experienced arrhythmias that set off their implanted defibrillators, and they were found to have higher T-wave alternans than those who did not have arrhythmias.

"One implication of our study is that the changes in the ECG you see with anger are what you see in a stress test," Lampert said. "Is the anger test as good as a stress test? This suggests that it is."

The study also helps show why anger can lead to sudden death, she said. "Feeling angry can bring on arrhythmias," Lampert said. "It shows what anger does to the heart electrical system. In the laboratory, anger is predictive of having arrhythmias in the future."

It's possible that an anger test can be as predictive of future as a physical stress test, she said, "but it is too early to say we can implant a defibrillator on the basis of T-wave alternans."

And because the study indicates that anger can cause electrical instability of the heart, "it suggests that interventions aimed at controlling anger could be a way to decrease exposure to arrhythmias," Lampert said. That belief is being tested by a study now being done at Yale.

"We take people who have defibrillators, measure their T-wave alternans and enroll them in a self-control program," she said. "We want to see if we can perhaps improve their quality of life."

The study will last about five years, Lampert said. Meanwhile, some of its objectives can be put into real-life practice, she said.

"We are thinking about how we manage stress in our lifetimes," Lampert said. "We are thinking about psychological stress management. There are lots of ways people can manage stress in their lives."

An accompanying editorial by Dr. Eric J. Rashba, professor of medicine and director of electrophysiology at the Heart Center at Stony Brook University Hospital in New York, said that the study results "provide the first evidence that patients with higher levels of anger-induced T-wave alternans during provocative testing are at greater risk for ventricular arrhythmias detectable by implanted cardiac defibrillators."

Author: U.S. Department of Health and Human Services

References:

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Besley, K. R. (1999). Anger management: Immediate intervention by counselor coach. Professional School Counseling, 3(2), pp. 81-90.

Fetsch, R. J., Schultz, C. J., Wahler, J. J. (1999). A preliminary evaluation of the Colorado Rethink parenting and anger management program. Child Abuse and Neglect, 23(4), pp. 353-360.

Goldstein, A. P. & Glick, B. (1987). Aggression replacement training: A comprehensive intervention for aggressive youth. Champaign, IL: Research Press.

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