Journal of Contextual Behavioral Science 11 (2019) 34–43

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Journal of Contextual Behavioral Science

journal homepage: www.elsevier.com/locate/jcbs

A review of anger, hostility, and aggression from an ACT perspective T

a,⁎,1 b c
Olga V. Berkout , Diana Tinsley , Maureen K. Flynn
a
Department of Psychology, Texas A&M-Corpus Christi, 6300 Ocean Drive, Bay Hall 316, Corpus Christi, TX 78414, USA
b
Department of Psychology, University of Mississippi, 207 Peabody Hall, University MS 38677, USA
c
Department of Psychology, Metropolitan State University of Denver, 890 Auraria Pkwy, Denver, CO 80204, USA

A R T I C LE I N FO A B S T R A C T

Keywords: A growing body of literature has begun to examine anger, hostility, and aggression using the psychological
Psychological flexibility flexibility model among both youth and adults. This manuscript provides the first overview of this research.
Acceptance and Commitment Therapy Papers were included in this review if they were published in English, peer-reviewed, published through
Anger December 8th, 2017 on PsycInfo and PubMed, or were recommended during the review process. The research
Aggression
reviewed examines anger, hostility, and aggression in a variety of contexts, such as interpersonal difficulties,
Hostility
emotional difficulties (e.g., depression, posttraumatic stress disorder), impulse control, and externalizing. The
article also reviews Acceptance and Commitment Therapy-based interventions targeting problems related to
anger and aggression. Generally, there is support for the psychological flexibility model in this domain and
treatment studies have been demonstrated a beneficial impact of ACT on aggression and domestic violence in
adults. The literature in youth is extremely limited, although some supportive findings were demonstrated. More
extensive and methodologically stronger examinations would strengthen this area of study and are discussed.

1. Introduction (Cassiello-Robins & Barlow, 2016; Veenstra et al., 2018). Cognitive

Anger is often defined as a “negative” emotional reaction to per-
ceived provocation (Novaco, 2011). Anger is linked to aggression and
interpersonal problems and emphasized in the symptomatology of a
number of psychological disorders (Cassiello-Robbins & Barlow, 2016;
Fernandez & Johnson, 2016). Some scholars have used the term anger
to broadly encompass emotional reaction, cognition, and behavioral
response, whereas others more narrowly zeroed in on anger as an
emotion (Eckhardt, Norlander, & Deffenbacher, 2004; Fernandez, Day,
& Boyle, 2015). When more fine-grained distinctions are made, the
term hostility has been used to emphasize cognitive/attitudinal aspects,
such as viewing others and the world antagonistically (Cassiello-
Robbins & Barlow, 2016; Eckhardt et al., 2004). Aggression, or beha-
vior aimed at harming others, may be an expression of anger; however,
it can also be used as a tool to achieve a goal (e.g., instrumental ag-
gression, Fontaine, 2007; Veenstra, Bushman, & Koole, 2018).
Although anger is associated with problematic behavior, it is also a
functional natural emotion, which can motivate defense against a rea-
listic threat or inspire communication about an interpersonal problem
(Cassiello-Robins & Barlow, 2016; Deffenbacher, 2011). Anger is
viewed as problematic in the broader literature when it is excessive,
expressed as aggression, or causes distress or functional impairment
Behavioral Therapy (CBT) has been the most widely examined ap-
proach to addressing problematic anger (Lee & DiGiuseppe, 2018). CBT
focuses on reducing the experience and expression of anger through
reducing arousal, altering anger-provoking thoughts, and providing
alternative skills for navigating social situations and interpersonal
frustration (Kassinove & Tafrate, 2011). Although CBT based inter-
ventions have received empirical support, these are not universally
effective and treatment drop out continues to present difficulties (Berta
& Zarling, 2018). As such, scholars continue to examine other ap-
proaches.
One promising alternative is the psychological flexibility model and
its treatment application, Acceptance and Commitment Therapy (ACT).
Psychological flexibility is defined as the ability to flexibly relate to
private experiences and behave in a manner that is responsive to en-
vironmental contingencies and consistent with one's values (Hayes,
Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013). Psychological
flexibility is comprised of six processes: cognitive defusion, acceptance,
present moment focus, chosen values, committed action, and self as
context (see Levin, Hayes, & Vilardaga, 2012 for a review). The con-
verse of psychological flexibility, inflexibility, has been linked to
emotional difficulties and dysfunctional behavior (Chawla & Ostafin,
2007). ACT differs from CBT and other dominant perspectives in its

⁎
Corresponding author.
E-mail address: oberkout@gmail.com (O.V. Berkout).
1
Present/permanent address: Texas A&M Corpus Christi, 6300 Ocean Drive, Corpus Christi, TX 78412, USA.

https://doi.org/10.1016/j.jcbs.2018.12.001
Received 12 June 2018; Received in revised form 18 November 2018; Accepted 1 December 2018
2212-1447/ © 2018 Association for Contextual Behavioral Science. Published by Elsevier Inc. All rights reserved.
O.V. Berkout et al.
emphasis on altering how one relates to thoughts, feelings, and other
private experiences, rather than attempting to change these (Hayes,
Levin, Plumb-Vilardaga, Villatte, & Pistorello, 2013; Hayes, Barnes-
Holmes, & Wilson, 2012). The focus of ACT treatment is increasing
flexible responding to the environment and living consistently with
one's values, which is more strongly emphasized than distress reduction
(Ciarrochi, Bilich, & Godsel, 2010).
The psychological flexibility perspective can be applied to anger,
hostility, and aggression. Eifert and Forsyth (2011) present a con-
ceptual ACT model of anger difficulty. These scholars suggest that
people who struggle with anger may be more strongly attached to anger
provoking thoughts (e.g., fusion) and view themselves as unable to
control their anger (e.g., attachment to the conceptualized self). They
propose that anger may provide a means to avoid other unpleasant
private events, serving an experiential avoidance function. Eifert and
Forsyth (2011) further suggest that anger may make it difficult to en-
gage in behaviors consistent with one's values. Gardner and Moore
(2008) have similarly proposed that aggression may allow individuals
to avoid feeling threatened and vulnerable (their perspective is de-
scribed as the Anger Avoidance Model), consistent with experiential
avoidance.
An important point is that the psychological flexibility model con-
siders anger, aggression, and hostility in terms of their function and
does not view these as inherently problematic. For example, one could
behave aggressively while saving a child from a rabid animal and this
behavior would likely not be considered dysfunctional. The extent to
which individuals are able to behave in a psychologically flexible
fashion, responding to the environment and leading values consistent
lives, rather than the topography of the behavior itself is key (Eifert &
Forsyth, 2011).
2. Current review
The purpose of this manuscript is to summarize the literature on
psychological flexibility and ACT in relation to anger, hostility, and
aggression. English language based peer reviewed articles through
December 8th, 2017 on PsycInfo and PubMed were searched for the
terms: “psychological flexibility,” “experiential avoidance,” and
“Acceptance and Commitment Therapy” with “anger,” “aggression,”
“hostility,” and “violence.” Due to its emphasis on contextual beha-
vioral science, which includes the psychological flexibility model, the
Journal of Contextual Behavioral Science was similarly reviewed for
relevant articles. Articles presenting from these searches were ex-
amined by the authors for association with ACT relevant constructs and
focus on anger, hostility, and aggression. In addition to these efforts, we
included two articles suggested during the review process, which fo-
cused on constructs of interest. We were broadly inclusive of studies,
reviewing quantitative and qualitative data and case study and larger
sample examinations. Both youth and adults were included with many
samples being drawn from the United States (U.S.). Given the limited
research in the area, we chose to include the construct of externalizing,
which encompasses aggression and hostility, as well as poor impulse
control and noncompliance for youth (Tully & Hunt, 2015). To our
knowledge this review represents the first effort at providing an over-
view of anger, hostility, and aggression within the ACT literature.
3. Findings on relationships with psychological inflexibility
3.1. Anger expression and interpersonal problems
Interpersonal problems, such as domestic violence, aggression, and
vindictiveness are the most commonly examined behaviors in relation
to anger and psychological inflexibility. Gerhart, Baker, Hoerger, and
Ronan (2014) assessed the extent to which negative expectations about
social relationships account for the link between psychological inflex-
ibility and interpersonal difficulties. In this study, 159 university
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Journal of Contextual Behavioral Science 11 (2019) 34–43
students in the Midwestern U.S. completed standardized measures of
psychological inflexibility, attachment anxiety (i.e., discomfort in in-
timate relationships), hostility, and interpersonal problems (i.e., cold-
ness, avoidance, vindictiveness, and dominance). Psychological inflex-
ibility was found to interact with hostility to predict dominating (B =
0.00377, p < .01) and vindictiveness (B = 0.0025, p < .01), such that
relationships between hostility and these constructs were stronger at
higher levels of inflexibility. Relationships between attachment anxiety,
psychological inflexibility, and interpersonal problems were also de-
monstrated. Gerhart and colleagues (2014) suggested that participants
might engage in problematic interpersonal behaviors to avoid the dis-
comfort associated with hostility and that this may be particularly
challenging for those who are higher in psychological inflexibility.
Relationships between psychological inflexibility and anger ex-
pression have also been considered. Yavuz, Şahin, Ulusoy, Ipek, and
Kurt (2016) explored the relationships between psychological inflex-
ibility, anger, and interpersonal function among 34 men with Antisocial
Personality Disorder (ASPD) and 32 men without psychiatric symp-
toms, recruited in Turkey. Participants completed a structured clinical
interview and standardized questionnaires assessing anger, psycholo-
gical inflexibility, and other aspects of social function. Psychological
inflexibility demonstrated relationships with all measures of anger in
the clinical group: it was negatively related to anger control (r =
−0.50, p = .003) and positively correlated with trait anger (r = 0.54,
p = .001), anger internalization (r = 0.40, p = .021), and anger ex-
pression (r = 0.35, p = .047). Conversely, only anger control was si-
milarly associated with psychological inflexibility among controls.
Based on these findings, Yavuz and colleagues (2016) suggest that
psychological inflexibility is central in difficulties with anger and its
expression, particularly for clinical populations, such as ASPD.
Several studies focus on psychological inflexibility and intimate
partner violence. Shorey et al. (2014) examined the association be-
tween psychological inflexibility and perpetration of dating violence
among 109 male undergraduates at a Southeastern U.S. university.
Participants completed standardized questionnaires assessing psycho-
logical inflexibility, alcohol use, relationship satisfaction, and perpe-
tration of psychological (e.g., threats), physical, and sexual intimate
partner violence. All forms of dating violence were positively related to
psychological inflexibility (psychological aggression r = 0.42,
p < .001; physical aggression r = 0.24, p < .05; sexual coercion
r = 0.36, p < .001). Psychological inflexibility remained predictive of
psychological aggression and sexual coercion, after controlling for age,
relationship satisfaction, and alcohol use. A similar relationship to
physical aggression was not demonstrated after these variables were
controlled for. Shorey and colleagues (2014) suggest that psychological
inflexibility appears linked to dating violence and that further ex-
amination in larger samples may be helpful, particularly to help clarify
the relationship to physical aggression.
Reddy, Meis, Erbes, Polusny, and Compton (2011) studied re-
lationships between psychological flexibility and partner directed ag-
gression among 49 American heterosexual military couples. Partici-
pants completed standardized measures of psychological flexibility,
relationship adjustment, and psychological and physical aggression.
Men who had lower psychological flexibility were reported to be more
physically aggressive by their partners (β = -0.21, p = .037) and they
reported experiencing more physical aggression from their partners
(β = -0.35, p = .032). Similar relationships were not demonstrated for
women, although the relationship between psychological flexibility and
perpetration of physical aggression approached significance (β = -0.32,
p = .083). Negative associations between relationship adjustment and
psychological flexibility were also obtained. Reddy and colleagues
(2011) suggested that aggressive behavior might be used to avoid ex-
cess arousal among individuals facing the stress of returning after de-
ployment.
Bell and Higgins (2015) examined relationships between intimate
partner violence, psychological inflexibility, and childhood
O.V. Berkout et al.
victimization. Participants were 232 Midwestern U.S. community fe-
males who completed standardized measures of intimate partner vio-
lence, problem solving in social situations, experience of child abuse,
and psychological inflexibility. Many participants endorsed physical
intimate partner violence victimization (58% minor & 47% severe) and
perpetration (59% minor & 34% severe) over the course of the past
year. Path analysis was used to examine relationships. Childhood
physical abuse was associated with perpetration of intimate partner
violence. Childhood emotional abuse also had indirect effects via psy-
chological inflexibility and problematic problem solving approaches
(impulsivity/carelessness and negative problem orientation). Psycho-
logical inflexibility was associated with intimate partner violence per-
petration (β = 0.27) and had indirect effects on perpetration through
problematic approaches to social problem solving. An unexpected
finding, however, was that negative problem orientation was inversely
related to perpetration. Scholars suggested that this relationship may be
reflective of a tendency to avoid problems and thus potential situations
in which perpetration may occur. Bell and Higgins (2015) concluded
that psychological inflexibility was associated with perpetration of in-
timate partner violence, with some of its effects being obtained due to
detrimental impact on problem solving in social situations.
Researchers have examined relationships between psychological
inflexibility, anger, hostility, aggression, and other interpersonal pro-
blems. Scholars have suggested that individuals who are less psycho-
logically flexible may respond with anger and aggression as means to
avoid other more uncomfortable private events (Eifert & Forsyth, 2011;
Reddy et al., 2011). Consistently with this conceptualization, psycho-
logical inflexibility has been linked with greater trait anger and greater
expression of anger and aggression (Bell & Higgins, 2015; Reddy et al.,
2011; Shorey et al., 2014; Yavuz et al., 2016). Psychological inflex-
ibility was also found to interact with hostility to predict problematic
interpersonal behaviors, such that these relationships were stronger for
those who were more inflexible (Gerhart et al., 2014). Generally the
studies conducted in this area were consistent with the expected re-
lationships from the psychological flexibility perspective. Methodolo-
gically, these studies have strengths and limitations. Populations ex-
amined included community adult, military, individuals diagnosed with
ASPD, and college students, avoiding the common limitation of un-
dergraduate convenience samples. However, the majority also used
cross-sectional self-report methodology and subsequent research would
be strengthened by inclusion of longitudinal and more methodologi-
cally varied examinations.
3.2. Relationships with other emotional difficulties
Anger, hostility, and aggression may occur along with other emo-
tional difficulties. For example, anger attacks, which present as intense
anger accompanied by physiological arousal, appear common among
those struggling with depression and anxiety (Painuly, Grover, Gupta, &
Mattoo, 2011). Physical and verbal aggression have also been linked to
depression (Leonhardt, Lysaker, Vohs, James, & Davis, 2018). Ad-
ditionally, due to an established relationship between anger and Post-
traumatic Stress Disorder (PTSD), anger is included as a part of its di-
agnostic criteria (America Psychiatric Association, 2013). From a
psychological flexibility perspective, these relationships may be con-
sistent with the potential for anger to allow avoidance of emotional
pain (Eifert & Forsyth, 2011). Scholars have begun to examine these
associations and their links to potentially problematic expressions.
Gerhart, Heath, Fitzgerald, & Hoerger (2013) assessed the extent to
which psychological inflexibility, anger, and depression play a role in
contributing to difficulties with delaying gratification. Scholars ex-
pected that those who are less psychologically flexible would experi-
ence more negative emotions and would be more focused on short-term
consequences, rather than long-term benefit. Two hundred and two
undergraduates at a university in the Midwestern U.S. completed
standardized measures of psychological inflexibility, anger, depression,
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Journal of Contextual Behavioral Science 11 (2019) 34–43
and ability to delay gratification. Scholars tested a path analysis model,
in which psychological inflexibility predicted delay of gratification,
both directly and through depression and anger. Psychological inflex-
ibility had significant direct effects on delay of gratification (β = -0.22,
p = .001) and depression (β = 0.68, p = .001), as well as significant
indirect effects on anger via depression (β = 0.45, p = .001) and on
delay of gratification via depression and anger (β = -0.14, p = .001).
Gerhart and colleagues (2014) suggested that challenges dealing with
common negative emotions associated with psychological inflexibility
might contribute to difficulties in delaying gratification and engaging in
valued living.
Anger has been found to contribute to the relationship between
PTSD symptoms and aggression perpetration (Novaco & Chemtob,
2015). Scholars have begun examining the extent to which psycholo-
gical inflexibility plays a role in this relationship. Tull, Jakupcak,
Paulson, and Gratz (2007) evaluated the extent to which psychological
inflexibility contributes to anger and aggression among 113 student,
staff, and faculty men exposed to situations with potential for trauma.
Participants provided self-report information on past experience of
trauma, symptoms of PTSD, psychological inflexibility, the extent to
which they express emotions, anger, and aggressive behavior using
standardized measures. Psychological inflexibility was associated with
both anger (r = 0.19, p < .05) and aggression (r = 0.33, p < .01) and
aggression was positively related to PTSD symptoms (r = 0.32,
p < .01). Furthermore, psychological inflexibility (β = 0.19, p < .05)
and emotional inexpressivity (β = 0.18, p < .05) predicted aggression
after PTSD symptoms and trait anger were accounted for. The re-
lationship between PTSD symptoms and aggression was no longer sig-
nificant after these variables were included in the model, suggesting
that they serve as mediators. Tull and colleagues (2007) concluded that
psychological inflexibility and emotional inexpressivity might account
for aggressive behavior associated with PTSD.
Scholars have considered relationships between social anxiety,
anger, and aggression. Kashdan and McKnight (2010) suggest that some
socially anxious individuals may become angry and aggressive in re-
sponse to perceived rejection. Breen and Kashdan (2011) considered
the role of psychological inflexibility in the relationship between social
anxiety and anger in response to rejection. Participants were 170 un-
dergraduates at a Mid-Atlantic U.S. university who completed stan-
dardized measures of social anxiety, anger, and psychological inflex-
ibility and responded to a vignette asking them to imagine social
rejection (including anger and experiential avoidance responses). Self-
reported psychological inflexibility was positively related to state
(r = 0.41, p < .01) and trait anger (r = 0.37, p < .01), as well as the
tendency to hold anger in (r = 0.57, p < 0.01). Social anxiety symp-
toms were positively associated with measures of state and trait anger
and with anger and anger suppression in response to the rejection
vignette. The interaction between social anxiety and experiential
avoidance was a significant predictor of anger suppression in response
to imaged rejection. Participants low in social anxiety and low in ex-
periential avoidance engaged in less anger suppression in response to
vignettes compared to participants high in social anxiety or experiential
avoidance. Breen and Kashdan (2011) suggested that individuals who
are higher in experiential avoidance may struggle more with adaptively
handling anger and emphasized the extent to which flexible responding
was important to address social challenges.
Kashdan, Breen, Afram, and Terhar (2010) examined the relation-
ship between anger and psychological inflexibility among 148 under-
graduates at a Mid-Atlantic U.S. university. Participants were asked to
write an autobiographical narrative associated with experiencing an-
xiety, which was coded for experiential avoidance, coping, and emo-
tional experience. Participants completed standardized measures of
social anxiety, depression, anger, psychological inflexibility, and emo-
tion regulation. Data were collected at both an initial session and a
three-month follow up. Anger was unrelated to experiential avoidance
coded from the narrative activity. Initial psychological inflexibility was
O.V. Berkout et al.
associated with less outward anger expression (r = -0.21, p < .05)
during the follow up assessment, however, this relationship was no
longer significant after initial anger expression, negative affect, and
anxiety symptoms were controlled for. Scholars suggested that re-
lationships between anger and experiential avoidance as coded in the
narrative might have been weaker because the writing prompt focused
on anxiety, rather than anger. Kashdan and colleagues (2010) re-
commended that more longitudinal and multimethod research on these
relationships be conducted.
Overall, several studies examining psychological inflexibility, anger,
and aggression in relation to other emotional difficulties have been
conducted. Generally, psychological inflexibility has been linked to
anger and aggression in these examinations (Breen & Kashdan, 2011;
Tull et al., 2007) and appears to interact with anger and depression in
relation to difficulty in delaying gratification (Gerhart et al., 2014).
Additionally, psychological inflexibility was found to partially explain
the relationship between PTSD symptoms and aggression (Tull et al.,
2007). Findings were generally supportive of the idea that inflexible
responding to private events may contribute to aggression and other
problematic behaviors. However, the studies reviewed also had some
limitations. With the exception of Tull and colleagues (2007) inclusion
of other university employees, studies relied on college student sam-
ples. Examinations tended to be primarily cross-sectional (Breen &
Kashdan, 2011; Gerhart et al., 2014; Tull et al., 2007) although
Kashdan and colleagues (2010) studied relationships over a three-
month period. Breen and Kashdan (2011) and Kashdan and colleagues
(2010) included vignette response and narrative writing, broadening
the methodology used. However, self-report methodology remained the
primary approach and a limited number of studies have been con-
ducted.
3.3. Psychological inflexibility and externalizing in youth
Most studies of psychological inflexibility and anger, hostility, and
aggression have been conducted in adult samples. Aggressive behavior
and hostility in youth is encompassed in the broader construct of ex-
ternalizing, which also includes difficulties with poor impulse control
and noncompliance (Tully & Hunt, 2015). Given the extremely limited
literature on psychological inflexibility in youth, we chose to include
examinations of externalizing. A single study evaluating the relation-
ships between externalizing and experiential avoidance was identified.
Shea and Coyne (2017) assessed relationships between experiential
avoidance, victimization by relational aggression (actions aimed at
damaging social relationships), and psychological symptoms among
fifty eight 11–14 year old girls from the Northeastern United States.
Scholars proposed that those with a greater history of relational victi-
mization would endorse more experiential avoidance and psychological
difficulty. Participants completed standardized measures of experiential
avoidance, victimization by relational aggression, and internalizing and
externalizing difficulties, and a task assessing response to social ex-
clusion (Cyberball). History of victimization via relational aggression
was positively related to experiential avoidance. Experiential avoidance
was found to predict externalizing behavior (β = 0.31, p < .001) after
controlling for victimization and was similarly linked to greater inter-
nalizing symptoms. Experiential avoidance was additionally predictive
of sad mood following exclusion in the behavioral task. Shea and Coyne
(2017) suggested that externalizing behavior could serve an avoidance
function, allowing girls to evade unpleasant peer interactions by be-
having aggressively. A summary of youth and adult studies examining
relationships between anger, aggression, hostility, and related con-
structs with psychological inflexibility is provided in Table 1.
37
Journal of Contextual Behavioral Science 11 (2019) 34–43
4. ACT interventions findings
4.1. Adults with anger and aggression difficulties
4.1.1. Anger and aggression
Scholars have assessed the impact of ACT based interventions on
anger and aggression among adults. Donahue, Santanello, Marsiglio,
and Van Male (2017) applied an ACT group intervention to 23 male
veterans in the Northwestern U.S. who reportedly struggled with anger
and aggression using a single group design. The intervention targeted
mindfulness, acceptance, defusion, self as context, values, and com-
mitted action, and consisted of 12 weekly 90-min group sessions. Par-
ticipants completed standardized measures of anger, physical and
verbal aggression, psychological inflexibility, and quality of life at pre-
treatment, post-treatment, and six-week follow up, and provided feed-
back on the intervention. Participants reported decreased physical ag-
gression (d = 0.53, p < .05) and psychological inflexibility (d = 0.65,
p < .01) at post-treatment and decreased inflexibility (d = 0.86,
p < .01) and difficulties with one's temper at follow up (d = 0.49,
p < .05). However, there were no significant changes in verbal ag-
gression or quality of life. The rate of attrition was 30% and occurred
within the first three sessions; those who completed treatment tended to
rate it as effective, a good use of their time, and endorse that they would
recommend it to others. Moreover, they found that the protocol was not
too long and many commented that they learned useful skills. Donahue
and colleagues (2017) concluded that ACT presents a feasible treatment
option for veterans with anger difficulties.
Harvey, Henrickson, Bimler, and Dickson (2017) also studied the
effects of an ACT intervention on New Zealand military service per-
sonnel anger, aggression, distress, and use of drugs and alcohol. The
intervention targeted all six hexaflex processes over the course of a five-
day group treatment course. Two hundred and sixty two soldiers with
psychological, social, occupational, or legal problems participated in
this study. Participants were referred by military command on the basis
of struggling with substance use difficulties. Soldiers were assigned to
the intervention or waitlist control group based on availability and
timing of the referral. Participants completed standardized measures of
substance use, anger and aggression, stress, anxiety, locus of control,
and use of emotion regulation strategies at the beginning of treatment
and at one-month post intervention. Attrition rates were 66.7% for the
intervention and 44.6% for the waitlist control group. Compared to
those in the waitlist control group, those who received the intervention
experienced a greater decrease in physical (d = −0.38, p < .05) and
verbal (d = - 0.37, p < .05) aggression and perceived stress (d =
−0.43, p < .05) and a greater increase in use of emotion management
(d = 0.69, p < .05). Additionally, greater decrease in perception of
powerful others having control over one's life was demonstrated for the
intervention group. There was a significant decrease in alcohol use for
those in the intervention group, although the between group compar-
ison of alcohol use change did not attain significance. Harvey and
colleagues (2017) concluded that the study provided support for the use
of an ACT intervention for military personnel and noted that partici-
pants qualitatively reported positive perceptions of the intervention.
They suggested that larger more rigorous examinations using rando-
mized controlled trial methodology and long-term follow up would
strengthen the field.
Eisenbeck, Shietz, and Szekeres (2017) compared the impact of an
ACT intervention to treatment as usual (TAU) among 17 Hungarian
inmates charged with violent crimes and placed in pretrial detention.
Participants completed standardized measures of psychological inflex-
ibility, depression, anxiety, and valued living at pretreatment, post-
treatment, and three month follow up. Participants were randomly as-
signed to TAU (a CBT intervention) or an ACT based program targeting
all aspects of psychological flexibility. Both programs consisted of ten
weekly 90-min group sessions. Due to correctional transfer ten parti-
cipants (five in each group) remained at post-treatment. Scholars found
O.V. Berkout et al. Journal of Contextual Behavioral Science 11 (2019) 34–43

Table 1
Summary of relationships between anger, hostility, aggression, and psychological inflexibility.
Study Sample Age: Mean (SD) Measurement Design Relationship to Inflexibility

Gerhart et al. (2014) 159 primarily female 24.00 (6.00) AAQ-II Cross-sectional survey Stronger relationships for hostility with
university students AQ-H interpersonal problems at higher level
Yavuz et al. (2016) 34 men with ASPD & 32 men ASPD: 31.60 AAQ-II Cross-sectional survey and Relates negatively to anger control and
without (7.78) clinical interview positively to anger and expression for
Without: 36.56 STAXI ASPD
(9.74)
Shorey et al. (2014) 109 male undergraduates 18.44 (0.75) AAQ-II Cross-sectional survey Positively related to psychological
CTS−2 aggression and sexual coercion
Reddy et al. (2011) 49 heterosexual military Soldiers: 35.00 AAQ-II Cross-sectional survey & Males higher in inflexibility reported to be
couples partners (7.39) partner report more aggressive
Partners: 34.00 CTS−2
(8.43)
Bell and Higgins (2015) 232 community females 31.96 (10.09) AAQ Cross-sectional survey Related to greater perpetration of IPV
CTS−2
Gerhart, Heath, Fitzgerald, and 202 primarily female 19.50 (3.00) AAQ-II Cross-sectional survey Positive effect on anger and negative effect
Hoerger (2013) undergraduates PED-A on delay of gratification
Tull et al. (2007) 113 men exposed to trauma 26.41 (5.00) AAQ Cross-sectional survey Predicted aggression over anger and PTSD
BDHI symptoms
STAXI
Breen and Kashdan (2011) 170 primarily female 21.29 (5.19) AAQ-II Cross-sectional survey and Positively related to anger and anger in
undergraduates STAXI-II vignette response
Kashdan, Breen et al. (2010) 148 primarily female Age not reported AAQ Longitudinal survey & No significant relationships
undergraduates MAI narrative
Shea and Coyne (2017) 58 adolescent girls 12.26 (0.98) AFQ-Y CBCL-YSR Cross-sectional survey & Experiential avoidance associated with
behavioral task greater externalizing

Note: AAQ=Acceptance and Action Questionnaire (Hayes et al., 2004); AAQ-II = Acceptance and Action Questionnaire-II (Bond et al., 2007, 2011); AFQ-
Y= Avoidance and Fusion Questionnaire for Youth (Greco, Lambert, & Baer, 2008); AQ-H = Aggression Questionnaire Hostility (Buss & Perry, 1992); BDHI = Buss-
Durkee Hostility Inventory (Buss & Durkee, 1957); CBCL-YSR = Child Behavior Checklist – Youth Self-Report (Achenbach & Rescorla, 2001); CTS-2 =Revised
Conflict Tactics Scale (Straus, Hamby, Boney-McCoy, & Sugarman, 1996); MAI = Multidimensional Anger Inventory (Siegel, 1986); PED-A= PROMIS Emotional
Distress-Anger (Cella et al., 2010); STAXI = State-Trait Anger Expression Inventory (Spielberger, 1988); STAXI-II = State-Trait Anger Expression Inventory-II
(Spielberger, 1999). Mean and standard deviation (SD) for age provided when available.

that self reported values consistent behaviors increased for participants
in ACT from pre to post-treatment and that these participants were
higher on this measure compared to TAU at post-treatment (η2 = 0.54,
p = 0.02) and at three month follow up (η2 = 0.73, p = 0.02). No other
differences were obtained. Scholars suggested that changes in values
consistency, rather than psychological inflexibility, may have been re-
flective of greater focus on values over the course of the intervention
(Eisenbeck, et al., 2017).
Razzaque (2012) studied the effectiveness of an ACT intervention on
three patients in a British psychiatric intensive care unit using a case
study design. The intervention included defusion, self as context, va-
lues, and mindfulness delivered via 20-min daily sessions over the
course of two to three weeks. Participants had lengthy histories of self-
harm or violence towards others; two were diagnosed with Bipolar
Disorder and one with Schizoaffective Disorder. Nursing staff assessed
observed violent behaviors and verbal expressions of the desire to self-
harm were assessed through interviews; both of these metrics did not
use standardized assessment. Clinical Global Index, a structured rating
scale, was additionally used to evaluate illness severity. All participants
were rated as decreasing violent behavior and reported other positive
symptom change (e.g., fewer derogatory auditory hallucinations,
greater confidence in impulse control), although this rating did was not
made using a standardized measure limiting conclusions. All partici-
pants received lower illness severity ratings after treatment. Razzaque
(2012) suggested that ACT was a promising intervention for reducing
aggression among seriously mentally ill.
4.1.2. Intimate partner violence
Several studies have evaluated the potential of ACT to reduce en-
gagement in intimate partner violence. Zarling, Lawrence, and
Marchman (2015) examined the effects of a group ACT intervention in
a randomized controlled trial among 101 male and female treatment
seeking participants. Participants were randomly assigned to receive
ACT or an attention control supportive intervention; both were
delivered in groups. The ACT intervention addressed mindfulness, de-
fusion, acceptance, values, and committed action and was provided via
12 weekly sessions lasting two hours each. Participants completed
standardized measures of psychological and physical aggression in in-
timate relationships, psychological inflexibility, and difficulties in
emotion regulation. Seventy two percent of participants in ACT and
about 72.5% of participants in the control condition completed post-
treatment assessments. Participants in ACT reported less psychological
(d = 0.40) and physical aggression (d = 0.36) at post-treatment and six
month follow up (psychological aggression d = 0.96 and physical ag-
gression d = 0.79). Additionally, participants in ACT evidenced a
greater reduction in psychological and physical aggression from pre-
treatment to six-month follow up. Participants in ACT, but not the
control condition, experienced declines in psychological inflexibility
and difficulties in emotion regulation. Psychological inflexibility
mediated reductions in psychological and physical aggression, sug-
gesting theoretically consistent therapeutic change. Zarling and col-
leagues (2015) suggested that findings were supportive of applicability
of ACT to the treatment of intimate partner violence and that change
appeared to occur in a theoretically consistent fashion.
In another examination, Zarling, Bannon, and Berta (2017) com-
pared an ACT based program, Achieving Change Through Values-Based
Behavior (ACTV) to a traditional CBT/Duluth model treatment, which
focused on changing problematic beliefs around masculinity and power
and control of women. Data from 3474 men, court ordered to partici-
pate in a batterer intervention program, were analyzed in this study.
The study was conducted in Iowa and participants were assigned to
conditions based on availability and scheduling considerations. The
ACTV intervention includes a focus on values, committed action, ac-
ceptance, mindfulness, defusion, and an emphasis on behavioral skills,
such as assertiveness and conflict resolution. Both interventions con-
sisted of 24 weekly group sessions that were an hour and a half to two
hours long. Criminal justice data on the occurrence and frequency of
violent offenses during and after completion of the program were

38
O.V. Berkout et al. Journal of Contextual Behavioral Science 11 (2019) 34–43

et al., 1996); DAR = Dimensions of Anger Reactions Scale (Novaco, 1975); VLQ= Valued Living Questionnaire (Wilson, Sandoz, Kitchens, & Roberts, 2011). Mean and standard deviation (SD) for age provided when
2008); AQ = Aggression Questionnaire (Buss & Perry, 1992); AQ-SF = Buss Perry Aggression Questionnaire Short Form (Diamond & Magaletta, 2006); CTS-2-PA = Conflict Tactics Scale-2 Physical Assault Scale (Straus
Note: AAQ = Acceptance and Action Questionnaire (Hayes et al., 2004); AAQ=II = Acceptance and Action Questionnaire-II (Bond et al., 2011); AFQ-Y = Avoidance and Fusion Questionnaire for Youth (Greco et al.,
compared. During the intervention, significantly fewer ACTV vs. CBT/

Participant highlighted group connection as contributing to

Low rate of domestic violence recidivism and decrease in

Duluth participants committed offenses that led to charges (6.4% vs.
12.3%). Within twelve months after treatment completion a markedly

Lower violent recidivism for those receiving ACT

Lower psychological and physical aggression and
Decreased physical and verbal aggression in ACT
lower percentage of ACTV participants (7.6%) engaged in general

Increase in values consistent behaviors in ACT

Decreased physical aggression & inflexibility
violent recidivism compared to those in the Duluth/CBT (12.1%) con-
dition. Similarly, a smaller proportion of those in ACTV (5.3%) had
domestic assault charges compared to those in the CBT/Duluth (7.7%)

psychological inflexibility for ACT

group over the year following treatment. Treatment dropout rates of
38.9% for ACT and 27% for the CBT/Duluth condition were obtained.

Decrease in violent behavior

Zarling and colleagues (2017a) concluded that ACTV presents a pro-

experiential avoidance
treatment engagement
mising alternative to the traditional Duluth/CBT treatment and may be
more effective in lowering recidivism rates.
Zarling and Berta (2017) provide a qualitative case study high-

Major Finding
lighting the experiences of Ed, a participant receiving treatment for
interpersonal violence perpetration in the Midwestern United States. Ed
reported high alcohol use and frequent interpersonal difficulties with
his girlfriend, which resulted in an altercation with police involvement.
As a result, he received charges of domestic assault and was court or-

ACT vs. waitlist control, nonrandom

Randomly assigned to ACT vs. CBT

dered to attend ACTV. Although Ed was resistant to treatment at first,

ACT vs. Duluth/CBT, nonrandom

Single group ACT intervention

Single group ACT intervention

Randomly assigned to ACT vs.
he later made a connection with one of the other participants and over
time reported that he began to realize that there were problems in his
current relationship. At the end of treatment, Ed acknowledged that he
gained insight into his behaviors and emotions and had a better un-

attention control
Case description

Case description
derstanding of his values. Zarling and Berta (2017) further note that

assignment

assignment
more randomized controlled studies are needed to understand factors
that influence treatment and how much and what quality of training is
Design
necessary for ACTV group facilitators.
Berta and Zarling (In Press) examined the impact of ACTV among 23

No formal measures
male domestic violence perpetrators in the Midwestern United States in

AFQ-Y Recidivism
Staff observation
a single group design. Participants in this study were incarcerated to
permit them to complete treatment after a fourth contempt of court

CTS− 2-PA
Recidivism
Measures

charge for failing to complete a community domestic violence program.

AAQ-II

AAQ-II

AAQ-II
AQ-SF
DAR

VLQ
The majority of participants (52%) identified as Native American and
AQ

all were male. ACTV was delivered via 24 sessions lasting two hours
each, which were provided three times per week. Concurrent to the
Primarily 20–24; range < 20

ACTV program, participants received treatment as usual via meetings

with a psychiatrist and counselor. Participants completed standardized
Age data not provided

measures of experiential avoidance, psychopathy, adverse childhood

Age: Mean (SD)

experiences (such as abuse and living with household members who

54.83 (14.57)

33.45 (10.25)

36.00 (10.00)
26.47 (8.06)

31.45 (7.39)

were struggling with mental illness or substance abuse), and attach-

to > 40

Late 30's

ment. Legal records on recidivism for one-year post treatment com-

pletion were examined. Participants were comparable to other domestic
violence samples on attachment and exhibited higher psychopathy
scores. They additionally reported an average of 3.94 adverse child-
3474 men court ordered to batterer intervention
17 male inmates charged with violent offenses

hood experiences. Scholars found that experiential avoidance decreased

101 primarily female adults with relationship
23 male veterans with anger and aggression

262 primarily male military personnel with

over the course of treatment (d=-4.73). One participant received a

Single male in treatment for interpersonal

23 incarcerated male domestic violence

domestic violence charge and 24% a violent criminal charge over the
year following program completion. Scholars highlighted the beneficial
Three patients in psychiatric ICU

impact of treatment on experiential avoidance and the low rate of do-

mestic violence recidivism (4.5%) as strengths of the intervention.
substance use difficulties

Overall, these studies suggested that ACT interventions offer a

violence perpetration

promising approach to addressing aggressive behavior (Donahue et al.,

2017; Harvey et al., 2017; Razzaque, 2012) and its occurrence in in-
timate partner relationships (Berta & Zarling, In press; Zarling et al.,
perpetrators
Summary of adult intervention studies.

difficulties

2015; Zarling et al., 2017; Zarling & Berta, 2017). Additionally, ACT
program
Sample

based interventions appear promising among legally involved in-

dividuals (Eisenbeck et al., 2017; Zarling et al., 2017; Berta & Zarling,
In press), which may be more challenging than those who are vo-
Zarling, Bannon et al. (2017)

luntarily seeking treatment. However, the literature remains limited.

Zarling and Berta (2017)
Eisenbeck et al. (2017)
Donahue et al. (2017)

Few studies have been conducted and only two (Zarling et al., 2015;
Harvey et al. (2017)

Zarling et al. (2015)

Berta & Zarling ( )

Eisenbeck et al., 2017) used randomized controlled trial methodology,

Razzaque (2012)

with one of these being a small sample of 17 participants (Eisenbeck

et al., 2017). More extensive examination and independent replication
available.

of findings would strengthen empirical support for ACT for aggressive

Table 2

Study

behavior. Adult intervention study characteristics, measures, and key

outcomes are summarized in Table 2.

39
O.V. Berkout et al. Journal of Contextual Behavioral Science 11 (2019) 34–43

Note: AFQ-Y = Avoidance and Fusion Questionnaire for Youth (Greco et al., 2008); PEQ-R = Revised Peer Experiences Questionnaire (Prinstein, Boergers, & Vernberg, 2001); RSQ = Responses to Stress Questionnaire
4.2. Interventions with youth

Children experienced less difficulty with anger and Although ACT has not been extensively examined in the treatment

Decreased frequency, intensity, and duration of

of anger, hostility, and aggression in youth, a small number of studies
Increase in active problem solving in ACT have been conducted in this area. Chang and Hwang (2017) explored
whether an ACT-based protocol could decrease anger and anxiety in
children training in the martial art of Taekwondo. This study was ex-
ploratory in nature and did not use standardized measures. The authors
suggested that, due to its competitive and aggressive nature, partici-
pation in martial arts could evoke anger and anxiety. Nine elementary
school aged children in Seoul, Korea received eight daily hour and a
half intervention sessions. The intervention was based on an ACT and
Major Findings

mindfulness approach and included acceptance, defusion, present mo-

irritability

outbursts

(Connor-Smith, Compas, Wadsworth, Thomsen, & Saltzman, 2000). Demographic information on gender & age mean and standard deviation (SD) provided when available.

ment focus, and value clarification. Participants provided information

on their emotional experience and perception of the intervention via
unstructured self-report and providing ratings after each session. These
Randomly assigned to ACT vs. waitlist control

evaluations indicated that children endorsed more positive attitudes

towards Taekwondo and experienced less difficulty with anger and ir-
ritability, although standardized measures were not used in the eva-
Single group ACT/mindfulness based

luation (Chang & Hwang, 2017). While interesting, this study was
limited in its description of methodology. Evaluation of improvement
appears to have been subjective rather than informed by statistical
evaluation.
Theodore-Oklota, Orsillo, Lee, and Vernig (2014) evaluated the
Single case design

impact of a three-session ACT-based intervention on relational aggres-

sion. The ACT-based intervention included mindfulness, defusion, ac-
intervention

ceptance, and values focused exercises and consisted of three sessions

Design

delivered during 48-min class periods over the course of two weeks.
Participants were 210 seventh graders at a New England middle school,
whose classrooms were randomized to treatment or waitlist control.
Behavioral observation of anger episodes

Participants completed standardized measures on social interactions,

experiential avoidance, and psychopathology before starting the pro-
gram and were assessed again at three-month follow up. The ACT in-
tervention was found to have a positive impact on the use of active
problem solving in peer conflict (β = 0.15, p = 0.03), although rela-
Measurement unclear

tional aggression, experiential avoidance, and psychopathology symp-

toms were not affected. Theodore-Oklota and colleagues (2014) sug-
gested that the program may have been too brief to have an impact on
Measures

experiential avoidance, but noted that the positive impact on active

AFQ-Y
PEQ-R

problem solving to address conflict was promising.

RSQ

Ruiz and Perete (2015) examined the application of an ACT in-

formed protocol in a single case of a five-year old boy with problematic
Age: Mean (SD)

12.45 (0.51)

expressions of anger (e.g., derogatory comments to peers when he was

jealous, yelling, and crying). The protocol consisted of four 20-min
intervention sessions implemented over a three-week period. Inter-
9.89

5.00

vention sessions included components focused on increasing psycho-

logical flexibility drawing on Relational Frame Theory perspective
taking. Additionally, exercises, such as holding a difficult posture, or
210 primarily male eight graders

abruptly ending a video game and then mindfully reflecting on the

Nine elementary school aged

experience were used to increase flexible responding. A token economy

Single case male child

was also used to help reduce angry outbursts. Effectiveness was mea-
sured through frequency, duration, and intensity of outbursts as re-
corded by his mother. During treatment, the child evidenced sig-
nificantly fewer anger outbursts (Tau-U = .542, p = .004) with lower
Summary of youth intervention studies.

children

intensity (Tau-U = .476, p = .014) and shorter duration (Tau-U =

Sample

.574, p = .002). Scholars suggested that ACT presents a promising

treatment approach to problematic childhood anger. Notably, in this
Theodore-Oklota et al. (2014)

study Samuel's mother, who is also the second author of this manu-
script, delivered the intervention, while being supervised by the first
Chang and Hwang (2017)

Ruiz and Perete (2015)

author. Although parent-training interventions commonly include par-

ents in at home skill practice, it is possible that this dual role may have
influenced interpretation.
Very limited research has been conducted on ACT interventions for
youth anger and aggression difficulties. Although the authors including
Table 3

Study

these studies are breaking new ground, methodological improvements

would strengthen conclusions that could be drawn. For example, Chang

40
O.V. Berkout et al.
and Hwang (2017) and Ruiz and Perete (2015) did not use standardized
measures in their examinations, which may limit the ability to make
comparisons with future studies. Additionally, Ruiz and Perete had a
parent serve as both an author and the deliverer of the intervention.
Potentially this dual role may have influenced the author's perspective.
Theodore-Oklota and colleagues (2014) used both standardized mea-
sures and random assignment, but did not find treatment group dif-
ferences in experiential avoidance and relational aggression. However,
this study also found that participants in ACT used more positive pro-
blem solving, suggesting that some benefit was obtained (Theodore-
Oklota et al., 2014). As noted by Theodore-Oklota and colleagues
(2014) the brevity of the intervention may not have been sufficient to
demonstrate lasting benefit after a three-month period. Key character-
istics of youth intervention studies are summarized in Table 3.
5. Discussion
5.1. Relationships with psychological inflexibility
The psychological flexibility model emphasizes flexible responding
to private events and value consistent behavior (Hayes et al., 2013).
Conceptual applications of this perspective have emphasized the po-
tential for anger and aggression to allow individuals to avoid un-
pleasant private events (e.g., experiential avoidance; Eifert & Forsyth,
2011). Individuals who are more inflexible might be expected to ex-
perience anger and aggression more due to the tendency towards ex-
periential avoidance. The literature was generally consistent with this
prediction: individuals who were higher in inflexibility tended to report
more anger and aggression (Bell & Higgins, 2015; Reddy et al., 2011;
Shorey et al., 2014; Yavuz et al., 2016). Experiential avoidance was
similarly linked to youth externalizing behavior (Shea & Coyne, 2017).
Of note, the psychological flexibility model emphasizes values con-
sistent behavior, more so than psychological distress (Ciarrochi et al.,
2010). Response to private events, rather than whether they are ex-
perienced is ultimately most important: some support for the role of
psychological flexibility in adaptive responding has been obtained. Tull
and colleagues (2007) found that psychological inflexibility mediated
the link between PTSD symptoms and aggression. Although not all
examinations demonstrated expected theoretically consistent relation-
ships (e.g., Kashdan et al., 2010), support for the psychological flex-
ibility model has been obtained.
5.2. Methodological considerations in examinations of relationships
As common for emerging areas in psychology, many of the studies
reviewed used cross-sectional self-report methodology to assess con-
structs of interest. Self-report methodology can permit scholars to ex-
plore new areas with limited expenditure of resources. These studies
have generally demonstrated expected relationships in the areas of
anger, hostility, and aggression. However, greater integration of other
methods, such as behavioral tasks, legal records, and longitudinal ex-
aminations would strengthen the field. Additionally, although other
populations were included, college students, who may not be re-
presentative of the general population, were the most common group
studied. A single study was identified examining relationships among
youth. Continued efforts to broaden the populations studied would
improve the literature base.
An important methodological consideration is measurement of
psychological flexibility and its processes. With a few exceptions, the
Acceptance and Action Questionnaire-II (AAQ-II; Bond et al., 2011) and
its prior versions were used to evaluate psychological flexibility. AAQ-II
has been described as a measure of psychological inflexibility by its
developers (Bond et al., 2011). However, scholars have argued that the
AAQ-II focuses primarily on experiential avoidance and fusion and does
not adequately represent all of the components of psychological flex-
ibility (Francis, Dawson, & Golijani-Moghaddam, 2016). Inclusion of
41
Journal of Contextual Behavioral Science 11 (2019) 34–43
other measures that better capture other psychological flexibility pro-
cesses in future research would be beneficial. Additionally varied
measures were used to assess psychological inflexibility, anger, hosti-
lity, and aggression, potentially tapping into different aspects of these
constructs. Given the fairly limited literature, this aspect has the po-
tential to influence findings, although the relationships obtained were
generally consistent.
5.3. Impact of ACT interventions
Scholars have examined the impact of ACT on anger and aggression.
ACT appears to decrease engagement in aggressive behavior (Donahue
et al., 2017; Harvey et al., 2017; Razzaque, 2012) and intimate partner
violence (Zarling et al., 2015; Zarling et al., 2017; Zarling & Berta,
2017; Berta & Zarling, In Press). Examinations of ACT for aggression
outside the domestic violence context have demonstrated small to
medium effect sizes but fairly high dropout rates (30%, Donahue et al.,
2017; 66.7%, Harvey et al., 2017). The particularly high drop out rate
in Harvey and colleagues (2017) study may be attributable to use of a
population who also struggled with substance use. Medium to large
effect sizes for aggression and decreased recidivism were obtained in
examinations of ACT for domestic violence (Zarling et al., 2015; Zarling
et al., 2017). Dropout rates of about 28% (Zarling et al., 2015) and
about 38.9% (Zarling et al., 2017) were obtained in these studies,
which are lower than typical for domestic violence intervention pro-
grams (Berta & Zarling, In press). Of additional importance, many ex-
aminations also found theoretically consistent changes in psychological
flexibility processes over the course of ACT based interventions
(Donahue et al., 2017; Eisenbeck et al., 2017; Zarling et al., 2015; Berta
& Zarling, In press).
Examinations among youth are much more limited, although there
are some positive findings. Scholars have found that ACT based inter-
ventions appear to decrease aggression (Chang & Hwang, 2017; Ruiz &
Perete, 2015) and increase adaptive social problem solving (Theodore-
Oklota et al., 2014). However, support for the intervention is not uni-
versal and the sole group examination using statistical analyses and
random assignment failed to find group differences in experiential
avoidance, relational aggression, or psychopathology (Theodore-Oklota
et al., 2014). It is difficult to make conclusive statements given the
extremely limited literature and more studies of ACT in youth are
needed.
5.4. Methodological considerations in intervention studies
Overall stronger support for ACT as an intervention for aggression
has been obtained among adults, however, the need for further research
remains. The majority of these evaluations used quasi-experimental
designs and only two randomized controlled examinations have been
conducted (Eisenbeck et al., 2017; Zarling et al., 2015). As research in
this area is limited, quasi-experimental studies have contributed con-
siderably to beginning to establish ACT as a promising intervention for
aggression. However, a greater number of randomized controlled trials
or carefully conducted single case designs supporting the intervention
would provide stronger support and permit for systematic reviews
consistent with contemporary recommendations for identifying evi-
dence based treatments (Tolin, McKay, Forman, Klonsky, & Thombs,
2015). Additionally, the populations examined have been primarily on
military individuals (Donahue et al., 2017; Harvey et al., 2017) and
domestic violence perpetrators (Berta & Zarling, In press; Zarling et al.,
2017; Zarling et al., 2015). Determining the extent to which ACT based
treatments are beneficial in other groups would improve the current
literature base. Measurement of outcomes and processes used varied
methodology. Inclusion of legal records in addition to self-report data is
a strength of several studies. However variability in the measures used
to assess constructs of interest may also influence findings. As the lit-
erature expands, the impact of measurement variability may be
O.V. Berkout et al.
clarified. The youth intervention literature remains extremely limited
and would be strengthened by clear descriptions of methodology, in-
clusion of standardized measures, and examinations including random
assignment.
5.5. Conclusions and future directions
Although research on the psychological flexibility model as applied
to anger and aggression remains limited, support for this perspective
has been obtained. Relationships with anger, hostility, and aggression
have overall been consistent with the psychological flexibility model
and ACT interventions appear promising. However, the body of litera-
ture remains limited and would be enhanced by future research em-
ploying stronger methodology and a broader set of populations.
References
Achenbach, T. M., & Rescorla, L. A. (2001). Manual for the ASEBA school-age forms and
profiles. Burlington, VT: University of Vermont Research Center for Children, Youth
and Families.
America Psychiatric Association (2013). (DSM-5)Diagnostic and statistical manual of mental
disorders (5th ed.). Washington, DC: American Psychiatric Publishing.
Bell, K., & Higgins, L. (2015). The impact of childhood emotional abuse and experiential
avoidance on maladaptive problem solving and intimate partner violence. Behavioral
Sciences, 5(2), 154–175. https://doi.org/10.3390/bs5020154.
Berta, M., & Zarling, A. (In Press). A preliminary trial of an Acceptance and Commitment
Therapy-Based program for incarcerated domestic violence offenders. Violence and
Victims.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K., Orcutt, H. K., & Zettle, R. D. (2007).
Preliminary psychometric properties of the Acceptance and Action Questionnaire—II:
A revised measure of psychological flexibility. Unpublished manuscript.
Bond, F. W., Hayes, S. C., Baer, R. A., Carpenter, K. M., Guenole, N., Orcutt, H. K., &
Zettle, R. D. (2011). Preliminary psychometric properties of the Acceptance and
Action Questionnaire–II: A revised measure of psychological inflexibility and ex-
periential avoidance. Behavior Therapy, 42(4), 676–688. https://doi.org/10.1016/j.
beth.2011.03.007.
Breen, W. E., & Kashdan, T. B. (2011). Anger suppression after imagined rejection among
individuals with social anxiety. Journal of Anxiety Disorders, 25(7), 879–887. https://
doi.org/10.1016/j.janxdis.2011.04.009.
Buss, A. H., & Durkee, A. (1957). An inventory for assessing different kinds of hostility.
Journal of Consulting and Clinical Psychology, 21(4), 343–349. https://doi.org/10.
1037/h004690.
Buss, A. H., & Perry, M. (1992). The aggression questionnaire. Journal of Personality and
Social Psychology, 63(3), 452–459. https://doi.org/10.1037/t00691-000.
Cassiello-Robbins, C., & Barlow, D. H. (2016). Anger: The unrecognized emotion in
emotional disorders. Clinical Psychology: Science and Practice, 23(1), 66–85. https://
doi.org/10.1111/cpsp.12139.
Cella, D., Riley, W., Stone, A., Rothrock, N., Reeve, B., Yount, S., & Hays, R. (2010). The
Patient-Reported Outcomes Measurement Information System (PROMIS) developed
and tested its first wave of adult self-reported health outcome item banks:
2005–2008. Journal of Clinical Epidemiology, 63(11), 1179–1194. https://doi.org/10.
1016/j.jclinepi.2010.04.011.
Chang, D., & Hwang, S. (2017). The development of anger management program based
on acceptance and commitment therapy for youth taekwondo players. Journal of
Exercise Rehabilitation, 13(2), 160–167. https://doi.org/10.12965/jer.1732882.441.
Chawla, N., & Ostafin, B. (2007). Experiential avoidance as a functional dimensional
approach to psychopathology: An empirical review. Journal of Clinical Psychology,
63(9), 871–890. https://doi.org/10.1002/jclp.20400.
Ciarrochi, J., Bilich, L., & Godsel, C. (2010). Psychological flexibility as a mechanism of
change in Acceptance and Commitment Therapy. In R. Baer’s (Ed.). Assessing mind-
fulness and acceptance: Illuminating the processes of change (pp. 51–76). Oakland, CA:
New Harbinger Publications, Inc.
Connor-Smith, J. K., Compas, B. E., Wadsworth, M. E., Thomsen, A. H., & Saltzman, H.
(2000). Responses to stress in adolescence: Measurement of coping and involuntary
stress responses. Journal of Consulting and Clinical Psychology, 68(6), 976–992.
https://doi.org/10.1037/0022-006x.68.6.976.
Deffenbacher, J. L. (2011). Cognitive-Behavioral conceptualization and treatment of
anger. Cognitive and Behavioral Practice, 18(2), 212–221. https://doi.org/10.1016/j.
cbpra.2009.12.004.
Diamond, P. M., & Magaletta, P. R. (2006). The short-form Buss-Perry Aggression
Questionnaire (BPAQ-SF): A validation study with federal offenders. Assessment,
13(3), 227–240. https://doi.org/10.1177/1073191106287666.
Donahue, J. J., Santanello, A., Marsiglio, M. C., & Van Male, L. M. (2017). Acceptance and
Commitment Therapy for anger dysregulation with military veterans: A pilot study.
Journal of Contemporary Psychotherapy, 47(4), 233–241. https://doi.org/10.1007/
s10879-017-9361-z.
Eckhardt, C., Norlander, B., & Deffenbacher, J. (2004). The assessment of anger and
hostility: A critical review. Aggression and Violent Behavior, 9(1), 17–43. https://doi.
org/10.1016/s1359-1789(02)00116-7.
Eifert, G. H., & Forsyth, J. P. (2011). The Application of Acceptance and Commitment
42
Journal of Contextual Behavioral Science 11 (2019) 34–43
Therapy to problem anger. Cognitive and Behavioral Practice, 18(2), 241–250. https://
doi.org/10.1016/j.cbpra.2010.04.004.
Eisenbeck, N., Sheitz, K., & Szekeres, B. (2017). A brief Acceptance and Commitment
Therapy-based intervention among violence-prone male inmates delivered by novice
therapists. Psychology, Society, & Education, 8(3), 187. https://doi.org/10.25115/
psye.v8i3.173.
Fernandez, E., Day, A., & Boyle, G. J. (2015). Measures of anger and hostility in adults.
Measures of Personality and Social Psychological Constructs, 74–100. https://doi.org/
10.1016/b978-0-12-386915-9.00004-8.
Fernandez, E., & Johnson, S. L. (2016). Anger in psychological disorders: Prevalence,
presentation, etiology and prognostic implications. Clinical Psychology Review, 46,
124–135. https://doi.org/10.1016/j.cpr.2016.04.012.
Fontaine, R. G. (2007). Disentangling the psychology and law of instrumental and re-
active subtypes of aggression. Psychology, Public Policy, and Law, 13(2), 143–165.
https://doi.org/10.1037/1076-8971.13.2.143.
Francis, A. W., Dawson, D. L., & Golijani-Moghaddam, N. (2016). The development and
validation of the Comprehensive assessment of Acceptance and Commitment Therapy
processes (CompACT). Journal of Contextual Behavioral Science, 5(3), 134–145.
https://doi.org/10.1016/j.jcbs.2016.05.003.
Gardner, F. L., & Moore, Z. E. (2008). Understanding clinical anger and violence. The
anger avoidance model. Behavior Modification, 32, 897–912. https://doi.org/10.
1177/0145445508319282.
Gerhart, J. I., Heath, N. M., Fitzgerald, C., & Hoerger, M. (2013). Direct and indirect
associations between experiential avoidance and reduced delay of gratification.
Journal of Contextual Behavioral Science, 2(1–2), 9–14. https://doi.org/10.1016/j.jcbs.
2013.02.001.
Gerhart, J. I., Baker, C. N., Hoerger, M., & Ronan, G. F. (2014). Experiential avoidance
and interpersonal problems: A moderated mediation model. Journal of Contextual
Behavioral Science, 3(4), 291–298. https://doi.org/10.1016/j.jcbs.2014.08.003.
Greco, L. A., Lambert, W., & Baer, R. A. (2008). Psychological inflexibility in childhood
and adolescence: Development and evaluation of the Avoidance and Fusion
Questionnaire for Youth. Psychological Assessment, 20(2), 93–102. https://doi.org/10.
1037/1040-3590.20.2.93.
Harvey, S. T., Henricksen, A., Bimler, D., & Dickson, D. (2017). Addressing anger, stress,
and alcohol-related difficulties in the military: An ACT intervention. Military
Psychology, 29(5), 464–476. https://doi.org/10.1037/mil0000173.
Hayes, S. C., Strosahl, K., Wilson, K. G., Bissett, R. T., Pistorello, J., Toarmino, D., &
McCurry, S. M. (2004). Measuring experiential avoidance: A preliminary test of a
working model. The Psychological Record, 54(4), 553–578. https://doi.org/10.1007/
bf03395492.
Hayes, S. C., Barnes-Holmes, D., & Wilson, K. G. (2012). Contextual behavioral science:
Creating a science more adequate to the challenge of the human condition. Journal of
Contextual Behavioral Science, 1(1–2), 1–16. https://doi.org/10.1016/j.jcbs.2012.09.
004.
Hayes, S. C., Levin, M. E., Plumb-Vilardaga, J., Villatte, J. L., & Pistorello, J. (2013).
Acceptance and Commitment Therapy and Contextual Behavioral Science: Examining
the progress of a distinctive model of Behavioral and Cognitive Therapy. Behavior
Therapy, 44(2), 180–198. https://doi.org/10.1016/j.beth.2009.08.002.
Kashdan, T. B., & McKnight, P. E. (2010). The darker side of social anxiety. Current
Directions in Psychological Science, 19(1), 47–50. https://doi.org/10.1177/
0963721409359280.
Kashdan, T. B., Breen, W. E., Afram, A., & Terhar, D. (2010). Experiential avoidance in
idiographic, autobiographical memories: Construct validity and links to social an-
xiety, depressive, and anger symptoms. Journal of Anxiety Disorders, 24(5), 528–534.
https://doi.org/10.1016/j.janxdis.2010.03.010.
Kassinove, H., & Tafrate, R. C. (2011). Application of a flexible, clinically driven approach
for anger reduction in the case of Mr. P. Cognitive and Behavioral Practice, 18(2),
222–234. https://doi.org/10.1016/j.cbpra.2009.08.008.
Lee, A. H., & DiGiuseppe, R. (2018). Anger and aggression treatments: A review of meta-
analyses. Current Opinion in Psychology, 19, 65–74. https://doi.org/10.1016/j.copsyc.
2017.04.004.
Leonhardt, B. L., Lysaker, P. H., Vohs, J. L., James, A. V., & Davis, L. W. (2018). The
experience and expression of anger in posttraumatic stress disorder: The relationship
with metacognition. Journal of Mental Health, 1–6. https://doi.org/10.1080/
09638237.2018.1466036.
Levin, M. E., Hayes, S. C., & Vilardaga, R. (2012). Acceptance and commitment therapy:
Applying an iterative translational research strategy in behavior analysis. In J. G.
Madden (Ed.). APA handbook of behavior analysis, Vol. 2: Translating principles into
practice (pp. 455–479). Washington, D.C.: American Psychological Association.
Novaco, R. W. (1975). Anger control: The development and evaluation of an experimental
treatment. Oxford, England: Lexington.
Novaco, R. W. (2011). Perspectives on anger treatment: Discussion and commentary.
Cognitive and Behavioral Practice, 18(2), 251–255. https://doi.org/10.1016/j.cbpra.
2010.11.002.
Novaco, R. W., & Chemtob, C. M. (2015). Violence associated with combat-related
posttraumatic stress disorder: The importance of anger. Psychological Trauma: Theory,
Research, Practice, and Policy, 7(5), 485–492. https://doi.org/10.1037/tra0000067.
Painuly, N. P., Grover, S., Gupta, N., & Mattoo, S. K. (2011). Prevalence of anger attacks
in depressive and anxiety disorders: Implications for their construct? Psychiatry and
Clinical Neurosciences, 65(2), 165–174. https://doi.org/10.1111/j.1440-1819.2010.
02177.x.
Prinstein, M. J., Boergers, J., & Vernberg, E. M. (2001). Overt and relational aggression in
adolescents: Social-psychological adjustment of aggressors and victims. Journal of
Clinical Child & Adolescent Psychology, 30(4), 479–491. https://doi.org/10.1207/
s15374424jccp3004_05.
Razzaque, R. (2012). An acceptance and commitment therapy based protocol for the
O.V. Berkout et al.
management of acute self-harm and violence in severe mental illness. Journal of
Psychiatric Intensive Care, 9(02), 72–76. https://doi.org/10.1017/
s1742646412000258.
Reddy, M. K., Meis, L. A., Erbes, C. R., Polusny, M. A., & Compton, J. S. (2011).
Associations among experiential avoidance, couple adjustment, and interpersonal
aggression in returning Iraqi war veterans and their partners. Journal of Consulting
and Clinical Psychology, 79(4), 515–520. https://doi.org/10.1037/a0023929.
Ruiz, F. J., & Perete, L. (2015). Application of a relational frame theory account of psy-
chological flexibility in young children. Psicothema, 27(2), 114–119. https://doi.org/
10.7334/psicothema2014.195.
Shea, S. E., & Coyne, L. W. (2017). Reliance on experiential avoidance in the context of
relational aggression: Links to internalizing and externalizing problems and dys-
phoric mood among urban, minority adolescent girls. Journal of Contextual Behavioral
Science, 6(2), 195–201. https://doi.org/10.1016/j.jcbs.2017.03.001.
Shorey, R. C., Elmquist, J., Zucosky, H., Febres, J., Brasfield, H., & Stuart, G. L. (2014).
Experiential avoidance and male dating violence perpetration: An initial investiga-
tion. Journal of Contextual Behavioral Science, 3(2), 117–123. https://doi.org/10.
1016/j.jcbs.2014.02.003.
Siegel, J. M. (1986). The Multidimensional Anger Inventory. Journal of Personality and
Social Psychology, 51(1), 191–200. https://doi.org/10.1037/0022-3514.51.1.191.
Spielberger, C. D. (1988). Professional manual for the State-Trait Anger Expression Inventory
(STAXI). Odessa, FL, USA: Psychological Assessment Resources.
Spielberger, C. D. (1999). State-Trait Anger Expression Inventory-Second Edition. Odessa, FL,
USA: Psychological Assessment Resources.
Straus, M. A., Hamby, S. L., Boney-McCoy, S., & Sugarman, D. B. (1996). The Revised
Conflict Tactics Scales (CTS–2). Journal of Family Issues, 17, 283–316. https://doi.
org/10.1177/019251396017003001.
Theodore-Oklota, C., Orsillo, S. M., Lee, J. K., & Vernig, P. M. (2014). A pilot of an
acceptance-based risk reduction program for relational aggression for adolescents.
Journal of Contextual Behavioral Science, 3(2), 109–116. https://doi.org/10.1016/j.
jcbs.2014.03.001.
43
Journal of Contextual Behavioral Science 11 (2019) 34–43
Tolin, D. F., McKay, D., Forman, E. M., Klonsky, E. D., & Thombs, B. D. (2015).
Empirically supported treatment: Recommendations for a new model. Clinical
Psychology: Science and Practice, 22(4), 317–338. https://doi.org/10.1111/cpsp.
12122.
Tull, M. T., Jakupcak, M., Paulson, A., & Gratz, K. L. (2007). The role of emotional in-
expressivity and experiential avoidance in the relationship between Posttraumatic
stress disorder symptom severity and aggressive behavior among men exposed to
interpersonal violence. Anxiety, Stress, & Coping, 20(4), 337–351. https://doi.org/10.
1080/10615800701379249.
Tully, L. A., & Hunt, C. (2015). Brief parenting interventions for children at risk of ex-
ternalizing behavior problems: A systematic review. Journal of Child and Family
Studies, 25(3), 705–719. https://doi.org/10.1007/s10826-015-0284-6.
Veenstra, L., Bushman, B. J., & Koole, S. L. (2018). The facts on the furious: A brief review
of the psychology of trait anger. Current Opinion in Psychology, 19, 98–103. https://
doi.org/10.1016/j.copsyc.2017.03.014.
Wilson, K. G., Sandoz, E. K., Kitchens, J., & Roberts, M. (2011). The Valued Living
Questionnaire: Defining and measuring valued action within a behavioral framework.
The Psychological Record, 60(2), 249–272. https://doi.org/10.1007/bf03395706.
Yavuz, K. F., Şahin, O., Ulusoy, S., Ipek, O. U., & Kurt, E. (2016). Experiential avoidance,
empathy, and anger-related attitudes in antisocial personality disorder. Turkish
Journal of Medical Sciences, 46, 1792–1800. https://doi.org/10.3906/sag-1601-80.
Zarling, A., Lawrence, E., & Marchman, J. (2015). A randomized controlled trial of ac-
ceptance and commitment therapy for aggressive behavior. Journal of Consulting and
Clinical Psychology, 83(1), 199–212. https://doi.org/10.1037/a0037946.
Zarling, A., Bannon, S., & Berta, M. (2017a). Evaluation of Acceptance and Commitment
Therapy for domestic violence offenders. Psychology of Violence Advance. https://doi.
org/10.1037/vio0000097 Online Publication.
Zarling, A., & Berta, M. (2017b). An Acceptance and Commitment Therapy approach for
partner aggression. Partner Abuse, 8(1), 89–109. https://doi.org/10.1891/1946-
6560.8.1.89.