Hofstra Horizons Research

Managing Anger and Aggression

Howard Kassinove
Professor, Department of Psychology Director
Institute for the Study and Treatment of Anger and Aggression

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There had been virtually no discussion of anger problems during my own graduate training. Although I did learn about the biophysical aspects of emotions, such as heart rate and sweating, no attention was paid to the treatment of personal anger experiences, or the content of angry thoughts and how they related to clinical aggression. Imagine how unprepared I was when I opened a private practice and found that more than half my patients suffered from anger problems. I had little idea as to what to do and eventually decided to study anger as a specific problem.

Many scientific researchers, of course, have devoted their energies to anxiety and depression. In contrast, and as seen in Figure 1, a literature review shows that psychologists have devoted very little time to anger. When I learned about this situation, I grabbed the opportunity to contribute to our knowledge about this pervasive problem. My work led to the 1995 edited volume, Anger Disorders: Definition, Diagnosis, and Treatment, and to my co-authored 2002 text, Anger Management: The Complete Treatment Guidebook for Professionals. The latter book has been rather successful and has already been translated into Russian, Spanish and Arabic. I think this reflects the worldwide interest in anger as a clinical problem.

What Is Anger?

Anger refers to a self-perceived, negative emotional state. It’s different from anxiety and depression because anger is associated with specific thoughts relating to blame, intentionality and injustice. Thus, our patients say things such as, “It’s her fault … She made me angry … Her behavior is unfair … She could act better if she really wanted to … But, no … She just has it in for me.” Anger is also typically thought of as a moral emotion, because people often think that the triggers are unfair, wrong, unjust, etc. These morality-based thoughts usually lead to increased anger.

Anger is also associated with some degree of arousal, such as an increased heart rate, and behaviors such as yelling, becoming argumentative, throwing or breaking objects, and so on. One of the distinguishing and typical characteristics of anger is private, unspoken fantasies of revenge and a desire to hurt the perceived source of the anger. We all know of those well-publicized cases where adolescents or adults brooded about perceived injustices and eventually planned and carried out their revenge. The tragedies at Columbine High School and Virginia Tech are but two examples of this.

Of course, anger is a normal as well as a psychopathological emotion. We all feel angry on occasion. In fact, our research shows that typical adults from the community admit to feeling some degree of anger about once a week or so. Unfortunately, in some cases, the anger becomes intense and frequent, and endures for long periods of time. When this occurs, it’s time for anger management.

We usually think of anger as directed either inward or outward. Anger-in refers to agitated brooding, coupled with revenge fantasies. Anger-out refers to yelling, screaming, being needlessly argumentative, and perhaps throwing objects against the floor or wall. If the person hits someone else, with the intent to hurt that person, the behavior is then labeled as aggression.

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Figure 1
Negative emotion words in PsychInfo journal titles, by five-year periods.

Most people think of anger and aggression as strongly linked. On a daily basis, we read in the papers about fights, assaults, murders, etc., and are told that the aggression followed some passionate state of anger. In truth, aggression follows anger only 10 percent of the time. In 90 percent of anger incidents, there is no aggression. The anger is manifested only with internal agitation or with external pouting, sarcasm or verbal arguments. We believe that anger is an unrecognized problem in its own right and that we have to treat adults who are angry, as well as those who are aggressive. In fact, anger alone (without aggression) is related to interpersonal conflicts, negative evaluations at work, family unhappiness, lack of job advancement, diminished social opportunities, poor decision making, accidents, and so on. Since angry people are disliked, they are less likely to be invited to social events, out of fear of the anger-based conflicts that are expected to occur. What most people don’t know is that anger is a killer! People who are frequently and intensely angry show a marked increase in hypertension, cardiovascular disease, stroke, and perhaps even cancer. Angry people die younger. Finally, very strong anger can be highly disruptive, can cloud thinking, and can set the stage for crimes of passion.

Need for the Anger Management Institute

The Institute for the Study and Treatment of Anger and Aggression opened in September 2005, with the encouragement of the executive director of the Saltzman Community Services Center, Dr. Joseph R. Scardapane. The goal of the institute is to provide research-based services for community adults who suffer with personal anger problems or who have become aggressive and may be involved with the criminal justice system. In addition, the institute provides an opportunity for Ph.D. students in clinical psychology to enhance their treatment skills. We began with only two anger management therapists, since we were unsure about the need for the program. However, anger turned out to be a critical problem in the community, and we quickly began to receive referrals from a variety of sources. By April 2007, we expanded to nine anger management specialists with varying degrees of expertise and experience. Our four senior specialists are Christopher Browne, Andrew Corso, Ryan Quirk and Ian Whitney. Each has an earned master’s degree in psychology and three to five years of clinical experience in mental health clinics, hospitals, schools and prison facilities. In addition to their professional experiences, they have given scholarly presentations about the Hofstra anger management program in Belize, Russia, India and Korea, as well as at professional meetings in the United States. Their knowledge and professional experiences allow these senior specialists to provide high-quality services to applicants for anger management.

Our other anger management specialists are Mark Closson, Robert Gruenfelder and Stephanie Rodrigues, who also have earned master’s degrees in clinical psychology. Rounding out the team are Ranita Pekarsky and Kentaro Nakajima, who serve as intake workers and screen referrals to determine whether they are appropriate for the program. The Hofstra anger management team is highly multicultural. Ranita is fluent in Russian, Kentaro in Japanese, and Stephanie in Portuguese. Their backgrounds help us to understand the unique anger and aggression experiences of the adults we serve.

Although it is a relatively new program, we have already provided clinical services to more than 75 adolescents and adults from the community. About half of the referrals have come from local courts or the Nassau County Probation Department, while the rest represent direct applications from community residents or their family members. Program participants have ranged in age from 14 to 70, although we try to use age 16 as the lower limit for acceptance. Services are provided on an individual basis, with a program that is tailored to the specific needs of each person. Most other anger management programs are run in a group format and focus more on psychoeducational skills. Because we provide one-on-one services, we can focus on intervention techniques to actually change angry behaviors, rather than simply educate participants about anger.

Sample Cases

Anger and aggression appear in many different ways in society, and we are pleased to be able to treat people with varying types of anger problems. At the same time, this variability limits research opportunities since formal research programs typically focus on treatment programs for specific problems. Cases that are typical of our work include the following:

1) Ricardo, a 25-year-old high school graduate, came to the institute at the urging of his girlfriend and parents. He had a long history of physical assaults and violent outbursts, and was concerned that eventually he would seriously injure another person. Ricardo had joined a street gang while in the ninth grade and he had committed a number of robberies with an unloaded pistol. After he left the gang, he found that some of his friends were reluctant to spend time with him, out of fear that he would lose his temper. Ricardo was short and had a stocky build. His short stature was disturbing to him, as he believed that other people “looked down” on him and “disrespected” him. Ricardo said that he was always quick tempered and had trouble controlling his anger since he was very young. When he becomes angry, he directly confronts the offending person, and this has led to fistfights with both strangers and acquaintances. One fight resulted in an arrest for assault. Ricardo said that his anger triggers are individuals who bump into him while on the train or while walking to work, other drivers, family members (particularly his mother and sister), and his girlfriend.

2) John, a 43-year-old recently divorced man, was unemployed and on disability when he applied for anger management. A high school dropout with a violent family history as well as a history of alcohol abuse, he had a brother who was serving a life sentence for aggravated assault. John wanted treatment so that he could regain full visitation rights with his 5-year-old daughter. Although he was allowed to see her for a few hours, he had been denied overnight visitations after a loud argument with his former wife, in which she accused him of inappropriate sexual contact with the daughter. This led to his arrest. Two recent bar fights had also resulted when patrons who recognized him said, “I didn’t know that they served pedophiles here.”

3) Bobella, a 53-year-old convenience store employee, did not complete high school. At the initial interview, she admitted only to “lightly” pushing her stepfather during a verbal argument. Nevertheless, he fell and hit his head, and pressed charges against her. Although she did not have a previous criminal record, Bobella had a long history of being loud and quick tempered, with frequent use of profanity. She had many interpersonal conflicts at work with supervisors and peers. Referred by a legal adviser, Bobella said she wanted anger management to improve her interpersonal relationship skills. Unfortunately, the anger management sessions were variable and she was eventually sent to jail during treatment.

4) Sam, a 22-year-old Ivy League graduate, was arrested on felony charges after he attempted to strangle his girlfriend while he was drunk and after he had used cocaine. This occurred during his final year in college and led to a delay in graduation. During the incident, Sam claims to have lost consciousness and to have no awareness of his behavior until he woke up in jail. He admitted to a long substance abuse history that included use of cocaine, marijuana, mushrooms and alcohol. Sam seemed pleasant during intake; however, his thinking was unrealistic and grandiose. Although he said he harbored grudges and thoughts of revenge against a female roommate and an unnamed dean at the university, there was no indication that he would act on these thoughts.

5) Marsha, a 32-year-old lesbian, had been sexually abused by her father during the first 18 years of life. A bright woman with a master’s degree, Marsha had recently begun to unexpectedly scream, cry, complain, and make sarcastic remarks to her partner. She thought this emerged from anger at her father that she had never released. Her partner, she thought, was simply an available object of her anger. Marsha had previously been diagnosed with obsessive-compulsive disorder and generalized anxiety disorder, and was taking various medications. She said she frequently became angry at “many small things,” directed her anger at her partner, and then felt very guilty.

6) Eduardo, a 47-year-old engineer, was self-referred to the institute after having a loud argument with a co-worker. Evidently, he had a long history of sensitivity to real and imagined insults. In the current incident the co-worker called Eduardo “lazy.” This led to the argument, which caused quite a disruption in the workplace. Eduardo promised his supervisor that he would address his anger problem in order to avoid further interpersonal difficulties and a suspension. At intake, Eduardo seemed highly skeptical and suspicious. He spoke about a history of being constantly “wronged,” his many arguments with friends and co-workers, and impulsive actions. His hypersensitivity to relatively mild remarks, which he defined as “real insults,” led to concern about further outbursts or aggression at work and at home.

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Figure 2
Anger episode mode

Effective Anger Management Techniques

At the Institute for the Study and Treatment of Anger and Aggression, we don’t focus on vague personality factors that, in actuality, simply blame the angry person for being angry. Rather, we help our patients analyze individual episodes of anger in order to bring it under control. Our approach follows what is known as a cognitive-behavioral model.

In our anger episode model (Figure 2, Kassinove & Tafrate, 2002), we teach people that they have a degree of control over their anger. The model suggests that anger is not caused by the trigger itself, but appears when the trigger is illogically evaluated. People come in believing that their anger triggers make them angry. It’s unfortunate that in English, we use the word make in a haphazard way. Indeed, if someone hits you with a brick, that brick and person have made you bleed. If you are punched, the punch does make you black and blue. But words, or being ignored, or disrespected, really can’t make you angry. We operate on the principle that sticks and stones can break your bones, but words can never harm you, or make you angry – unless you think in inflammatory ways and let them! We show people that in order to become angry when they are ignored or disrespected, they have to appraise the trigger in some way. When an insult is thought of as awful or terrible, and when people believe that they can’t take it anymore, there is increased anger. The first step in anger management is to reasonably assess the anger trigger as legitimately bad, unwanted and unpleasant – but not more than that.

The development of internal anger experiences, as well as inappropriate patterns of expression, are treated with deep muscle relaxation, assertiveness training, social skills training, and with the pairing of relaxation with exposure to offending words. Thus, when we put patients into a deep state of relaxation and gently repeat the offending statement, anger reactions usually decrease. Nevertheless, most angry outbursts follow a pattern of automaticity. When verbally attacked, we have been programmed to react with statements such as, “Don’t be so stupid” or “You’re a jerk too!” These lead to nothing but more conflict. In assertiveness training, we practice (over and over) reacting to offenses by first taking a deep breath and then engaging in a more appropriate verbal response such as, “I feel annoyed and don’t like what you said. I want to talk about this with you.” It takes some time to undo the automatic pattern of responding to offensive verbal barbs with attacking statements, but it is very gratifying when it eventually happens.

Of course, sometimes anger is directed at a person who is dead or who has no interest in repairing a relationship. This observation was well stated in Robert Anderson’s 1970 Broadway play, I Never Sang for My Father, in which this line appeared: “Death ends a life, but it does not end a relationship, which struggles on in the survivor’s mind toward some final resolution, some clear meaning, which perhaps it never finds.” In cases that center on ruminations about others who are unavailable, we use forgiveness interventions. In this kind of intervention, we encourage angry adults to see the world from the perspective of the offender. We ask them to talk about the angering events from a different viewpoint, which is often a new experience for the angry person, and which often leads to change. We ask our patients to differentiate forgiveness from forgetting and condoning, and we reinforce what was said both by Bishop Desmond Tutu (“Without forgiveness there is no future”) and psychiatrist Thomas Szasz (“The stupid neither forgive nor forget; the naïve forgive and forget; the wise forgive but do not forget”). The goal of our specialized forgiveness interventions is to disengage memories of bad behaviors by others from the unnecessary bodily arousal that often accompanies memories of the triggering event.


Future Plans

Sadly, the future for anger management is bright. Anger is a basic human emotion and for many people it is intense, frequent and enduring. Based on the variety of referrals we have received so far, it seems there is much work for us to do. We hope the anger management program at the Saltzman Community Services Center will become known as an important local resource for helping angry adults and adolescents. On the other hand, it is well-known that human problems are never eradicated by treatment programs, since society keeps producing adults who are easily offended and who easily become infuriated. The real future lies in the development of prevention programs that can be implemented in schools, at home, as part of religious or summer camp training of youth, and so on. Hopefully, we can move in that direction in the years ahead.


References

Kassinove, H. (Ed.). (1995). Anger Disorders: Assessment, Diagnosis, and Treatment. Washington, DC: Taylor & Francis International Publishers.

Kassinove, H., & Tafrate, R.C. (2006). DVD/Video demonstrations to accompany Anger management: The complete practitioner’s guidebook for the treatment of anger. Atascadero, CA: Impact Publishers.

Kassinove, K., & Tafrate, R. (2005). Cognitive behavioral treatment for disruptive anger. In A. Freeman (Ed.), Encyclopedia of cognitive behavior therapy. New York, NY: Kluwer/Springer.

Kassinove, H., & Tafrate, R.C. (2002). Anger management: The complete practitioner’s guidebook for the treatment of anger. Atascadero, CA: Impact Publishers.

Tafrate, R.C., Kassinove, H., & Dunedin, R. (2002). Anger episodes of angry community residents. Journal of Clinical Psychology, 58, 1573-1590.


Photo: Copyright istockphoto.com. Photo by Kim Freitas.

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