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COMMENTARY

Cognitive and Behavioral Practice 18 (2011) 251–255www.elsevier.com/locate/cabp

Perspectives on Anger Treatment: Discussion and Commentary

Raymond W. Novaco, University of California, Irvine

ANGER control has been a societal agenda at least sinceclassical philosophers grappled with the regulation

of inner life and the enhancement of virtue—a campaignextended by the Victorians. Anger is the prototype of theclassic view of emotions as “passions” that seize thepersonality, disturb judgment, alter bodily conditions,and send behavior on a perilous course. Becoming“enraged” suggests being “rabid,” which connotes adiseased state of mind. Being angry, becoming mad, andcreating Bedlam (echoing the historic asylum) aresemantically and metaphorically linked. Classic motifs ofanger as passion, madness, and disease reverberate incontemporary concepts, such as qanger attacksq in thedepression literature (e.g., Fava & Rosenbaum, 1998,1999), which has now also emerged in the intermittentexplosive disorder literature (Kessler et al., 2006). Notonly does such terminology connote being “seized,” itconjures a pathological/disease entity that then“explains” aggressive behavior and then is suitably“treated” by medication.

Psychotherapeutic treatments for anger have gainedmomentum in the past several decades, and it isengaging to have these developing and new perspec-tives from the clinical scholars who have contributed tothis special series, intriguingly organized around thecomposite case study put forth by Santanello (2011).Three of the papers—those by Deffenbacher (2011),by DiGiuseppe (2011), and by Kassinove and Tafrate(2011), who are distinguished leaders in the field—follow the tradition of second-wave cognitive-behaviortherapy, whereas that by Eifert and Forsyth (2011)represents a third wave, which centrally deemphasizesthe therapeutic value of control over inner experience.Each presentation offers valuable insights about angertreatment, giving emphasis to different avenues ofintervention. Nevertheless, across these papers, there

1077-7229/10/251–255$1.00/0© 2010 Association for Behavioral and Cognitive Therapies.Published by Elsevier Ltd. All rights reserved.

are commonalities in approach to anger as a clinicalproblem and to the case of Mr. P.

Anger as a Clinical Problem and qAnger Disordersq

Understanding anger as a clinical problem is lessthan straightforward. The functionality of anger isunmistakable. In the face of adversity, it can mobilizephysical and psychological resources, energize behaviorsfor corrective action, and facilitate perseverance. Theproblem conditions, however, are not derivative ofanger per se, but instead result from anger dysregulation.In three of the contributions to this special series, theissue of diagnosis for anger arises. It has been proposedin various writings by four of the contributors that therebe a formal designation of “anger disorders”— e.g.,Eckhardt & Deffenbacher (1995), Kassinove (1995),Kasssinove and Tafrate (2002), and DiGuiseppe andTafrate (2007). That idea is also put forward in Feindler(2006), and there were earlier calls by Thorne (1953)and Barlow (1991). Thus far, however, the advocating offormal diagnostic categories for anger has not beenaccompanied by sufficient empirical grounds for thatproposition or by a coherent nosology, includingguidance for differential diagnosis.

Anger dysregulation is prototypically transdiagnostic. Itfits eminently with the comorbidity theme highlighted byHarvey, Watkins, Mansell, and Shafran (2004). Beingintrinsically related to threat perception, anger is mani-fested in a wide variety of psychiatric disorders (cf. Novaco,2010). Anger emerges in conjunction with delusions andcommand hallucinations in psychotic disorders, theemotional instability attributes of personality disorders,irritability and “attacks” in mood disorders, impulsecontrol disorders, intellectual disabilities, dementia, andexotic cultural-bound syndromes. As anger often resultsfrom trauma, it can be salient in PTSD, significantlyaffecting the severity and course of PTSD symptoms. Thecentral quality of anger in the broad context of clinicaldisorders is dysregulation—its activation, expression, andexperience occur without appropriate controls. Theharm-doing capacity of anger is unmistakable, but so isits potential to adversely affect prudent thought, core

252 Novaco

relationships, work performance, and physical well-being.It thus can play strongly in the functional impairmentcriterion across diagnostic categories.

Clinicians also should be mindful of troublesomedecisional quandaries associated with pathologizing anemotional state that has important energizing, informa-tional, and potentiating functions and that is a funda-mental survival mechanism with extensions to freedom-representational symbolic structures. Looming large hereare issues regarding coercion and control associated withformal diagnoses. Having a certified “anger disorder”might make for smoother billing of services and perhapsfor research funding, but it would increase the likelihoodthat persons already hospitalized, particularly forensicpatients, would be further detained and fitted with anadditional illness label.

Engagement in Anger Treatment

People become attached to their anger routines, whichcan be oddly satisfying. The psychosocial symbolism ofanger casts it as energizing, empowering, signaling,justifying, rectifying, and relieving. Neither personalintimates (such as Mr. P.'s) nor social gatekeepers(parents, school principals, employers, police, andmagistrates) are charmed by the mastery-toned elementsof anger, but rather are sensitized to and unsettled by thecontrary social metaphors of anger as eruptive, unbridled,savage, venous, burning, and consuming. Because of theinstrumental value of anger and aggression, many clientsdo not readily recognize the personal costs that theiranger routines incur; and because of the embeddednessof anger in longstanding psychological distress, there isinertia to overcome in motivating change efforts.

The importance of facilitating the client's engagementin treatment or building a therapeutic alliance ishighlighted in each of the three qmainstreamq CBTperspectives, and it is a focused stage of treatment in theapproach of Kassinove and Tafrate (2011). With forensicpopulations as part of their scope, they flag-up theimportance of that qpreparatoryq component. To facili-tate treatment engagement or therapeutic alliance, eachof those three perspectives involves the use of motivation-al interviewing (Miller & Rollnick, 2002). Further, theydescribe various techniques, such as the qparadox ofcontrol,q qwhat would happenq inquiries, and the qGestalttwo-chairq procedure by Deffenbacher (2011), theqreflecting backq and goal-setting by DiGiuseppe (2011),and systematic anger episode analysis and problemawareness building by Kassinove and Tafrate.

In fostering therapeutic engagement, a fundamentalidea is that the client must recognize, or be helped to see,the costs of his or her anger/aggression routines. Thepivotal value of identifying the costs of anger was perhapsfirst given attention by McKay, Rogers, and McKay (1989).

Clients are motivated to change when they can see thatthe costs of staying the same are higher than the costs oftrying to change. People who are prone to anger can bestubbornly rooted in their anger disposition, as reflectedin the qinflexibilityq characteristic of clients noted in all ofthe four perspectives; but, a further point is that serviceproviders all too often develop refractory views of highanger clients, as reflected in them being tagged asqtreatment resistant.q

The notion of qtreatment resistanceq puts the onus ofchange on the client or patient, which is indeed whereprimary responsibility rests. However, there is consider-able merit for change agents to adopt the alternativeperspective that many people having long-standingdifficulties with anger are not so much qresistantq tochange but lacking in qreadinessq for change, as HowellsandDay (2003) have well articulated. Moreover, Monahanand Steadman (in press) have turned this treatment-resistant notion completely on its head by asserting that,for offenders, the situation is more accurately character-ized as one of qclient-resistant services.q

Psychologists have known for decades about theimportance of the therapeutic relationship (cf. Nor-cross, 2002), and the therapeutic alliance remains acentral issue for optimizing psychotherapeutic gains(e.g., Ackerman & Hilsenroth, 2003; Lambert & Barley,2001). Central to the therapeutic alliance is validation.Each of the three mainstream CBT perspectives givesattention to the importance of validating the client'sexperiences, and the acceptance and commitment ther-apy (ACT) perspective of Eifert and Forsyth (2011)intrinsically entails this in its qacceptanceq theme, whichDiGiuseppe (2011) somewhat incorporates. Yet, whilevalidation facilitates alliance, all of the perspectives striveto encourage the client to reformulate values and goals.The ACT approach aims to move clients away from beingfused with their personal constructs and to clarify theirpersonal values to facilitate acting on them. Similarly,while perhaps more situation-focused, the approaches ofDeffenbacher (2011), DiGiuseppe, and Kassinove andTafrate (2011) strive to help clients identify personal goalsbearing on their well-being and see the disconnectionbetween those goals and their recurrent behavior.Therapeutic alliance is enhanced by the client recognizingthat the therapist is aiming to nurture the achievement ofhigh value goals.

Anger Assessment

Anger treatment best proceeds from case formulation.This is best done with a conceptual model havingestablished clinical utility for understanding the psycho-logical deficits associated with the person's anger signa-ture and psychological adjustment difficulties. Treatment

253Perspective on Anger Treatment

should target the salient dimensions of the person's angerdysregulation and do so in a way that is responsive to theclient's needs and capabilities. Also, attention to comor-bidity, such as substance abuse, psychosis, posttraumaticstress, depression, self-harm, and intellectual disabilities,comes strongly into play here. The presentations in thisspecial series give varying degrees of attention toassessment-based case formulation. Regarding standard-ized tests, the three mainstream CBT approachesincorporate such assessment, whereas the ACT approachapparently does not.

Anger Problem Background

qMeeting the person where he or she is,q asKassinove and Tafrate and others have put it withregard to treatment engagement, also bears on under-standing the problem history. The Eifert and Forsyth(2011) approach addresses this through attention toqcognitive fusion,q attachment to the conceptualizedself,q and qexperiential avoidanceq; Deffenbacher's(2011) approach incorporates Lazarus' appraisal pro-cesses and attends to potential origins in cultural/familial domains; DiGiuseppe (2011) highlights operantlearning systems; and Kassinove and Tafrate (2011)more centrally utilize the models of Beck and Ellis. Inthe discussion of the case of Mr. P., the papers givevarying degrees of weight to the family backgroundcontext, and it is surprising that there is so littlemention of his formative experiences with his father.The exposure to volatile parents has substantial impor-tance for understanding and predicting the anger andassaultiveness of clinical populations, and social infor-mation processing models, with their attendant con-structs of schemas and scripts, provide a usefulframework (Novaco & Taylor, 2008).

Self-Observation

Anger dyscontrol involves a serious degradation in self-monitoring. One cannot regulate troublesome internalstates without proficiency in self-monitoring. Metaphori-cally, high anger clients have malfunctioning or inoper-ative thermostats. From a self-regulatory perspective onanger control, self-monitoring is crucial to preventing theescalation of anger-aggression sequences and the erup-tion of chaotically expressed aggression when a provoca-tion threshold is exceeded in an otherwise aggression-inhibited person. In CBT anger treatment, self-monitor-ing involves detecting the cognitive, arousal, and behav-ioral signs of anger, as well as recognizing situationalelements that can prime anger and aggressive respond-ing. Kasssinove and Tafrate (2002) and Tafrate andKassinove, (2009) have provided many devices for self-monitoring training.

All four of the approaches incorporate self-observationin their treatment procedures. A major difference occursfor the ACT approach, which seems to take as its point ofdeparture that anger is a secondary emotion—it isthought to originate in pain or human suffering. Eifertand Forsyth (2011) assert that ACT does not involvehelping clients control or manage anger, as that woulddelay clients from taking effective action. Yet, self-observation is at the core of their approach, getting theclient to notice, acknowledge, and accept angry thoughts.

Arousal Reduction

At the heart of anger is physiological activation. To besure, affiliated psychological states, such as resentmentand hostility, or anger-driven revenge can be qcold,q butanger, which is an emotional state (not a qbehaviorq), hasautonomic, somatic, and central nervous system activa-tions as definitional properties. Arousal reduction orregulation is thus a fundamental part of anger treatment,and it is unfortunately given insufficient attention by CBTtherapists, who seem to have forgotten what Wolpe andLazarus taught us. One cannot be angry and relaxed atthe same time, and breathing is the central rhythm of thebody. None of the presentations in this special seriesincorporated an arousal-reduction component to theirtreatment schemes for Mr. P, who is a qhot responderq inmany situational contexts and comes to treatment sessionsfully wired. Mr. P's previous therapist apparently triedsome relaxation procedures, but did so unsuccessfully.Although Eifert and Forsyth's ACT approach alludes tomindfulness, which has arousal-reduction features (mind-ful breathing and deep relaxation) in its Buddhist origins,the authors say little about its integration into theirapproach.

Acceptance of Difficult Life Circumstances

People with anger control problems are often besetwith serious hardships. The advent of ACT (Hayes,Strosahl, & Wilson, 1999) has undeniably promptedCBT practitioners to recognize the importance ofqacceptance.q Eifert and Forsyth (2011) nicely delineateits application to anger and to helping Mr. P to changehow he responds to discomfort and to respond lessliterally to his thoughts. However, the supposition thatqpainq and qsufferingq are the origins of anger is notaltogether persuasive, as one can easily construe anyaversive event as qpain,q when pain is psychic. This notionsprings from a Buddhist framework, such as that of Hanh(2001), who has wonderful things to say about compas-sionate communication. Kassinove and Tafrate's (2011)incorporation of qforgivenessq and DiGiuseppe's (2011)qovercoming resentmentq are treatment components inthis same vein. Trauma does make for abject suffering,and while vulnerability indeed can be seen in anger

254 Novaco

experiences, even beneath the hardened exteriors ofviolent offenders, the comprehensive viability of theqsufferingq conjecture awaits confirmatory testing.

Person-Environment Interplay

Although recurrent anger is often a product of long-term exposure to adverse conditions or to acute trauma, itis nevertheless the case that anger is a product of agenticbehavior. Habitually hostile people create systemic con-ditions that fuel anger responding. Those who select high-conflict settings or recurrently inhabit high-stress envir-onments set the stage for their anger experiences. Asanger schemas solidify, anger is evoked with considerableautomaticity in reaction to minimal threat cues. Aggres-sive scripts that program antagonistic behavior are sociallyand contextually learned. For those high in avenues offriction, impoverished in support structures, and short incountervailing resources for inhibitory controls, angereasily becomes a default response. Focus on intrapsychicvariables is transparently inadequate when the personremains immersed in anger-engendering and support-impoverished contexts.

While the approaches of Deffenbacher (2011) andDiGiuseppe (2011) have an appreciation for contextualdeterminants and coping resources, among the presenta-tions here, it is only in the approach of Kassinove andTafrate (2011) that one sees emphasis being given toenvironmental exposure factors. They also point out thattheir avoidance and escape strategies are at variance withan ACT approach.

Range of Applicability

There are some puzzling aspects of the exposition ofthe therapeutic approaches and their hypotheticalapplication to the case of Mr. P. For the most part,there is little said about safety issues. While Mr. P hasreported not having any criminal sanctions for violentbehavior, has no military background, and has reportedto have never been assaultive with those in personallyclose relationships with him, he has an explosive temperand has a history of violent behavior. Just as creatingqsafetyq for a client is imperative for obtaining treatmentengagement, there must also be safety for the clinician toproceed with treatment in a way that truly qconnectsq withthe client. This is a complex issue, beyond the space limitsof this discussion piece. What can be noted from thepresentations, though, is that it was good to see Kassinoveand Tafrate (2011) call attention to the level of therapistexpertise, as well as to alluding to risks in working withcriminal offenders.

Because each of these approaches relies on cognitiveskills, there is the operative presumption that CBT foranger is not suitable for clients with intellectual disabil-ities. None of the expositions recognize that CBT for

anger has been successfully applied in controlled researchtrials to forensic patients with serious anger problems andhistories of violence (cf. Taylor & Novaco, 2005), andclinical research in that area is growing.

Although some of the contributors were less thansanguine about the prognosis for Mr. P, there have beenseven meta-analyses on the effectiveness of psychotherapyfor anger (Beck & Fernandez, 1998; Del Vecchio &O'Leary, 2004; DiGiuseppe & Tafrate, 2003; Edmonson &Conger, 1996; Gansle, 2005; Sukhodolsky, Kassinove, &Gorman, 2004; Tafrate, 1995), which overall have foundmedium to strong effect sizes, indicating that approxi-mately 75% of those receiving anger treatment improvedcompared to controls. CBT approaches have the greatestefficacy. However, meta-analytic reviews fail to includecase study reports and multiple baseline studies withclinical populations, for whom CBT has producedsignificant clinical gains for people far more disturbedand behaviorally problematic than Mr. P (e.g., Renwick,Black, Ramm, & Novaco, 1997); that is likewise the casefor some controlled clinical trials (Chemtob, Novaco,Hamada, & Gross, 1997; Taylor, Novaco, Gillmer,Robertson, & Thorne, 2005). There is ample reason tobe optimistic about making therapeutic gains with Mr. P.

Concluding Comments

This exposition of second-wave and third-wave CBTapproaches to anger in this special series will boost interestin the treatment of people who are psychologicallydistressed by this turbulent emotion. While the therapeu-tic mechanisms underlying treatment gains found inclinical research are not clear, nor has the sustainabilityor generalizability of those gains been well-established, wecan be fortified in providing remedies for anger dyscontroland enlightened by the diverse approaches to it that thesespecial series contributors have presented.

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Address correspondence to Raymond W. Novaco, Ph.D., Universityof California, Dept. of Psychology and Social Behavior, 4343 SBSGateway, Irvine, CA 92697; e-mail: rwnovaco@uci.edu.

Received November 6, 2010Accepted November 13, 2010Available online 13 December 2010