Motivation and emotion/Book/2021/Cognitive behaviour therapy for anger

Overview
Anger is a common emotion in everyday life and affects people in many ways. When this anger becomes severe and uncontrollable, anger management therapy may be a potential fix for this problem (Novaco, 2016).

Cognitive behaviour therapy (CBT) is an option for anger management therapy (Bond & Dryden, 2002). This chapter explores CBT for anger management. Initially, a theoretical framework is established for CBT and anger as an emotion. The purpose of CBT is explored, including the specific approach and therapy techniques developed. Secondly, CBT is applied to anger management, particularly the general approach and practical examples of some pre-discussed CBT techniques. An extensive case study is developed to illustrate CBT’s techniques. Lastly, the effectiveness of CBT as a treatment option is discussed using research studies.

Focus questions:
 * What is the theoretical background to CBT and Anger
 * How can CBT aid anger management
 * How effective is CBT at reducing anger

What is CBT?
CBT is a new wave therapy style built upon the premise that our thoughts are the core determinant of mental distress. Specifically, thoughts that cause this distress are called maladaptive thoughts, which do not have rational support or are illogical. These thoughts can be problematic as they push for unrealistic expectations, leading to stress and negative emotions (Bond & Dryden, 2002).

Case Study: Henry has a belief that she has to be perfect at all times if she wants to follow in her successful father’s footsteps

Can you see the maladaptive thought process here?

Henry wants to do well and follow his father, which is not inherently wrong. However, Henry has warped this neutral desire to do well into a rigid and unrealistic expectation always to be perfect. This belief is unrealistic because no one can be perfect as humans, and having this standard will inevitably have negative consequences (Bond & Dryden, 2002).



The reason why these thoughts potentially cause psychological distress is to do with a standard mental process called cognitive dissonance. Cognitive dissonance occurs when the conceptual idea of one's elf does not align with one’s reality (Harmon-Jones & Mills, 2019). So, in Henry's situation, if he were to fail an exam, it would not align with his view that he has to be perfect, creating a stressful situation. The biological purpose of dissonance is to generate healthy stress levels to encourage the resolution of the stressor (Harmon-Jones & Mills, 2019). An issue arises when behavioural action cannot remove this stressor, leading to extended stress. Prolonged high-stress levels can cause several health concerns such as anxiety, depression, weight gain and sleeplessness. Furthermore, emotional distress is common for someone who cannot reach their standard will experience frustration and potentially outbursts of anger (Harmon-Jones & Mills, 2019).

The ABC framework
How can someone resolve such maladaptive thoughts and beliefs? CBT takes a direct approach to deal with the issue. To understand this, Albert Ellis’s ABC framework can explore the foundations of CBT(Ellis, 1991).

A - Activating event

B - Belief surrounding that event

C - Consequences

Breaking the ABC framework down, the main idea of CBT, that thoughts are directly in control, is re-established. The event is somewhat insignificant compared to the resulting thoughts and will be covered only briefly in therapy. The ABC model is intuitive; it starts with an event, big or small; the events’ beliefs and thoughts follow. Lastly, due to these thoughts, the consequences are the emotions and behaviours that emerge (Ellis, 1991). See figure 1.

Case Study: Wilson was in a high-speed car accident earlier in the year; luckily, he survived but suffered a couple of broken bones. However, long after recovering, Wilson will not enter a moving vehicle as he believes he would crash if he were to drive again.

Can you identify A, B and C ?

A - The activating event was Wilson getting into the high-speed accident

B - The beliefs are that Wilson thinks that driving again will result in a second car accident

C - The consequences of this belief are that he is scared to drive and will actively avoid being in a moving vehicle.

Therapeutic techniques used in CBT
CBT targets the beliefs and thoughts, so by changing these beliefs, the negative emotions and maladaptive behaviour will be lessened or reversed (Bond & Dryden, 2002). Importantly, CBT practitioners do not replace maladaptive beliefs with overly positive thoughts; instead, they build up realistic provable beliefs (Bond & Dryden, 2002). So in the case of Wilson, saying that cars are 100% safe is a lie. Instead a therapist may acknowledging that driving is dangerous but with care can be done with a low chance of an accident in general. By building the idea that car accidents are uncommon and the previous accident was simply unlucky, Wilson may begin to lessen his irrational fear. Even if he cannot immediately get into a moving vehicle, by challenging the belief, Wilson may start to see how illogical the fear and thoughts are. It can be a long process but is generally quite effective (Bond & Dryden, 2002).

The primary way that practitioners challenge the maladaptive thoughts of clients is through disputing, which, to be specific, is questioning and providing evidence against a belief (Hofmann, 2013). Maladaptive beliefs are rigid and unrealistic beliefs; as such, there should be a large body of evidence to contradict them (Hofmann, 2013). The creative side of CBT comes into play in this situation, figuring out how to specifically shake a client’s beliefs. Often these beliefs are quite noticeable due to the wording that the client often uses; "have to", and "ought to" among others can be clear giveaways to rigid thinking. There are a wide variety of ways to dispute in CBT;

Basic level of disputing
Basic disputing is the most fundamental aspect of disputing; it involves objectively asking what evidence a client has to defend a particular belief. The goal is for the client to realise that there is non-real evidence to support it. Through practice, the client will no longer need the therapist’s intervention and dispute maladaptive thoughts by themselves (Hofmann, 2013).

Rational emotive imagery
Rational emotive imagery (REI) is where the more creative techniques begin. REI is a technique that harnesses the client’s imagination and either relives an experience or imagines a new one (Corey, 2015). The client will imagine a situation where a maladaptive thought process is involved and will step by step imagine the experience in total. The client will not only imagine the event's details but what they are feeling and thinking throughout; notably, the client will not try to suppress any maladaptive thoughts. Once complete, the client will do the same over again; however, they will only think and feel healthy emotions and thoughts this time. This approach trains the mind to think more healthily and desensitises the client if the event were to occur in the future (Corey, 2015).

Exposure therapy
Exposure therapy is where clients who have irrational beliefs about something will expose themselves to the medium over multiple sessions in a controlled environment. The purpose of this is to expose the irrational belief as evidence to the contrary gradually builds up over time (Foa et al., 2003). Bringing back the example of Wilson, If in a controlled environment, he went for a five-minute drive each week, he would slowly lessen his irrational fear of driving. The activity can be quite confronting for some and is potentially harmful if not carried out with care.

Social experimentation
Social experimentation is where the client, under the counsellor’s guidance, will undergo ‘social experiments’ to provide evidence against a particular maladaptive belief (Bond & Dryden, 2002). For example; A young man enjoys wearing makeup yet is worried about being judged. The counsellor may urge them to go out with makeup in a relatively safe environment and see if anyone comments or judges him. Ideally, the client will see that people are either apathetic or supportive of his choice of expression, thus shaking their maladaptive beliefs. However, social experimentation must be practised with caution; an event to support the irrational belief will be highly detrimental to therapy (Bond & Dryden, 2002).



Homework
Homework is one of the primary practices in CBT, it is essentially worksheets where the client puts the self disputing techniques that the therapist is trying to teach (Bond & Dryden, 2002). See figure 2.

Issues with these techniques
The main issue with these techniques is that they require a large amount of client engagement and motivation. The time and effort to complete some of these tasks to a decent level is high and may be too unapproachable for some clients. Furthermore, the techniques are quite cognitively advanced, as such, some clients with learning disabilities may have difficulty (Corey, 2015).

Summary of CBT theory
CBT is a school of therapy that focuses on changing thoughts about an event to correct emotions and behaviours. By using disputing techniques, clients will see how unrealistic and harmful their maladaptive beliefs are and change them to healthier thoughts with the counsellor’s guidance.

What is anger?
The  American Psychological Association (APA) categorises anger as an emotion that arises when one feels deliberately wronged by an individual or situation. Essentially it is the feelings that occur when an individual or group is treated unjustly (APA, 2021).



Anger is an evolutionary cognitive construct; it is in place to help humans survive and seek out correcting the source of antagonism. However, anger can be harmful if extended for prolonged periods, as it works similarly to the cognitive dissonance discussed before. Furthermore, anger can affect those around the suffering individual, potentially leading to unnecessary arguments and even physical harm to themselves or others (Novaco, 2016). See figure 3.

Anger management
Due to the adverse effects of anger, managing and controlling this anger has long been a topic of discussion. Anger management attempts to reduce anger’s physical and emotional symptoms (Lochman et al., 2004). From an emotional standpoint, anger management is the control of the actual emotion of anger. At the same time, events will still happen that potentially cause anger; good anger management reduces and controls those feelings (Lochman et al., 2004). The therapist will help the client regulate their body's reaction to anger from the physical side of anger management. Physical control is developed by controlling one's breathing, thus slowing the heart and decreasing the fight or flight response sent by the sympathetic nervous system (Lochman et al., 2004).

Application of CBT for anger management
CBT is an effective treatment of Anger disorders, especially in building control. Like the basic premises of CBT, anger results from a maladaptive belief about the situation (Deffenbacher, 2011). By changing this belief, CBT anger management therapists aim to reduce anger for similar future problems. CBT must follow the ABC framework to identify and understand the situation (Deffenbacher, 2011).

Case study
A case study will be used to understand the application of CBT for anger management.

Case Study: Bill is a semi-professional AFL player; at 22 years old, he is a highly-skilled player and hopes to get drafted soon. Bill always tries to play the best he can but often gets angry if he makes a mistake; this involves shouting, hitting the ground, and even lashing out at other teammates. Bill believes that he will be drafted to a professional team sooner by consistently playing at an exceptionally high level. When games are lost, especially when he could have played better, he is worried that he will no longer be seen as the best and will lose his chance at being drafted. Bill’s anger outbursts often make both himself and his team play worse, creating a vicious cycle of anger and underperformance. Recently the team has been fed up with Bill’s attitude and have asked him to look for help with his anger management. See figure 4.

What are the ABC's of Bills situation?

Answer: This is a complex situation as there are multiple layers; by breaking it down, the therapist can take on specific beliefs and thought processes

A - The activating event is Bill making mistakes

B - The belief is that if Bill does not play perfectly, he will not be drafted

C - The consequences of this belief are that Bill often gets angry at himself and his teammates in aggressive, potentially abusive ways.

By breaking the situation down into the ABC framework, the therapist will see precisely the maladaptive belief and theorise ways to tackle it. Simply being aware of the core belief that dictates behaviour can be instrumental to behaviour change. While a therapist is beneficial, it can be unnecessary, so CBT is prominent in “self help” (Deffenbacher, 2011). Here is a link to try it for yourself.

CBT technique specific approaches to the case study of Bill
Now that the basic understanding of the issue has been established, the therapist can begin the disputing process of Bill’s core belief.

Basic level of disputing:
This will be a role-play between the therapist and Bill:

Therapist: What evidence is there to suggest that to be drafted, you have to play perfectly?

Bill: To be drafted, you have to be the best of the best. I look at all these fantastic players on TV, and I know that there is no way I'll be chosen to compete against them if I'm not at least this good. For instance, look at Fred; he is one of the best players of all time; I bet he never made mistakes when he wanted to get drafted.

Therapist: Everybody is human, and mistakes are a natural part of being human; it is impossible to be perfect, let alone in the high-pressure environment of professional sports. As good as you say Fred is as a player, don’t you think he may have made mistakes now and again, logically thinking, he has to make mistakes sometimes, right?

Bill: Huh... I guess so. Now that I think of it, I do see him make mistakes sometimes.

Therapist: If he makes mistakes, like the rest of us do, don't you think you are too hard on yourself, saying that you can never make mistakes. Instead, what if you try to reword that thought a little so it is more realistic?

Bill: OK, how about "I want to be perfect, but I will make mistakes sometimes, and that is OK, I’m human, and I make mistakes."

This example is an abbreviated session. It may seem a little unnatural as it assumes a prior understanding in the client; however, the general idea of the therapy session remains. The therapist disputed the notion that he had to be perfect and provided reasonable evidence to support that claim. This disputing process caused Bill to look closer at his belief and change it into something healthier through working closely with the therapist. Repeating this mental dispute in therapy and at home will reduce the overly emotional and physical response to anger by changing the thoughts behind the anger response (Bond & Dryden, 2002).

REI
If the therapist was going to attempt REI with Bill, they would first have to establish a realistic situation that is likely to occur in the future and may lead to anger. From discussing it with Bill, a case was theorized where Bill made a mistake and the opposing team scored a goal. Initially, Bill imagines the situation with as much detail as possible, especially paying attention to his thoughts. Particularly, Bill emphasises his perfectionist thoughts leading up to the incident and the frustration following the mistake. The therapist will encourage Bill to delve into the anger and behaviours that potentially emerge, such as lashing out at teammates.

Following this, Bill will go through the entire event in his imagination again; however, the therapist will encourage him to replace the maladaptive thoughts with healthier ones. Bill imagines the football game again, approaching the specific mistake; Bill identifies the perfectionist thinking and attempts to change it. A suitable replacement might be; “I’m going to try my best”, rather than “I have to be the best”. After the mistake occurs, Bill attempts to change the anger reaction to something more realistic and helpful. Bill’s original thinking may have been something along the lines of, “I made a mistake, I'm useless, and I will never be drafted”. Instead, Bill attempts to change his thinking too; I made a mistake, but I am only human; all I can do is try my best. The chances of me being drafted will not be affected by a single mistake”.

The process of REI identified and corrected significant maladaptive thoughts in a typical situation; through repeated practice; Bill will have more control over his thoughts in-game.

However, due to the advanced nature of disputes going on during the session of REI, it requires a decent amount of experience to be done effectively. Clients must be actively aware of their maladaptive thoughts, and to be effective, REI will need suitable replacements to be effective (Deffenbacher, 2011).





Homework
Bill’s therapist may also assign him some homework between sessions to support the work in therapy. The basic level of CBT homework usually follows the basic ABC formatting (Bond & Dryden, 2002). Bill will write down what happened, what he felt and did as a result of the event and then write what he should have thought. Through actively thinking and writing, Bill purposefully builds his self disputing skills, allowing him to control his emotions in distressing situations.

A different application to homework is proofing, or evidence gathering, where Bill will seek information that disproves some of his maladaptive beliefs (Bond & Dryden, 2002). Bill believes he makes too many mistakes, whereas the therapist believes that this is over-exaggeration. Throughout the week of training sessions and games, Bill would record every costly mistake made. After the week, Bill comes back and is surprised that the number and severity of errors were much lower than he expected. Through doing this, Bill will realise that he doesn't make as many mistakes as he first thought and simply gives far too much weight to the mistakes that he does make. See figure 5.

While this does not directly target anger, it targets self-defeating thoughts that lead to irritation. Bill’s beliefs about himself will slowly change by constantly breaking down these maladaptive thoughts, and his anger management will improve overall.

A longitudinal approach
A firm idea of CBT’s approach to anger management therapy has been established; the question remains; how effective is this treatment overall? As such, two meta-analyses have been chosen, one from 1998 and one from 2016. A meta-analysis is a quantitative study used to equate and assess the results of previous research within a given period for a specific topic. These meta-analyses can determine a firm understanding of the effectiveness of CBT for treating anger and anger management.

Study from 1998
The 1998 study by Beck and Fernandez covered two decades worth of CBT anger management literature, totalling 50 specific studies. Overall they found that when compared to clients without treatment as a baseline, CBT anger management clients had a 76% improvement in controlling their anger. These results imply that CBT is an effective treatment option in anger management and encourage future research into optimising treatment (Beck & Fernandez, 1998).

Study from 2016
The 2016 study by Henwood, Chou and Browne focused on the effectiveness of CBT on anger management, with application to recidivism. This essentially asks whether CBT anger management prevented released criminals from reoffending (Henwood et al., 2015). Fourteen studies were used, with an overall indication that the CBT treatment decreased chances of reoffending by 23% and 28% in general and violent crimes, respectively (Henwood et al., 2015). This improvement is moderate, however considering the history of violent crimes, any progress is significant.

Particularly interesting was that more than half of the studies used were classified as high risk for selection bias. This bias means that the studies chose treatment groups based on what they thought would support their hypothesis the most. This potentially indicates that the data obtained may be subject to error (Henwood et al., 2015). See figure 6.

Implications of research
The two studies have interesting implications that will be discussed to build a firmer understanding overall. The first meta-analysis suggested a decent increase in anger management after treatment, which is initially promising. The second meta-analysis indicated a moderate improvement, especially in the case of violent crime. This is an important distinction because violent crime may have resulted from an outburst of anger. The results trending higher for reducing violent crime are highly supportive of CBT being effective for anger management. Given the age difference between both studies, yet similar results, it can be seen that CBT for anger management has remained consistent throughout clinical use.

Conclusion
Anger is a complex issue that therapy can tackle from many different perspectives, the purpose of this chapter was to provide information on a popular application; CBT. Initially, through theory research, an understanding of the basic tenets of CBT being the ABC framework and disputing was established. Furthermore, CBT in practice is often complex and creative in the pursuit of challenging maladaptive thoughts. Secondly, the understanding of anger as an emotion and anger management, in general, was understood with reference to the APA definition. Specific approaches of CBT to anger management were provided with examples. Particularly the case study following Bill was used to establish a thorough knowledge of CBT’s application. Lastly, two major meta-analyses found that CBT is quite effective for anger management therapy through decades worth of research. Overall CBT proves to be a reliable and effective treatment for anger management, and will continue to develop as a field of therapy.