Anger Regulation Interventions: Research and Rationale

1. Anger Regulation Interventions: Research and Rationale Karina Davidson, Ph.D. Columbia University College of Physicians & Surgeons

2. 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.

3. About the Instructor Dr. Davidson’s 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.

4. 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.

5. 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

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

7. 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)

8. 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

9. Anger Assessment Anger COGNITIVE BEHAVIORAL EMOTIONAL ANGER IN NON- VERBAL VERBAL CYNICAL SUSPICIOUS ANGER EXPERIENCE

10. Anger Assessment Cont. ANGER NON- VERBAL VERBAL CONSTRUCTIVE ANGER OUT? CONSTRUCTIVE DISCUSSION DESTRUCTIVE ANGER OUT RUMINATIVE DISCUSSION DESTRUCTIVE HOSTILE STYLE HOSTILE CONTENT

11. 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)

12. 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)

13. 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)

14. 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)

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

16. 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.

17. 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.

18. 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)

19. 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)

20. 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

21. 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

22. 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

23. 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

24. 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

25. 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)

26. 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

27. Anger Intervention Tailoring • Cognitive • thought stopping • trust building • Behavioral • assertiveness training • constructive anger discussion • Emotional • distraction • relaxation

28. Intervention Tailoring for Specific Populations • Women • Minorities • Elderly • Adolescents • Medical patients • Physically Violent clients • Others?

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

30. Where to get more information • http://pantheon.yale.edu/~tat22/empirically_supported_treatments.htm • http://www.eiconsortium.org/model_programs/wlliams_lifeskills_workshop.htm • http://www.therapeuticresources.com/82-38text.html