Dr. John Schinnerer
Kristen comes to therapy begrudgingly, stating that she has no problem with anger. She is prone to angry outbursts particularly when she feels criticized. She usually places blame on other people when things go badly. She admits she spends a good part of her day irritated at people or events in her life. When she gets upset, she yells, screams and throws things.
Most psychologists have seen their share of angry patients like Kristen. Seasoned psychologists work with angry clients as often as they work with anxious clients. Yet the majority of studies on difficult emotions have focused on depression and anxiety rather than anger and aggression.
Given this shortage of research on anger, the question remains, what is the best way to treat anger? This article will look at the most effective scientifically-proven, evidence-based treatments for reducing anger.
Diagnosing Problem Anger
Most individuals feel angry about 3-4 times per week. In a 1997 study by Howard Kasinove, Ph.D., 58% of anger episodes involve shouting or yelling. In more than 50% of anger episodes, the recipient of the anger was either a loved one or a friend. Ten percent of anger episodes include physical aggression, such as hitting, shoving or throwing things. Even within this 10%, the aggression is relatively mild - throwing small objects such as pens or pencils.
The truth remains that anger remains one of the most pressing issues facing us today. With the rapidly accelerating pace of life, and a continuously growing population living in close proximity, there is increasing potential for anger to lead to destruction and terror on a massive scale. Learning to manage anger is vital to ensure the peaceful and productive continuation of the human race.
How do you know if you have a problem with anger?
People with problematic anger have anger episodes that more frequently, with more intensity and which last longer than normal. Individuals with anger issues report more frequent and intense physical aggression, more negative verbal responses, more drug use and negative consequences of their anger (e.g., high blood pressure, damaging relationships and interfering with work performance). To sum up, those with anger problems have anger that adversely impacts their personal relationships, their health, and their work.
Interestingly, there is no diagnostic criteria for anger problems in the DSM, the diagnostic manual for psychology. While there are criteria for anxiety and depression issues, there is little to nothing for anger (one exception is Intermittent Explosive Disorder). So the point at which anger becomes a ‘problem’ is a difficult one to pinpoint.
At present, there is no consensus about how helpful it would be to have a diagnostic criteria for anger. Some say it would help to define which clients get which treatment. Others say that extreme anger is merely a symptom of another disorder like borderline personality, narcissism, anxiety or depression.
Evidence-Based Approaches to Reduce Anger
Despite problems at the diagnostic level, therapists are faced daily with the issue of teaching patients how to reduce the frequency, intensity and duration of their anger. So what treatments have been shown in research to have a positive effect on anger?
There are 4 types of treatments which have been shown in studies to be effective in reducing anger - relaxation training, skills training, cognitive-behavioral therapy (CBT) and some combination of these (multicomponent therapy).
Relaxation training involves teaching clients skills to relax on command. This might involve skills such as progressive-muscle relaxation, deep breathing, mindfulness and/or guided imagery. The new relaxation skills are then paired with a single word, such as ‘breathe’ or ‘calm’, which is repeated to activate the relaxed feeling during moments of stress.
Skills training involves teaching clients the needed skills to be successful in specific situations in order to reduce stress. For instance, new parents would be taught parenting skills - what to look for, how to read an infant’s nonverbal coos, and how to respond appropriately to each basic need (e.g., hunger, sleepiness, pain, discomfort, desire to play). People who get angry at work might be taught appropriate assertiveness to get their needs met at the office and interrupt the anger cycle there.
Cognitive-behavioral therapy (CBT) revolves around teaching clients that thoughts and feelings can be untrue. A central skill in CBT is learning to recognize thoughts and feelings which are untrue, challenging them and replacing them with constructive ones.
Multicomponent therapy is a combination of the above. For example, combining relaxation therapy with CBT and social skills training, to ensure clients absorb the best from each treatment method.
Two large studies both reported similar findings. Here are the most effective to the least effective treatment methods for treating problematic anger…
In 1995, a study by R. Tafrate, Ph.D. compared these four approaches and found that relaxation-based treatment had the largest impact on reducing anger (effect size = 1.16). The next biggest impact was multicomponent therapy (effect size =1.00). Cognitive therapies was next with an effect size of 0.93. And skills training came in as least effective. In fact, relaxation training came out on top in another meta-analysis in 1996, followed by multicomponent, cognitive and social skills (Bowman-Edmondson & Cohen-Conger, 1996).
What do these “effect sizes” translate to in real terms? Fernandez and Beck (2001) showed that as a result of CBT therapy…
What’s more, the positive changes in anger and aggression may be maintained up to a year later (Deffenbacher, Dahlen, Lynch, Morris and Gowensmith, 2000).
A 1998 study found that people who received CBT for anger issues were “better off than 76%” of those who did not receive treatment (Beck and Fernandez, 1998). It seems reasonable to assume that relaxation and multicomponent therapies would have a greater impact than this as this study only looked at the effectiveness of CBT.
What is the Most Effective Method for Receiving Training?
Most of the research has been done on group therapy for anger management skills. There seemed to be an assumption that group was the best means to treat anger issues. However, research does not seem to support this assumption. A 2003 study found that individual therapy is more effective than group therapy for many (DiGiuseppe and Tafrate, 2003). This was particularly true for very angry clients who were resistant to change and bonded with others in group who reinforced attitudes that worsened anger.
With the onset of the internet, there was interest in how effective a computer-based anger management program might be. Computer-based anger programs were found to be as effective as group therapy in a study by Timmons and others (1997).
What are the Goals of Treatment?
Another important question is the objectives of an anger management program. Anger is difficult to breakdown into it’s respective parts. And growth only tends to happen in those areas that are measured. Awareness is the first step. So it’s critical to have an idea what you are aiming for with an anger management program. Here is a list of the goals and objectives of an effective anger management program…
All of these are important areas of which to be mindful if you are looking to reduce your own anger.
In conclusion, there is a need for more research in anger and the forms of treatment that help to reduce it. Research has shown that relaxation training, CBT, skills training and multicomponent approaches all have a positive impact in alleviating problem anger. Studies also show that individual therapy seems to be more effective than group and that computer-based training is as effective as group therapy. As we move forward, there is a need to differentiate normal anger from problematic anger. There is also a need for greater specificity in measuring anger for the purposes of definitively proving the effectiveness of anger management programs.
Beck, R., & Fernandez, E. (1998). Cognitive-behavioral therapy in the treatment of anger: A meta-analysis. Cognitive Therapy and Research, 22, 63-74.
Bowman-Edmondson, C., & Cohen-Conger, J. (1996). A review of treatment efficacy for individuals with anger problems: Conceptual, assessment, and methodological issues. Clinical Psychology Review, 16, 251-275.
Deffenbacher, J., Dahlen, E., Lynch, R., Morris, C., & Gowensmith, W. (2000). An application of Beck’s cognitive therapy to general anger reduction. Cognitive Therapy and Research, 24, 689-697.
DiGiuseppe, R., & Tafrate, R. (2003). Anger treatment for adults: A meta-analysis review. Clinical Psychology: Science and Practice, 10, 70-84.
Fernandez, E., & Beck, R. (2001). Cognitive-behavioral self-intervention versus self-monitoring of anger: Effects on anger frequency, duration and intensity. Behavioral and Cognitive Psychotherapy, 29, 345-356.
Kassinove, H., Sukhodolsky, D., Tsytsarev, S. & Solovyova, S. (1997). Self-reported anger episodes in Russia and America. Journal of Social Behavior and Personality, 12, 301-324.
Tafrate, R.C. (1995). Evaluation of treatment strategies for adult anger disorders. In H. Kasbinove (Ed.), Anger disorders: Definition, diagnosis, and treatment (pp. 109-130). Washington, DC: Taylor & Francis.
Timmons, P., Oehlert, M., Sumerall, S., Timmons, C., & Borgers, S. (1997). Stress inoculation training for maladaptive anger: Comparison of group counseling versus computer guidance. Computers in Human Behavior, 13, 51-64.
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