Working With Anger

In Working With Anger, Dr. Lorne Korman demonstrates his approach to treating clients who present with problems of anger and aggression. This integrative approach to anger treatment recognizes that the underlying causes of anger and aggression problems vary by individual. An important aspect of treatment involves assessing the underlying emotional, behavioral, cognitive, and motivational processes that may be contributing to a client's anger problems. Therapy often involves teaching clients about anger and personal anger cues, and enhancing the client's motivation to reduce anger.

In this session, Dr. Korman works with a man in his 30s with anger and aggression issues surrounding road rage. He first educates the client about anger, then provides strategies for monitoring his feelings and reducing angry behavior.

Dr. Korman's approach to treating anger and aggression problems is integrative. His approach has been influenced by a number of theoretical orientations, including dialectical behavior therapy (DBT), emotion-focused therapy, and cognitive behavior therapy.

This integrative approach to anger treatment recognizes that the underlying causes of anger and aggression problems frequently vary by individual. An important aspect of treatment therefore involves assessing the underlying emotional, behavioral, cognitive, and motivational processes that may be contributing to clients' anger problems. That is, rather than viewing anger problems as having a single, consistent cause, the approach emphasizes the importance of assessing for specific and often interdependent processes, learned behaviors, and functional deficits associated with clients' anger problems so that these may be targeted in therapy.

After establishing a clear contract to work on reducing anger, maladaptive angry behaviors are typically targeted on an episode-by-episode basis. As in many cognitive–behavioral approaches, clients initially are instructed to complete a daily diary of their angry actions and thoughts, including any emotions they experienced. Considerable emphasis is placed on identifying and educating clients about covert angry behaviors that frequently precipitate overt angry and aggressive behaviors. These covert behaviors include fantasizing about revenge, "injustice collecting," ruminating and obsessing, scanning the environment for violation, hostile attributions, and blaming and judging.

In order to assess the maladaptive processes, learned behaviors, and the deficits contributing to clients' anger problems, functional analysis is used to explore specific episodes of clients' problem anger and aggressive behaviors. On occasion, particular processes may also be evident from clients' in-session behaviors, including angry interactions with the therapist. Appropriate interventions are then selected to target the specific emotional, cognitive, or behavioral problems identified by the clinician.

These problems, and their appropriate interventions, include:

• Deficits in the ability to be aware of or symbolize primary emotional experience like sadness and fear, often accompanied by the tendency to express secondary anger, usually are addressed by psychoeducation, mindfulness and focusing exercises, and with emotion awareness exercises.
• Clients' lack of motivation to address anger problems is addressed through motivational interviewing and DBT commitment strategies.
• Habitual angry acting and thinking styles are addressed by thought and behavioral records, mindfulness, and the rehearsal of new, incongruent behaviors.
• Difficulties tolerating primary emotional experiences like sadness, fear, frustration, and anger are addressed by training in distress tolerance skills.
• Deficits in the ability to express anger in a healthy way are addressed through training in adaptive anger communication strategies.
• Deficits in the ability to express emotions other than anger are addressed by emotion awareness exercises and by training in communication skills.
• Contingency-based angry reactions are addressed by withdrawing contingencies reinforcing problem behaviors and by shaping and practicing adaptive incongruent responses.
• The presence of maladaptive beliefs or attitudes engendering angry behaviors is addressed by psychoeducation.
• Cognitive distortions engendering anger are addressed by psychoeducation, training in identifying cognitive appraisals and automatic thoughts, and through cognitive restructuring.
• Deficits in assertiveness skills are addressed by assertiveness training.
• Classically conditioned ultrasensitivity or problematic angry reactions to loss, shame, and fear-related cues are addressed by insight strategies, exposure to relevant cues, and extinction.
• An angry ruminative or obsessive style is addressed by using thought records and by thought stopping.
• The inability to forgive is addressed by forgiveness training and practice.
• The inability to accept and resolve prior experiences of violation, hurt and loss is addressed by psychoeducation and radical acceptance.
• A rigid, humorless cognitive style is addressed by training in humor.

This approach has been used to treat individuals who have problems with anger and aggression, clients with comorbid anger and addiction (including gambling) problems, and angry individuals who have borderline personality disorder or other personality disorders.

This treatment is not intended to treat individuals who score high on indices of psychopathy.

Lorne Korman, PhD, CPsych, is the director of research of the British Columbia Provincial Youth Concurrent Disorders Program and clinical assistant professor of psychiatry at the University of British Columbia, Vancouver. Previously he was founder and head of the Anger and Addiction Clinic at the Centre for Addiction and Mental Health and assistant professor of psychiatry at the University of Toronto, Ontario. He is a registered psychologist and received his PhD in clinical psychology from York University in Toronto, Ontario.

Dr. Korman has authored publications on the treatment of comorbid anger and addictions, problem gambling, borderline personality disorder, and on emotion and change processes in psychotherapy. His research includes randomized control trials of integrated treatments for comorbid anger and addictions, and studies examining the relationships between anger, problem gambling, and intimate partner violence. Dr. Korman has taught numerous workshops on anger and addictions and on dialectical behavior therapy and borderline personality disorder across Canada and internationally.

• Feindler, E. L. (2006). Anger-related disorders: A practitioner's guide to comparative treatments. New York: Springer.
• Greenberg, L. S., & Paivio, S. C. (1997). Working with emotions in psychotherapy. New York: Guilford Press.
• Kassinove, H. (1995). Anger disorders. Washington, DC: Taylor and Francis.
• Korman, L. M. (2005). Treating anger and addictions concurrently. In W. J. Skinner (Ed.), Treating concurrent disorders: A guide for counselors (pp. 215–234). Toronto, Ontario: Centre for Addiction and Mental Health.
• Korman, L. M., & Collins, J. C. (2005). Violence and anger history interview. In W. J. Skinner (Ed.), Treating concurrent disorders: A guide for counselors (pp. 235–248).Toronto, Ontario: Centre for Addiction and Mental Health.
• Korman, L. M., Collins, J. C., Dutton, D., Dhayananthan, B., Littman-Sharp, N., & Skinner, W. J. (2008). Problem gambling and intimate partner violence. Journal of gambling studies, 24(1), 13–23.
• Korman, L. M., Collins, J. C., Littman-Sharp, N., Mercado, V., McMain, S., & Skinner, W. J. (in press). Integrated treatment for comorbid anger and gambling. Psychotherapy Research.
• Korman, L. M., Cripps, E., & Toneatto, T. (2008). Problem gambling and anger: Integrated assessment and treatment. In M. Zangeneh, A. Blaszczynski, & N. E. Turner (Eds.), In the pursuit of winning: Problem gambling theory, research, and treatment (pp. 251–270). New York: Springer.
• Korman, L. M., & Greenberg, L. S. (1996). Emotion and therapeutic change. In J. Panksepp (Ed.), Advances in biological psychiatry, Vol. II (pp. 1–22). Greenwich, CT: JAI Press.
• Linehan, M. M. (1993). Cognitive–behavioral treatment of borderline personality disorder. New York: Guilford Press.

APA Videos

• Dialectical Behavior Therapy
  Alexander L. Chapman
• Dialectical Behavior Therapy for Adolescents With Multiple Problems
  Alec L. Miller
• Emotionally Focused Therapy With Couples
  Leslie S. Greenberg
• Emotion-Focused Therapy Over Time
  Leslie S. Greenberg
• Problem-Solving Therapy
  Arthur M. Nezu and Christine Maguth Nezu
• Responding Therapeutically to Patient Anger
• Treatment With Defiant and Aggressive Adolescents
  Fred J. Hanna

APA Books

• Constructive and Destructive Behavior: Implications for Family, School, and Society
  Edited by Arthur C. Bohart and Deborah J. Stipek
• Forgiveness Is a Choice: A Step-by-Step Process for Resolving Anger and Restoring Hope
  Robert D. Enright
• Helping Clients Forgive: An Empirical Guide for Resolving Anger and Restoring Hope
  Robert D. Enright and Richard P. Fitzgibbons
• Road Rage: Assessment and Treatment of the Angry, Aggressive Driver
  Tara E. Galovski, Loretta S. Malta, and Edward B. Blanchard
• Therapy With Difficult Clients: Using the Precursors Model to Awaken Change
  Fred J. Hanna