Available online at www.sciencedirect.
com
Cognitive and Behavioral Practice 18 (2011) 251–255
COMMENTARY
Perspectives on Anger Treatment: Discussion and Commentary
Raymond W. Novaco, University of California, Irvine
AN G classical
ER controlphilosophers grappled
has been a societal with
agenda at the
leastregulation
since
of inner life and the enhancement of virtue—a campaign
extended by the Victorians. Anger is the prototype of the
classic view of emotions as “passions” that seize the
personality, disturb judgment, alter bodily conditions,
and send behavior on a perilous course. Becoming
“enraged” suggests being “rabid,” which connotes a
diseased state of mind. Being angry, becoming mad, and
creating Bedlam (echoing the historic asylum) are
semantically and metaphorically linked. Classic motifs of
anger as passion, madness, and disease reverberate in
contemporary concepts, such as qanger attacksq in the
depression literature (e.g., Fava & Rosenbaum, 1998,
1999), which has now also emerged in the intermittent
explosive disorder literature (Kessler et al., 2006). Not
only does such terminology connote being “seized,” it
conjures a pathological/disease entity that then
“explains” aggressive behavior and then is suitably
“treated” by medication.
Psychotherapeutic treatments for anger have gained
momentum in the past several decades, and it is
engaging to have these developing and new perspec-
tives from the clinical scholars who have contributed to
this special series, intriguingly organized around the
composite case study put forth by Santanello (2011).
Three of the papers—those by Deffenbacher (2011),
by DiGiuseppe (2011), and by Kassinove and Tafrate
(2011), who are distinguished leaders in the field—
follow the tradition of second-wave cognitive-behavior
therapy, whereas that by Eifert and Forsyth (2011)
represents a third wave, which centrally deemphasizes
the therapeutic value of control over inner experience.
Each presentation offers valuable insights about anger
treatment, giving emphasis to different avenues of
intervention. Nevertheless, across these papers, there
1077-7229/10/251–255$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies.
Published by Elsevier Ltd. All rights reserved.
www.elsevier.com/locate/cabp
are commonalities in approach to anger as a clinical
problem and to the case of Mr. P.
Anger as a Clinical Problem and qAnger Disordersq
Understanding anger as a clinical problem is less
than straightforward. The functionality of anger is
unmistakable. In the face of adversity, it can mobilize
physical and psychological resources, energize behaviors
for corrective action, and facilitate perseverance. The
problem conditions, however, are not derivative of
anger per se, but instead result from anger dysregulation.
In three of the contributions to this special series, the
issue of diagnosis for anger arises. It has been proposed
in various writings by four of the contributors that there
be a formal designation of “anger disorders”— e.g.,
Eckhardt & Deffenbacher (1995), Kassinove (1995),
Kasssinove and Tafrate (2002), and DiGuiseppe and
Tafrate (2007). That idea is also put forward in Feindler
(2006), and there were earlier calls by Thorne (1953)
and Barlow (1991). Thus far, however, the advocating of
formal diagnostic categories for anger has not been
accompanied by sufficient empirical grounds for that
proposition or by a coherent nosology, including
guidance for differential diagnosis.
Anger dysregulation is prototypically transdiagnostic. It
fits eminently with the comorbidity theme highlighted by
Harvey, Watkins, Mansell, and Shafran (2004). Being
intrinsically related to threat perception, anger is mani-
fested in a wide variety of psychiatric disorders (cf. Novaco,
2010). Anger emerges in conjunction with delusions and
command hallucinations in psychotic disorders, the
emotional instability attributes of personality disorders,
irrit ability and “attacks” in mood disorders, impulse
control disorders, intellectual disabilities, dementia, and
exotic cultural-bound syndromes. As anger often results
from trauma, it can be salient in PTSD, significantly
affecting the severity and course of PTSD symptoms. The
central quality of anger in the broad context of clinical
disorders is dysregulation—its activation, expression, and
experience occur without appropriate controls. The
harm-doing capacity of anger is unmistakable, but so is
its potential to adversely affect prudent thought, core
252
relationships, work performance, and physical well-being.
It thus can play strongly in the functional impairment
criterion across diagnostic categories.
Clinicians also should be mindful of troublesome
decisional quandaries associated with pathologizing an
emotional state that has important energizing, informa-
tional, and potentiating functions and that is a funda-
mental survival mechanism with extensions to freedom-
representational symbolic structures. Looming large here
are issues regarding coercion and control associated with
formal diagnoses. Having a certified “anger disorder”
might make for smoother billing of services and perhaps
for research funding, but it would increase the likelihood
that persons already hospitalized, particularly forensic
patients, would be further detained and fitted with an
additional illness label.
Engagement in Anger Treatment
People become attached to their anger routines, which
can be oddly satisfying. The psychosocial symbolism of
anger casts it as energizing, empowering, signaling,
justifying, rectifying, and relieving. Neither personal
intimates (such as Mr. P.'s) nor social gatekeepers
(parents, school principals, employers, police, and
magistrates) are charmed by the mastery-toned elements
of anger, but rather are sensitized to and unsettled by the
contrary social metaphors of anger as eruptive, unbridled,
savage, venous, burning, and consuming. Because of the
instrumental value of anger and aggression, many clients
do not readily recognize the personal costs that their
anger routines incur; and because of the embeddedness
of anger in longstanding psychological distress, there is
inertia to overcome in motivating change efforts.
The importance of facilitating the client's engagement
in treatment or building a therapeutic alliance is
highlighted in each of the three qmainstreamq CBT
perspectives, and it is a focused stage of treatment in the
approach of Kassinove and Tafrate (2011). With forensic
populations as part of their scope, they flag-up the
importance of that qpreparatoryq component. To facili-
tate treatment engagement or therapeutic alliance, each
of those three perspectives involves the use of motivation-
al interviewing (Miller & Rollnick, 2002). Further, they
describe various techniques, such as the qparadox of
control,qqwhat would happenq inquiries, and the qGestalt
two-chairq procedure by Deffenbacher (2011),the
qreflecting backq and goal-setting by DiGiuseppe (2011),
and systematic anger episode analysis and problem
awareness building by Kassinove and Tafrate.
In fostering therapeutic engagement, a fundamental
idea is that the client must recognize, or be helped to see,
the costs of his or her anger/aggression routines. The
pivotal value of identifying the costs of anger was perhaps
first given attention by McKay, Rogers, and McKay (1989).
Novaco
Clients are motivated to change when they can see that
the costs of staying the same are higher than the costs of
trying to change. People who are prone to anger can be
stubbornly rooted in their anger disposition, as reflected
in the qinflexibilityq characteristic of clients noted in all of
the four perspectives; but, a further point is that service
providers all too often develop refractory views of high
anger clients, as reflected in them being tagged as
qtreatment resistant.q
The notion of qtreatment resistanceq puts the onus of
change on the client or patient, which is indeed where
primary responsibility rests. However, there is consider-
able merit for change agents to adopt the alternative
perspective that many people having long-standing
difficulties with anger are not so much qresistantq to
change but lacking in qreadinessq for change, as Howells
and Day (2003) have well articulated. Moreover, Monahan
and Steadman (in press) have turned this treatment-
resistant notion completely on its head by asserting that,
for offenders, the situation is more accurately character-
ized as one of qclient-resistant services.q
Psychologists have known for decades about the
importance of the therapeutic relationship (cf. Nor-
cross, 2002), and the therapeutic alliance remains a
central issue for optimizing psychotherapeutic gains
(e.g., Ackerman & Hilsenroth, 2003; Lambert & Barley,
2001). Central to the therapeutic alliance is validation.
Each of the three mainstream CBT perspectives gives
attention to the importance of validating the client's
experiences, and the acceptance and commitment ther-
apy (ACT) perspective of Eifert and Forsyth (2011)
intrinsically entails this in its qacceptanceq theme, which
DiGiuseppe (2011) somewhat incorporates. Yet, while
validation facilitates alliance, all of the perspectives strive
to encourage the client to reformulate values and goals.
The ACT approach aims to move clients away from being
fused with their personal constructs and to clarify their
personal values to facilitate acting on them. Similarly,
while perhaps more situation-focused, the approaches of
Deffenbacher (2011), DiGiuseppe, and Kassinove and
Tafrate (2011) strive to help clients identify personal goals
bearing on their well-being and see the disconnection
between those goals and their recurrent behavior.
Therapeutic alliance is enhanced by the client recognizing
that the therapist is aiming to nurture the achievement of
high value goals.
Anger Assessment
Anger treatment best proceeds from case formulation.
This is best done with a conceptual model having
established clinical utility for understanding the psycho-
logical deficits associated with the person's anger signa-
ture and psychological adjustment difficulties. Treatment
 Perspective on Anger Tr eatment
should target the salient dimensions of the person's anger
dysregulation and do so in a way that is responsive to the
client's needs and capabilities. Also, attention to comor-
bidity, such as substance abuse, psychosis, posttraumatic
stress, depression, self-harm, and intellectual disabilities,
comes strongly into play here. The presentations in this
special series give varying degrees of attention to
assessment-based case formulation. Regarding standard-
ized tests, the three mainstream CBT approaches
incorporate such assessment, whereas the ACT approach
apparently does not.
Anger Problem Background
qMeeting the person where he or she is,q as
Kassinove and Tafrate and others have put it with
regard to treatment engagement, also bears on under-
standing the problem history. The Eifert and Forsyth
(2011) approach addresses this through attention to
qcognitive fusion,q attachment to the conceptualized
self,q and qexperiential avoidanceq; Deffenbacher's
(2011) approach incorporates Lazarus' appraisal pro-
cesses and attends to potential origins in cultural/
familial domains; DiGiuseppe (2011) highlights operant
learning systems; and Kassinove and Tafrate (2011)
more centrally utilize the models of Beck and Ellis. In
the discussion of the case of Mr. P., the papers give
varying degrees of weight to the family background
context, and it is surprising that there is so little
mention of his formative experiences with his father.
The exposure to volatile parents has substantial impor-
tance for understanding and predicting the anger and
assaultiveness of clinical populations, and social infor-
mation processing models, with their attendant con-
structs of schemas and scripts, provide a useful
framework (Novaco & Taylor, 2008).
Self-Observation
Anger dyscontrol involves a serious degradation in self-
monitoring. One cannot regulate troublesome internal
states without proficiency in self-monitoring. Metaphori-
cally, high anger clients have malfunctioning or inoper-
ative thermostats. From a self-regulatory perspective on
anger control, self-monitoring is crucial to preventing the
escalation of anger-aggression sequences and the erup-
tion of chaotically expressed aggression when a provoca-
tion threshold is exceeded in an otherwise aggression-
inhibited person. In CBT anger treatment, self-monitor-
ing involves detecting the cognitive, arousal, and behav-
ioral signs of anger, as well as recognizing situational
elements that can prime anger and aggressive respond-
ing. Kasssinove and Tafrate (2002) and Tafrate and
Kassinove, (2009) have provided many devices for self-
monitoring training.
253
All four of the approaches incorporate self-observation
in their treatment procedures. A major difference occurs
for the ACT approach, which seems to take as its point of
departure that anger is a secondary emotion—it is
thought to originate in pain or human suffering. Eifert
and Forsyth (2011) assert that ACT does not involve
helping clients control or manage anger, as that would
delay clients from taking effective action. Yet, self-
observation is at the core of their approach, getting the
client to notice, acknowledge, and accept angry thoughts.
Arousal Reduction
At the heart of anger is physiological activation. To be
sure, affiliated psychological states, such as resentment
and hostility, or anger-driven revenge can be qcold,q but
anger, which is an emotional state (not a qbehaviorq), has
autonomic, somatic, and central nervous system activa-
tions as definitional properties. Arousal reduction or
regulation is thus a fundamental part of anger treatment,
and it is unfortunately given insufficient attention by CBT
therapists, who seem to have forgotten what Wolpe and
Lazarus taught us. One cannot be angry and relaxed at
the same time, and breathing is the central rhythm of the
body. None of the presentations in this special series
incorporated an arousal-reduction component to their
treatment schemes for Mr. P, who is a qhot responderq in
many situational contexts and comes to treatment sessions
fully wired. Mr. P's previous therapist apparently tried
some relaxation procedures, but did so unsuccessfully.
Although Eifert and Forsyth's ACT approach alludes to
mindfulness, which has arousal-reduction features (mind-
ful breathing and deep relaxation) in its Buddhist origins,
the authors say little about its integration into their
approach.
Acceptance of Difficult Life Circumstances
People with anger control problems are often beset
with serious hardships. The advent of ACT (Hayes,
Strosahl, & Wilson, 1999) has undeniably prompted
CBT practitioners to recognize the importance of
qacceptance.q Eifert and Forsyth (2011) nicely delineate
its application to anger and to helping Mr. P to change
how he responds to discomfort and to respond less
literally to his thoughts. However, the supposition that
qpainq and qsufferingq are the origins of anger is not
altogether persuasive, as one can easily construe any
aversive event as qpain,q when pain is psychic. This notion
springs from a Buddhist framework, such as that of Hanh
(2001), who has wonderful things to say about compas-
sionate communication. Kassinove and Tafrate's (2011)
incorporation of qforgivenessq and DiGiuseppe's (2011)
qovercoming resentmentq are treatment components in
this same vein. Trauma does make for abject suffering,
and while vulnerability indeed can be seen in anger
254 Perspective onNovaco
Anger Tr eatment 255

DiGuiseppe,
experiences, R., & Tafrate,
even R. C. (2007).
beneath Understanding
the hardened exteriors angerofdisorders. anger hasW.been
Miller, successfully
R., & Rollnick, S. (2002). applied ininterviewing:
Motivational controlled research
New York: Oxford University Press. Preparing people for change (2n d ed.). New York: Guilford.
violent offenders, the comprehensive viability of the trials to forensic patients with serious anger problems and
Eckhardt, C. I., & Deffenbacher, J. L. (1995). Diagnosis of anger Monahan, J., & Steadman, H. (in press). Extending violence
qsufferingq
disorders. Inconjecture
H. Kassinove awaits
(Ed.), confirmatory
Anger disorders:testing.
Definition, histories
reductionof principles
violenceto(cf. Taylor
justice- & Novaco,
involved 2005),
persons with and
mental
diagnosis, and treatment (pp. 27–48). Washington, DC: Taylor & clinical research
illness. in that
In J. Dvoskin, area isR.growing.
J. Skeem, Novaco, & K. Douglas (Eds.),
Francis. Person-Environment Interplay Applying social science to reduce violent offending. New York: Oxford
Edmonson, C. B., & Conger, J. C. (1996). Areview of treatment efficacy
Although some of the contributors were less than
University Press.
Although recurrent
for individuals with angeranger is often
problems: a product
Conceptual, of long-and
assessment, sanguine
Norcross, about
J. C. (2002).thePsychotherapy
prognosis for Mr. P, there
relationships have Therapists
that work: been
termmethodological
exposure toissues. Clinical
adverse Psychology
conditions or Review,
to acute16,trauma,
251–275.it seven meta-analyses
contributions on the effectiveness
to the responsiveness of patients.of psychotherapy
New York: Oxford
Eifert, G. H., & Forsyth, J. P. (2011). The application of acceptance and
is nevertheless the case that anger is a product of agentic for University
anger (Beck Press.& Fernandez, 1998; Del Vecchio &
commitment therapy to problem anger. Cognitive and Behavioral Novaco, R. W. (2010). Anger and psychopathology. In M. Potegal, G.
behavior.
Practice,Habitually
18, 241–250.hostile people create systemic con- O'Leary, 2004; DiGiuseppe & Tafrate, 2003; Edmonson &
Stemmler, & C. Spielberger (Eds.), Handbook of anger
ditions
Fava, M., that fuel anger
& Rosenbaum, responding.
J. F. (1998). AngerThose attackswho select high-
in depression. Conger, 1996; Gansle,
(pp. 465–498). New York: 2005; Sukhodolsky, Kassinove, &
Springer.
conflict settings
Depression or recurrently
and Anxiety, 8,59–63.inhabit high-stress envir- Gorman,
Novaco, W. 2004; Tafrate,
W., & Taylor, J. L.1995),
(2008).which overall
Anger and have found
assaultiveness of male
Fava, M., & set
onments Rosenbaum,
the stageJ. for
(1999). Anger
their attacks
anger in patients with
experiences. As forensic
medium topatients
strongwith developmental
effect disabilities:
sizes, indicating thatLinks to volatile
approxi-
depression. Journal of Clinical Psychiatry, 60,21–24. parents. Aggressive Behavior, 34, 380–393.
anger schemas solidify, anger is evoked with considerable mately 75% of those receiving anger treatment improved
Feindler, E. L. (2006). Anger-related disorders: A practitioner's guide to Renwick, S., Black, L., Ramm, M., & Novaco, R. W. (1997). Anger
automaticity
comparativein reactionNew
treatments. to minimal threat cues. Aggres-
York: Springer. compared
treatmenttowith
controls.
forensic CBT approaches
hospital have
patients. Legal andthe greatest
Criminological
sive scripts
Gansle, that program
K. A. (2005). antagonistic
The effectiveness behavioranger
of school-based are socially efficacy. However,
Psychology, meta-analytic reviews fail to include
2, 103–116.
andinterventions
contextually and learned.
programs:For A meta-analysis.
those high Journalin avenuesof School
of case study
Santanello, A. reports
P. (2011).and multiplecase
A composite baseline
study ofstudies with with
an individual
Psychology, 43, 321–341. angeras
clinical a presenting problem.
populations, for whom Cognitive
CBT has and Behavioral
producedPractice, 18,
friction, impoverished in support structures, and short in 209–211.
Hanh, T. N. (2001). Anger: Wisdom for cooling the flames. New York:
countervailing
Riverhead Books. resources for inhibitory controls, anger significant clinical gains for people far more disturbed
Sukhodolsky, D. G., Kassinove, H., & Gorman, B. S. (2004). Cognitive-
easily A.
Harvey, becomes a default
G., Watkins, response.
E., Mansell, W., & Focus
Shafran,on R. intrapsychic
(2004). Cognitive andbehavior
behaviorally
therapy problematic than Mr.
for anger in children P (e.g., Renwick,
and adolescents: A meta-
variables is transparently
behavioural processes acrossinadequate
psychological when the person
disorders. Oxford: Oxford Black, Ramm,
analysis. & Novaco,
Aggression 1997);
and Violent that is9,likewise
Behavior, 247–269. the case
University Press. in anger-engendering and support- Tafrate,
for someR. C.controlled
(1995). Evaluation
clinicaloftrials
treatment strategies Novaco,
(Chemtob, for adult anger
remains immersed
Hayes, S. C., Strosahl, K., & Wilson, K. G. (1999). Acceptance and disorders. In H. Kassinove (Ed.), Anger disorders: Definition, diagnosis,
impoverished contexts.
commitment therapy: An experimental approach to behavior change. New
Hamada, & Gross,
and treatment 1997; Taylor,
(pp. 109–129). Novaco,
Washington, Gillmer,
DC: Taylor and Francis.
York: Guilford. Robertson,
Tafrate, R. C., &&Kassinove,
Thorne, 2005). There
H. (2009). Angerismanagement
ample reason to
for everyone.
Howells, K., & Day, A. (2003). Readiness for anger management: Clinical
While the approaches of Deffenbacher (2011) and be optimistic aboutAtascadero,
Impact Publishers: making therapeutic
CA. gains with Mr. P.
and theoretical issues. Clinical Psychology Review, 23,319–337. Taylor, J. L., & Novaco, R. W. (2005). Anger treatment for people with
DiGiuseppe (2011)
Kassinove, H. (1995). have
Anger an appreciation
disorders: Definition, for contextual
diagnosis, and treatment. developmental disabilities. Chicester, England: John Wiley & Sons.
determinants
Washington, and DC: coping
Taylor &resources,
Francis. among the presenta- Taylor, J. L., Novaco, R. W., Gillmer, B. T., Robertson, A., & Thorne, I.
Kasssinove,
tions here,H.,it &isTafrate,
only inR.theC. (2002).
approach Angerofmanagement:
Kassinove The andcomplete Concluding
(2005). A controlled Comments
trialofindividual cognitive-behavioural anger
treatment guidebook for practitioners. Atascadero, CA: Impact.. treatment for people with intellectual disabilities and histories of
Tafrate (2011) that one sees emphasis being given to
Kassinove, H., & Tafrate, R. C. (2011). Application of a flexible, This exposition
aggression. British of second-wave
Journal and third-wave
of Clinical Psychology, CBT
44, 367–382.
environmental
clinically drivenexposure
approach factors. They also
for angerreduction point
in the caseout thatP.
of Mr. Thorne, F. C. (1953).
approaches The in
to anger frustration-anger-hostility
this special series willstates: A new
boost interest
their avoidance
Cognitive and escape
and Behavioral strategies
Practice, are at variance with
18, 222–234. diagnostic classification. Journal of Clinical Psychology, 9, 334–339.
in t he treatment of people who are psychologically
Kessler,
an ACT R. approach.
C., Coccaro, E. F., Fava, M., Jaeger, S., Jin, R., & Walters, E.
(2006). The prevalence and correlates of DSM-IV intermittent distressed by this turbulent emotion. While the therapeu-
Address correspondence to Raymond W. Novaco, Ph.D., University
explosive disorder in the National Comorbidity Survey Replica- tic mechanisms underlying treatment gains found in
of California, Dept. of Psychology and Social Behavior, 4343 SBS
tion. Archives ofRange of Applicability
General Psychiatry, 63, 669–678. clinical Irvine,
research are note-mail:
clear,rwnovaco@uci.edu.
nor has the sustainability
Gateway, CA 92697;
Lambert, M. J., & Barley, D. E. (2001). Research summary on the or generalizability of those gains been well-established, we
There are relationship
therapeutic some puzzling aspects of outcome.
and psychotherapy the exposition
Psycho- of
can be fortified
Received November in providing remedies for anger dyscontrol
6, 2010
thetherapy, 38, 357–361.
therapeutic approaches and their hypothetical
McKay, M., Rogers, P. D., & McKay, J. (1989). When anger hurts: Quieting and enlightened
Accepted November 13,by 2010
the diverse approaches to it that these
application to the case of Mr. P. For the most part,
the storm within. Oakland, CA: New Harbinger. special series
Available contributors
online 13 December 2010have presented.
there is little said about safety issues. While Mr. P has
reported not having any criminal sanctions for violent
behavior, has no military background, and has reported References
to have never been assaultive with those in personally
Ackerman, S. J., & Hilsenroth, M. J. (2003). A review of therapist
close relationships with him, he has an explosive temper characteristics and techniques positively impacting the therapeu-
and has a history of violent behavior. Just as creating tic alliance. Clinical Psychology Review, 23,1–33.
Barlow, D. H. (1991). Disorders of emotion. Psychological Inquiry, 2,
qsafetyq for a client is imperative for obtaining treatment 58–71.
engagement, there must also be safety for the clinician to Beck, R., & Fernandez, E. (1998). Cognitive-behavioral therapy in the
proceed with treatment in a way that truly qconnectsq with treatment of anger: A meta-analysis. Cognitive Therapy and Research,
22,63–74.
the client. This is a complex issue, beyond the space limits Chemtob, C. M., Novaco, R. W., Hamada, R. S., & Gross, D. M. (1997).
of this discussion piece. What can be noted from the Cognitive-behavioral treatment for severe anger in posttraumatic
presentations, though, is that it was good to see Kassinove stress disorder. Journal of Consulting and Clinical Psychology, 65,
and Tafrate (2011) call attention to the level of therapist 184–189.
Deffenbacher, J. (2011). Cognitive-behavioral conceptualization and
expertise, as well as to alluding to risks in working with treatment of anger. Cognitive and Behavioral Practice, 18, 212–221.
criminal offenders. Del Vecchio, T., & O'Leary, K. D. (2004). Effectiveness of anger
treatments for specific anger problems: A meta-analytic review.
Because each of these approaches relies on cognitive Clinical Psychology Review, 24,15–34.
skills, there is the operative presumption that CBT for DiGiuseppe, R. (2011). A comprehensive treatment program for a case
anger is not suitable for clients with intellectual disabil- of disturbed anger. Cognitive and Behavioral Practice, 18, 235–240.
DiGiuseppe, R., & Tafrate, R. C (2003). Anger treatment for adults: A
ities. None of the expositions recognize that CBT for meta-analytic review. Clinical Psychology:Science and Practice, 10, 7084.