Weitere ähnliche Inhalte Ähnlich wie Anger management-psychologist-psychiatrist-therapist-training (20) Kürzlich hochgeladen (20) Anger management-psychologist-psychiatrist-therapist-training4. Definition of Anger
Anger is a negative, phenomenological (internal) feeling
state, which is associated with
Cognitive and perceptual distortions
Subjective labeling
Physiological changes, and
Action tendencies to engage in socially constructed and
reinforced behavioral scripts that often involve approach
behaviors and loud verbal behaviors
© J. Ryan Fuller, 2016
7. Anger is common
Anger is a basic emotion (Plutchik, 1980)
Anger is frequently experienced even by normative
samples (Tafrate, Kassinove, & Dundin, 2002)
Anger is a clinical problem (Lachmund, DiGiuseppe, &
Fuller, 2005)
© J. Ryan Fuller, 2016
8. Effects of Anger
Maladaptive
Interpersonal conflict
Violence
Poor Driving
Inappropriate risk taking
Poor decision making
Health risks
Substance abuse
Adaptive
Alerts goal blocked
Communicates feeling and
perception of injustice
Deters threat
Prepares body for physical
assault
© J. Ryan Fuller, 2016
9. Proposed Anger Diagnoses
1. Generalized Anger without Aggression
2. Generalized Anger with Aggression
3. Situational Anger Disorder without Aggression
4. Situational Anger Disorder with Aggression
5. Adjustment Disorder with Angry Mood
© J. Ryan Fuller, 2016
12. DSM Diagnoses
Antisocial Personality Disorder
Borderline Personality Disorder
Conduct Disorder
Generalized Anxiety Disorder (GAD)
Intermittent Explosive Disorder
Major Depressive Disorder
Obsessive-Compulsive Disorder (OCD)
Narcissistic Personality Disorder
Oppositional Defiant Disorder
Panic Disorder
Paranoid Personality Disorder
Passive Aggressive Personality
Disorder
Post-traumatic Stress Disorder
(PTSD)
© J. Ryan Fuller, 2016
13. How do we measure anger?
© J. Ryan Fuller, 2016
14. Clinical Instruments
STAXI-II (Spielberger, 1999)
Experience
State
Trait
Expression
Anger- In
Anger- Out
Anger- Control
ADS (DiGiuseppe & Tafrate, 2003)
Behavioral Domain
Arousal Domain
Motives Domain
Provocations
Cognitive
© J. Ryan Fuller, 2016
23. Anger Treatment Research
Cognitive Restructuring, Skills Training, and
Relaxation.
Angry Undergraduates (Deffenbacher et.al, 1986).
Veterans with PTSD (Novaco et.al., 1997).
Outpatients (Fuller, et. al 2010)
Exposure may be a useful treatment (Tafrate &
Kassinove, 1998; McVey, 2000).
© J. Ryan Fuller, 2016
24. What treatments work?
Cognitive Therapy
Relaxation
Skills Training
Combined
Exposure Based
© J. Ryan Fuller, 2016
26. Treatment Efficacy
Good News
Many treatments influence change in many different
types of clients: college students, outpatients, prison
inmates, and spouse abusers
Equally effective regardless of age and gender
© J. Ryan Fuller, 2016
27. Treatment Efficacy (2)
Good News
Change is large (effect sizes for most effective are
around 1.00 for Cohen’s d)
Follow-up studies support maintenance
Bad News
Most studies use volunteers
These effect sizes are smaller than those found for
anxiety and depression treatment- socially sanctioned,
adaptive at times, less attention (DiGiuseppe & Tafrate
2003)
© J. Ryan Fuller, 2016
29. What are the general
challenge and questions to
implementing treatment?
© J. Ryan Fuller, 2016
30. Questions about Angry
Outpatients
How do I establish a therapeutic alliance with an angry
client?
How do I establish a therapeutic alliance with violent
client?
How do I cultivate, enhance, and maintain motivation
for change with angry clients?
© J. Ryan Fuller, 2016
32. Review negative facts
It’s really not that bad- anger is normal and
manly.
• Interpersonal conflicts
• Medical problems
• Negative Evaluations by others
• Car accidents
• Substance abuse
© J. Ryan Fuller, 2016
36. Catharsis
“I have to get it out. It is not healthy to keep it
in.”
Venting or “unbottling”
• Leads to increases in anger feelings (Ebbesen, 1975)
• Leads to increases in aggression
(Bushman, Baumeister, and Stack (1999)
© J. Ryan Fuller, 2016
37. Clinical Focus with Angry
Clients
Do you validate anger?
Which part?
Cognitions, feelings, expressions
Important for therapeutic alliance and maybe your
safety.
© J. Ryan Fuller, 2016
38. Clinical Focus with Angry
Clients (2)
Keep the Stages of Change Model in mind
(Prochaska & DiClemente (1983).
Precontemplative: no intention of change,
unaware problem or sees the problem
Contemplative: thinking about the problem
Preparation: decision to change
Action: implementing change
Maintenance: already changed, own tx, relapse
© J. Ryan Fuller, 2016
42. Community Model
Anger groups have run for years, but never
systematically studied
Goals of the study
Describe population,
Clearly define the treatment,
Assess viability of fee-for-service treatment
research in anger population
Evaluate efficacy
© J. Ryan Fuller, 2016
43. Goals
Who are we treating?
What is the treatment?
What are the outcomes of treatment?
© J. Ryan Fuller, 2016
44. Population
Assessment of research participants
SCID 1 and 2
PDSQ
ADS
STAXI
BDI
Exclusionary Criteria
Actively psychotic
Group Inappropriate
© J. Ryan Fuller, 2016
45. Treatment Measures
Anger Disorders Scale
State-Trait Anger Expression Inventory
Beck Depression Inventory
Idiosyncratic Anger Measures
Situation
Symptom
Behavior
© J. Ryan Fuller, 2016
46. Recruitment and Fees
Recruitment
Advertised, Professional Referral, Self-Referral
Phone Interview
Fees and Compensation
$50 per session
$200 reimbursement for perfect attendance
$150 reimbursement for missing one session
© J. Ryan Fuller, 2016
47. Screening
Criteria for Inclusion
Self-identified as having anger problems and
requested treatment.
Significantly disturbed by anger as measured
by the STAXI-II, the idiosyncratic anger forms,
& the clinical interview.
Criteria for Exclusion
Actively psychotic
Group Inappropriate
© J. Ryan Fuller, 2016
49. Clinical Syndromes
Axis 1 Current (Past)
Anxiety Disorder: 4/12 (9)
Mood Disorder: 9/12 (8)
Substance/Alcohol: 3/12 (7)
© J. Ryan Fuller, 2016
50. Personality Disorders
Axis 2 Frequency
Passive Aggressive 7
Depressive 6
Obsessive Comp 5
Borderline 4
Narcissistic 4
Avoidant 4
Dependent 1
Histrionic 1
Paranoid 1
© J. Ryan Fuller, 2016
51. Treatment
Manual
Session 1-3 Overview and Model
Session 4-9 Skills Acquisition
Session 10-14 Exposure plus Coping
Session 15-16 Relapse Prevention
General
Organized by components
Flexible, but skill focused
© J. Ryan Fuller, 2016
53. ANGER SITUATION
Pre-treatment, Mid-treatment, & Post-treatment
Changes
0
20
40
60
80
100
*Intensity (0-
100)
Frequency
(per month)
Duration
(minutes)
Life
Interference
(0-100)
Pretreatment
Midtreatment
Posttreatment
© J. Ryan Fuller, 2016
54. ANGER SYMPTOM
Pre-treatment, Mid-treatment, & Post-treatment
Changes
0
10
20
30
40
50
60
70
*Intensity (0-
100)
Frequency
(per month)
Duration
(minutes)
Life
Interference
(0-100)
Pretreatment
Midtreatment
Posttreatment
© J. Ryan Fuller, 2016
55. Anger Disorder Scale (ADS)
Pre-treatment to Post-treatment Changes
0
20
40
60
80
Pretreatment * Posttreatment
© J. Ryan Fuller, 2016
56. Beck Depression Inventory - II
Total Score
Pre-treatment to Post-treatment Changes
0
5
10
15
20
25
30
Pretreatment * Posttreatment
© J. Ryan Fuller, 2016
57. Limitations
Sample size
Self-referred participant group that were highly motivated
No treatment control group
Independent coding of fidelity would be preferable
Self-report, rather than objective physiological/ behavioral
measures
Administering treatment by one therapist
© J. Ryan Fuller, 2016
58. Implications
Many suffering from anger problems seek anger
treatment
Slightly different demographic sample also appear to
benefit from CBT based treatment
High levels of comorbidities between anger and other
disorders in outpatient samples
© J. Ryan Fuller, 2016
60. What are the client skills?
Self-monitoring
Consequential Thinking & Time Projection
Problem Solving
Assertiveness Training
Cognitive Rehearsal & Disputation
Relaxation
Response Prevention
© J. Ryan Fuller, 2016
62. Cognitions
Negative vs. Positive
Expectancies
Attribution
Specific vs. Global
Stable vs. Unstable
Internal vs. External
Cognitive Triad
Self
World
Future
Irrational vs. Rational
© J. Ryan Fuller, 2016
64. Cognitive-Behavioral
Therapies (Continued)
Behavioral Therapies
Cognitive Therapy (CT)
Rational Emotive Behavior Therapy (REBT)
Problem Solving
Dialectical Behavior Therapy (DBT)
Acceptance and Commitment Therapy (ACT)
Functional Analytic Psychotherapy (FAP)
© J. Ryan Fuller, 2016
66. CBT – what are the
strategies?
CBT attempts to change behaviors by modifying:
Antecedents/Cues
Beliefs, Emotions, Stressors
Processes
Acceptance/Willingness/HFT/Distress Tolerance
Consequences
Reinforcers / Punishers / Modeling
© J. Ryan Fuller, 2016
79. Irrational Beliefs (IB)
Demandingness
Low-frustration Tolearnce (LFT)
Awfulizing
Global Evaluation of Worth
© J. Ryan Fuller, 2016
80. ABC Cognitive Anger Chain
Let’s imagine a few:
A1 = [Fill in the blank]
B1 = [Fill in the blank]
C1 = [Fill in the blank]
© J. Ryan Fuller, 2016
81. Cognitive Therapies
Intervening at the Inference or Belief
What are common cognitions?
• Hostile attribution or intent
• Controllable/Preventable
• Automatic thought with themes of lack of respect, injustice, inequity
• Dichotomous thinking
• Demandingness of others
• Low-frustration tolerance
• Global Evaluation of Others’ Worth
© J. Ryan Fuller, 2016
82. Primary Cognition
• Is the bully suffering from low self-esteem?
• Does he/she really think little of himself and his
abilities?
• Low self-esteem is associated with depression
• High temporally unstable self-esteem results in
anger when threatened (Baumeister, Smart, Boden
1996)
• What personality dimension will you see?
© J. Ryan Fuller, 2016
83. Cognitive Interventions
• Similar to those for depression and anxiety
• Cognitive restructuring?
• Rehearsal
• Disputing
• Emphasis
• Demands on others
• Global evaluation of worth
© J. Ryan Fuller, 2016
84. Cognitive Emphasis:
Demandingness
• Disappointment is infrequent without expectations
• Demands or schemas are cognitive expectations about reality
• Discrepancies between expectation and reality lead to anger
• What is the first response of the high trait anger person?
• Has this person always behaved this way?
• What are the chances tonight?
© J. Ryan Fuller, 2016
86. ABC Cognitive Anger Chain
Let’s imagine a few here for anger- and then do a
chain.
A1 = [Fill in the blank]
B1 = [Fill in the blank]
C1 = [Fill in the blank]
© J. Ryan Fuller, 2016
87. Secondary Disturbance
A1 B1 C1
Poor work
performance by
new younger
boss---> I might
lose my job
The economy is
terrible.
I must be an idiot.
Panic
A2 B2 C2
Panic about losing
job. It is my new
bosses fault.
I can’t tolerate
this.
If he respected
me I wouldn’t
have to feel this
way.
This isn’t fair, I’ve
been here 15
years.
He is a snot
nosed rich who
was given this job!
Anger
Sends a hostile
threatening email
to the boss, and
carbon copies
coworkers.
A3 B3 C3
Inappropriate
email.
I shouldn’t have
done that.
This situation is
really awful!
I really am a loser
and outcast, and
now everyone
knows it.
Shame
Starts drinking
more than usual,
and considers
quitting.
© J. Ryan Fuller, 2016
88. Secondary Coping
A1 B1 C1
Poor work performance by
new younger boss---> I
might lose my job
The economy is really bad.
I made a really big mistake,
and now it is a good idea to
follow that misstep, with
some good steps.
Concern
A2 B2 C2
Concern about job. I can tolerate this even
though it is incredibly
uncomfortable. It is really
hard being in this spot. I
have been in tough spots
before, and gotten out. I
can go and address the
issues in my evaluation,
and my new boss.
Concern
Frustration
Drafts a written action plan
proposing ways to address
negative bullets in his
evaluation.
© J. Ryan Fuller, 2016
90. Problem Solving:
A Misplaced Fundamental
Definitions
Problem: a situation that presents difficulty
Problem Solving: a structured strategy that elicits a
multitude of responses that contains steps to maximize
the likelihood of implementing a viable one
© J. Ryan Fuller, 2016
91. Problem Solving
Examples
1. Difficult situation at work with client, vendor, employer,
employee
2. I am getting into arguments with my spouse
3. How to furnish a new room
4. My diet plan is not producing the results I want
5. I can’t find a job or appropriate romantic partner
© J. Ryan Fuller, 2016
92. Problem Solving:
An Empirical Approach
Goldfried and Davison (1976)
1. General Orientation
2. Define problem
3. Generation of Alternatives
4. Decision making
5. Verification
© J. Ryan Fuller, 2016
93. Problem Solving: Step 1
General Orientation
a. Normalize- assume that situation is a normal part
of life
b. Acknowledgement- that it is possible others have
coped with something similar
c. Inhibit- halt the tendency to respond with initial
impulse
© J. Ryan Fuller, 2016
94. Problem Solving: Step 2
Define problem
a. Operationalize- define all aspects of the
issue in concrete (observable and measurable)
ways
b. Dissect- reclassify parts into smaller more
manageable elements
© J. Ryan Fuller, 2016
95. Problem Solving: Step 3
Generation of Alternatives
a. Brainstorming
i. Criticism omitted
ii. Welcome novelty and divergence
iii. Encourage quantity of ideas
iv. Improvement and integration of
suggested ideas
© J. Ryan Fuller, 2016
96. Problem Solving: Step 4
Decision making
Temporal Consequential Thinking (TCT)
i. What is the probability it will achieve the
desired result?
ii. If it does work what are the likely
advantages in the immediate, near, mid,
and long-term future?
iii. What are the likely disadvantages in the
immediate, near, mid, and long-term future?
© J. Ryan Fuller, 2016
97. Problem Solving: Step 5
Verification & Assessment
Test-Operate-Test-Exit
(TOTE; Miller, Galanter & Pribram, 1960)
Was the implemented plan effective?
1. Yes→ Exit
2. No→ Go back to step 4
© J. Ryan Fuller, 2016
99. Assertiveness
Definition
What is it not?
Aggressive
Passive
Definition #1
Assertiveness: proper expression of any emotion other
than anxiety toward another person- Joseph Wolpe
(1973)
© J. Ryan Fuller, 2016
101. Assertiveness
Two Critical Components in definition
The communication of feelings, desires, wants, and
preferences
The acceptance of another person’s right of refusal
and recognition he/she may also agree but not act
congruently
© J. Ryan Fuller, 2016
102. Assertive Communication
Four Communication Statements
When. . . . . . . . . . (Specific Behavior and Context)
I feel. . . . . . . .(Specific Emotional State, this is ONE
word, not a metaphor or simile)
Because. . . . (What I tell myself that causes the
emotion, not about him/her)
What I would appreciate/like. . . . . . . .(Specific
request of other person)
© J. Ryan Fuller, 2016
103. Assertive Acceptance
My Communication Rights
I have a right to tell someone what I am feeling.
I have a right to ask for what I want.
After communicating
Assertive Acceptance Statements
Recognition others may not give us what we want
I recognize that I may not get what I want even when someone
says I will.
Other people have a right to ignore my requests, deny my
requests, promise to grant my request and then not fulfill the
commitment And/Or become emotionally upset
© J. Ryan Fuller, 2016
106. © J. Ryan Fuller, 2016
Thought Experiment
•Imagine someone who you love and have known for a
long time, a parent, mate, a sibling child, friend.
•Is there something that they do regularly that really angers
you?
•Imagine that person engaging in that act.
107. © J. Ryan Fuller, 2016
Thought Experiment
• Have you ever had these thoughts while
angry with this person?
• I cannot believe that he or she did it again.
• How could he or she do it again?
108. © J. Ryan Fuller, 2016
Thought Experiment
•These cognitive responses show shock.
•Count how frequently the person has done the act.
•Multiply by how much time you know them.
•They have done the act you are angry at hundreds of
times, yet you cannot believe they have done it again!
109. © J. Ryan Fuller, 2016
Thought Experiment
•My spouse leaves the milk out on the counter every
morning before work.
•How often? About 5 times per week.
•How long? We have been married for 13 years.
•She has done it 5 x 52 x 13 = 3,380 times.
•So, why are you still surprised.