understanding clinical anger and violence: the anger avoidance model

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http://bmo.sagepub.com/ Behavior Modification http://bmo.sagepub.com/content/32/6/897 The online version of this article can be found at: DOI: 10.1177/0145445508319282 2008 32: 897 originally published online 9 July 2008 Behav Modif Frank L. Gardner and Zella E. Moore Model Understanding Clinical Anger and Violence: The Anger Avoidance Published by: http://www.sagepublications.com can be found at: Behavior Modification Additional services and information for http://bmo.sagepub.com/cgi/alerts Email Alerts: http://bmo.sagepub.com/subscriptions Subscriptions: http://www.sagepub.com/journalsReprints.nav Reprints: http://www.sagepub.com/journalsPermissions.nav Permissions: http://bmo.sagepub.com/content/32/6/897.refs.html Citations: What is This? - Jul 9, 2008 OnlineFirst Version of Record - Oct 23, 2008 Version of Record >> at UNIV PRINCE EDWARD ISLAND on November 18, 2014 bmo.sagepub.com Downloaded from at UNIV PRINCE EDWARD ISLAND on November 18, 2014 bmo.sagepub.com Downloaded from

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Page 1: Understanding Clinical Anger and Violence: The Anger Avoidance Model

http://bmo.sagepub.com/Behavior Modification

http://bmo.sagepub.com/content/32/6/897The online version of this article can be found at:

 DOI: 10.1177/0145445508319282

2008 32: 897 originally published online 9 July 2008Behav ModifFrank L. Gardner and Zella E. Moore

ModelUnderstanding Clinical Anger and Violence: The Anger Avoidance

  

Published by:

http://www.sagepublications.com

can be found at:Behavior ModificationAdditional services and information for    

  http://bmo.sagepub.com/cgi/alertsEmail Alerts:

 

http://bmo.sagepub.com/subscriptionsSubscriptions:  

http://www.sagepub.com/journalsReprints.navReprints:  

http://www.sagepub.com/journalsPermissions.navPermissions:  

http://bmo.sagepub.com/content/32/6/897.refs.htmlCitations:  

What is This? 

- Jul 9, 2008 OnlineFirst Version of Record 

- Oct 23, 2008Version of Record >>

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Understanding ClinicalAnger and ViolenceThe Anger Avoidance ModelFrank L. GardnerLa Salle UniversityZella E. MooreManhattan College

Although anger is a primary emotion and holds clear functional necessities,the presence of anger and its behavioral manifestations of aggression/vio-lence can have serious emotional, health, and social consequences. Despitesuch consequences, the construct of clinical anger has to date suffered fromfew theoretical and treatment advancements and has received insufficientresearch attention. Thus, the purpose of this article is to introduce the AngerAvoidance Model, which is a new conceptualization of clinical anger and itsbehavioral manifestations. The Anger Avoidance Model suggests that amonganger patients, a chronic early aversive history leads to information process-ing biases and emotion regulation deficits, which in turn result in intenseefforts to avoid the experience of anger. This avoidance takes the form of hos-tile rumination (cognitive avoidance) and aggressive and violent behavior(behavioral avoidance). This model holds clear implications for research andtreatment of this challenging clinical phenomenon.

Keywords: anger; violence; avoidance; aggression; emotion regulation

The emotion of anger is a natural, biologically necessary primary emo-tion innate to all human beings. The subjective emotional experience

of anger may vary from mild (irritation) to severe (rage) and is character-ized by both cognitive biases reflecting exaggerated prediction, interpreta-tion, and oversensitivity to violation by others and physiological arousal,which is reflected by sympathetic nervous system arousal and increasedmuscular tension (Deffenbacher, Demm, & Brandon, 1986). Anger mayalso function as a secondary emotion by serving as an affective response toother emotional states. By way of example, fear, which may be experienced

Behavior ModificationVolume 32 Number 6

November 2008 897-912© 2008 Sage Publications

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Authors’ Note: Correspondence concerning this article should be addressed to Frank L. Gardner,1900 West Olney Avenue, Box 842, Philadelphia, PA 19141; e-mail: [email protected].

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as intolerable, is often associated with a strong feeling of uncontrollabil-ity/vulnerability and can in turn become a discriminative stimulus for thesecondary emotion of anger.

Although, to many, anger may seem like a maladaptive response to inter-personal distress, the emotion is actually intended to serve an adaptivefunction, as it has as its most basic purpose the preparation of human beingsto respond to real threats in the environment (Kemper, 1987). However,when generalized to contexts beyond those in which it is likely to be usefuland adaptive, this otherwise normal emotion can lead to chronically height-ened arousal and is associated with dysfunctional and problematic behav-ior. For many individuals, heightened intensity, frequency, and duration ofanger, which we have defined as “clinical anger,” are precursors to a vari-ety of interpersonal, health, occupational, and legal difficulties (DelVecchio & O’Leary, 2004; Kassinove & Sukhodolsky, 1995).

Yet although clinical anger and its behavioral manifestations often resultin significant intrapersonal and interpersonal consequences, there are cur-rently no criteria for the diagnosis of an anger disorder (Diagnostic andStatistical Manual of Mental Disorders, 4th ed., text revision; DSM-IV-TR;American Psychiatric Association [APA], 2000). In the context of the cur-rent psychiatric nosology, anger serves only as a contributing characteristicfor numerous mental disorders (APA, 2000), such as posttraumatic stressdisorder (PTSD), mood disorders, impulse control disorders, and borderlinepersonality disorder. Due in part to the absence of diagnostic criteria of itsown, to date, there have been no epidemiological investigations of prob-lematic anger (DiGiuseppe & Tafrate, 2003). However, there is a largeempirical base to support its serious clinical relevance. In recent investiga-tions, 36% of patients meeting criteria for major depressive disorder, 61%of patients meeting criteria for Bipolar II disorder (Benazzi, 2003), and48% of patients meeting criteria for PTSD (Murphy et al., 2004) reportedsubstantial difficulties with anger. Frueh, Henning, Pellegrin, and Chobot(1998) found that measures of anger were significantly elevated in patientsexperiencing combat-related PTSD and were highly related to occupationalimpairment even when controlling for PTSD severity. In addition, Erwin,Heimberg, Schneider, and Liebowitz (2003) found that individuals withsocial anxiety disorder experienced greater elevations of anger andexpressed their anger in more problematic ways than did nonanxious con-trols. This same study further suggested that high levels of anger predictedpremature termination from treatment and a generally less satisfactoryresponse to an empirically supported treatment for social anxiety disorder.Similarly, exposure therapy was shown to be less effective for individuals

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with high levels of pretreatment anger in patients meeting criteria for PTSD(Foa, Riggs, Massie, & Yarczower, 1995). In yet another study, Fava andRosenbaum (1998) found that approximately one third of depressed outpa-tients presented with anger attacks, which were defined as the sudden andintense experiencing of anger, accompanied by symptoms indicative of theactivation of autonomic arousal (such as rapid heart rate, sweating, hotflashes, and chest tightness).

Previous Theoretical Considerationsof Anger and Aggression

Although there are clear comorbidities between anger and other disor-ders, cognitive-behavioral conceptual models of anger have actually beensparse. Thus, prior to a discussion of the development of our AngerAvoidance Model, a description of the theoretical model that has dominatedto date is warranted.

To date, the most commonly discussed model for explaining angerdyscontrol and its consequences is the cognitive content specificity model.This model, in its various forms, postulates that specific cognitions, mostlikely related to unrealistic demands, expectations, or assumptions aboutthe behavior of others, result in the emotional experience of anger and arein turn associated with physiological changes (Kassinove & Tafrate, 2002).To describe the relationship between anger and aggressive/violent behavior,the model suggests that heightened anger results in socially constructedovert behavioral responses in the form of aggression/violence and thesebehavioral responses essentially function to discharge the anger. In turn,this process is typically reinforced by immediate interpersonal outcomes(i.e., getting what one wants). Although this position is central to the cog-nitive content specificity model of anger and aggression, recent researchstrongly suggests that aggressive behavior does not in fact reduce the levelof experienced anger. In fact, to the contrary, empirical findings suggestthat venting aggressive behavior (i.e., hitting a punching bag) actually leadsto an increase in the experience of anger (Bushman, 2002).

In essence, the cognitive content specificity model of anger and aggres-sion views (distorted) cognitive content as the central feature in anger, as itis suggested to be in other emotional states (Beck, Brown, Steer, Eidelson,& Riskind, 1987; Kassinove & Tafrate, 2002). This position fundamentallyplaces the misappraisal of environmental events as central to the under-standing of and ultimately the treatment for problematic anger and views

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behavioral excesses or deficits such as aggressive/violent behavior as adirect result of the emotion of anger. From this perspective, anger has beendefined as “a felt state that is negative and, thus, generally to be avoided”(Kassinove & Tafrate, 2006, p. 5).

Although the cognitive content specificity model has been the primarymodel for understanding high levels of anger and its associated conse-quences, the model appears to have several flaws: (a) Because anger is anatural human emotion, it is problematic to view anger as something to beavoided; (2) the anger treatments that have been based on this model havedemonstrated questionable efficacy, thus calling into question the theoreti-cal model from which they have been developed (Santanello, Gardner, &Moore, 2008); and (c) the model has not integrated more contemporaryresearch on emotion and emotional disorders.

The Anger Avoidance Model:Integrating New Developments

Given the previously noted presence of anger within other clinical pop-ulations, the paucity of consideration of anger in the scientific literature,and the difficulties with the cognitive content specificity model, we havedeveloped a new model for understanding clinical anger and its behavioralmanifestations. This model, which we have termed the Anger AvoidanceModel, draws on several key developments in the study of other emotionaldisorders (see Figure 1 for a schematic representation of the entire AngerAvoidance Model).

Anger and the Emotional Disorders

In recent years, as greater emphasis has been placed on developing amore comprehensive understanding of the processes involved in emotionaldisorders, findings in experimental psychopathology have highlighted thesignificant overlap between anxiety and mood disorders (Barlow, Allen, &Choate, 2004; Brown, Campbell, Lehman, Grisham, & Mancill, 2001;Mineka, Watson, & Clark, 1998). In fact, it has been suggested that emo-tional disorders share foundational psychosocial and biological diathesesand the expression of particular symptom clusters are in fact minor varia-tions of a broader syndrome. This has been referred to as negative affectsyndrome (NAS; Barlow et al., 2004). Using structural equation modelingas a base methodological approach, Barlow et al. (2004) developed a model

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for understanding anxiety and mood disorders (referred to as emotional dis-orders) that confirms earlier descriptions of a tripartite model of emotionaldisorders described by Clark and Watson (1991).

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Aversive History(Maltreatment, Neglect)

+Biological Vulnerability

Hostile Anticipation(External Scanning,Attentional Biases,

Attributions of PersonalViolation)

Specific Life Event

Impaired Emotional Processing &Emotion Dysregulation

Internalized Avoidance(Hostile Rumination)

Externalized Avoidance(Aggressive Behavior)

Experience of Anger(Including Heightened Physiological Arousal)

Figure 1Model of Clinical Anger

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In the tripartite model, emotional disorders are distinguished by varyingcombinations of negative affect, positive affect, and autonomic arousal.When viewing emotional disorders from this conceptualization, the com-monalities across the varying DSM-defined emotional disorders are moresignificant than the variations. For example, negative affect and autonomic(somatic) arousal are highly (positively) correlated with panic disorder,which in turn is not correlated with positive affect. Both depression andsocial anxiety, on the other hand, are highly correlated with negative affect(positive correlation) and positive affect (negative correlation) yet are min-imally correlated with autonomic arousal. With this in mind and given thenumerous empirical findings regarding the comorbidity of anger with avariety of current diagnostic categories, rather than suggest the need for anew diagnostic category for “anger disorders” (DiGiuseppe & Tafrate,2003; Kassinove & Sukhodolsky, 1995), clinical anger may best be viewedas a specific variation of NAS. In fact, Mineka et al. (1998) suggested that“it now is obvious that this general Negative Affect dimension is not con-fined solely to mood and anxiety disorders, but is even more broadly relatedto psychopathology” (pp. 397-398). From this perspective, we suggest thatanger is positively correlated with negative affect, is negatively correlatedwith positive affect, and is positively correlated with somatic arousal. Inessence, this would place anger as a mixed emotional disorder manifestingthe heightened distress found in both anxiety and mood disorders, theheightened autonomic arousal most often seen in panic disorder and gener-alized anxiety disorder, and the absence of positive feelings such as joy andhappiness (anhedonia) most typical of depression and social anxiety disor-der. This is graphically presented in Table 1.

Etiological Considerations

The triple vulnerabilities model proposed by Barlow et al. (Barlow,2002; Barlow et al., 2004) has been helpful in describing the developmentof other emotional disorders, and similarly, we suggest that it is useful forconceptualizing the development of clinical anger and its behavioral mani-festations. In the triple vulnerabilities model, three important diathesesinteract in a synergistic manner to result in the ultimate development andpresentation of an emotional disorder.

The first diathesis is biological and reflects the myriad of researchdemonstrating the biological and genetic contribution to basic tempera-ments (Barlow, 2002). Specifically relevant to the conceptualization pre-sented herein, Barlow (2002) has suggested that individuals with high

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levels of anger and those with panic disorder appear to be similar in theirbiological vulnerabilities. In fact, recent research offers some preliminarysupport for the proposition that individuals experiencing anger and/or anx-iety do in fact experience similar levels of physiological arousal (Wenzel &Lystad, 2005). Yet although an individual’s biological vulnerability func-tions as a type of inherent risk factor for the development of an emotionaldisorder, a biological vulnerability does not appear to predict the laterdevelopment of specific emotional disorders. Rather, it sets the stage for theultimate manifestation of these disorders by resulting in a general overre-sponsiveness to stress and challenge.

The second vulnerability has been described as the general psychologi-cal diathesis and reflects the impact of specific life experiences on the indi-vidual. It is these experiences that have been postulated to contribute to thedevelopment of anxiety, depression, and related affective states by produc-ing a general sense of uncontrollability (Barlow, 2002). Yet with respect toanger, Barlow (2002) has suggested that patients experiencing clinicallyrelevant anger differ from patients experiencing anxiety in that rather thanthe perception of uncontrollability experienced by anxious patients, angrypatients may experience an exaggerated sense of mastery and control.However, our observations from working with clinical anger patients in ouranger specialty clinic do not support the proposition that angry individualsexperience an exaggerated sense of mastery and control. Rather, we suggestthat angry patients actually exhibit as great a sense of uncontrollability/vulnerability as anxious patients but choose a fight (as opposed to flight)response based on both biological factors noted earlier and specific earlylearning histories and modeling experiences. It is important to note that inour conceptualization of clinical anger (Anger Avoidance Model), percep-tions of uncontrollability are as problematic for the clinical anger patient asthey are for the anxious patient. However, as angry and anxious patientstypically encounter very different early learning histories, they experiencedifferent affective and behavioral responses to their perceptions of uncon-trollability. Erwin et al.’s (2003) findings suggesting a strong relationship

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Table 1Anger and Negative Affect Syndrome

Emotional Disorder Positive Affect Negative Affect Arousal

Anxiety Moderate to high Moderate to high Moderate to highDepression Low Moderate to high LowAnger Low Moderate to high Moderate to high

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between social anxiety and trait anger provide some indirect, albeit tenta-tive, support for the idea that anger does not reflect an exaggerated sense ofmastery or control but instead reflects a different response to an extremesense of uncontrollability and vulnerability. We suggest that the early aver-sive histories noted among angry individuals culminate in feelings of vul-nerability, which in turn become stimuli for the experience of anger.

It has already been demonstrated that the biologically based tempera-ments of anxious and angry patients share some clear similarities (Wenzel& Lystad, 2005). Yet although some similarities between anxious and angrypatients do of course exist, there appear to be several significant ways thatthe learning histories of anxious and angry patients differ, thus resulting indifferent general psychological vulnerabilities. Patients with anxiety disor-ders frequently describe parents/caretakers as less supportive, less sociallyengaged, exerting greater control over the decision making of theirchildren, and generally more enmeshed in their children’s lives (Barlow,2002). This does not appear to be the case with patients experiencing clin-ical anger. In fact, recent findings from our lab suggest that the early expe-riences of angry patients are actually more similar to those found inchronically depressed patients (meeting criteria for dysthymic disorder) asdescribed by McCullough (2000). This early environment is often chroni-cally aversive and is characterized by (a) a harsh and punitive environment(often including a history of neglect or mistreatment), (b) being subjectedto a hazardous social and/or familial environment where caretakers and/orfamily members cannot protect or even hurt their children as well as eachother, and (c) the experience of chronic physical and/or emotional pain.Together, these variables culminate in an intense emotional environment inwhich physical and psychological safety and survival become most impor-tant. We suggest that individuals who confront such early histories experi-ence intense emotion along with a pervasive sense of powerlessness, whichculminates in a level of anger/rage that is subjectively overwhelming. Infact, we have found that in both clinical (n = 60) and nonclinical (n = 250)samples, early aversive history does in fact predict levels of trait anger,as measured by the State Trait Anger Expression Inventory (STAXI;Spielberger, 1988). In turn, individuals exposed to a chronic early aversivehistory manifest significantly higher levels of trait anger and anger reactiv-ity than individuals who have not been exposed to such a harsh early history(Gardner, Moore, Wolanin, Alm et al., 2006; Gardner, Moore, Wolanin,Deutsch, & Marks, 2006).

One question may be suggested by our recent empirical finding con-firming the etiological similarities between patients experiencing clinical

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anger and those experiencing chronic depression (Gardner, Moore,Wolanin, Alm et al., 2006). That is, because the early learning histories ofboth clinical anger patients and chronically depressed patients are largelycharacterized by chronically harsh and punitive early environments, why doclinical anger patients not then develop chronic depressive disorders instead?Referring back to the triple vulnerabilities model, in response to the simi-lar early environments, we hypothesize that patients who are more biolog-ically prone to heightened levels of autonomic arousal are likely to respondwith clinical anger, whereas those with a different biologically based tem-perament are likely to respond with lower levels of arousal and as suchdemonstrate overt and covert manifestations consistent with a chronicdepressive disorder. Although this hypothesis is an open empirical question,it is consistent with our conceptualization of anger as sharing tripartitemodel characteristics with both depression and anxiety.

Information Processing Biases

The third synergistic vulnerability for emotional disorders has beenlabeled the specific psychological diathesis (Barlow, 2002), which is anintegration of the individual’s biological temperament and his or her earlysocial learning history from the first two diatheses. In the case of dysfunc-tional anger, the specific psychological diathesis often displays as cognitive(information processing) biases for violation-relevant stimuli. We suggestthat in response to the highly aversive early social-familial environments thatare common for patients with dysfunctional anger, a functional survival-based tendency evolves in which the individual with clinical anger scansthe external environment for early signs of potential personal (physical orpsychological) violation. We have created the term hostile anticipation torepresent the angry patient’s perseverative hypervigilance for signs of hos-tile intent and personal violation. We view the hypervigilance for signs ofexternal danger in angry patients as analogous to the hypervigilance forsigns of internal danger often noted in anxious patients.

Yet although anxious patients often present with excessive self-focusedattention and see physical sensations, social evaluation, and unacceptablethoughts as a sign of potential danger, Barlow (2002) has suggested thatrather than the excessive self-focused attention most often seen in anxiouspatients, the angry patient is likely to manifest a nearly exclusive externalfocus of attention. Consistent with this hypothesis, a number of recent stud-ies have demonstrated specific information processing biases in angry indi-viduals. One recent study found that those individuals in a college student

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sample scoring high on trait anger did in fact make more global and exter-nal attributions than anxious or nonangry/anxious controls (Langton &Wenzel, 2004). Similarly, Aquino, Martinko, and Douglas (2004) foundthat hostile attributions mediated the relationship between external eventsand reported anger in an organizational context. In yet another study,Cohen, Eckhardt, and Schagat (1998) found that individuals high in traitanger demonstrated attentional biases toward anger-related cues followinginsult. Finally, Wenzel and Lystad (2005) found that angry subjects ratedthe likelihood of angry explanations for ambiguous events higher than anx-ious or nonanxious/nonangry controls. Taken together, these studies do infact suggest that specific information processing biases exist amongpatients experiencing clinical levels of anger. The consequence of theseinformation processing biases is that an inordinate number of otherwiseinnocuous life events will instead be interpreted as threatening or danger-ous, thus triggering the emotion of anger.

Emotion Regulation and Avoidance

Based on our ongoing experience with clinical anger patients and recentlaboratory findings, it appears that patients manifesting clinical anger alsomanifest significant difficulties with emotion processing, which has beendefined as “the way in which an individual processes stressful life events”(Baker, Holloway, Thomas, Thomas, & Owens, 2004, p. 1272; see alsoRachman, 2001). When such events are not fully integrated and processed,a chronic reliance on avoidance as a coping strategy is likely to occur. Wesuggest that when these individuals experience levels of affect that are per-ceived to be intolerable (i.e., anger), the avoidance typically takes the formof overt aggressive or violent behavior, or covert cognitive processes suchas hostile rumination. Studies from our laboratory, recently presented else-where, indicate that difficulties in emotion regulation do in fact mediate thepreviously noted relationship between early aversive history and trait angerand anger reactivity (Moore, Gardner, & Wolanin, 2006).

Behavioral avoidance. Recent studies suggesting that aggressive behav-ior serves an affect regulation function (Bushman, Baumeister, & Phillips,2001) and interpersonal violence in particular may function as a means ofregulating emotion (Jakupcak, Lisak, & Roemer, 2002), are consistent with,and can be explained by our laboratory finding that emotion regulation dif-ficulties mediate the relationship between early aversive history and traitanger and anger reactivity (Moore et al., 2006). Thus, in the Anger

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Avoidance Model proposed herein, ineffectively processed anger becomesa cue for cognitive avoidance in the form of hostile rumination and/orbehavioral avoidance in the form of overt aggressive behavior (verbal orphysical). Seen in this light, aggressive/violent behavior is conceptualizedas an overt avoidance or escape response and functions to reduce the fullexperience of anger (and the fear that may have been the initial stimulus forthe anger). Consequently, it is negatively reinforced. To expand, overtaggressive/violent behavior serves as an escape from the stimulus that ledto the anger response by either eliminating the stimulus itself (i.e., the indi-vidual who has “wronged” the angry client withdraws from the situation)or by changing the form of the stimulus (i.e., the individual acts differentlytoward the angry client).

Anecdotal clinical findings also suggest that aggressive/violent behaviormay serve an avoidant function in many clients who seek psychologicaltreatment. Clinicians working with violent offenders frequently note thatpatients with clinical anger often report “feeling nothing” both during andimmediately after an aggressive outburst (DiGiuseppe, Fuller, & Fountain,2006; Gardner, Moore, Ronkowski, & Wolanin, 2006) and tend to scoreextremely high on the anger suppression subscale of the STAXI (Gardner,Moore, Wolanin, Alm et al., 2006). According to the Anger AvoidanceModel, these psychometric findings would appear to reflect the attenuation(avoidance) of the emotion of anger and not simply a motivationally basedreluctance to admit to experiencing anger or engaging in aggression.

Although the avoidant function of aggressive/violent behavior seen inmany clients may be confused with instrumental aggressive/violent behav-ior, it is important to note that the theoretical position presented herein doesnot suggest that all acts of violence come from an effort to avoid the expe-rience of anger. Although the form of the behavior is the same in bothgroups, the functions of the behaviors differ. In one group, the function ofthe behavior is the reduction or elimination of affect, whereas in the othergroup, the function of the behavior is appetitive and seeks to achieve an endby way of control or manipulation. In fact, we suggest that there are actu-ally two subgroups within the population of individuals manifesting aggres-sive/violent behavior. The first subgroup includes individuals who useaggressive behavior in an instrumental fashion as a means of achieving con-trol over others or as a means of making others, feel, think, or act differ-ently. These individuals report no clear pattern of chronic early aversivehistory, demonstrate no significant difficulty in emotion regulation, andexperience little (if any) discernable anger. We have termed this group

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instrumental aggressors. In contrast, the second subgroup includes individu-als whose aggressive/violent behavior functions as a form of overt avoidance/escape from the experience of anger. This subtype is defined by an earlyaversive history, extensive experiential avoidance, and difficulties in emo-tion regulation, and it displays significantly elevated scores on measures oftrait anger and anger reactivity. It is this second subgroup, which we havetermed avoidance/escape aggressors, that appears to use aggressive/violentbehavior as a form of avoidance or escape, as conceptualized by the AngerAvoidance Model. Recent studies from our laboratory support this con-tention within a clinical population court mandated following violentoffenses (Gardner, Ronkowski, Wolanin, & Moore, 2006).

Cognitive avoidance. As previously stated, ineffectively processedanger becomes a cue for behavioral avoidance in the form of overt aggres-sive behavior and/or cognitive avoidance in the form of hostile rumination.In terms of cognitive avoidance, hostile rumination differs from hostileanticipation (introduced earlier) in that hostile rumination functions as amanifestation of experiential avoidance by repetitive and recurrent think-ing about perceived historical and/or present violations and consequences,whereas hostile anticipation is a future-oriented cognitive appraisal of boththe likelihood and consequences of personal violation. With this distinc-tion in mind, the avoidant function of hostile rumination would beexpected to follow the same pattern seen in worry (Borkovec, 1994). Thenegatively reinforced (i.e., avoidant) function of rumination has beenshown in numerous studies demonstrating reduced emotional and physio-logical arousal and poorer emotional processing during rumination (Clark& Collins, 1993; Pennebaker, 1997; Teasdale, 1999). As such, hostilerumination would appear to function in a manner similar to worry inpatients with generalized anxiety disorder by attenuating the full experi-ence of emotion. This occurs because rumination is typically past or futureoriented, and thus, the individual does not have an in-the-moment experi-ence of anger. The emotion-attenuating function of ruminative processes isthus negatively reinforced and results in an increase in frequency(Borkovec, Ray, & Stober, 1998). Recent findings support the suggestionthat rumination is a maladaptive effort to cope with affect and is associatedwith cognitive biases, sustained negative mood states, and impaired prob-lem solving (Joorman, Dkane, & Gotlib, 2006). This finding is consistentwith the myriad of interpersonal difficulties often found among angerpatients (Kassinove & Sukhodolsky, 1995).

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Contrary to previous hypotheses suggesting that individuals experienc-ing high levels of anger posses and exaggerated sense of mastery and con-trol, hostile rumination and/or aggressive behaviors do not appear to becoping efforts indicative of an exaggerated sense of mastery and control(although at some level both might be desired). Rather, they seem to beineffective efforts at reducing, eliminating, or totally blocking emotion thathas previously been associated with personal danger and vulnerability. Wecontend that individuals with clinical anger have an exaggerated sensitivityto the experience of emotion, which has become strongly associated withpersonal danger through chronic early aversive environments. Seen in thismanner, the angry individual is consumed with issues relating to interper-sonal safety (both physical and psychological) in response to a world per-ceived as dangerous and uncontrollable. Thus, from the perspective of theAnger Avoidance Model, the problem is not the emotion of anger per se.Instead, what is most problematic is the belief that emotion (and anger inparticular) is intolerable, and the subsequent inflexible overgeneralized useof avoidance through the use of overt (behavioral) and covert (cognitive)responses in an desperate effort to reduce, eliminate, or otherwise controlthe emotion of anger and maintain personal safety (see Figure 1).

Conclusion

Although components of the Anger Avoidance Model are currentlyunder additional empirical investigation, the development of this modelof clinical anger has benefited from existing research on both emotionand emotional disorders and has garnered preliminary support in a labo-ratory setting. It is hoped that the Anger Avoidance Model advances thestudy of clinical anger in general, provides a better understanding of clin-ical anger and its behavioral manifestations, and leads to the developmentof newer and more effective treatments for anger and violence. Althoughthe construct of anger has historically not been investigated at the samelevel as other emotions, such as anxiety and depression, it remains a chal-lenging clinical phenomenon in need of further attention and empiricalexploration.

References

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Aquino, K., Martinko, M., & Douglas, S. (2004). Overt anger in response to victimization:Attributional style and organizational norms as moderators. Journal of OccupationalHealth Psychology, 9, 152-164.

Baker, R., Holloway, J., Thomas, P. W., Thomas, S., & Owens, M. (2004). Emotional pro-cessing and panic. Behaviour Research and Therapy, 42(11), 1271-1287.

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Moore, Z. E., Gardner, F. L., & Wolanin, A. T. (2006, July). Emotion regulation, early aver-sive history, and trait anger. Paper presented at the annual convention of the AmericanPsychological Association, New Orleans, LA.

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Frank L. Gardner, PhD, ABPP, is a professor and director of the PsyD program in clinicalpsychology at La Salle University in Philadelphia, Pennsylvania. He is also the director of theCenter for the Treatment and Study of Anger and Violence at La Salle’s CommunityPsychological Services Center. He has published two books and a number of articles in theareas of mindfulness, experiential avoidance, schemas, and clinical sport psychology.

Zella E. Moore, PsyD, is an assistant professor of psychology at Manhattan College in NewYork City. In addition, she is the associate director of research and development for the Centerfor the Treatment and Study of Anger and Violence at La Salle’s Community PsychologicalServices Center. She has published two books and a number of articles in the areas of ethics,mindfulness, clinical sport psychology, and eating disorders.

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