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Warwick BABCP conference: pre-conference workshop on anger (1st post)

OK, the annual summer British Association for Behavioural & Cognitive Psychotherapies conference has come around again and this year it is back at Warwick University.  As usual there are a wealth of one-day pre-conference workshops - a dozen in all this year.  I'm off in a few minutes to Ray Novaco & John Taylor presenting on "Anger dysregulation: assessment, case formulation, and treatment".  

The workshop publicity states: Anger dysregulation occurs in various personality, psychosomatic, and conduct disorders, in schizophrenia, in bipolar mood disorders, in organic brain disorders, in impulse control dysfunctions, in disorders resulting from trauma, and it is the emotional driver of challenging behaviour for persons with intellectual disabilities. Anger treatment should be grounded in assessment of anger control deficits and be case formulated.  Substantial validity and utility for a multi-modal approach to the assessment of anger among clients, including those having intellectual disabilities, has been obtained in clinical research, as interfaced with anger treatment. Psychometric, staff-rated, and interview methods of assessment will be presented.  Case formulation will be practised using an anger dysregulation model.  Our CBT stress inoculation approach to anger treatment will be illustrated and fundamentals of the approach will be demonstrated and practised for use in anger treatment sessions.

Key learning objectives

1.  Familiarity with anger self-report and staff-rated psychometric instruments and their clinical use 
2.  Ability to implement client self-monitoring procedures
3.  Use of an imaginal provocation test for anger to assess treatment gains
4.  Ability to do case formulation from anger assessment and anger dysregulation model
5.  Understanding cognitive restructuring, arousal reduction, & behavioural skills therapy components
6.  Proficiency in provocation hierarchy procedures in stress inoculation format
7.  Familiarity with treatment outcome evaluation procedures

Key references 
Novaco, R. W., & Taylor, J. L.  (2015). Reduction of assaultive behavior following anger treatment of 
forensic hospital patients with intellectual disabilities. Behaviour Research & Therapy, 65, 52-59. 
Novaco, R. W. (2010).  Anger and psychopathology. In M. Potegal, G. Stemmler, & C. Spielberger (Eds.). Handbook of anger (pp. 465-497).  New York: Springer.
Taylor, J. L., & Novaco, R. W. (2005).  Anger treatment for people with development disabilities.    Chicester, England: Wiley.
Novaco, R. W. (2003).  The Novaco Anger Scale and Provocation Inventory Manual.  Los Angeles:             Western Psychological Services.

... and now I'm writing having attended the workshop.  How did it go?  "OK".  What was good included the key issues of alerting & informing me much more about anger, about anger assessment, and about approaches to anger treatment.  This is definitely helpful and very much why I signed up for this workshop in the first place.  I am a very experienced CBT therapist, but I'm naive about treating anger.  We have so much teaching on anxiety and depression and so little typically in our training on anger.  I guess part of this is because clients don't frequently present ... in my experience ... asking for help with anger.  However for a decade or so now I've had Posternak & Zimmerman's findings nagging in the back of my mind.  In the the abstract of their paper "Anger and aggression in psychiatric outpatients"they write "BACKGROUND: This study sought to evaluate the degree of anger and aggression experienced by psychiatric outpatients and to determine whether anger is as prominent an emotional state in these patients as are depression and anxiety. We also sought to determine which Axis I and Axis II disorders were associated with increased rates of subjective anger and aggressive behavior. METHOD: 1300 individuals presenting to a psychiatric outpatient practice underwent semistructured interviews to evaluate current DSM-IV Axis I (N = 1300) and Axis II disorders (N = 687). Levels of subjective anger and aggression during the preceding week were assessed in each patient, and the odds ratios were calculated for each disorder. A multiple regression analysis was performed to determine which psychiatric disorders independently contributed to the presence of subjective anger and aggressive behavior. RESULTS: Approximately one half of our sample reported currently experiencing moderate-to-severe levels of subjective anger, and about one quarter had demonstrated aggressive behavior in the preceding week. This level of anger was found to be comparable to the levels of depressed mood and psychic anxiety reported by our sample. Major depressive disorder, bipolar I disorder, intermittent explosive disorder, and cluster B personality disorders independently contributed to the presence of both anger and aggression. CONCLUSION: Anger and aggression are prominent in psychiatric outpatients to a degree that may rival that of depression and anxiety; it is therefore important that clinicians routinely screen for these symptoms."

So that's one rather startling study from over ten years ago.  Well how about this year's paper from Okuda & colleagues ... "Prevalence and correlates of anger in the community: results from a national survey" ... with its abstract reading "Introduction Little is known about the prevalence and correlates of anger in the community. METHODS: We used data derived from a large national sample of the U.S. population, which included more than 34,000 adults ages 18 years and older. We defined inappropriate, intense, or poorly controlled anger by means of self-report of the following: (1) anger that was triggered by small things or that was difficult to control, (2) frequent temper outbursts or anger that lead to loss of control, or (3) hitting people or throwing objects in anger. RESULTS: The overall prevalence of inappropriate, intense, or poorly controlled anger in the U.S. population was 7.8%. Anger was especially common among men and younger adults, and was associated with decreased psychosocial functioning. Significant and positive associations were evident between anger and parental factors, childhood, and adulthood adverse events. There were strong associations between anger and bipolar disorder, drug dependence, psychotic disorder, borderline, and schizotypal personality disorders. There was a dose-response relationship between anger and a broad range of psychopathology. CONCLUSIONS: A rationale exists for developing screening tools and early intervention strategies, especially for young adults, to identify and help reduce anger."

Well, well ... it does look like I'm right here.  Anger seems something of an iceberg problem.  Quite possibly I will only occasionally get clients coming with this as a key item that they're troubled by, but it is likely to be a difficulty that quite a high percentage of clients suffer with.  I think I need to screen for it better and have a clearer idea of what treatments could be helpful.  I've bitten the bullet and ordered myself a second hand copy of "The international handbook of anger" .  It's an eye-watering £131.03 new on Amazon, but I've gone for a still expensive second hand copy.  I notice that amongst the 32 book chapters (and nearly 600 pages) is one on "The nature and measurement of anger" which is likely to give me a good overview on screening and assessment.  For now Ray Novaco gave us the DAR-7, a seven item version of his "Dimensions of anger reactions (DAR)" questionnaire, in the workshop handouts.  Irritatingly this questionnaire, as apparently with so many of the anger assessment instruments, is copyright.  I notice that an even shorter version of this screening measure performs well in the recent paper by Forbes et al "Utility of the Dimensions of Anger Reactions-5 (DAR-5) scale as a brief anger measure".  And the DAR-5 is given in its entirety in another recent Forbes et all paper "Evaluation of the dimensions of anger reactions-5 (DAR-5) scale in combat veterans with posttraumatic stress disorder", which (happy days!) is downloadable in free full text from ResearchGate.

The main body of the conference approaches rapidly, so I probably won't write more about this workshop on anger.  The main take-home messages are that it has confirmed my suspicion that 1.) anger is a significant problem in the general population, in clients coming for help with anxiety & depression, and in many "special populations". 2.) we don't screen for these difficulties adequately and much suffering is missed. 3.) there are approaches that genuinely make a difference (see, for example, the results reported in Novaco & Taylor's 2015 paper).  So it's a workshop I'm very glad to have attended.  Now it's up to me whether I make sure it makes a genuine difference to my therapeutic practice.

For what happened at the conference proper, see the next post "Warwick BABCP conference: 1st morning - trauma memories & a master presentation on four decades outcome research (2nd post)".


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