I. Description of TreatmentII. Theoretical Bases

III. Applications and ExclusionsIV. Empirical StudiesV. Case Illustration

VI. SummaryFurther Reading

GLOSSARY

aggression Behavior intended to cause psychological orphysical harm to someone or to a surrogate target. The be-havior many be verbal or physical, direct or indirect.

anger A negatively toned emotion, subjectively experiencedas an aroused state of antagonism toward someone orsomething perceived to be the source of an aversive event.

anger control The regulation of anger activation and its in-tensity, duration, and mode of expression. Regulation oc-curs through cognitive, somatic, and behavioral systems.

anger reactivity Responding to aversive, threatening, or otherstressful stimuli with anger reactions characterized by auto-maticity of engagement, high intensity, and short latency.

anger schemas Mental representations about environment–be-havior relationships, entailing rules governing threateningsituations. They affect anger activation and behavioral re-sponding.

cathartic effect The lowering of the probability of aggressionas a function of the direct expression of aggression towardan anger-instigator. The lowering of arousal associatedwith such catharsis is more or less immediate and can bereversed by re-instigation.

escalation of provocation Incremental increases in the proba-bility of anger and aggression, occurring as reciprocallyheightened antagonism in an interpersonal exchange.

excitation transfer The carryover of undissipated arousal, orig-inating from some prior source, to a new situation having anew source of arousal, which then heightens the probabilityof aggression toward that new and more proximate source.

frustration Either a situational blocking or impeding of be-havior toward a goal or the subjective feeling of beingthwarted in attempting to reach a goal.

hostility An attitudinal disposition of antagonism toward an-other person or social system. It represents a predisposi-tion to respond with aggression under conditions ofperceived threat.

inhibition A restraining influence on anger expression. Therestraint may be associated with either external or internalfactors.

provocation hierarchy A set of provocation scenarios pro-gressively graduated in degree of anger-inducing featuresfor the client. It is constructed by the therapist in collabo-ration with the client during the early stages of treatmentand is used in the stress inoculation procedure.

stress inoculation A three-phased, cognitive-behavioral ap-proach to therapy, involving cognitive preparation/conceptu-alization, skill acquisition/rehearsal, and application/follow-through. Cognitive restructuring, arousal reduction,and behavioral coping skills training are the core treatmentcomponents. Therapist-guided, graded exposure to stressorsoccurs in the application phase, where the client’s enhancedanger control skills are engaged.

violence Seriously injurious aggressive behavior, typicallyhaving some larger societal significance. The injury may beimmediate or delayed.

Anger Control Therapy

Raymond W. NovacoUniversity of California, Irvine

41Encyclopedia of PsychotherapyVOLUME 1

Copyright 2002, Elsevier Science (USA).All rights reserved.

I. DESCRIPTION OF TREATMENT

A. Topic Introduction and Definition

Providing psychotherapy for persons having recur-rent anger problems is a challenging clinical enterprise.This turbulent emotion, ubiquitous in everyday life, is afeature of a wide range of clinical disorders. It is com-monly observed in various personality, psychosomatic,and conduct disorders, in schizophrenia, in bipolarmood disorders, in organic brain disorders, in impulsecontrol dysfunctions, and in a variety of conditions re-sulting from trauma. The central problematic character-istic of anger in the context of such clinical conditions isthat it is “dysregulated”—that is, its activation, expres-sion, and effects occur without appropriate controls.Anger control treatment, a cognitive-behavioral inter-vention, augments the client’s self-regulatory capacity. Itaims to minimize anger frequency, intensity, and dura-tion and to moderate anger expression. It is an adjunc-tive treatment for a targeted clinical problem and thus isnot meant to address other or more general psychother-apeutic needs. Clinical interventions for problems ofanger seek to remedy the emotional turbulence that isassociated with subjective distress, detrimental effectson personal relationships, health impairments, and themanifold harmful consequences of aggressive behavior.The main components of anger control treatment arecognitive restructuring, arousal reduction, and en-hancement of behavioral skills. A key feature of its im-plementation is therapist-guided progressive exposureto provocation, in conjunction with which anger regula-tory coping skills are acquired.

B. Core Characteristics of Clients

A common characteristic of people having seriousanger problems is that they resist treatment, largely dueto the functional value that they ascribe to anger indealing with life’s adversities. Because anger can be co-mingled with many other clinical problems (such aspersonality disorder, psychoses, or substance abuse),getting leverage for therapeutic change can be an elu-sive goal, particularly when referrals for anger treat-ment entail some element of coercion. Efforts toachieve clinical change are challenged by the adaptivefunctions of anger as a normal emotion, such that it isnot easily relinquished. Anger is often entrenched inpersonal identity and may be derivative of a traumaticlife history. Because anger activation may be a precur-sor of aggressive behavior, while being viewed as asalient clinical need, it may at the same time present

safety concerns for the clinician and be unsettling formental health professionals to engage as a treatmentfocus. Although many high-anger patients present witha hard exterior, they can be psychologically fragile, es-pecially those having histories of recurrent abuse ortrauma, or when abandonment and rejection have beensignificant life themes. Because anger may be embed-ded with other distressed emotions, accessing anger isoften not straightforward.

C. Assessment Issues

Anger treatment best proceeds from proficient angerproblem assessment. However, assessment itself pres-ents many challenges, because of the multidimensional-ity of anger (cognitive, physiological, and behavioralfeatures) and because the true level of anger may bemasked by the person in reaction to the testing situa-tion. In many assessment contexts, particularly forensicones, people are not inclined to report that they havehigh anger dispositions. Even when clients are treat-ment-seeking, they may not be altogether forthcomingabout their anger because an “angry person” labelingcarries unflattering connotations. Effectively targetinganger treatment, as well as ascertaining therapeuticgains, hinges on assessment proficiency, which is bestdone by a multimethod approach utilizing interview,psychometric, clinical rating, and behavioral observa-tion methods, as well as archival and physiologicalmethods when possible.

D. Levels of Intervention

Psychotherapy for anger control can occur at severallevels of intervention: (1) General clinical care foranger; (2) psychoeducational “anger management”provision, typically delivered in a group format; and(3) anger treatment, which is best provided on an indi-vidual basis and may require a preparatory phase to fa-cilitate treatment engagement. The intervention levelsreflect the degree of systematization, complexity, anddepth of therapeutic approach. Increased depth is asso-ciated with greater individual tailoring to client needs.Correspondingly, greater specialization in techniquesand in clinical supervision is required at higher levels.

E. Anger Control Treatment: A Stress Inoculation Approach

Cognitive-behavioral anger treatment targets endur-ing change in cognitive, arousal, and behavioral sys-tems. It centrally involves cognitive restructuring and

42 Anger Control Therapy

the acquisition of arousal reduction and behavioralcoping skills, achieved through changing valuations ofanger and augmenting self-monitoring capacity. Be-cause it addresses anger as grounded and embedded inaversive and often traumatic life experiences, it entailsthe evocation of distressed emotions (e.g., fear and sad-ness) as well as anger. Therapeutic work centrally in-volves the learning of new modes of responding to cuespreviously evocative of anger in the context of relatingto the therapist (“transference”), and it periodicallyelicits negative sentiment on the part of the therapist tothe frustrating, resistive, and unappreciative behaviorof the client (“countertransference”). Anger treatmentthat has followed a “stress inoculation” approach uti-lizes provocation hierarchy exposure. The inoculationmetaphor is associated with the therapist-guided, pro-gressive exposure to provocation stimuli. This occursin vitro through imaginal and role-play provocations inthe clinic, and in vivo through planned testing of cop-ing skills in anger-inducing situations identified by theclient’s hierarchy.

Stress inoculation for anger control involves the fol-lowing key components: (1) Client education aboutanger, stress, and aggression; (2) self-monitoring ofanger frequency, intensity, and situational triggers; (3)construction of a personal anger provocation hierarchy,created from the self-monitoring data and used for thepractice and testing of coping skills; (4) arousal reduc-tion techniques of progressive muscle relaxation, breath-ing-focused relaxation, and guided imagery training; (5)cognitive restructuring of anger schemas by alteringattentional focus, modifying appraisals, and using self-instruction; (6) training behavioral coping skills in com-munication, diplomacy, respectful assertiveness, andstrategic withdrawal, as modeled and rehearsed with thetherapist; and (7) practicing the cognitive, arousal regu-latory, and behavioral coping skills while visualizing androle-playing progressively more intense anger-arousingscenes from the personal hierarchies.

Provocation is simulated in the therapeutic contextby imagination and role-play of anger incidents fromthe hierarchy scenarios, produced by the collaborativework of client and therapist. The scenarios incorporatewording that captures the client’s perceptual sensitivi-ties on provoking elements, such as the antagonist’stone of voice or nuances of facial expression. Each sce-nario ends with provocative aspects of the situation(i.e., not providing the client’s reaction), so that itserves as a stimulus scene. The therapist directs thisgraduated exposure to provocation and knows themoderating variables that will exacerbate or buffer themagnitude of the anger reaction, should the scene need

to be intensified or attenuated in potency. Prior to thepresentation of hierarchy items, whether in imaginal orrole-play mode, anger control coping is rehearsed, andarousal reduction is induced through deep breathingand muscle relaxation. Successful completion of a hier-archy item occurs when the client indicates little or noanger to the scene and can envision or enact effectivecoping in dealing with the provocation.

Following the completion of the hierarchy, an effortis made to anticipate circumstances in the client’s lifethat could be anger-provoking and the obstacles toanger control that might arise. This is done as a re-lapse prevention effort, especially as people havinganger difficulties are often without adequate support-ive relationships to provide reinforcement for angercontrol. Follow-up or booster sessions are typicallyarranged to provide support, to ascertain what copingskills have proven to be most efficacious, and to boosttreatment in areas in need of further work. Because ofthe reputations acquired by high-anger people, the re-actions of others to them can be slow to change. Thiscan lead to relapse and requires therapeutic attentionat follow-up.

F. Treatment Preparatory Phase Needed

Some seriously angry clients may be quite am-bivalent about earnestly engaging in assessment andtreatment, and in some clinical service contexts, par-ticularly forensic settings, angry patients may be veryguarded about self-disclosure. Because of the instru-mental value of anger and aggression, many clients donot readily recognize the personal costs that theiranger routines incur; because of the embeddedness ofanger in long-standing psychological distress, there isinertia to overcome in motivating change efforts. Insuch circumstances, a treatment “preparatory phase” isimplemented, involving a block of five to seven ses-sions, varying with client competence and motivation.The aim is to foster engagement and motivation, whileconducting further assessment and developing thecore competencies necessary for treatment, such asemotion identification, self-monitoring, communica-tion about anger experiences, and arousal reduction. Itserves to build trust in the therapist and the treatmentprogram, providing an atmosphere conducive to per-sonal disclosure and collaboration. Since the prepara-tory phase can be pitched to the client as a “trialperiod,” its conclusion then leads to a more explicitand informed choice by the client about starting treat-ment proper.

Anger Control Therapy 43

II. THEORETICAL BASES

A. Anger and Threat

The conception of anger as a product of threat per-ceptions, as having confirmatory bias characteristics(i.e., the perception of events is biased toward fit withexisting anger schemas), as being primed by aversiveprecursors, and as having social distancing effects (i.e.,expressing anger keeps people away) can be found inthe writings of Lucius Seneca, who was Nero’s tutor infirst-century Rome. Seneca was the first to write system-atically about anger control. Like other Stoic philoso-phers who negate the value of emotions, his view ofanger was almost exclusively negative. Although hisidea of anger control was largely that of suppression,Seneca recognized the powerful role of cognition as adeterminant of anger, advocated cognitive shift and re-framing to minimize anger, and saw the merit of a calmresponse to outrageous insult. However, he discountedthe functional value of anger, which thereby led him tomiss the principle of regulation.

Since the writings of Charles Darwin, William James,and Walter B. Cannon, anger has been viewed in termsof the engagement of the organism’s survival systems inresponse to threat and the interplay of cognitive,physiological, and behavioral components. It is an ele-mentary Darwinian notion that the adaptive value of acharacteristic is entailed by its fitness for the environ-ment; if the environment changes, that characteristicmay lose its adaptive value, and the organism mustadjust. The activation of anger may usefully serve toengage aggression in combat and to overcome fear, butin most everyday contexts, anger is often maladaptive.

Many theories of emotion have enlarged upon theDarwinian view of emotions as reactions to basic sur-vival problems created by the environment and uponCannon’s idea that internal changes prepare the bodyfor fight or flight behavior. Thus, emotion has com-monly been viewed as an action disposition. Some con-temporary theorists postulate that emotion is controlledby appetitive and aversive motive systems in the brain,with the amygdala serving as a key site for the aversivemotivational system, and neurobiological mechanismsassociated with amygdala involvement in aversive emo-tion and trauma are being studied in various laborato-ries. Most generally, when people are exposed to stimulisignifying present danger or reminders of trauma, theyare primed for anger reactions. Anger is intrinsicallyconnected to threat perception.

B. Anger and Cognition

Central to therapeutic prescriptions for anger controlis the idea that emotion is a function of cognitive ap-praisal. That is, anger is produced by the meaning thatevents have and the resources we have for dealing withthem, rather than by the objective properties of theevents. Important work in this regard was done byLazarus on appraisal processes and on stress copingstyles, yet there is dispute about how pivotal is appraisalin the activation of anger. Berkowitz alternatively assertsthat aversive events trigger basic associations to aggres-sion-related tendencies as a “primitive” or “lower order”processing, which is then paralleled by anger in associa-tion. “Higher order” processing, such as appraisal, isthen subsequent to the rudimentary reactions, and angercan be elaborated by the appraisal. Similarly, Beck hasconjectured that anger derives from “primitive” process-ing in defense against threat, in which mode informationis rapidly compartmentalized. Negative biases and over-generalization lead to information-processing errors andanger activation. Appraisal processing (activation of be-liefs and interpretations) may then follow this primalthinking mode. What Beck adds is that automaticthoughts are activated in the primal mode and that theseare the roots of emotional distress.

This differentiation between “lower order” and“higher order” processing may otherwise be viewed asa distinction between “automatic” versus “controlled”operations. Sometimes anger occurs as a fast-triggered,reflexive response, while other times it results from de-liberate attention, extended search, and conscious re-view. There is nothing necessarily “primitive” aboutautomaticity in anger responding, as anger schemasand aggressive scripts, which are acquired through so-cial learning, can produce rapid reaction to provocationstimuli. Furthermore, central cognitive processes canoverride reflexive responding to aversive stimulation.Otherwise we would be very angry on most trips to thedentist, and professional boxers in the ring would be ina continuous state of rage.

Social information processing models of aggressivebehavior, such as that of Huesmann, view the humanmind as analogous to a computer. Anger schemas arethus understood as macro knowledge structures, en-coded in memory, that filter our perceptions and areused to make inferences. Aggressive scripts are subrou-tines that serve as guides for behavior, laying out thesequence of moves or events thought to be likely tooccur and the behavior thought to be possible or ap-propriate for a certain situation.

44 Anger Control Therapy

The main thrust of such conceptions is that angerand its associated behavior are cognitively mediated.Correspondingly, anger control interventions target theway in which people process information, remembertheir experiences, and cognitively orient to new situa-tions of stress or challenge. Therapeutic change ofschemas linked to anger prevents the occurrence ofanger, and the self-regulation of anger once activated iseffected by controlled use of cognitive self-control tech-niques, such as calming self-instructions and relaxationimagery, combined with other arousal reduction andbehavioral coping strategies.

C. Cognition, Arousal, and Behavior Reciprocities

Intrapsychic, dispositional systems are the principalfocus of psychotherapy, and, in that regard, anger hasthree main subsystems or domains: cognitive, physiolog-ical, and behavioral. Cognitive dispositions for anger in-clude knowledge structures, such as expectations andbeliefs, and appraisal processes, which are schematicallyorganized as mental representations about environ-ment–behavior relationships entailing rules governingthreatening situations. Arousal or physiological disposi-tions for anger include high hormone levels (neurotrans-mitters) and low stimulus thresholds for the activation ofarousal. Anger is marked by physiological activation inthe cardiovascular, endocrine, and limbic systems, and bytension in the skeletal musculature. Behavioral disposi-tions include conditioned and observably learned reper-toires of anger-expressive behavior, including aggressionbut also avoidance behavior. Implicit in the cognitive la-beling of anger is an inclination to act antagonistically to-ward the source of the provocation. However, an avoidantstyle of responding, found in personality and psychoso-matic disorders, can foment anger by leaving the provo-cation unchanged or exacerbated.

Thus, it can be seen that these dispositional subsys-tems are highly interactive or interdependent. Anger-linked appraisals influence arousal levels, high arousalactivates aggression and overrides inhibition, and an-tagonistic behavior escalates aversive events and shapesanger schemas and scripts for anger episodes as behav-ioral routines are encoded. In turn, the personal dispo-sitional system interfaces with the environmental, suchas when anger and aggression drive away pacific peo-ple, leaving one with angry and aggressive companions,who not only incite anger but from whom one contin-ues to learn anger responding and anger-engenderingappraisals, which further heighten arousal.

D. Person–Environment Context and Systems

Anger and anger control difficulties should be un-derstood contextually. This assumes that recurrentanger is grounded in long-term adaptations to inter-nal and external environmental demands, involving arange of systems from the biological to the sociocultu-ral. The adaptive functions of anger affect the socialand physical environmental systems in which the per-son has membership. Anger experiences are embed-ded or nested within overlapping systems, such as thework setting, the work organization, the regionaleconomy, and the sociocultural value structure. Angerdeterminants, anger experiences, and anger sequelaeare interdependent.

The interrelatedness of system components providesfor positive and negative feedback loops. When a systemmoves away from equilibrium, negative feedback loopsserve to counteract the deviation, such as when the self-monitoring anger reactions prompt deep breathing orcognitive reappraisal to achieve anger control. In con-trast, anger reactions can be augmented by positive feed-back, which is a deviation amplification effect. Angerdisplays in a situation of conflict tend to evoke angerand aggression in response, which then justify the origi-nal anger and increase the probability of heightened an-tagonism. Such anger–aggression escalation effects arewell-known in conflict scenarios, whether interpersonalor international.

Intervention proceeding from a contextual modelexamines environmental, interpersonal, and disposi-tional subsystems that shape anger reactions. Al-though recurrent anger is often a product of long-termexposure to adverse conditions or to acute trauma, itis nevertheless the case that anger is a product of agen-tic behavior. People who select high-conflict settingsor recurrently inhabit high-stress environments setthe stage for their anger experiences. Those who arehabitually hostile create systemic conditions thatfuel continued anger responding that is resistant tochange. As anger schemas solidify, anger is evokedwith considerable automaticity in reaction to minimalthreat cues. Aggressive scripts that program antago-nistic behavior, which exacerbates anger difficulties,are socially and contextually learned. Focus on in-trapsychic variables is transparently inadequate whenthe person remains immersed in anger-engenderingcontexts. Coordinated efforts of a multidisciplinarytreatment team may be required.

Anger Control Therapy 45

III. APPLICATIONS AND EXCLUSIONS

Anger control therapy is an adjunctive treatment.Across categories of clients, the key issues regardingappropriateness for this therapy are (1) The extent towhich the person has an anger regulatory problem, im-plying that acquisition or augmentation of anger con-trol capacity would reduce psychological distress, theprobability of aggression or other offending behavior,or a physical health problem, such as high blood pres-sure; (2) whether the person does recognize, or can beinduced to see, the costs of his or her anger and aggres-sion routines and is thus motivated to engage in treat-ment; and (3) whether the person can sit and attend forapproximately 45 minutes. The latter criterion appliesespecially to hospitalized patients. The stress inocula-tion approach to anger has been successfully applied toinstitutionalized mentally disordered (schizophreniaand affective disorders) and intellectual disabled per-sons (mild to borderline). Because resolution on theissue of treatment engagement is often elusive, ananger treatment “preparatory phase” has been devel-oped and implemented in work with forensic patients.Such preparatory work would also be appropriate forpersons who have anger dysregulation in conjunctionwith trauma.

People with violent behavior problems are often re-ferred for anger treatment (e.g., incarcerated offendersand spousal abusers or enraged drivers in the commu-nity). However, anger treatment is not indicated forthose whose violent behavior is not emotionally medi-ated, whose violent behavior fits their short-term orlong-term goals, or whose violence is anger mediatedbut not acknowledged. Little is known about the effi-cacy of cognitive-behavior therapy anger treatmentwith psychopaths, but it is doubtful that it would besuitable. As well, persons who are acutely psychotic orwhose delusions significantly interfere with daily func-tioning are not suitable candidates for this self-regula-tory treatment. Persons with substance abuse disordersalso require prior treatment to engage in anger therapy.Successful case applications are given later.

IV. EMPIRICAL STUDIES

Research on anger treatment lags substantially be-hind that for problems of depression and anxiety, yetthere is convergent evidence that various cognitive-

behavioral interventions produce therapeutic gains inanger control. However, there have been few random-ized control studies with seriously disordered patients.Such studies have more commonly been done with col-lege student volunteers, selected as treatment recipi-ents by upper quartile scores on self-reported traitanger, by having expressed interest in counseling foranger management, and by volunteering over the tele-phone. Such sample inclusion criteria do not reflect theclinical needs of the angry patients seen by mentalhealth service providers in community and institu-tional settings. Existing meta-analytic reviews of treat-ment efficacy are overloaded with college studentstudies and fail to include case study reports and multi-ple baseline studies, which have typically involved realpatients with serious problems. Nevertheless, statisticalcomputations in reviews across dozens of controlledstudies have found medium effect sizes for anger treat-ments, indicating that the large majority of treated par-ticipants were improved.

Cognitive-behavior therapy approaches that havenot followed the stress inoculation framework haveproduced significant treatment gains, such as those byDeffenbacher and his colleagues using cognitive andrelaxation methods with college student volunteerswithout demonstrable clinical pathology or violencehistory. However, such treatment study participants donot reflect the clinical needs of the angry patients seenby mental health service providers in community andinstitutional settings. In contrast to college student vol-unteer studies, a controlled anger treatment trial withseriously disordered Vietnam veterans by Chemtob,Novaco, Hamada, and Gross in 1997, which wasmissed in the Beck and Fernandez meta-analysis in1998, obtained significant treatment effects on multiplemeasures of anger reactions and anger control for thestress inoculation anger treatment, compared to a mul-timodal, routine care control treatment condition. Theanger control treatment gains with these severe post-traumatic stress disorder patients, who had had in-tense, recurrent postwar problems with anger andaggressive behavior, were maintained at 18-month fol-low-up. Other control group studies involving success-ful outcomes for the modified stress inoculationapproach to anger treatment with clinical populationshave included adolescents in residential care, adoles-cent offenders, forensic patients, and mentally retardedadults. Exemplary work on anger control with adoles-cents has been done by Feindler and her colleagues.

Multiple case studies involving a variety of seriousclinical disorders have provided empirical support for

46 Anger Control Therapy

the efficacy of cognitive-behavioral anger treatmentand the stress inoculation approach. These include ahospitalized depressed patient, child abusing parents,chronically aggressive patients, an emotionally dis-turbed boy, a brain damaged patient, mentally handi-capped patients, adolescents in residential treatment,and institutionalized forensic patients.

Brief cognitive-behavioral therapy “anger manage-ment” has been successfully used in prisons, often de-livered in group format, varying from 3 to 16 sessionsacross studies. However, outcome evaluation assess-ments in these prison-based studies have been thin,and results of efficacy have been uneven. In this regard,the treatment engagement issues highlighted earlier aremost relevant, and the interventions used have notbeen firmly based in a designated treatment protocol.Because the through-put client service needs of institu-tions and community agencies are formidable, greaterattention needs to be given to the development ofgroup-based intervention for anger.

V. CASE ILLUSTRATION

A. Case Description

Mr. A is a man in his thirties, who received angertreatment in a forensic hospital. He had a highly dys-functional home background. He was truant fromschool and reported abnormal psychological experi-ences, resulting in the involvement of the psychiatricservices. In his teens, he developed a substance abuseproblem and associated with a delinquent peer groupthat encouraged a violent presentation. Persistent pettytheft associated with substance abuse and aggressionled to placement in secure facilities. There, the experi-ence of both using violence and being bullied had aprofound effect on him.

He married and had a child, but his wife left himwhile he was serving a short prison sentence. Follow-ing a period of homelessness, he was imprisoned for as-sault. He was diagnosed with schizophrenia and whilehe resisted this, he would allude to having a specialdestiny after an encounter with extraterrestrials whohad given him the power to benefit mankind. He wassubsequently transferred to a psychiatric hospital,where he made a number of attacks on staff. He was ul-timately transferred to community accommodation,but he was ejected for theft and noncompliance. Hewas readmitted to a local hospital, following arrest forreckless damage and police assault. He then again as-

saulted one of the staff, so badly that this led to his ad-mission to a maximum security hospital.

There, his psychotic symptoms soon remitted, but hewas reported to be demanding and antiauthoritarian,continually challenging the rules and reacting aggres-sively to any perceived threat to his self-image. A trans-fer to a local hospital was unsuccessful due to hisaggressive, demanding manner and drug misuse. Hestruggled to cope with his readmission and maintainedan antiestablishment attitude. He made frequentthreats toward staff and was physically assaultive. Mak-ing little progress, he made a serious attempt at suicide,which was related to despair at his continued deten-tion. When under stress, his positive psychotic symp-toms could emerge. His close relationships havingdisintegrated, he was very worried about future inti-mate relationships.

B. Treatment Application

Mr. A received anger treatment by staff psycholo-gists. He was happy to attend sessions but initiallyfound it difficult to engage in tasks. He was anxiousabout being not listened to and was resistant to beinggiven advice. He often refused to participate, argued hisown point, talked on a tangent, or reduced everythingto a joke. He was insistent that he should not be rushedand feared being overwhelmed. Establishing a support-ive relationship and a sensitive pacing of therapy wasvital to engagement. As he came to view his therapistsas being nonjudgmental and working in his interests,he became less defensive and more willing to completetasks such as anger diaries and hierarchical inoculationexercises. As treatment progressed, he became more re-silient to provocation and less likely to conclude thatothers were personally attacking him. He found alter-native ways of viewing situations that previously hadinitiated angry attempts to restore his self-esteem. Hebecame more aware of his heightened level of physio-logical arousal in problematic situations and used ten-sion reduction methods, including relaxation andtaking time-outs to create social distance from provok-ing events. He learned to approach staff to discuss mat-ters of dispute and received support from his peers foranger control.

Illustrative incidents: (1) Another patient accused Mr.A of not repaying a debt. As this was said in public, Mr.A thought this was a deliberate attempt to humiliatehim and being angry, wanted to show that he was notsomeone “to be trifled with.” However, he managed tostay calm and avoid violence; instead he responded in a

Anger Control Therapy 47

way that minimized loss of face and reminded himselfof the negative consequences of physical violence. Later,he reassessed the situation, reasoning that the other pa-tient was struggling with a life sentence for murder andhad been picking on others, not just targeting him. Dis-cussing the event with friends, they reinforced his viewand reassured him that they did not believe the accusa-tion. (2) Having been recommended for transfer to alower security hospital, a visit to that local hospital wasarranged. One hour before leaving for his visit, it wascancelled because of events at the local hospital. Ini-tially he was convinced that there was a sinister motive,feeling that the staff were trying to renege on the agree-ment. He became angry. However, he used arousal re-duction techniques, and had a discussion with staff,who rearranged the visit. Staff remarked that he listenedto their explanation and trusted them to resolve the sit-uation, rather than behave self-destructively.

C. Treatment Gains and Transfer

Level of care staff observed that Mr. A generallybegan to take others’ perspectives into account, and hispsychiatrist reported that he was less impatient, less in-stantly demanding, and better able to listen and to dis-cuss issues in a constructive manner. His gains in angercontrol led to a recommendation for transfer to hislocal hospital, and staff there reported being impressedwith what they felt was a positive change in his presen-tation. His self-reported improvement in anger controland progress through the provocation hierarchy intreatment sessions thus received validation from wardstaff observations of his behavior and by the judgmentof his attending psychiatrist who arranged the transferto a lower security hospital.

VI. SUMMARY

Anger control therapy is a cognitive-behavioral treat-ment. It aims to augment the regulation of anger that hasbecome problematic in frequency, intensity, duration, andmode of expression. In its fullest form of intervention,it utilizes a “stress inoculation” approach, the heart ofwhich involves therapist-guided, progressive exposureto provocations in the clinic and in vivo, in conjunctionwith which coping skills are modeled and rehearsed.

Training in self-monitoring, cognitive reframing, arousalreduction, and behavioral coping skills are the essentialcomponents of the treatment. Some clients require apreparatory phase for treatment engagement.

See Also the Following ArticlesArousal Training � Beck Therapy Approach � MultimodalBehavior Therapy � Post-Traumatic Stress Disorder

Further ReadingBeck, A. T. (1999). Prisoners of hate: The cognitive basis of

anger, hostility, and violence. New York: Harper Collins.Beck, R., & Fernandez, E. (1998). Cognitive behavior ther-

apy in the treatment of anger: A meta-analysis. CognitiveTherapy and Research, 22, 63–75.

Berkowitz, L. (1993). Aggression: Its causes, consequences, andcontrol. New York: McGraw-Hill.

Chemtob, C. M., Novaco, R. W., Hamada, R., & Gross, D.(1997). Cognitive-behavioral treatment for severe anger inposttraumatic stress disorder. Journal of Consulting andClinical Psychology, 65, 184–189.

Feindler, E. L., & Ecton, R. B. (1986). Adolescent anger control:Cognitive therapy techniques. New York: Pergamon Press.

Huesmann, L. R. (1998). The role of social information pro-cessing and cognitive schema in the acquisition and main-tenance of habitual aggressive behavior. In R. Geen & E.Donnerstein (Eds.), Human aggression: Theories, research,and implications for social policy (pp. 73–109). San Diego,CA: Academic Press.

Lang, P. J. (1995). The emotion probe: Studies of motivationand attention. American Psychologist, 50, 372–385.

Lazarus, R. S. (1991). Emotion and adaptation. Oxford: Ox-ford University Press.

Meichenbaum, D. (1985). Stress inoculation training. NewYork: Pergamon Press.

Novaco, R. W. (1986). Anger as a clinical and social problem.In R. Blanchard & C. Blanchard (Eds.), Advances in the studyof aggression, Vol 2. (pp. 1–67). New York: Academic Press.

Novaco, R. W. (1997). Remediating anger and aggressionwith violent offenders. Legal and Criminological Psychol-ogy, 2, 77–88.

Novaco, R. W., & Chemtob, C. M. (1998). Anger and trauma:Conceptualization, assessment, and treatment. In V. M. Fol-lette, J. I. Ruzek, & F. R. Abueg (Eds.), Cognitive behavioraltherapies for trauma (pp. 162–190). New York: Guilford.

Siegman, A. W., & Smith, T. W. (1994). Anger, hostility, andthe heart. Hillsdale, NJ: Erlbaum.

48 Anger Control Therapy