Introduction
Frequent, intense, and enduring anger, including dysfunctional affective expression and suppression, is associated with significant and comprehensive social, socioemotional, vocational and physical health impairment (e.g. Tafrate, Kassinove and Dundin, Reference Tafrate, Kassinove and Dundin2002), the extent of which classifies difficulties in anger management as a serious public health problem.
Few well-controlled studies have been conducted evaluating cognitive behavioral treatment interventions of anger. Those with the strongest empirical support include cognitive interventions (Deffenbacher, Dahlen, Lynch, Morris and Gowensmith, Reference Deffenbacher, Dahlen, Lynch, Morris and Gowensmith2000), skills training (Deffenbacher, Reference Deffenbacher and Caballo1998), relaxation (Deffenbacher, Huff, Lynch, Oetting and Salvatore, Reference Deffenbacher, Huff, Lynch, Oetting and Salvatore2000), and formats representing different combinations of these (Deffenbacher, Filetti, Lynch, Dahlen and Oetting, Reference Deffenbacher, Filetti, Lynch, Dahlen and Oetting2002). These interventions have proven effective across a variety of clinically angry populations (e.g. Chemtob, Novaco, Hamada, Gross and Smith, Reference Chemtob, Novaco, Hamada, Gross and Smith1997). However, there is no scientific evidence indicating that clinicians outside of university or hospital settings utilize empirically tested anger treatments. Generalization of cognitive-behavioral treatment effectiveness to traditional populations, such as psychiatric outpatients, is warranted (Tafrate et al., Reference Tafrate, Kassinove and Dundin2002).
To our knowledge, only one descriptive analysis has been conducted on anger-disordered adult outpatients (Grodnitzky and Tafrate, Reference Grodnitzsky and Tafrate2000). This study utilized exposure exclusively as an intervention with a small group of court-mandated clients. Unfortunately, few studies have evaluated the efficacy of psychotherapy on treatment-seeking individuals from the community (Del Vecchio and O'Leary, Reference Del Vecchio and O'Leary2004). Given the high number of anger-disordered clients presenting for treatment in private clinical settings (Lachmund, DiGiuseppe and Fuller, Reference Lachmund, DiGiuseppe and Fuller2005), it is important to determine if cognitive behavioral psychotherapy is feasible and effective for adults seeking fee-for-service treatment.
Comprehensive diagnostic information on adults seeking outpatient treatment for anger is a prerequisite in making a determination about treatment effectiveness. Unfortunately, frequent diagnostic confusion complicates outpatient treatment of anger (Lachmund et al., Reference Lachmund, DiGiuseppe and Fuller2005). The Diagnostic and Statistical Manual of Mental Disorders, Fourth Edition-Text Revised (DSM-IV-TR; American Psychiatric Association, 2000) does not include an exclusive anger diagnosis, but a variety of disorders include anger as a diagnostic symptom, including Post-Traumatic Stress Disorder, Oppositional Defiant Disorder, Paranoid and Borderline Personality Disorders. Furthermore, related constructs of aggression, hostility, irritability, and resentment permeate the nosology (e.g. Generalized Anxiety Disorder, Antisocial Personality Disorder, Passive Aggressive Personality Disorder) while “anger attacks”, but not anger per se, is included as a diagnostic specifier in Panic Disorder, Major Depressive Disorder, and Intermittent Explosive Disorder. Inaccurate diagnosis complicates case conceptualization, treatment planning and prognoses and, importantly for patients seeking help for anger, raises practical financial issues; lacking an Axis I diagnosis may prevent third party reimbursement.
Method
This pilot study tested the efficacy of an extended CBT protocol, largely based on the work of Deffenbacher and McKay (Reference Deffenbacher and McKay2000), DiGiuseppe and Tafrate (Reference DiGiuseppe and Tafrate2002), Kassinove and Tafrate (Reference Kassinove and Tafrate2004) and clinical experience.
Participants
A sample of 12 participants (5 men and 7 women), presenting for outpatient treatment of anger problems, was intended to represent the typical angry patients treated by mental health practitioners in outpatient facilities. Their inclusion was contingent upon anger being the primary cause of distress and functional impairment.
All patients received structured clinical interviews as an initial step in describing the diagnostic characteristics of these patients. Diagnostic information revealed the sample to be a close approximation of how Tafrate et al. (Reference Tafrate, Kassinove and Dundin2002) describe a traditionally defined clinical sample. They were diagnosed with 29 Axis I and 34 Axis II disorders with high rates of comorbidity.
Treatment
Treatment consisted of 16 2-hour sessions of a group-based cognitive-behavioral anger management program, the goal of which was the development of adaptive coping skills. As suggested by Deffenbacher (2000), session length and the number of sessions were increased in order to maximize the treatment dose in the hope of improving treatment efficacy and viability (attrition and satisfaction). The treatment included didactic and Socratic methods of instruction and completion of exercises during and outside of sessions to increase skill acquisition, until participants indicated readiness for exposure exercises. Specifically, cognitive restructuring emphasized the use of the theoretical model to understand anger episodes and the Rational Emotive Behavior Therapy (REBT) techniques of disputing irrational beliefs, rehearsing rational beliefs and Self-Instructional Training (SIT). Behavioral skills training included problem-solving, consequential thinking and assertiveness. Relaxation training included paced respiration. Motivational interviewing techniques were employed throughout. A key component of the intervention, imaginal exposure required participants to imagine events that typically trigger anger and use reviewed coping strategies to modulate anger. Relapse prevention was a final focus of treatment.
Measures
All participants received the Structured Clinical Interview for DSM-IV Diagnosis (SCID-1; First, Spitzer, Gibbon and Williams, Reference First, Spitzer, Gibbon and Williams2002) and the Structured Clinical Interview-II for DSM-IV Diagnosis (SCID-II; First, Gibbon, Spitzer, Williams and Benjamin, Reference First, Gibbon, Spitzer, Williams and Benjamin1997) to diagnose Axis I and II disorders, respectively. Four measures of anger were used to determent treatment efficacy from pre- to post-treatment: the Trait Anger Scale (TAS) of the State-Trait Anger Expression Inventory-II (STAXI-II; Spielberger, Reference Spielberger1999) for overall level of anger, the Anger Disorders Scale (ADS; DiGiuseppe and Tafrate, Reference DiGiuseppe and Tafrate2004) was also used as an outcome measure, and the Anger Situation Form (Deffenbacher and McKay, Reference Deffenbacher and McKay2000) and Anger Symptom Form (Deffenbacher and McKay, Reference Deffenbacher and McKay2000) for ideographic components of anger. Other outcome measures included the Beck Depression Inventory-II (BDI-II; Beck, Steer and Brown, Reference Beck, Steer and Brown1996) for depressive symptoms, and the Outcome Questionnaire (OQ; Lambert et al., Reference Lambert, Hansen, Umphress, Lunnen, Okiishi, Burlingame, Huefner and Reisinger1996) for current symptom distress, interpersonal relations, and social role congruence. Finally, the Working Alliance Inventory (WAI; Horvath and Greenberg, Reference Horvath and Greenberg1989) assessed therapeutic alliance.
Results
T-tests were conducted on outcome measures to evaluate effects of treatment. Given the directional nature of all hypotheses, one-tailed tests were used. A Bonferroni correction was used with an adjusted alpha of .0091. At this level, five significant differences were found. Cohen's d was used to represent effect sizes, which were calculated by dividing pre-treatment/post-treatment differences by pooled standard deviations. We determined whether the improvement reached clinically significant change based on Jacobson and Truax's (Reference Jacobson and Truax1991) methods. For the A calculation method, a clinically meaningful difference was determined with a two-standard deviation change from pre-treatment, and the reliable change index (RCI), a gauge of change compared to the standard error (SE).
T-tests indicated significant changes in Trait Anger Scale T-scores from pre- (M = 67.67, SD = 10.58) to post-treatment (M = 57.17, SD = 8.24), t (11) = 3.22, p < .01 (d = 1.12). ADS total score also changed significantly (M = 76.08, SD = 14.02, pre vs. M = 60.33, SD = 7.37, post), t (11) = 4.02, p < .01 (d = 1.47). Depressive symptoms, as represented by the BDI-II score, decreased from pre- (M = 25.33, SD = 12.34) to post-treatment (M = 9.45, SD = 8.20), t (11) = 4.80, p < .01 (d = 1.55). Effect sizes for all three of these nomothetic scales were large. Clinical significance classified patients into four categories: deteriorated, unchanged, improved, and recovered. The majority of patients received classifications of improved or recovered on the TAS (frequency of 10 out of 12 participants), BDI (11 out of 12), and ADS scores (11 out of 12), with the vast majority of those categorized as improved.
Anger Situation-Intensity (pre- M = 85.42, SD = 13.89 vs. post-test M = 37.50, SD = 27.09), t (11) = 5.20, p < .01 (d = 2.39) and Anger Symptom-Severity (M = 69.17, SD = 27.87 vs. M = 30.58, SD = 27.64), t (11) = 4.16, p < .01 (d = 1.39) scores were both significantly reduced. However, the other subscale scores of these idiosyncratic forms did not reach statistical significance.
Discussion
As hypothesized, while the frequency of anger provocations remained constant, the frequencies of physiological anger symptoms decreased. Significant improvements were found from pre- to post-treatment on both measures of anger and depression. In addition, the effect sizes for these two measures were large and closely approximated those in previous studies (DiGiuseppe and Tafrate, Reference DiGiuseppe and Tafrate2003). Most important were the clinically meaningful changes. Again, 10 and 11 (respectively) of the 12 patients were either in the improved or fully recovered range on these general measures of anger.
Addressing problematic avoidance of anger triggers is considered to be an imperative component of the described intervention. Once the participants developed coping strategies, they were encouraged to refrain from avoidance and escape behaviors. The data indicated that participants were able to confront anger provoking situations while still experiencing significant decreases in the emotional intensity and physiological arousal previously associated with these triggers. The alleviation of the avoidance-rumination cycle may be responsible for relapse prevention. Additionally, motivational enhancement and REBT skills are important contributors to indicated positive outcome. Cognitive restructuring based upon REBT is learned quickly and can be easily utilized in a variety of settings without ongoing professional contact, making these skills suitable for time-limited psychotherapy.
Importantly, participants reported high satisfaction with the treatment. Extending the number and length of sessions allowed ample time to process problems presented during homework review, address resistance, and enable group members to assist one another. It allowed for more clinician-patient contact, and possibly more importantly, for more interpersonal exchanges among group members (Yalom, Reference Yalom1985).
Limitations and directions for future research
The following improvements for strengthening the findings of this pilot study are suggested for future research: larger sample size, inclusion of a treatment control group, independent coding of fidelity, utilization of objective physiological/behavioral measures, and administration of treatment by different therapists. The relative contributions of each of the active ingredients of the treatment protocol (i.e. REBT skills, relaxation) would warrant delineation through a design that allows for variations in participants groups. Despite these important limitations, this study provided preliminary diagnostic information about a poorly understood population, and indicated promise for the use of a cost-effective, time-limited and most importantly, empirically based intervention approach. Given the pernicious effects of anger sequelae, continued development of innovative treatment approaches, longitudinal studies, and multi-site randomized-controlled trials (RCTs) are warranted to address this serious public health problem.
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