Anger Regulation Interventions: Research and Rationale

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Anger Regulation Interventions Research and
Rationale

• Karina Davidson, Ph.D.
• Columbia University College of Physicians
  Surgeons

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About the Instructor
Karina Davidson, Ph.D. is an Associate Professor
of Medicine and Intervention Research Director of
the Behavioral Cardiovascular Health
Hypertension Program at Columbia College of
Physicians and Surgeons in New York.
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About the Instructor

• Dr. Davidsons research focuses on psychosocial
  interventions with patients with cardiovascular
  disease. She is also interested in personality
  intervention at the primary, secondary, and
  tertiary stages of these diseases. She has
  conducted randomized controlled trials primarily
  in anger management but has recently developed an
  interest in depression reduction and subsequent
  improvement in cardiovascular parameters such as
  uncontrolled hypertension and silent ischemia.

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About the Instructor

• She is the Chair of the Society of Behavioral
  Medicine committee on Evidence-based
  Behavioral-Medicine, a task force charged with
  improving and implementing evidence-based
  principles for behavioral medicine researchers,
  practitioners and students. She has taught
  evidence-based psychotherapy theory and practicum
  courses for a number of years to clinical
  psychology graduate students at both University
  of Alabama and Dalhousie University.

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Learning Objectives

• You will learn
• Current controversies in Anger Disorder area
• Anger and Anger Disorder diagnosis available
• Evidence-based criteria for judging anger
  regulation interventions
• Results from anger regulation intervention
  research

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Performance Objectives

• Appreciate the need for better diagnoses within
  the Anger disorder area
• Understand the importance of evidence-based
  criteria for evaluating trial results

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Rationale for Treating Anger

• Anger has often been linked to domestic violence
  (Brondolo, DiGiuseppe, Tafrate, 1997)
• U.S. has one of the largest homicide rates in the
  world (Eckhardt Deffenbacher, 1995).
• Anger can have a negative impact on interpersonal
  and familial relationships (Brondolo et al.,
  1997 Williams Williams, 1993)

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Why should you care about anger?

• 20 of Americans experience anger problems
  (Williams Williams, 1993)
• Angry clients experience a multitude of stressors
• Angry clients are difficult to treat

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Anger Assessment
Anger
COGNITIVE
BEHAVIORAL
EMOTIONAL
ANGER IN
NON- VERBAL
VERBAL
CYNICAL SUSPICIOUS
ANGER EXPERIENCE
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Anger Assessment Cont.
ANGER
NON- VERBAL
VERBAL
DESTRUCTIVE ANGER OUT
CONSTRUCTIVE ANGER OUT?
CONSTRUCTIVE DISCUSSION
RUMINATIVE DISCUSSION
DESTRUCTIVE HOSTILE STYLE
HOSTILE CONTENT
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Anger Assessment Cognitive

• Cook-Medley Hostility Scale (Cook Medley, 1954)
• Cynicism/Mistrust subscale, Buss Durkee Hostility
  Scale (Buss Durkee, 1957)
• Anger-In subscale, Anger Expression Scale
  (Spielberger, Johnson, Russell, Crane, Jacobs,
  Worden, 1985)

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Anger Assessment Emotional

• Anger subscale, Aggression Questionnaire (Buss
  Perry, 1992)
• Anger Experience subscale, Multidimensional Anger
  Inventory (Siegel, 1986)
• Trait Anger Scale (Spielberger, Jacobs, Russell,
  Crane, 1983)

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Anger Assessment Behavioral

• Anger Out (Spielberger et al., 1985)
• Physical and Verbal Aggression subscales,
  Aggression Questionnaire (Buss Perry, 1992)
• Positive and Negative Anger Discussion (Davidson,
  Chambers, Mason, MacGregor Gidron, 1997)

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Anger Assessment Observed

• Modified Type A Structured Interview (Hall
  Davidson, 1995a)
• Potential for Hostility, Hostile Style (emotional
  and behavioral Hall Davidson, 1995b)
• Observed Anger-In, Anger-Out (cognitive
  behavioral Gidron Davidson, 1996)
• Observed Constructive Anger Behavior--Verbal
  (behavioral Davidson et al., 2000)

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Anger Disorders Assessment

• Ambiguity of the operational definition of anger
  disorders (DiGiuseppe, 1999).
• Correlations between anger and other negative
  affective traits.

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Anger Disorders Assessment

• Lack of diagnostic criteria in the DSM-IV.
• Eckhardt and Deffenbacher (1995) have proposed
  three anger disorders they believe should be
  added to the DSM-IV
• The authors employed the dimensions of angry
  affect, cognitive distortions, and physiological
  arousal to create the theoretical anger
  disorders.

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Anger Disorders Assessment

• Adjustment Disorder with Angry Mood, is similar
  to Adjustment Disorder with Anxiety however, it
  is characterized by an angry affect.
• Situational Anger Disorder, With Aggression and
  Without Aggression appropriate for persons who
  experience intense anger reactions related to
  certain situations or themes.

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Anger Disorders Assessment

• Generalized Anger Disorder, With and Without
  Aggression resembles Generalized Anxiety
  Disorder, except in this case, the person
  experiences persistent and pervasive anger
  (Eckhardt Deffenbacher, 1995 Thomas, 1998)

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Anger Disorder Assessment

• The Anger Disorder Scale, 6th Revision (ADS-VI-R)
  is a self-report inventory that was developed
  based on the diagnostic criteria proposed by
  Eckhardt and Deffenbacher (1995).
• The Anger Disorder Scale, Sixth Revision
  (ADS-VI-R DiGiuseppe Tafrate, 1999)

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Evidence-based Criteria

• 1. Procedures for Identifying Relevant Treatment
  Outcomes
• A. Literature reviewers
• B. Literature search process
• C. Acceptable sources in the literature peer
  review required
• D. Include refuting evidence and null findings
• E. Obtaining missing information

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Criteria for Classification as a Beneficial
Treatment1

• A. At least two between-group design studies of
  the same treatment treating the same target
  problem,with prospective design and random
  assignment of subjects to conditions
• Findings must show the treatment to be (1) better
  the control or comparison groups on target
  problem assessments or (2) equivalent to an
  existing empirically supported treatment

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Criteria for Classification as a Beneficial
Treatment

• OR
• B. At least two within group design studies of
  the same treatment treating the same target
  problem, showing the treatment to be better than
  the control or comparison conditions on target
  problem assessments following establishment of a
  reliable baseline

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Criteria for Classification as a Beneficial
Treatment

• AND
• C. The majority of applicable studies must
  support the treatment
• D. The treatment procedures must show acceptable
  adherence to the treatment manual

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Anger Regulation Interventions

• Tafrate (1995) conducted a meta-analysis of
  treatment outcome studies focusing on anger
• Only 17 studies found in the literature met
  inclusion criteria (e.g., adults seeking
  treatment for their anger problems, attendance at
  two sessions, and comparison with another
  experimental condition

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Anger Regulation Interventions

• The studies were grouped into the following
  psychotherapy treatment strategies
• cognitive therapies (e.g., self-instructional
  training)
• relaxation-based therapies (e.g., systematic
  desensitization)
• skills-training therapies (e.g., assertiveness
  training)
• multi-component treatments (e.g., stress
  inoculation and cognitive-behavioral)

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Anger Regulation Interventions

• Systematic Desensitization was most effective in
  treating anger with an effect size of 1.63
• followed by Multi-component and Self-instruction
  therapies, both of which had average effect sizes
  of 1.00
• Cognitive therapy was also found to be effective
  with an effect size of .93

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Anger Intervention Tailoring

• Cognitive
• thought stopping
• trust building
• Behavioral
• assertiveness training
• constructive anger discussion
• Emotional
• distraction
• relaxation

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Intervention Tailoring for Specific Populations

• Women
• Minorities
• Elderly
• Adolescents
• Medical patients
• Physically Violent clients
• Others?

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Summary

• Many clients will have anger issues
• First step Anger assessment
• Second step Motivation for treatment
• Third step Review evidence for anger intervention

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Where to get more information

• http//pantheon.yale.edu/tat22/empirically_suppor
  ted_treatments.htm
• http//www.eiconsortium.org/model_programs/wlliams
  _lifeskills_workshop.htm
• http//www.therapeuticresources.com/82-38text.html