Contents
Introduction
1
Chapter 1 The Basics
2
Chapter 2 The anger episode model
3
Chapter 4 Overview of the Anger Management Programme
5
Preparing for change
5
Changing
5
Chapter 5 Assessing and increasing motivation
6
Stages of change
6
Increase motivation
6
Chapter 6 Developing a strong Therapeutic Alliance
7
Chapter 7 Increasing awareness of anger
7
Increasing awareness
7
Chapter 8 Avoidance and escape
8
Chapter 9 Managing physical arousal
8
Chapter 10 Building life skills
8
Chapter 11 Social Problem Solving
10
Chapter 12 Exposure
10
Chapter 13 Fostering cognitive change 1
11
Chapter 14 Fostering cognitive change 2
12
Chapter 15 Forgiveness
12
Anger as a disorder is based on intensity, frequency and
duration. Anger management is about reducing the arousal to anger and when it
does come reacting to it differently.
Foundational items when working with a client
1.
Shared understanding of anger
a.
Types of trigger
b.
Difference between feeling and expression
c.
Purpose
d.
Short term maintainers
e.
Longer term effects
2.
Understanding of what I contribute to my anger, i.e.
my interpretations
Next steps: ensure motivation to change, if not work on this
in terms of consequences of anger.
Process it’s not a little insight that’s going to help it’s
a lot of practice.
One thought: the world is a difficult place, with
disappointment, disagreement and people acting badly. The aim her is to problem
solve and accept to navigate to construct most of the life that you ant.
Other thought: the world should be a certain way and if it’s
not I will get angry to create it like that.
So, change for the first is to learn coping strategies to
deal with life, the other says we need to change others.
Anger seems useful in lower doses with more simple
situations that anger can give the fuel to resolution, someone talking in the
cinema. With more powerful anger, in more complex situations, anger seems to
lead to no one winning. When angry, your motor and cognitive performance
declines.
Yerkes Dodson= optimal emotional activation is moderate
provides most efficient performance for complex tasks. Simple tasks you can be
highly activated.
Cue utilisation: we use cues from the environment to problem
solve and complete other complex tasks
When under aroused we pay no attention to cues
When moderately aroused we only pay attention to our anger,
we cease to have other cues suggest options
Everything that agrees with our personal desire is true,
everything that is not puts us in a rage.
Anger is someone else has done wrong (blame) and has
threatened something (victim) that I hold dear.
Intensity
High anger: rage, crazed, rabid,
Middle: angered, indignant, mad
Lower anger: irritated, annoyed, bothered,
Develop a shared anger vocabulary with your client.
Some client’s belief they will achieve ore of their goals
with hyperbole, my wife never…
Hyperbole and catastrophising like the boy who cried wolf,
they mean less with every utterance.
Duration
Some are quick and explosive, some seethe inside for years.
The repetition both keeps them alive and intensifies them.
You can’t be angry and relaxed at the same time, so
increasing being relaxed, decreases anger.
Anger gets constructed via
1.
Distortions
a.
Misunderstanding another’s intention
2.
Awfulizing
a.
It was terrible what they did
3.
Low frustration tolerance
a.
I can stand it
4.
Negative global view of others
a.
They were such a dork
5.
Negative global view of self
a.
They made a fool of me
6.
Demandingness
a.
The world shouldn’t be that way
Anger triggers are culturally specific, i.e. what should be
done. People have anger scripts, what triggers them, the range of response to
denote what it means to them.
Anger script: what is your anger script, how you think, your
behaviours what they mean, what is in and out of script. You learn scripts and
you learn your script, some you identify, some you use, but you understand all
of them.
Hostility: the desire to reduce the capacity of someone
through minimising, removing power, hurting, abusing, ignoring, it’s a sense of
dislike and opposition to the person or group.
The level of hostility
is a factor of how central the belief is held, is it fleeting, on the basis of
an episode or is it a life time’s work. So is it hostility based on surface or
central beliefs. If the former then this can be changed with contact, knowledge
and interaction with the group or person concerned.
When you are hostile to a person or group you tend to avoid
them which maintains your hostile beliefs about them
Aggression: a motor behaviour, ranging from a focus on
objects not person where harm could happen, to outright not caring if I hurt,
to I am going to hurt.
You get aggression with or without anger, the latter is
where you seek to get things, and you aren’t angry. So hostile vs instrumental
aggression.
Basic emotions: sadness, disgust, joy, anger, fear, acceptance
and surprise
Almost all angry clients blame the other\world for their
anger. AEM: Trigger, appraisal, personal experience, expression and outcomes.
80% of angry episodes are because the other did something unwatned
and unexpectedly, happened in the late afternoon, the others are the person
getting angry with inanimate objects or unfair life events.
You are most often angry with someone you like, love or know
well.
Anger: an unexpected and unwanted preventable action of
someone that threatens something you value
Themes of anger, disappointment and unfairness.
Awfulizing leads to a series of complaints that takes time
away from dealing with the problem.
Appraisal problems
1.
Misinterpret intentions of others
2.
Awfulizing
3.
Low frustration tolerance
4.
Global negative view of other
5.
Global negative view of self
6.
Demandingness.
LFT relates to awfulizing and also that life should be
without problems as either you are too important or problems are the sign that
something has gone wrong, and a perfect attitude is required
High anger people have more intense and longer feelings,
high levels of physical affect.
Anger expression can be outward or inward, verbal, physical,
gestural. Inward anger gets expressed indirectly, so hurting the other indirectly
Outward anger is associated with a faster tempo of speech
and longer utterances. Most anger is expressed verbally, blaming, criticising,
insulting. Outward expressed anger results in many negative consequences,
relationships affected. Some people try to control their outward expression and
end up brooding and holding grudges.
The outcomes of anger are worse than the causes of it
Short term outcomes reinforce behaviour: operant
conditioning. Occasional anger that is
minimal in intensity seems helpful, where frequent high intensity anger isn’t.
Reinforces
1.Behavioural compliance
2. Feeling strong
3. Attention
4. Other feelings are take away
Outcomes
Revenge fantasies evoke a sense of control, a fantasised
version, which is pleasurable.
Anger as a problem is difficult to address, as people feel
shame about its outcomes, they feel strong through having it, and people tend
to avoid you if you get angry, so its isolating and leads to a diminished
social value.
Angry clients can
think in simple terms of their angry situation in terms of stereotypes,
generalisations and the like.
Anger leads to poor decision making and increased risk
taking. Anger is associated with substance misuse, get angry, get drunk\stoned.
Given what I’ve gone through I deserve it.
Motor behaviour is disrupted when angry, so operating
machinery is dangerous as is driving a car
Readiness to aggress leads to a higher state of arousal. Being
aroused, i.e. knock at the door who is it, leads to increase levels of
irritability, a perceptual bias towards injustice,
One reason to aggress is retaliation, and vengeance:
justice, also to try to repair their angry mood, I will feel better if I get
even. However catharsis is wrong with anger, expressing aggression leads to
more aggression. Aggression might feel good as the unjust thought has been
countered, there is a surge of energy, focus is taken off the anger.
Anger affects the immune system, cholesterol and correlates
with CHD. Trait is more strongly correlated that state. Suppressed anger can
result in increase pain.
Client strategies:
1.
reduce arousal, manage triggers, build social
skills
2.
Cognitive
a.
Rational responding
b.
Acceptance
c.
Forgiveness
1.
Strong WA
a.
Empathy and understanding the wrong that they
face
2.
Increase anger understanding
a.
Phenomenon
b.
Effects
1.
Stimulus control
a.
Manage triggers, avoid, delay, minimise, escape
2.
Manage physical arousal
a.
Relaxation prior, during and after
i.
PMR
ii.
Calming breathing
3.
Life skills
a.
Problem solving
i.
Clients can become fixated on one problem
b.
Assertiveness
i.
Clients can blame which increases tension
c.
Acceptance
d.
Forgiveness
4.
Exposure
Life happens, misfortune and unpleasantness is part of the picture.
Accepting the world isn’t perfect will help with anger, so reduce black and
white, either everything is as it should be or it’s a disaster.
The other aspect is angry clients take themselves very
seriously as if they didn’t make sure the law is upheld the world would go to
hell in a handcart. Clients
catastrophise the event and catastrophise their ability to cope.
Anger rumination and seeking revenge are past orientated and
hurt both the transgressor and the angry client.
Motivation to change can relate to how much anger is my
problem or others. They make me angry.
DiClemente and Prochaska
1.
Pre-contemplative
a.
There is no problem for the client, but others
see there is
2.
Contemplative
a.
There might be a problem, client evaluating pros
and cons
3.
Preparation (ideal stage for therapy)
a.
Desire to change established and preparing for
how
4.
Action
a.
Implementing action
5.
Maintenance
6.
Lapse
Move from pre-contemplative to contemplative
1.
Fact review
2.
Short and long term consequences
3.
Effect of catharsis
4.
Working with client resistance
Fact review
1.
Anger creates
a.
relationship problems:
i.
creating conflicts
ii.
Others dislike you
iii.
Hurting those you love
b.
Physical problems
i.
Driving
ii.
Damage to objects
c.
health problems
i.
increase
in heart problems and shorter life
d.
Danger problems
i.
Increase risk taking, drive fast, drink and
drugs , assault by other
e.
Efficiency
i.
Harder to think clearly
Outcomes
Anger gets compliance through intimidation. Which is the
short term benefit and the longer term cost. Investigate this via time
projection, young child, employee shouted at
Catharsis
Expressing anger, is likely to lead to more expression due
to operant conditioning. It reinforces the way of seeing the world, you right
me wrong. Reconnects the interpretation, emotions and behaviours. Behaving
angrily practices that response. Repressing anger causes problems too, the idea
is to get less angry in the first place.
Decrease client resistance
Resistance is a response to dominance.
Paradoxical intent is to prescribe the symptom and to join
the resistance.
Greenson 67 first one to talk about the WA. WA: goal, task,
bond
We have an automatic pilot that helps us through our lives,
not run out of milk, petrol etc. So we are not aware of what we do. So stage
one of any intervention is to increase awareness. Once awareness increases you
can anticipate and interrupt potential problems.
Past episodes: notice to build a reasonable response, cheese
on the floor angered you because of it, and the day you had etc.
Self monitoring: anger episode record: start to notice the
early warning sings.
Avoid, leave trigger situations. Delay dealing with them.
This can help clients not have to deal all of life’s problems but should be
avoided if avoidance is a standard
approach for them and then leads them to problematic outcome. Judicious use can
prevent further damage
Avoidance provides a temporary emergency anger control
measure. This is stimulus control. Most triggers are repetitive and
predictable. This buys time to practice other strategies that we can then
apply.
1.
Planned avoidance
2.
Avoidance by time delay
a.
Respond to trigger later in a calmer state
3.
Use alternative ways of responding
a.
Get someone else to express the problem
b.
Email don’t phone
4.
Escape
a.
Leave the field
b.
Take time outs
c.
Planned escape
d.
Use distraction to manage rumination, take a
task and do it mindfully
Anger comes from protecting us physically, but fight or
flight usually counter productive in the long term, we need to find solutions.
Anger makes problem solving harder, behaviourally and cognitively. However it
is hard to change anger appraisals whilst emotion I high.
Relaxation dampens the fight or flight response.
Cue controlled, say relax, breathe out, let tension go.
Diaphragmatic breathing
Mindfulness
1.
Social interaction skills
2.
Assertiveness skills
3.
Specialised motor skills
a.
I.e. if you can do your job more effectively,
less complaints, less anger and frustrating experiences
Assertive asserting our desires and beliefs without reducing
those of others.
Common social skills
1.
Eye contact
a.
direct contact without staring
2.
Distance
a.
Not too far\close
3.
Posture
a.
Face forwards
4.
Body contact
a.
Shake hands before and after
5.
Listening
a.
Validate, acknowledge to signal listening has
happened
6.
Reception
a.
Be open to what the other is saying
7.
Greeting others
a.
The important first impression
8.
Giving\accepting compliments
a.
Smooths relationships, so grateful and
appreciative person
9.
Following instructions
10.
Making a request
a.
Ask rather than demand
11.
Refusing to say no to a request
a.
Acknowledging the other
12.
Accepting criticism
a.
Large source for anger
13.
Giving criticism
a.
Use a shit sandwich but listen to the response
14.
Accepting no for an answer
15.
Disagreeing and contradicting
16.
Apologising
a.
Sorry with a how it wont go wrong next time
helps. Excuses don’t
Social skills training methods:
1.
Discussion
2.
Warm up exercises
a.
Do parts of the task
b.
Or similar
3.
Role playing
a.
Reverse roles
4.
Modelling
5.
Assignments
6.
Reinforcements
Assertiveness
Assertiveness: direct, honest and appropriate expression of
feelings. So don’t embellish, exaggerate, be indirect.
1.
Feeling talk
a.
use the
when then format
2.
Facial expression
a.
Practice a range of facial expressions for
emotions
3.
Contradictions
a.
Practice
a range of saying no’s
b.
Value both your and their view point, show
interest in theirs
4.
I language
a.
Often clients appeal to rules or logic rather
than expressing their desires
The goal of assertiveness is
better expression and communication.
If something accords with our desires its true, if not it
puts us in a rage. Angry clients don’t see challenges as problems to be solved,
rather they are wrong, unfair, unjust and shouldn’t be like that, and therefore
I feel angry. Likewise if you don’t attempt to solve problems it doesn’t
develop your problem solving ability, so that you are more likely to get angry
as problems are more insurmountable. Problem solving 4 step approach from D’Zurilla
Steps for Problem solving
1.
Clearly identify the situation and generate
potential solutions
a.
Use a when then to identify the problem trigger
if interpersonal, to avoid excess baggage
b.
Brain storm the solutions (clients can be
extreme, confront or avoid and have difficulty with the middle ground)
2.
Assess probable consequences of each choice,
short term and long term
3.
Select best alternative and put into practice
a.
Ensure that this is the best for the client
thought asking questions, rather through the consequences to see if a selection
is desirable and possible
4.
Implement and evaluate
Avoidance whilst useful will limit growth in the long term,
as it may reinforce that the problem is insolvable
Four techniques
1.
Trigger review
2.
Verbal exposure
3.
Imaginal exposure
4.
In vivo exposure
Exposure helps through breaking the automaticness of
response which is the result of conditioning.
So as we expose we do things differently and break that conditioning. In
the early days of a relationship there may be a few seconds to interpret each
part of the anger dance, now the thoughts are no longer needed. The response
prevention blocks operant conditioning, as well as the conditioned response.
Trigger review: anger in the room on describing triggers as
an opportunity to exposure. Catharsis is practicing something, increases
associative conditioning between two things. Therapists need to contain
sessions so excessive anger isn’t going to be helpful.
Ask a client to slow down, and to recount the angry episode
without anger to help the therapist listen. Again the big thing to highlight is
the difference between the anger feeling and its expression
Verbal Exposure
Most anger situations are social in nature.
Identify the first moment anger rises, and then how it
develops from the triggers point of view, and how the client responds. In really understanding the barb to replicate
it, you are also giving the client a real understanding of what goes on for
them, so that they will break the automaticity of the response. They can see
piece by piece things escalating.
As you expose, get the client to rate the anger level, and
then just to notice what happens in their body to describe it to you and then
to breathe into it. Exposure is seeking to maximise the ability to tolerate the
feeling of anger without response and to increase understanding of the triggers.
So that would be stage one, stage two would be to
1.
Add a coping statement
2.
Try problem solving
3.
Try being assertive
4.
Try a relaxation technique
Only use barbs when you have a motivated client and a good
TA.
There are non verbal triggers, where you can use imagery
instead
1.
Driving
2.
Non working objects
3.
Institutional practices, e.g. government
Create the scene imaginally, don’t respond to it, and at the
end of the scene use PMR, which is a systematic desensitisation approach. So
relax, expose, relax, repeat. You could also inject coping . this statements at
the key points.
Becks cognitive restructuring: go to maintain cycles to help
restructure, i.e. Other people are untrustworthy, so interpret biasedly and act
on the basis that they are trying to gain advantage. That will make you angry
and hostile which in turn will affect how they are with you.
The idea is to show that bad things happen to people and
that they are unpleasant, inconveniences that are a problem that need dealing
with somehow, even if just by accepting them. This is as opposed to the anger
response which is it is unfair, it shouldn’t happen. The triggers mainly only
threaten, prestige, time and money.
Sequence of thought
They are bad, did a bad thing which is awful, that they
shouldn’t have done . The fight response was designed to protect lives.
Learn four thoughts about the trigger and the trigger will
be diminished.
1.
Awfulizing
a.
Notice how dreadful the event is made. Compare
that with other things that could go wrong and put it on a scale. Make this more realistic. Do any good things
comes out of bad things?
2.
Low frustration tolerance
a.
Notice how you have coped with similar things
before. Notice if someone said I will kill a baby if you don’t stay with it you
would stay with it. Maybe notice how this is unpleasant and you wish you didn’t
have it, but not that I cant bear it.
3.
Demandingness
a.
Clients change desires to rules. But this
ignores reality and places dictatorial rules on others.
4.
Global self\Other rating
a.
They are all bad, I am the victim. Reality says
though that all people do good and bad things, some more one than another.
Don’t characterise a person on the basis of one act, they are complex.
Accept the initial interpretation: but show how you could
interpret it differently, this loosens the sense that it was the trigger that
made me angry, its what I thought of it.
You have to do this or this perpetuates the big mistake.
Not forgiving means rehearsing past aversive events, future
revenge events and harbouring grudges.
So ruminate, blame, and harbour feelings of revenge.
To forgive is to develop feelings of empathy for the person
whilst not denying their offence.
True forgiveness happens when you could take revenge but
choose not to, rather you forgive.
To forgive someone is to empathise with them, to be
compassionate to them whilst not denying their offense.
Forgiveness is when we are done wrong by another and we
offer them compassion and love. Even though they have no right to these and we
have the right to resentment.
Forgiveness happens over time
Stages of forgiveness
1.
Establish safety
a.
Personal control is established of ADL
2.
Reconstruction
a.
Tell the story repeatedly to fill in more detail
Forgiveness distinction from other concepts
1.
Acceptance
a.
I forgive what you did but do not accept it and
will work tirelessly to stop it happening again
2.
Excusing
a.
I forgive, I do not find reasons to excuse what
you did, it was bad and I don’t want it to happen again
3.
Compensation
a.
I forgive, I don’t seek anything back in return,
what you did hurt me, but I offer you compassion as a person and seek nothing
back from you.
Unforgiving
Stay in the role of victim
Ruminate over event and perpetrator
Fantasise about revenge
Beliefs that revenge will lead to closure
Forgiving
Feelings of empathy to the
whole of the offender, rather than just the bad behaviour. Hate the sin,
love the sinner. Sees the person as a whole, rather than just their sin, there
are more parts to them than just their crime
Four stages in forgiveness
1.
Uncover the anger
a.
Discover detail of event, all feelings around
it, all effects
2.
Deciding to forgive
a.
CBA on resentment
b.
Letting go of the past
c.
Creating goals for the future
3.
Work phase
a.
Understand and empathise with the other
i.
What led to this behaviour
ii.
How was their childhood
iii.
Develop empathy for them
iv.
Acceptance of the pain of what they did
1.
Though not seeking revenge
2.
Through not ruminating
3.
Through not fantasizing about revenge
4.
Through not demonising them
5.
Through doing something good for them, or
offering them a gift
4.
Release and deepening
a.
Finding meaning in the suffering
b.
Re-understanding the past
c.
Developing the future on the basis of the
aversive past.
