Approaches To Therapy

Discrete Anger Therapy

In Discrete approaches anger is identified as the clear focus of the therapy and it is broadly separated from other clinical issues or problems in intervention. This is so even when it is adjunctive to a wider programme of therapy. Discrete approaches are sub-classified as Discrete/Directed if the nature and scope of intervention is guided by assessment, or as Discrete/Autonomous if assessment is minimal and the intervention is delivered on an inflexible and stand alone basis. The latter includes several large scale programmes delivered within criminal justice systems targeting offenders with a history of aggression and violence, but with little or no assessment of anger variables.

Most of the literature in this domain refers to a wide spectrum of therapies comprising a mix of approaches and components. Broadly, most follow a cognitive-behavioural orientation. Although much of this has remained true to the cognitive framework classically advanced by Beck (Deffenbacher et al., 2000), without question the most influential intervention system in this area has been provided by Novaco (1975, 1977, 1994b).

Novaco proposes that the anger experience is a function of four dimensions that interact over time:

• External events;

• Cognitive appraisals;

• Physiological arousal; and

• Behavioural reactions.

The time-line analysis is helpful for seeing how provocations may result in angermediated responses and identifies points in this sequence at which interventions might be appropriate.

Consistent with this model, Novaco's (1975, 1977) early cognitive-behavioural 'anger management' therapy consisted of a multi-component therapy package seeking to target each of the four identified dimensions. The therapy components were organised within Michenbaum's (1975,1985) stress inoculation phases of treatment (Michenbaum & Novaco, 1978; Novaco, 1977):

1. The 'cognitive preparation phase' is predominantly educational in that the client learns about the nature of anger and the therapeutic rationale. More is also learned about client's anger patterns, by both the client and the therapist, through active monitoring and reflection. This involves the use of anger diaries and the constructing of personal hierarchies of provoking situations or triggers for anger.

2. The 'skills acquisition phase' involves the client learning new ways of coping, which may help anger to be managed more effectively. These skills include utilising arousal control techniques, cognitive restructuring, problem solving, self-instruction techniques and alternative behavioural responses. In general it involves the modelling and rehearsal of these cognitive, affective and behavioural techniques.

3. The 'application training phase' encourages clients to use their new understanding and skills. This can be done through imaginal visualisation, scenario role-play, and in vivo implementation of acquired skills.

Generally, prototypic 'anger management' packages can be characterised as discrete, time-limited, protocol-driven interventions that are essentially psycho-educational in nature. As they are tailored more to problem areas than the specific needs of individual clients, they can often be implemented with a minimal degree of participant assessment. Equally, participation can require a lower level of personal investment and disclosure than other interventions. The therapy provides information concerning the nature of anger and attempts to instil new skills and solutions for critical incident management. The methods typically involve explicit step-by-step instruction of new skills, modelling, role-playing, feedback to help shape new behaviours and skills, and personal assignments to practice these skills. The aim of all such therapy is to develop preventative, regulatory and response focussed anger-control skills.

Although much work in the literature is subsumed under the heading of anger management the exact nature and content of these approaches often varies widely in practice. The basic format has understandably been adapted considerably to meet the needs of populations with distinctive issues and/or the constraints or demands of the clinical setting or practitioner preference. Apart from being delivered in either individual or group formats, one of the most evident differences has been in terms of therapy length. The length of a session can vary widely and so can the number of sessions. The number of sessions typically range between six (Dangel, Deschner & Rasp, 1989; Stermac, 1986) and 24 or 25 (Dowden, 1999; Winogron, 1997) with an average of about 12 sessions (DiGiuseppe & Tafrate, 2003). However, even two-session interventions have been explored (McDougall et al., 1990; Munro & McPherson, 2001) and the presence or absence of additional booster or relapse prevention sessions is also relevant (Dowden, Antonowicz & Andrews, 2003). Now self-administered computerised anger programmes are also beginning to appear in the literature (Bosworth, Espelage & DuBay, 1998) although these have not yet been applied to clinical populations. Such differences make simple comparison problematic.

It is of note that even in the face of increasing recognition that 50 to 100+ hours of therapy may be necessary to make significant gains with individuals who have complex clinical and forensic anger problems (Howells et al., 2005), some authors continue to argue that interventions in excess of eight sessions may be inefficient or even counterproductive (Glancy & Saini, 2005). Determination of such matters has yet to be achieved.

Across such approaches, however, there does appear to be a consensus that the cognitive, arousal and behavioural domains are all systemically important to the instigation and expression of anger, and hence they use variations of the Novaco-style multi-component intervention. Again, however, they may differ in terms of the emphasis given to a particular domain or strategy. Some may be almost entirely educational or insight-based in nature, with the presumption that new information will lead to positive change. Others place predominant focus on cognition and cognitive restructuring or arousal control or exposure-based techniques to weaken the bond between stimulus and response. Some may emphasise behavioural skills enhancement. Thus, although most practitioners have tended to follow a Novaco-esque multi-modal CBT approach, it should be cautioned that no two programmes are likely to comprise the same elements in equivalent fashion. This can be viewed as problematic but it is at least consistent with models of emotional regulation that recognise the existence of multiple pathways towards the experience and expression of emotion (Power & Dalgleish, 1999; Teasdale, 1999). For some individuals anger seems predominantly shaped by their appraisals and attributions; for others it may be more automatic. Alternatively, pathways of activation may be situationally triggered. However, rarely are clients assessed, or offered one therapy as opposed to another, with such issues in mind.

In noting that not all cognitive behaviour therapy (CBT)-based interventions are the same, we have argued (Ramm, 1998) that this is not just about chosen constituents but also reflects differing levels of complexity, modalities of delivery and degree of tailoring to individual client need. In this regard, Novaco, Ramm & Black (2001) make a critical distinction between 'anger management' and 'anger treatment', the latter reflecting this more idiographic approach to assessment and content.

'Anger treatment' therefore describes those interventions that are substantially informed and directed by assessment and therefore result in a much more bespoke and intensive approach to therapy. This includes the integration of assessment and treatment activities; investment in the therapeutic relationship and motivational processes; a greater focus on formative experiences; targeting enduring change in cognitive, arousal and behavioural systems; and addressing distressed emotions (anxiety, sadness, anger) in the therapeutic arena. As we have previously discussed, this necessitates a more formulation-driven, interactive and more intensive therapy, clearly requiring more client contact. Although many of the methods found in 'anger management' may be used, these may involve more intensive application and augmentation. This may follow an identified protocol and be delivered in individual or group format but requires a relatively high degree of psychological sophistication by therapists in order to tailor treatment to individual patient need. This requires specialist therapist training and appropriate ongoing supervision.

In contrast to CBT, there are few reports of psycho-dynamic or analytic interventions being used as Discrete interventions for anger problems (Lanza et al., 2002; Quayle & Moore, 1998).

Integrative Anger Therapy

Integrative anger approaches do not identify anger as the focus of therapy. They are sub-classified as Integrative/Embedded if addressing anger is in fact subsumed within a larger therapy process, or as Integrative/Constituent if addressing anger can still be seen a clear component of a larger, more general therapy.

The predominant 'Integrative' approaches are various forms of psychoanalytic therapy. These are of particular interest because anger features as an important factor in many complex psychodynamic formulations of human functioning and distress (Fairburn, 1978; Freud, 1912; Kernberg, 1992; Klein, 1957; Kohut, 1978, 1984 and Winnicott, 1958) and is explored in relation to key constructs such as 'transference', 'attachment', 'repression', and 'projection' issues.

Despite this, anger rarely enjoys specific consideration in psychoanalytic literature, perhaps because it is often understood as being an undifferentiated process rather than isolated for particular attention. Because addressing anger is usually 'Embedded' in the therapy process, it is not considered in the focussed fashion that is common in other approaches (such as CBT). Secondly, angry-aggressive individuals are likely to find engagement in most forms of psychodynamic psychotherapy difficult, as the therapeutic style and content may serve to magnify perceptions of being challenged or judged and lead quickly to deep resentment towards the therapist. Despite this, it is our view that either directly or (more likely) indirectly, these orientations may have much more to contribute to this area than is conventionally recognised. This is especially so in the conceptualisation and operationalisation of key process elements (such as the therapeutic relationship) in therapy, and the treatment of anger problems that do not manifest themselves in overt aggression towards others (for example, passive aggression; unacknowledged anger; anger towards the self).

Other forms of Integrative interventions that address anger also exist. One example is interpersonal therapy (IPT) (Klerman et al., 1984), which is now acknowledged as being directly applicable to various forms of emotional distress (Stuart & Robertson, 2003; Weissman et al., 2000). In this context, it can be described as an Integrative/Embedded therapy because, although anger may be acknowledged within the therapy, rather than focussing on it directly, it is addressed through broader therapeutic processes. In the case of IPT, this process is a collaborative attempt to reduce psychological symptoms by targeting relationship difficulties. This focus on the interpersonal dimension is arguably salient to anger (since anger is generally an interpersonal emotion) but IPT, like other integrative therapies, can hardly be described as an 'anger treatment'.

When constituent components for addressing anger can still be identified within a broader integrative intervention, these can be termed 'Integrative/Constituent' anger interventions. It is argued that the application of CBT elements to address anger within a broader CBT intervention, or the targeting of specific anger-related 'procedures' within a Cognitive Analytic Therapy (Ryle & Kerr, 2002), or modules to develop specific anger coping skills within Dialectical Behaviour Therapy (DBT) (Linehan, 1993), all potentially constitute'Integrative/Constituent' anger interventions.

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