Brondolo et al.

Brondolo, E., DiGiuseppe, R., & Tafrate, R. C. (1997). Exposure-based treatment for anger problems: Focus on the feeling. Cognitive and Behavioral Practice, 4(1), 75-98.

Function. Anger functions "prepare and protect individuals from harm" but "can become problematic if [it is] evoked too frequently and too intensely," or if it lasts too long. May also be problematic if it is "associated w/ patterns of aggression or avoidance that interfere w/ work or interpersonal relations" (76).

Perceptions/Cognitions. Several "cognitive processes" contribute to anger, including "overestimating rejection by others, catastrophizing, overgeneralization, dichotomous thinking, and mind reading" (76). "In general, individuals respond w/ anger to situations regarded as unfair, unjust, dangerous, or frustrating, and in which the offense is judged to be intentional. Angry individuals may hold a variety of faulty beliefs about the intentionality of the violation or the degree to which they can tolerate the offense. Anger-prone individuals may feel that other people must be nice, behave fairly, or show proper respect (e.g., 'If people aren't polite, it means they don't respect me; I can't tolerate any message in which I am not respected'). The degree to which people hold irrational beliefs about fairness and other issues is associated with their propensity to feel angry" (77-78).

"Attitudes toward the effectiveness of aggression may influence the choice of anger expression style (Lazarus, 1991). Examples of irrational beliefs that may lead to the aggressive expression of anger include ideas about the relationship between suppressed anger and illness (e.g., 'If I don't express my anger I will get sick or go crazy'); incorrect beliefs about the relationship between the expression of anger and the communication of personal values (e.g., 'If I don't express my anger, I am giving permission for the person to do this bad or immoral or provocative thing'); and faith in the effectiveness of aggression (e.g., 'If I threaten them, they will listen to what I say').

"Cognitions associated with the anxious or resentful suppression of anger may include ideas about the dangers of retaliation if they express anger (e.g., 'If I express myself, the other guy will blast me'); concerns about losing control (e.g., 'If I let my feelings out, I'll never stop hitting or yelling and I'll destroy the other person or go crazy'); or cynical beliefs about the effectiveness of the effort (e.g., 'It doesn't matter what I say or do, nothing will ever change. I have no personal power')" (78).

Physical Sensations. "In acute states of anger and anxiety, people can report feeling a dry mouth, racing heart rate, rapid breathing, and muscle tension. There is also evidence that hostile or habitually angry individuals display greater cardiovascular reactivity (i.e., greater blood pressure responses) in response to interpersonal provocations (Suls & Wan, 1993). In turn, the unpleasant sensations associated with physical arousal can foster more aggressive behavior and hostile attitudes (Berkowitz, 1990)" (78). 

Behaviors. "In reflective responses, individuals can modulate the experience of emotion, and develop a reasoned response to provocation. In impulsive responses, the reaction is automatic, triggered by the experience of the anger. Impulsive responses can include both aggressive behavior, characterized by yelling, hitting, or the immediate, but resentful, suppression of anger, seen in sulking, pouting, or withdrawal. This contrast among calm reflection, aggressive expression, and resentful suppression reflects a common distinction drawn by researchers (Spielberger et al., 1985). These dimensions can also be conceptualized as calm assertion, aggression, and resentful passivity" (79).

Models of Anger. "The chain of events leading to an aggressive or suppressed response to anger starts with a trigger or provocation. The link between a particular trigger and an angry response may depend on an individual's learning history. Classical conditioning can account for relations between some triggers, such as tone of voice and anger (Salzinger, 1995). Cognitive processes, such as estimation errors, may increase the likelihood of detecting or perceiving a provocation (Lazarus, 1991). A negative mood or physical discomfort can make a previously neutral stimulus more likely to evoke anger (Berkowitz, 1990). Certain situations, which are unjust or dangerous, also make it more likely that individual will experience anger (Harburg et al., 1979).

An Anger-Evoking Chain. "The triggers may set in motion a chain of events characterized by heightened arousal, fueling the tendency to focus on the threat and make more negative judgments about it (Berkowitz, 1990; Novaco, 1975). The ability to make reasoned or analytic judgments about the situation may diminish, as the angry person favors a more impulsive style of information processing (Ellis, 1994). Heightened arousal and rapid automatic information processing may propel the angry individual toward impulsive behavior. Depending on the circumstances, this may result in a resentful suppression of anger or an aggressive outburst (Harburg et al., 1991; Novaco).

"The process may be interactive. For example, muscle tension and discomfort increases the likelihood that a situation will be viewed as provocative. In turn, the experience of being provoked and the resulting anger can increase muscle tension. The tendency to use a dichotomous thinking process both increases (79) the likelihood that a stimulus will be perceived as provocative and then engenders difficulties in resolving conflict situations...

"By bringing trigger stimuli to conscious awareness, therapists try to "break the chain" that links these triggers to automatic and destructive thoughts and actions. By exposing the person to the experience of anger, without permitting any retaliatory action, the automatic emotional response to the trigger stimulus can be extinguished. Breaking the link between the trigger and arousal may permit the development of a more reasoned approach to conflict" (80).

Treatment Models. "[Many] programs emphasize a skills-building approach, employing assertiveness training or social skills training plus relaxation and self-control among other techniques (Deffenbacher, 1988; Friedman et al.; Novaco, 1975; Schneider & Byrne, 1985)" (80). 

Brondolo et al.'s Model. 

Introducing the Techniques.

"The first step is a cognitive exercise designed to inspire hope by "accentuating the positive." The therapist works with each client to identify existing strengths in anger management and conflict resolution. The discussion also focuses on the benefits of effective anger management. By starting with an emphasis on success, the task of effectively managing anger does not seem so daunting. 

"For example, in the agent groups, we begin each session by "Starting with something good." This is a technique we have previously used with patients with OCD to encourage a continued focus on the ability to tolerate anxiety (Brondolo, 1994). In the anger management groups, agents begin the group by identifying some moment in the past week in which they felt happy, proud, interested, or satisfied. In marital therapy and in groups for aggressive children, participants start the session by identifying a specific example in which anger was managed in a reasonable way (e.g., "Tell me something good that happened this week. Tell me a time when you felt angry or mad, but handled the anger in an effective and reasonable way").

"It may also be helpful to "accentuate the negative" by highlighting the costs of excessive anger. Some of these costs can include impaired concentration, marital disruption, violence, etc. By focusing on the costs of the inappropriate behavior, we hope to generate motivation for the effort to change (Azrin & Nunn, 1973)" (82). 

Analyzing Triggers

"The thorough behavioral assessment of the anger-evoking stimuli is the goal of this component. The key to the success of the entire treatment package is the careful analysis of those aspects of a situation (i.e., the tone, the gestures, the verbal content, or the environment) that started the chain of angry emotion. Teaching skills in behavioral analysis is the first step. 

"One way we obtain information about the specific anger-evoking trigger is to ask people to tell us or act out the story of the provocation. The first time, if they wish, they can tell the whole story without stopping. The next round, we stop them at each step along the way and ask them to identify and rate the intensity of their feelings...

"Initially the agent simply told the group the entire story. To understand why this situation was so provocative for the agent, we asked her to begin to role play the situation from a period about 10 or 15 minutes before she encountered this motorist. To help her identify the feelings and thoughts she experienced during this exchange, she was frequently reminded to use the "Feeling Board." This is a large board containing a list of about 30 feelings (angry, embarrassed, relaxed, etc.). At the bottom of the board is a line extending from one side of the board to the other, with one end marked 1 (not at all) and the other end marked 100 (as much as possible). At each step in the story, the agent picked ou  a word to describe how she was feeling. We prompt this analysis by interrupting and asking: "You were driving down Broadway at about 5:00 P.M. and you were on your way back to the office. How did you feel? How much did you feel that way?" As the agent continues, the prompting persists: For example, "Now you are stopped at the light and you see a guy running toward you. How did you feel? How much did you feel that way? What were you thinking?" (83)

Inspiring Hope

"Cognitive restructuring can be an important component of treatments for
both anger and anxiety...
"We use the concept of core values to identify the cognitive schemas that organize people's response to anger-evoking triggers. Values (i.e., caring, equality, trust, brotherhood, community, integrity, accomplishment, etc.) are a positive and easily accessible way of labeling a set of internal beliefs and ideas each person possesses...

"One common cognition held by angry people is that the failure to express anger in the face of a provocation is tantamount to giving permission to the other person to continue to behave in the provocative way. In this case, the expression of anger is used to control other people's behavior. The patients may fear that without the anger expression ritual, the situation will become hopelessly out of control...

"To tackle these objections, the therapist can highlight the integrity of people's values. For example, in the situation described above, the woman values marital fidelity and loyalty. It is helpful to explicitly identify these values as good and beneficial" (84). 

"The therapy is aimed at helping her change the way she upholds the valuesnot the values themselves. The therapist needs to distinguish between the value (i.e., marital fidelity and loyalty) and the methods for coping with violations of this value (i.e., screaming and attacking when a husband looks at other women). The failure to display rage when a violation has occurred does not mean that the client is accepting the violation. Clients can be encouraged to remember that this restraint is necessary to permit a search for a more effective method for achieving the goals" (85). 

Staying in Control, Not Accepting Abuse

"Instead, we emphasize that emotional control is a prerequisite for devising an effective response to injustice. The fact that all good martial arts training begins with training in emotional control is a good metaphor for angry clients. Sometimes a loud voice or a sharp remark is an effective and appropriate response to a provocation. However, these responses need to be employed in a deliberate, planned manner, when it seems like the most effective strategy" (85). 

Reducing Arousal

"Participants need some reasonable and reliable methods for controlling their internal agitation. It is helpful to make explicit the connection between excess arousal and certain styles of information processing (i.e., hypervigilance to threats). One way to teach relaxation skills is to begin with a very simple abdominal breathing exercise, and then adapt many of the exercises provided in Progressive Relaxation (Jacobson, 1974)" (85). 

Exposure

"The majority of sessions are spent on exposure techniques. Repeated and prolonged exposure to an anger-evoking stimulus is designed to extinguish the frequency and intensity of the emotional response to the trigger stimulus. Prolonged exposure to the emotion itself--the anger experienced during the provocation--reduces some of the fear and resentment associated with the experience of anger, independent of the actual provocation. As individuals learn to tolerate the experience of anger, they may become more flexible in their responses to provocation. Response prevention acts to break the association between affect (anger) and automatic, ineffective behaviors (aggression or resentful passivity).

"All exposure sessions begin with a brief period of relaxation. It is helpful for people to start from a low level of tension or they may escalate their emotional response too quickly and fail to learn they can control their feelings. In group sessions, there is a 5-minute relaxation period prior to beginning and ending the exposure sessions with each group member. 

"During the exposure, we use the worst, most awful, most ego-damaging comments or threats first. This is the most straightforward way of demonstrating that there is nothing to fear. In the exposure sessions, the client is presented with the provocations for a prolonged period, and asked to try to calm down while being exposed to the provocation. This prolonged exposure is designed to allow the emotional response to the presentation to extinguish" (86).