Anger is a basic human emotion that transcends cultural boundaries. However, despite its universality, an exact definition agreed upon by all people is lacking (Norcross & Kobayashi, 1999). Physiologically, brain centers in the amygdala are connected to anger processing. Because the information processing that takes place in this brain structure is primitive, anger can be triggered inappropriately and without the individual's knowledge of the cause. In psychodynamic terms, past events and experiences suppressed in the unconscious can be the source of generated anger. In cognitive-behavioral terms, anger is described as an interaction of behavior, cognition, and physiological arousal (Ambrose & Mayne, 1999). According to Deffenbacher (1999), anger may be aroused by specific external events, a mix of these external events with the anger-related memories they elicit, and internal stimuli such as emotions or thoughts. It results when "events are judged to involve a trespass upon the personal domain, an insult to or an assault upon ego identity, a violation of values and expectations, and/or unwarranted interference with goal-directed behavior" (p.297).
Two main ways to treat anger involve helping patients to prevent anger activation or helping them to regulate anger manifestation. The former is generally a longer and more difficult approach due to the fact that early emotional behavior patterns are hard to change or eliminate. Therefore, the moderation of anger may prove to be a more effective route of therapy (Ambrose & Mayne, 1999). Many different schools of psychotherapy have addressed the problem of anger. Because of the lack of a universally identical definition for anger, there is debate regarding the best way to treat it. According to Kobayashi and Norcross (1999), "without a consensus on the identified phenomenon, we will continue to disagree on the proper psychotherapy of anger disorders" (p.277). However, by exploring the various characteristics of the different schools of psychotherapy, similarities and compatibilities become apparent, which can lead to a more integrative and eclectic approach to anger management.
The Psychodynamic Approach
The psychodynamic approach can be traced to Sigmund Freud in the late 19th century and the early part of the 20th century. He first concentrated on a cathartic method to release repressed emotions associated with past experiences and then began to focus on a free association method and the development of transference (Messer, 2001). Underlying the psychoanalytic perspective is the idea of the unconscious. The unconscious is where past experiences and true emotions are hidden. Manifestation of an undesirable trait, such as anger, along with excessive use of defense mechanisms lead to the assumption of a deeper conflict hidden within the unconscious. Psychodynamic techniques try to gain access to the unconscious and make the patient aware of the underlying conflict (Phares and Trull, 2001). Among the emphases of psychodynamic therapy are a focus on the evocation and expression of emotion to uncover the patient's unconscious issues, the importance of emotional insight in which the patient can experience and comfortably understand his emotion, a concentration on a patient's behaviors that thwart the progress of therapy, the importance of childhood and other past experiences and relationships, the development of transference between the patient and therapist, and the role of confrontation and interpretation to access the patient's true desires and conflicts that are embedded within the unconscious (Blagys & Hilsenroth, 2000).
In terms of anger, a psychodynamic view would hold that a patient's anger is part of an aggressive drive and that emotional expression will lead to a catharsis and, ultimately, reduce the anger (Ambrose & Mayne, 1999). A patient's expression of anger may be indicative of a deeper conflict within the unconscious. Therefore, via the direct approach of the therapist and the various techniques of psychodynamic therapy, this underlying conflict can be conjured up to the conscious awareness of the patient.
The Humanistic, Phenomenological, Existential Approach
The origins of the humanistic, phenomenological, existential approach can be traced to the thinking of existentialist philosophers such as Kierkegaard, Nietzsche, and Heidegger. Their influence is seen in the many humanistic-existential therapies used today, one of the most important being that of Carl Roger's client-centered therapy (Van Deurzen, 2000). Some of the main focuses under this school of psychotherapy include the concentration on the present experience, the encouragement of self-discovery of answers, an appreciation of the uniqueness of humans, the importance of congruency and unconditional positive regard, the emphasis on empathy, and the pursuit of individual growth and wholeness (Elliott, 2001). According to Elliott (2001), a therapist in this school of psychotherapy is nondirective, thus allowing the client to develop his own awareness. The therapist also tries to emphasize the client's internal self-relationships and not concentrate on relationships with others. One of the keys to this type of therapy is a fostering of empathy in a therapeutic environment in which the client can feel comfortable to engage in his search for self-awareness and answers. The therapist accomplishes this through "empathic reflection, empathic following ("uh-huh's"), and empathic affirmation (offering support for client distress or pain)" (p.42).
In terms of the problem of anger, a humanistic-existentialist approach would focus on the importance of truly attempting to understand the client's emotion and validating his experience that generates the anger. If this empathy on the part of the therapist is not conveyed, the client will become defensive and justify his anger. Under this approach of psychotherapy, anger is seen as a reaction to a threat to the sense of self worth (DiGiuseppe, 1999).
The Gestalt Approach
The Gestalt approach to therapy can be seen as a component of the broader school of humanistic, phenomenological, and existential therapies. The origins of the Gestalt approach to psychology can be traced to Frederick Perls in the mid 20th century. The aim in Gestalt therapy is
"the integration of the thinking, feeling, and sensing processes" (Dye & Hackney, 1975, p.44). The emphasis in Gestalt therapy is on the present experience, the perception of the person as a whole, and immediate awareness of emotion and action. The therapist concentrates on, not interpreting, but attempting to make a person aware of his present thoughts, feelings, and actions (including nonverbal behavior). By doing this, attempts are made to break through the five layers that Perls called phony, phobic, impasse, implosive, and explosive in order to reach a person's real self (Phares & Trull, 2001).
One way to reach the true self is to use techniques to evoke emotion. According to Paivio (1999), this process involves establishing an empathetic relationship between client and therapist, evoking core emotion and exploring present bad feelings, and restructuring the emotion structures that prove to be maladaptive. A Gestalt technique used for this purpose is the empty-chair technique in which clients are encouraged to express in the present their feelings and conflicts to an imagined other in the empty chair in order to evoke true emotion and conflicts within the self or with another. According to Elliott (2001), "primary adaptive emotions (e.g., sadness at loss, anger at violation) need to be fully expressed in order to access implicit emotion schemes and associated adaptive action tendencies" (p.43). In terms of anger, the specific type dictates the therapeutic approach. For instance, anger problems sometimes involve an over- control of the emotion, thus producing stress, or an under-control of it, thus causing interpersonal conflicts. Therefore, therapeutic techniques, one being the Gestalt two-chair dialogue, may "emphasize accessing over-controlled adaptive anger and exploring secondary or defensive anger in order to access underlying hurt, fear, or shame" (Paivio, 1999, p. 312).
The Behavioral Approach
The origins of the behavioral approach can be traced to Pavlov's work on classical conditioning in the early part of the 20th century. In terms of therapy, the idea is that a response that has been conditioned can, theoretically, be unconditioned via a similar process. Another
important aspect of the behavioral approach can be traced to Skinner in the mid 20th century and his work with operant conditioning in which reinforcements and punishments are used to condition responses. This process is influential is behavior modification (McGinn & Sanderson, 2001).
The aim of behavioral therapy is to decrease excessive behavior or increase deficient behavior. This can be accomplished through a diverse spectrum of techniques including systematic desensitization, exposure therapy, behavior rehearsal, contingency management, and aversion therapy (Phares & Trull, 2001). In terms of problems with emotions, such as anger, many of these techniques apply. For instance, a contingency management plan in which the expression of anger is controlled by manipulating its consequences is a possibility.
The Cognitive Approach
Cognitive therapy can be traced to Beck's work in the mid 20th century on a treatment for depression. The therapy is now applicable to a broader range of emotional problems, including anger. The cognitive view is that emotions are influenced by one's thoughts and cognitive appraisals, and, therefore, maladaptive thinking patterns are the key to understanding one's psychopathology. A cognitive therapist's goal is to get a patient to become aware of his maladaptive thinking patterns and uncover the patient's core beliefs about himself and his surroundings in order to actively help him change these schemas and, thus, reduce his emotional or behavioral problem (McGinn & Sanderson, 2001).
The idea of restructuring one's cognitions is illustrated through Ellis's Rational Emotive Therapy (RET). The basic goal with this therapy is to make an individual confront his maladaptive thinking so that he can change it. The view of this technique is that it is a person's beliefs about an experience that generate behavioral or emotional problems (Ellis, 1999). Thus, concerning anger, the implication is that a person must become aware of his maladaptive
cognitions about a situation or experience, through the help of the therapist, and then attempt to reinterpret and change them, thus leading to a reduction of anger.
The Cognitive-Behavioral Approach
Now, although pure versions of these approaches are still seen, there have been an increasing number of approaches to treating emotional disorders that integrate the cognitive and behavioral approach. One such example is the change in Ellis's RET to REBT, which includes a behavioral component in which the patient engages in an activity that challenges his belief system (Ellis, 1999). The cognitive-behavioral approach to therapy generally relies on the present experience, as opposed to past childhood ones, and it aims to directly reduce symptoms (e.g., via cognitive restructuring, etc.) as well as implement strategies designed at building skills (e.g., problem solving, etc.). The cognitive-behavioral therapist plays an active role in deciding with the patient what the focus and goals of the session and therapy are and leads the course of the treatment. However, although the therapist is very directive in this approach, "CBT attempts to empower the patient, and thus there is an emphasis on providing the patient with skills to offset negative emotional states and dysfunctional behavior" (McGinn & Sanderson, 2001, p.28).
An Eclectic Approach to the Management of Anger
Thus far, it has been shown that different schools of psychotherapy (namely psychodynamic, humanistic/phenomenological/existential, Gestalt, behavioral, and cognitive) conceptualize emotional problems, such as anger, differently and employ different techniques in therapy. There is no answer as to which one is the right one. Studies have indicated the effectiveness of some of these approaches to therapy, while other approaches require more research. For instance, Edmondson and Conger (1996) report that studies published between 1970 and 1994 that were included in their review indicate that different cognitive and behavioral treatments proved to be moderately effective for people with anger problems. Also, in a meta-analysis of 50 studies exploring the effectiveness of CBT as it relates to anger, Beck and Fernandez (1998) report, "it can be inferred that the average subject in the CBT condition was better off than 76% of control subjects" (p.70). CBT has a significant amount of research supporting its effectiveness. Despite the lack of abundant research supporting some of the other schools of therapy, claims can be made that each type of therapy contributes something unique and may be more or less effective depending on the patient and his particular problem (Conger & Edmondson, 1996).
By exploring the different schools of psychotherapy, it can be seen that in order to create a program for managing anger in adults, different aspects of each approach to therapy should be integrated. Because there is not one approach that has proven to be most effective for the treatment of anger, a combination of the compatible characteristics from each school should be used. One aspect to be included in this program is that of empathy, which underlies just about every school of psychotherapy. In order for the patient to develop trust and become comfortable enough to express himself and change, there needs to be a therapeutic alliance between the patient and therapist (Paivio, 1999).
Next, another aspect that the five approaches to therapy have more or less in common is the notion of making the patient aware. In the psychodynamic approach, the therapist tries to access the unconscious, thus making the patient aware of the underlying conflict. In the humanistic approach, the therapist encourages the client to seek his own answers, thus making him aware of his needs and desires. In the Gestalt approach, the therapist strives to make the person aware of his core emotions that he is presently feeling as well as his current actions and thoughts. In the cognitive-behavioral approach, the therapist attempts to make the patient aware of his maladaptive thinking patterns. Thus, the concept of making an individual aware of his cognitions, action, and emotions are essential to any therapy program. Another aspect that most of the approaches have in common is the focus on the present experience. This should be included in the creation of the anger management program as well. Even though the psychodynamic approach traditionally focuses on past experiences, some psychodynamic therapists have advocated a focus on present experiences instead of past ones (Messer, 2001).
In addition to these compatible characteristics from the different approaches that can be used in the creation of the anger management program, another characteristic shared by most of the schools is that of evoking and expressing emotions and thoughts. The psychodynamic approach focuses on bringing out repressed emotions from the unconscious. The Gestalt approach aims to evoke emotion by confronting the person and frustrating him enough to break through his phony layer and expose his true emotions and self. Also, the cognitive-behavioral approach attempts to discover a person's cognitions and allow him to uncover and express core beliefs. Moreover, in terms of the therapist's role, a combination of the directive approach of psychodynamic and cognitive-behavioral therapy and the nondirective approach of humanistic and Gestalt therapy can be made in that the therapist takes an active role but, ultimately, strives to foster an empowerment within the individual to actively assess, express, and change oneself.
The Program for Anger Management
This program, designed to manage anger in adults, should include those aspects of the five schools of psychotherapy, which have been shown to be compatible. These include a therapeutic alliance involving empathy; a concentration on present feelings, thoughts, and actions; a focus on making the patient aware of his core cognitions, beliefs, and emotions; an attempt to encourage the expression of these cognitions, beliefs, and emotions; and the importance of empowering the patient with the skills needed to restructure maladaptive tendencies and, thus, promote healthy functioning.
Using these points as a framework, the program should last about 15 weeks, meeting one hour per week. Short-term therapies are shown to last anywhere from 10-25 sessions for brief psychodynamic therapy (Messer, 2001), from 12-15 sessions for brief CBT (McGinn & Sanderson, 2001), and from 12-20 sessions for brief humanistic-existential therapy (Elliot, 2001). The initial sessions should be devoted to establishing a therapeutic alliance in which the therapist genuinely conveys empathy and understanding for the patient. Once this alliance is established, the patient and the therapist should agree on the therapeutic goals in order to foster productive therapy sessions (DiGiuseppe, 1999). Also within the initial sessions, the patient should be educated as to the physiological components of anger and what triggers them so that the patient fully understands what the emotion involves. Next, the patient should explore situations that generate anger and how he specifically responds to them. Throughout the anger management program, a daily anger log should be kept following the SORCK-AD form. These techniques proved to be effective in a study by Bry and Kellner (1999) of emotionally disturbed adolescents.
Throughout the course of therapy, the empathy established in the first session should be continued. Also, the therapist should not strive to interpret the patient's actions and feelings, but rather he should strive to empower the patient with the ability to become aware of his core cognitions and emotions and express them. This will enable the patient to restructure any maladaptive schemas and move forward to actively engage in activities where he can utilize these more adaptive and positive schemas. To do this, the patient will engage in cognitive restructuring techniques accompanied by behavioral techniques such as exposure to angering stimuli, role-playing, skills training, contingency procedures, and problem solving. Also, the use of relaxation techniques, such as imagery or progressive muscle relaxation, should be employed to calm the body and diminish the amount of physiological arousal, and thus diminish the anger response (McGinn & Sanderson, 2001). During each session these techniques should be practiced with the therapist, and then the patient should continue with homework assignments between sessions. This entails maintaining the daily anger log, practicing relaxation techniques, and engaging in behavior activities that practice using restructured schemas.
During each session, the therapist and patient will go over the homework assignments and address any new issues that may have arisen. By the end of the anger management program, the patient, hopefully, will have become aware of the stimuli that anger him, his physical and psychological responses to the angering stimuli, the context of the situations, and the consequences of his responses. He will have mastered the ability to uncover and express his true emotions and cognitions, and, thus, he will have been able to restructure them in order to allow more adaptive functioning.
According to Ambrose and Mayne (1999), "anger remains one of the most significant problems facing our society today. In a world growing more crowded, with the pace of life increasing exponentially, … there is growing potential for anger to play a destructive role on a frighteningly large scale" (p.362). Thus, addressing the issue of anger in psychotherapy is important. However, the lack of a universal consensus for the conception of anger and exactly how to treat it makes addressing the issue difficult. Although the different schools of psychotherapy possess many distinct characteristics, it has been shown in this paper that many of these characteristics overlap and that different aspects of the various approaches are compatible. This leads to the conclusion that a more integrative approach to the problem of anger should be considered that utilizes the similarities between the schools of psychotherapy. However, according to Conger and Edmondson (1996), the difficulty in creating a specific universal therapeutic approach to the treatment of anger arises in the fact that there are many different aspects of anger and different types of people, thus leading to the suggestion that different treatment approaches should be employed and tailored to the specific type of person and problem.
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