رفتاردرمانی شناختی مردان و خشم: سه مطالعه موردی

The treatment of men with anger problems presents significant challenges for practitioners. This article discusses a cognitive-behavioral, individual therapy, approach within the framework of three single case studies involving men. Treatment challenges and methodology are presented. Key treatment issues included: establishing a therapeutic relationship; facilitating understanding of the cognitive basis of anger; and addressing male-role socialization messages and male-identity schema that contributed to the experience and expression of anger in these men. Limitations relative to the small sample (n = 3) and the lack of a randomized control group preclude any definitive statements regarding the effectiveness or generalizability of the intervention. Nevertheless, the study highlights important theoretical and practical concerns for practitioners and future researchers to consider when working with men and anger.

According to the National Institute of Justice Centers for Disease Control and Prevention (1998), men are the primary perpetrators of interpersonal violence. Other studies have indicated that men are also the primary perpetrators of workplace aggression (Anfuso, 1994 and Paul and Townsend, 1998) and road rage (AAA Foundation, 1997), which has been characterized as the expression of anger and frustration at other drivers (Smart, Mann, Zhao, & Stoduto, 2005). Even though not all violence or aggression is necessarily rooted in anger, one could argue that anger plays a significant role in many instances of violent or aggressive behaviors. Norlander and Eckhardt (2005) have suggested that despite differing opinions about the role of anger in interpersonal violence, it is hard to ignore mounting evidence indicating that anger is not only a risk factor for interpersonal violence, but that anger is a characteristic of interpersonal violence perpetrators. Such expression of anger through aggression often has dire consequences for the angry person, for those around him or her, and for society at large. Therefore, it would seem logical that efforts to reduce acts of violence and aggression by men should include helping men cope with anger more effectively. Review of Anger Treatments DiGiuseppe and Tafrate (2003), in a meta-analytic review of anger treatments, suggested that the literature on anger has been hampered by a reliance on “undergraduate subjects, short treatment lengths, and a dearth of studies using individual sessions” (p. 71). In another meta-analytic review of the literature on cognitive behavior therapies (CBT) and anger, Beck and Fernandez (1998) reviewed 50 studies and found that only 1 relied on adult volunteers as subjects. The rest of the studies fell into categories such as college students, school children, juvenile delinquents, clinical adolescents, abusive spouses/parents, and inmates. Furthermore, a review of 23 anger treatment outcome studies by DelVecchio and O’Leary (2004) revealed that 17 of those studies (74%) relied on undergraduate college students, 3 studies focused on male veterans, and 3 other studies focused on adults that did not fall into any of these two categories; only 1 study (Tafrate & Kassinove, 1998) had been published in the recent literature. A review of recently published outcome studies using CBT to treat anger reveals that, with the exception of Tafrate and Kassinove (1998) and Grodnitzky and Tafrate (2000), the majority of published anger treatment studies can be classified as relying either on college students (Deffenbacher, Dahlen, Lynch, Morris, & Gowensmith, 2000) or special populations. A sample of these special populations includes, among others, prisoners convicted of violent offenses (Echeburua et al., 2006, Howells et al., 2005 and Ireland, 2004), offenders with intellectual disabilities (Taylor et al., 2002 and Taylor et al., 2005), aggressive drivers (Galovski & Blanchard, 2002), cocaine-dependent individuals (Reilly & Shopshire, 2000), or anger related to other disorders such as Asperger’s syndrome (Attwood, 2004). The studies that did not rely on either of the above-mentioned groups (Tafrate and Kassinove and Grodnitzky and Tafrate) primarily used a repeated imaginal or in-vivo exposure as the main strategy for anger reduction. One could argue that the overreliance on college populations, mandated clients, or special groups highlights the gap that exists in the current research regarding the focus on adult, self-referred men, and raises questions around the generalization of such findings to self-referred individuals. This article begins to address such issues by focusing on adult men who initiated treatment. Men and Anger As stated, a review of the literature on anger treatment underscores two significant issues: the lack of focus on self-referred, nonoffender men; and the lack of attention given in treatment to the effect of specific male-role socialization messages that shape men’s masculine identity schemas, and how such beliefs contribute to the experience and expression of anger and other emotions. Some authors have theorized that men generally are not socialized to express vulnerability and nurturing, and instead receive and internalize familial and sociocultural-bound messages that reinforce a “take charge” stance (Levant, 1997 and Mills and Rubin, 1992). Such male-role socialization often creates a masculine identity that normalizes the expectation, in boys and men, of an independent and tough attitude, which in turn normalizes the expression of anger and aggression (Cox et al., 2000 and Levant, 1997). Campbell (1993) suggested that, for men, anger may serve as an instrument to buffer against vulnerability, to establish control over situations, and to gain the respect of peers. Furthermore, Copenhaver, Lash, and Eisler (2000) studied a sample of 163 men and argued that men with high levels of adherence to such male role identity experience greater levels of what they described as masculine gender-role stress (MGRS). Copenhaver et al., define MGRS as “the tendency for such men to experience distress in the context of situations they appraise as a challenge or threat to their masculine identity” (p. 406). The authors suggest that men with high-MGRS experience higher levels of anger when compared with men with low-MGRS. Purpose of the Study This study outlines a therapeutic approach to treat anger in men that differs significantly from other anger treatments in the sense that it addresses the concerns expressed by DiGiuseppe and Tafrate (2003): the study focuses on self-referred adult men undergoing a fairly lengthy treatment approach, 16 sessions, delivered through individual therapy. Additionally, the treatment addresses specific challenges that practitioners may face when working with angry men, namely: the establishment of a therapeutic relationship; facilitating awareness of cognitive themes associated with anger; and the uncovering and restructuring of maladaptive male-identity schemas that relate to the experience and expression of anger. The treatment described here includes traditional cognitive, behavioral, and psychoeducational strategies to help decrease levels of trait anger and improve overall functioning. The general components of treatment include the following: assessment of anger and general emotional symptoms in order to establish a therapeutic baseline; development of a therapeutic alliance; exploration of significant childhood experiences and the impact of such on the formation of relevant schemas; cognitive conceptualization of anger through the delineation of specific cognitive themes that underlie anger, with special focus on male-role socialization messages; challenging and reframing dysfunctional thinking; and the implementation of behavioral strategies to improve coping skills, including the assertive and socially responsible communication of anger and other emotions. Healthy Anger Versus Toxic Anger When treating anger one must make the distinction between the experience and expression of anger that is healthy and functional versus the anger that is dysfunctional, unhealthy, or “toxic.” Anger in itself is a common human emotion that when experienced and expressed in a healthy and functional manner, with mild to moderate levels of arousal, helps the individual to communicate feelings clearly, directly, and assertively, and to implement socially appropriate corrective measures to resolve an unwanted situation (e.g., injustice or unfairness) (DiGiuseppe, 1995). However, anger becomes maladaptive or toxic when it is experienced and/or expressed in ways that have a detrimental effect on the angry individual and others. This maladaptive expression of anger detracts from the individual’s ability to identify and implement healthy measures to resolve unwanted situations. It is this maladaptive or toxic anger that becomes the target of treatment. The notion of “toxic anger” implies that anger has become a harmful, destructive, or deadly agent. Such anger may be expressed as aggression, verbal or physical, with high levels of internal or external arousal; “stuffing” the emotion and avoiding its healthy expression; passive-aggressively or indirectly; or by redirecting the anger toward other pathologies such as substance abuse (Gilbert et al., 1998, Larimer et al., 1999 and DeMoja and Spielberger, 1997), self-cutting (AbuMadini and Rahim, 2001, Harris, 2000 and Matsumoto et al., 2004), and bulimia (Meyer et al., 2005). Three Angry Men The three cases reviewed for this study—Paul, Vince, and Keith—had similar personal, demographic, and experiential characteristics. The three clients were adult, white males ranging in age from 32 to 47, married with children, and employed in positions of responsibility. Relevant childhood data revealed that the men shared the experience of growing in abusive home environments, where they were regularly exposed to either severe and harsh verbal criticism or physical aggression by one or both parents. In all three cases the maladaptive expression of parental anger seemed to be a common occurrence throughout their formative years. Paul described his mother as an “angry, manipulative, hypercritical, mentally cruel, and physically abusive woman.” His father was described as “emotionally unavailable.” The parents seemed to argue constantly. Vince’s father was described as “angry and abusive,” and his mother as “quiet and passive.” Along the same lines, Keith saw his father as an “alcoholic,” “a mean and nasty person” who got “nastier and meaner” during his drinking episodes. His mother was described as emotionally detached and unexpressive. For each of the men, such childhood experiences had contributed to the formation of maladaptive core beliefs that they held about themselves, others, and the world at large. Paul related that from an early age, after years of being belittled and criticized, he began to believe “there was something wrong with me” and that “I was not good enough.” As an adult he often thought “I am not as good as my co-workers.” His view of others was punctuated by suspiciousness and distrust. He generally saw others as nontrustworthy individuals who “will take advantage of you if you let them.” Similarly, Vince saw himself as “inferior to others,” and he viewed life and others in general as being “unstable and undependable.” Keith’s self-view was punctuated by beliefs that he was “worthless” and that he “did not matter” to others, including his family. He articulated the belief that his family only saw him as a “meal ticket.” Despite their childhood experiences and the negative beliefs about the self and others, each man had strived to succeed and had managed to do so, at least in a professional or business perspective. Paul was a successful midlevel executive with master’s degrees in engineering and business administration. Vince had received a number of promotions at work and had been recently promoted to supervisor at the auto plant where he worked. Keith was a self-employed building contractor who had developed a successful business that allowed him to provide a comfortable lifestyle for his family. However, despite their successes, the men felt strong insecurities that underscored a sense of being inferior to others, as well as a hypervigilance and alertness to perceived criticisms and slights. They often felt “disrespected” and “belittled” by others. One could argue that their drive to succeed was their attempt to compensate for their own sense of unworthiness. Another common characteristic among the three men was a rather demanding and task-oriented attitude that characterized their interactions across various spheres of functioning. Paul saw himself as a “taskmaster” who, at work and at home, pushed himself and others hard to get results. Vince was described by his wife as “overly demanding.” He verbalized rigid rules as to how others, particularly those close to him, “should” behave. He prided himself in his “strict approach” to discipline—an approach that often caused conflict with his stepchildren. Keith admitted that he was an “intense” and “demanding” person. This demanding, perfectionist, and task-oriented attitude had served a useful and functional purpose for each of the men. All three believed that such an attitude had been instrumental in their successes at work and in their individual careers. Therefore, they were not necessarily ready to change. The challenge in therapy would be to let the men see how such traits might have been useful in some aspects of their lives, but not so useful in interpersonal relationships, and in many instances how they had contributed to their unhealthy expressions of anger. Although the three men were self-referred to treatment, they had done so after much internal deliberation following significant pressure exerted by their spouses or employers to “do something” about their anger. The three men were facing the possibility of either divorce or loss of employment (in the case of Paul). Paul and Keith had each experienced a “last straw” event resulting in the need to seek treatment. For Paul it was a fit of road rage in which he challenged a motorist to a fistfight while his wife and children sat terrorized in the car with him. In the case of Keith it was an episode of rage, including destruction of property and verbal abuse, toward his 15-year-old daughter when she returned home after running away for 2 days. At that point his wife threatened to leave and take the children, thus underscoring the long-standing toxic impact that Keith’s anger had had upon the family throughout the years. For Vince, on the other hand, it was a gradual accumulation of arguments with his wife and stepchildren that led him to seek treatment. The men acknowledged that they had anger problems and that they did not want to lose their families. However, they expressed a qualified admission of responsibility for their emotional and behavioral reactions as they saw themselves as “targets” of others’ provocations. Assessment Process The assessment process included a clinical interview to obtain a detailed biopsychosocial history and to identify internalized messages that contributed to the onset and maintenance of toxic anger. The men completed the State-Trait Anger Expression Inventory (STAXI; Spielberger, 1988) and the adult psychiatric outpatient version of the Brief Symptom Inventory (BSI; Derogatis, 1993). The STAXI measures the experience and expression of anger along six scales (state anger, trait anger, anger in, anger out, anger control, and anger expression) and two subscales (anger temperament and anger reaction). For the purpose of this study the focus was on the trait anger scale. The trait anger scale includes 10 items that measure “the disposition to perceive a wide range of situations as annoying or frustrating and the tendency to respond to such situations with more frequent elevations of state anger” (Spielberger, p. 1). Internal consistency for the trait anger scale is α = .87. Trait anger scores are interpreted by converting the raw scores to T scores that correspond to percentile ranks which in turn are compared with scores of other individuals similar to age and gender. Scores that fall within the 25th and 75th percentile are considered to be within the normal range (Spielberger). The BSI (Derogatis, 1993) is a 53-item instrument that assesses psychological distress along nine scales: anxiety (AX), depression (DEP), interpersonal sensitivity (I-S), hostility (HOS), phobic anxiety (P-A), obsessive-compulsive (O-C), somatization (SOM), paranoid ideation (P-I), and psychoticism (PSY). There is also a global severity index (GSI), which gives an overall measure of psychological distress. The BSI is interpreted by converting the raw scores to T scores. A score of 63 or above on the GSI, or two scores of 63 or above on any of the other scales, is considered indicative of psychological distress. Internal reliability for the nine scales of the BSI range from a low α = .71 for psychoticism to a high of α = .85 for depression. Test-retest reliability measures range from .68 (SOM) to .91 (P-A). Test-retest reliability of the GSI scale is .90 (Derogatis). Internal reliability for the GSI has been reported by Baider et al. (2004) at .96. The men also maintained a treatment log where they kept track of the frequency and intensity of anger episodes using a subjective units of distress scale (SUDS; Wolpe, 1990) ranging from 1 to 10 (1 = mild disappointment, 10 = enraged). The log became a means for self-monitoring as well as a way to provide an ongoing source of assessing progress throughout treatment. An objective of the initial assessment was to evaluate the client’s perception of the problem and level of readiness to change. Although each client admitted that anger at times had been a problem, there was also a significant level of ambivalence toward changing. This ambivalence is consistent with the contemplation stage as outlined by Prochaska, Norcross, & DiClemente’s (1994) stages-of-change model. Prochaska et al. maintain that “contemplators want to change, but this desire exists simultaneously with an unwitting resistance to it” (p. 110). This unwitting resistance seemed driven by their belief that their anger served a functional purpose, and that it was generally provoked by others’ transgressions. The assessment process also revealed useful information relative to how the path of anger expression varied from man to man. Paul and Keith reported “flying off the handle” with a “hair trigger” temper. Vince, on the other hand, seemed to “stew” in his anger before reacting aggressively. This knowledge had therapeutic implications: Key tasks for both Paul and Keith would be to heighten their awareness of anger cues (cognitive, physiological, behavioral, affective, and situational) so as to help diffuse volatile situations; prevent further escalation of anger; and increase the probability of implementing strategies to facilitate healthier outcomes. Vince, on the other hand, had some awareness of anger cues but he did not know how to act in such situations. He was aware of the thoughts that fueled his anger, but he did not know how to challenge or reframe them in order to alter the outcome. Therefore, such thoughts played out unchallenged in his mind and created a slow boil that led to a toxic anger response. Treatment Cognitive-behavior therapies have been found to work effectively in the reduction of anger (Beck and Fernandez, 1998, Deffenbacher et al., 2000 and Reilly and Shopshire, 2000). In the model outlined in this study, treatment was conceptualized as moving through three stages outlined by Meichenbaum, 1985 and Meichenbaum, 1996 with specific objectives that underscored the work through each stage. The first stage, Sessions 1 to 3, focused on helping the client develop a conceptual understanding of anger by increasing his awareness of the impact of thoughts and beliefs on emotional and behavioral responses. Another key objective of this first stage of treatment was to establish a therapeutic alliance with the angry client. The overall goal of the second stage, Sessions 5 to 12, was to help the client acquire specific cognitive and behavioral skills to manage anger effectively. During this stage clients learned to identify, challenge, and restructure specific anger-inducing cognitions. Within that process specific attention was given to the identification and restructuring of internalized gender-role socialization messages that possibly influenced dysfunctional expression of anger. The third stage, Sessions 13 to 16, focused on applying and generalizing therapeutic gains to the client’s life outside therapy, reinforce successes, and troubleshoot problems in managing anger. Individual sessions were defined by specific themes (see Table 1) and followed a structured framework outlined by Beck (1995). The first 12 sessions were provided on a weekly basis and the last 4 sessions took place every other week.

Although the three clients presented in this study appeared to have benefited from this treatment, additional research is needed to validate the key treatment variables discussed in the previous section. Therefore, larger and controlled studies would help to more accurately assess the effectiveness of the intervention. Nevertheless, the findings do provide some directions for future studies that may want to assess the impact of such variables on treatment outcomes. The sample in this study was small (n = 3) and homogeneous (adult white males). The men in the study were also fairly intelligent and educated, with capacity for good levels of insight. Although at the onset of treatment the clients manifested a level of ambivalence indicative of the contemplation stage of change ( Prochaska et al., 1994), they were not in outright denial. So questions remain as to how well such treatment would fare with more culturally diverse populations as well as with more resistant clients. Future studies could also assess whether the cognitive themes expressed by angry clients do occur sequentially and whether that sequence leads to the escalation of the intensity of the experience and expression of anger. Finally, more research is also needed to evaluate the relationship between male-role socialization messages, male-identity schema and anger, with particular attention given to how such messages may shape the way that angry men experience and express their anger. Nevertheless, the men in this study reported not only a reduction of anger, but also improved symptomatology. At the end of treatment each client believed that he had a better understanding of the cognitive basis of anger, and more clearly recognized the dysfunctional role that anger had played in his life. The men also felt empowered, as a result of the cognitive-behavioral skills acquired in therapy, to cope with adversity or setbacks and communicate anger and other emotions in more socially appropriate ways.