The Application of Acceptance and Commitment Therapy to Problem Anger

Available online at www.sciencedirect.com

Cognitive and Behavioral Practice 18 (2011) 241–250www.elsevier.com/locate/cabp

The Application of Acceptance and Commitment Therapy to Problem Anger

Georg H. Eifert, Chapman UniversityJohn P. Forsyth, University at Albany, State University of New York

1077© 20Publ

The goal of this paper is to familiarize clinicians with the use of Acceptance and Commitment Therapy (ACT) for problem anger bydescribing the application of ACT to a case of a 45-year-old man struggling with anger. ACT is an approach and set of interventiontechnologies that support acceptance and mindfulness processes linked with commitment and behavior change processes. Here, weoutline an ACT model of problem anger, extend that analysis to a clinical case, and illustrate ACT intervention strategies andassessment considerations. As will be seen, ACT teaches individuals to “act on life, not an anger” by choosing and committing to liveconsistently with personal values rather than acting on anger feelings and associated behavioral impulses.

ANGER is a ubiquitous and particularly destructiveemotion, and although it is often easy to spot, it is

much harder to define in scientific terms. The process ofanger can be ignited by a number of events, typicallystarting with the experience of emotional hurt anddiscomfort, and quickly followed by judgment andblame directed at self or others. This process can setinto motion a wide range of behavioral predispositions toact. Problem anger, as we see it, is this predispositionmanifesting in anger behavior, and where the conse-quences of that behavior are damaging to self and others.

Our intention here is to lay out a conceptualizationof problem anger based on Acceptance and Commit-ment Therapy (or ACT, said as one word; Hayes,Stroshal, & Wilson, 1999), and then to apply thatanalysis to the case of Mr. P (Santanello, 2011). ACT, asmany readers know, is a newer behavior therapy, builtupon a technical account and model of humansuffering and its alleviation. The model explains howindividuals get entangled in language and verbal-symbolic behavior processes that trap them in a strugglewith thoughts and emotions they experience as aversive(Hayes, Barnes-Holmes, & Roche, 2001). ACT has twomajor goals: (a) acceptance of unwanted thoughts andfeelings whose occurrence or disappearance clientsoften cannot control, and (b) commitment and actiontoward living a life consistent with a client's values. ACTinvolves both acceptance and change, and uses several

-7229/10/241–250$1.00/010 Association for Behavioral and Cognitive Therapies.ished by Elsevier Ltd. All rights reserved.

metaphorical, experiential, and behavior change tech-nologies to undermine processes that support narrowingof behavioral options, while creating broader and moreflexible patterns of behavior that help clients move inthe direction of chosen life goals (Forsyth & Eifert,2008; Luoma, Hayes, & Walser, 2007).

Before we move on, we wish to acknowledge that ouranalysis of Mr. P is limited to the case description aspresented, and is arguably speculative. Nonetheless, wehope that some of what you are about to read may behelpful in illustrating ACT as applied to problem anger(see Eifert, McKay, & Forsyth, 2006).

ACT Model of Problem Anger

All human beings carry the capacity to experience andexpress anger. Yet, if you look past the experience ofanger and the associated urge to act, you will often find avulnerable human being who is hurting in some way(Hanh, 2001; McKay, Rogers, & McKay, 2003). Indeed,there is ample evidence linking emotional and physicalpain (including loss) with anger (Berkowitz, 1993; Smith& Gallo, 1999). One approach is to address the paindirectly and its functional relationship with angerbehavior. Another tactic is to target the anger itself, andthe often-destructive consequences of anger manifest inanger behavior. There are whole industries built aroundmanaging anger, the feeling, and its outward expression.Yet, unless we can address processes that transform pain(physical or emotional) into anger, we may never get thekind of durable solution to problem anger that we seek,and truly address the main social ills that seem to flowfrom anger behavior.

http://dx.doi.org/

242 Eifert & Forsyth

Anger typically occurs in an interpersonal context andstems from at least four related sources (Eifert et al.,2006): (a) thoughts, typically of judging or blaming,suggesting that other people (or the self) have violatedor failed to meet personal needs, or firmly held ideasabout right and wrong, rules about conduct, and so on;(b) strong belief in these thoughts, which are held asliterally true, such that judgment and blame are treatedas properties or qualities of self and other behavior (e.g.,“that bastard screwed me over” is not simply a thought,but “bastard” and “screwed over” are seen as qualities ofthe person and their actions and intentions); (c) stronglybelieved-in thoughts catalyze unpleasant emotionalresponses, from feelings of hurt, fear, anxiety, tension,shame and guilt, and ultimately anger and rage; and (d)strong urges or impulses to resolve the welling discom-fort are translated into actions, namely efforts to rightthe presumed injustice by struggling to control otherpeople, particularly their behavior, in order to have one'sneeds met.

With problem anger, the terminal point in thissequence is often anger behavior, and this behaviortends to create more problems than it solves. Angerbehavior is also largely ineffective in the long-term as ameans to reduce or eliminate painful anger-feelings andassociated feelings of hurt, shame, and guilt. Suchbehavior does tend to get in the way of the life peoplewant, and imperils or destroys relationships. It may alsoadversely affect work, health, and well-being, and reduceoverall enjoyment of life (McKay et al., 2003; Suarez,Lewis, & Kuhn, 2002).

From an ACT point of view, anger is a naturalconsequence of six related processes that can lead to anarrowing of behavioral options or, in ACT terms,“psychological inflexibility.” This is defined as “theinability to modulate behavior in response to how usefulit is––changing behavior when change is needed andpersisting when persistence is needed––so as to accom-plish value-guided ends” (Hayes & Strosahl, 2004, p. 25).We briefly describe each of the six processes below, andthen apply them to Mr. P's case. We will also describehow they link up with ACT targets for change thatpromote psychological flexibility, which is the ability tocontact the present moment more fully and to eitherchange or persist with goal-directed behavior whendoing so serves to accomplish desired ends (Hayes &Strosahl, 2004, p. 5). As we do that, it is important to beappropriately cautious. Despite a growing literaturesupporting the operation of each of the six processesacross various forms of human suffering (see Hayes,2008; Hayes et al., 2006), there is relatively little worklinking these processes directly to problem anger and itstreatment. We hope that this case series may advanceand encourage that kind of work.

Cognitive Fusion and Defusion

Conscious or automatic thought, usually in the form ofevaluative judgment and blame, can transform pain intofull-blown anger. Within ACT, the form or frequency ofsuch thoughts tends to be less important than the fact thatpeople frequently buy into them and do what they seemto demand, even when doing so is largely unhelpful.Cognitive fusion is a term used within ACT to describe thetendency for humans to get caught up in the content ofwhat they are thinking and to take their thoughts literally,believing that these thoughts accurately describe howthings are rather than seeing them as what they are: justthoughts. More technically, cognitive fusion refers to thedominance of automatic and derived stimulus functionsentailed in language over more direct and experientialfunctions with the end result that “literal evaluativestrategies dominate in the regulation of human behavior,even when less literal and less judgmental strategies wouldbe more effective” (Hayes, 2004, p. 13).

For instance, if someone said the word lemon, it islikely that you could see it in your mind's eye and perhapsexperience some of its tart properties. Yet, thinking lemondoes not make you a lemon, right? You are not thatthought. This point is often lost on people struggling withanger, including other related forms of emotional andpsychological pain (e.g., guilt, shame, stress, anxiety). Thethought “you hurt me” is not just a thought like “this is alemon” for someone who is struggling with anger. It is anunacceptable thought, linked with unpleasant feelings(e.g., hurt, embarrassment, and shame), other thoughtssuch as intention (e.g., “she meant to hurt me”) andjudgment (“that's not right”), and one's sense of self (e.g.,“I am inadequate, weak, or stupid”), and thus appears todemand some action.

Judgment here appears to be a quality of the pain andits source. What we often overlook is that this process ofevaluating is not a property of what is being evaluated––although to the person who is doing the evaluating itappears to be so. Ramnerö and Törneke (2008) providethe example of a woman who states that her “anxiety isunbearable.” She sees the unbearability as a characteristicof her anxiety, not as the result of her own relationalresponding. In fact, human beings can evaluate just aboutanything in innumerable ways, and yet fail to see that thisprocess is arbitrary (i.e., largely shaped by socialconvention) and not a property of nature (e.g., a rose isa rose, whether you call it stupid, beautiful, ugly, precious,dumb). When a person is hurting and adds layers ofjudgment and blame, it does little to ameliorate the hurt,but only shifts responsibility for the hurt to anotherperson (“you did this to me”), and with that shift thehurting person becomes a victim. The important skill tolearn here is to learn to recognize the evaluations thatour mind constantly comes up with and, based on past

243ACT on Life, Not on Anger

experience, decide when acting on these evaluations islikely to be helpful and when it is not.

Cognitive fusion is neither bad nor good. It is a naturalbyproduct of language processes. The critical question iswhether it is helpful or not in a particular situation. Withproblem anger, fusion with pain plus judgmental evalu-ation more or less goes on unchecked, and the result incases of problem anger is often this: the initial experienceof hurt morphs and transforms into anger and anarrowing of behavioral options in the form of whatseems like inevitable and justifiable anger behavior.

ACT employs several defusion exercises to weakencognitive fusion where it is unhelpful. Such exercises, ofwhich mindfulness may be a part, help clients let go of theidea that one's thoughts are valid descriptions andexplanations of one's experiences. Instead, clients gainperspective to see their thoughts as only thoughts. Anotherway to conceptualize this is in terms of the distinctionbetween self-as-content (I am my thoughts) and self-as-process (I am having the thought that…). Self-as-contenttends to emerge from cognitive fusion, whereas self-as-process denotes a more defused and flexible stance.

Attachment to the Conceptualized Self Versus

Self-as-Context

This is another form of cognitive fusion because it isfusion with one's self-concept (the stories we tell aboutourselves). People become invested in how they perceive(conceptualize) themselves. In short, people literallybelieve their own stories about who they are, even whendoing so results in significant harm. The truth of the storiesis irrelevant because the stories are accepted as true.

Attachment to the conceptualized self results in rigidbehaviors aimed at validating or defending one's stories,which contributes to psychological inflexibility. Withanger, this can manifest as attachment to being right,being loved, looking smart, not making mistakes, havingone's needs met regularly, or ideas about fairness, justice,and how people ought to be treated. It can also manifestas holding on to personal narratives or stories about one'slife, including relations between the past and the presentand the present and the future (“I've always been a loosecannon”). Anything that may threaten the conceptualizedself, in turn, is a likely trigger and target for angerbehavior. A rigid attachment to the conceptualized selfmay manifest in many ways (e.g., defensive resistance andexcessive reasons and justifications for behavior, thoughts,and feelings; ways of speaking that link the self withevaluative labels or with the past; rigid rules of conduct).

Detachment from the conceptualized self requirescognitive defusion, a process of distancing oneself fromspecific thoughts to gain psychological flexibility. Clientsare encouraged to step back from and observe their

personal narratives and stories, noticing that their storyabout themselves is different from the person doing thenoticing. For instance, just as you can notice and observeobjects in the world around you, you can also just noticeand observe thoughts, sensations, urges. This may involvelearning to notice that the stories clients tell aboutthemselves (e.g., “I inherited depression from mymother” or “I've always been hot-headed”) are just oneof several possible stories that could be told, that suchstories can be held lightly and looked at in terms of howthey function, and more important, that attachment toone or more particular stories may not be working well.

Experiential Avoidance Versus Acceptance

Anger can serve as a powerful means to avoidemotional and psychological pain. The emotion ofanger can quickly mask psychological hurt and pain andredirect attention away from the self and toward otherpeople who are seemingly responsible for the hurt. Withthis shift may come a sense of power and control. Thisshift also can keep people from recognizing and dealingwith their pain, while fostering ruminative thinking abouthow one might get back at the people who seeminglytriggered the hurt and anger to begin with. Language andcognition make it possible for pain linked with anger togeneralize to many life areas, which is part of the reasonwhy anger can be so destructive, and at the same time, sodifficult to avoid.

Experiential avoidance is a term used within ACT todescribe rigid and inflexible efforts to escape from or avoidunpleasant private events—thoughts, emotions, and bodilysensations—and the circumstances that might occasionthem (Hayes et al., 1999; Hayes, Wilson, Gifford, Follette, &Strosahl, 1996). It also involves attempts to change theform or frequency of these events to make them lesspainful, even when doing so results in significant harm(e.g., substance abuse, physical violence). Such attempts,often in the form of direct change efforts, requireconsiderable effort, typically do not work in the long-term to avert pain and reduce anger, and end up causingmore suffering and damaging relationships (Tangney,Wagner, Hill-Barlow, Marschall, & Gramzow, 1996).

There are many ways that one can avoid painfulemotional and psychological triggers for anger, includingthe discomfort associated with anger itself. For instance,attributing blame and responsibility for one's pain tosomeone else is a powerful strategy to avoid takingresponsibility for the hurt and the pain one is experienc-ing in the moment. Even when these attributions arecorrect, their long-term effects are often deleterious; thecritical issue here, as with cognitive fusion, is to helpclients explore whether such strategies have worked in thelong run in terms of producing the desired outcome, or


whether such strategies have not worked, leaving clientsfeeling like their life has been reduced to the size of apostage stamp.

Acceptance literally means to take what is offered, andentails (a) remaining in contact with painful experiences(b) without attempting to alter their form or frequencyand (c) persisting in actions that are consistent with one'spersonal values. As such, acceptance-based strategiesoppose experiential avoidance while offering somethingnew. Such acceptance fosters new and more flexible waysof relating to painful or uncomfortable emotional andpsychological experiences. The effectiveness of accep-tance strategies has been demonstrated in the treatmentof such diverse problems as chronic pain, anxietydisorders, self-injurious behaviors, and smoking (for acomprehensive review, see Hayes et al., 2006).

Disconnection From the Present Moment

Behavior therapists have traditionally adopted a here-and-now focus with their clients precisely because thepresent is where problems manifest and are amenable tochange. The present is also the place where we can act tomake a difference in our lives. Anger can underminecontact with the present, which then becomes a placedominated by anger-related private and public behavior,and for many people these behaviors are hurtful obstaclesto creating a meaningful life.

If clients are fused with their private events, they are“living in their heads” and are not in contact with what isgoing on in their life in the present, moment-to-moment.Not only is their focus on their inner world, it is alsolocated in the past or future, remembering and antici-pating painful events, ruminating about past wrongs,imagining retribution to the wrong-doers, or ponderinghow to get back or get even in the future.

The antidote to such disconnection is mindful contactwith the present moment. In its most basic form,mindfulness is about focusing our attention on thepresent moment and making direct contact with ourpresent experiences, with acceptance and without de-fense, and with as little judgment as possible (Kabat-Zinn,1994). The functions of mindfulness within ACT are tofoster defusion, to help clients become observers ratherthan responders to their experience, and to foster greatertolerance of and kindness towards the experience ofunwanted cognitions and emotions. Another importantfunction of mindfulness is to promote greater contactwith present contingencies that may be more useful inshaping and guiding behavior. A variety of strategies areused within ACT to foster mindfulness, both in sessionand outside of session, and we will describe one of themlater in the section on intervention strategies for problemanger.

Unclear Values

The dominance of language and cognition, coupledwith significant pain, self-defense, and avoidance, cangreatly interfere with a good quality of life in domainssuch as relationships, intimacy, family, work, recreation,health, or spirituality. Within ACT, anger is a problemprecisely because anger behavior dominates over otherbehaviors in life domains that are important to the client.Pain, anger, and anger behavior become so central, thatclients often lose sight of their values, or what is reallyimportant to them.

A central aim of ACT is to help clients clarify theirvalues and then find ways to more fully enact them. Valuesprovide direction for action. They are enacted in patternsof action designed to reach specific goals. Values can belikened to a lighthouse or compass that shows clients thedirection they want to move in. Goals are specific concretewaypoints on the map, places they plan to visit as theymove in the direction of their values. Goals involve actionspeople can put on a list, complete, and then tick off.Values, on the other hand, cannot be attained orcompleted––they are ongoing commitments that arereflected in moment-to-moment actions. We cannot ever“finish” a value (Dahl & Lundgren, 2006). For instance, ifa client values intimacy, there are many ways in which thatvalue can be enacted, and one could create a list of goalsand then check them off when completed. Yet, the valueof intimate connection with other human beings is notsomething that one can finish or check off; there is alwaysmore than can be done.

Thus, the critical question is whether actions aremoving a client toward or away from what they caredeeply about, or want to be about as a human being.Without having clear values, clients find it difficult to act.They feel “stuck,” and their behavior becomes habitualand automatic, which is itself a common feature ofproblem anger and a form of psychological inflexibility.One of the goals of ACT is to help clients focus on theirvalues and clarify them so that they can direct theirbehavior toward actions that foster what matters in theirlives. One could start this process in treatment byexploring a client's response to the following question:If anger weren't such a problem for you (or “if we couldmake anger just disappear”), then you'd be doing what?

Inaction With Respect to Values

Inaction with respect to values is a clear indication ofpsychological inflexibility (Luoma et al., 2007). Inactioncomes from different sources, including being unclearabout one's values. It also is a by-product of experientialavoidance in which clients are so consumed withdefending themselves from painful experiences thatthey cannot act, or act in ways that are damaging to


them and what they truly care about. Or, if they do act,their actions are likely to be ineffective or maladaptiveand exacerbate their problem. A major goal of ACT is toget clients to act, but in ways that are in the service of theirvalues—in other words, value-guided action as opposed toanger-guided behavior.

Case Conceptualization

An ACT Approach to Problem Anger

From the case description of Mr. P, one could extractbehaviors that fit each of the six processes that arebelieved to promote psychological inflexibility. In fact, auseful exercise here would be to go back to the casedescription and see if you can identify each of the sixprocesses, or at least some of them before reading on.Here, we will provide a brief outline of how weconceptualize Mr. P's problems from an ACT perspective.

An ACT case conceptualization tends to be functionaland focuses on the six processes described earlier. Mr. Pseems to have a long history of learning that theexpression of anger behavior is normal and adaptive.Thus, it is likely that he has learned, directly or indirectly,that anger behavior is associated with positive conse-quences, whereas the expression of a range of normalhuman emotions (e.g., sadness and fear) was often metwith punishing consequences. It also seems that his angeris precipitated by events that evoke other unpleasantemotions, and thus one might expect that Mr. P will bemore prone to experience and express anger whenfeeling various forms of discomfort (e.g., stress).

Being punished for the healthy expression of emotion,in turn, likely shaped the use of various emotionregulation strategies to avoid punishing consequences(i.e., early history of reinforcement for experientialavoidance), with anger expression being linked withshort-term reinforcing consequences. Anger is a powerfulemotion that can quickly overshadow other forms of painand discomfort, and thus can function as a form ofexperiential avoidance. Mr. P appears to engage in angerbehavior when pain threatens to overwhelm him. He thenengages in blame and external attributions of responsi-bility as reasons for action or inaction (e.g., not takingresponsibility for making changes in therapy), and thusavoids personal responsibility for his choices and actions(e.g., being verbally aggressive toward others). Collective-ly, these actions may function to reduce the hurt anddiscomfort he experiences prior to anger episodes.

Moving beyond this basic history, there is evidence forfusion, the conflation of thoughts with reality—in severalparts of the case description. For instance, he seems tofirmly believe the story that “he does not have an angerproblem” and that “external stressors are the realproblem.” Holding on to this story leads to a shift,where other events and people are held responsible for

the stress and discomfort Mr. P experiences, rather thanhim taking responsibility for how he responds to histhoughts, feelings, and emotions. Fusion with judgmentalthoughts about the “nagging” girl-friend, “idiot drivers,”and his “blaming” and “misunderstanding” formertherapist all lead to one basic conclusion: other peopleare at fault. Believing (“buying into”) these anger-triggering thoughts are the psychological equivalent ofpouring gasoline on a fire to put it out. The illusion thatthe mind creates here is that nagging and idiot areproperties of people, when they are nothing more thanthoughts. Mr. P also appears fused with the thought thathe is basically powerless and at the mercy of his anger, andthus is more or less a victim of idiots, nags, jerks, and otherwrongdoers in his life.

Mr. P seems to be fused with his sense of self too,describing himself as someone that is “difficult to handle”and as a person that others are intolerant of. The story isthat others need to change, not me, and it is they (notme) who have the problems: “I am not a jerk like otherpeople; others ought to know that, including knowingwhat I want, need, and desire.” And, it is important to bestrong, with anger behavior being a reasonable way toshow that. He also appears entangled in a victim story, andis afraid of opening up, being vulnerable, and takingresponsibility for his behavior. Facing these issuessquarely would likely be difficult for Mr. P, not simplybecause it would hurt facing his unpleasant feelings, butalso because he may need to face the social and othercosts caused by his choices and anger behavior.

In terms of values, it seems that Mr. P has not givenmuch thought to what he wants his life to be about asindicated by his somewhat ambivalent response to hisexpectations for treatment, namely, “I guess I'd like toenjoy my life more.” What does seem clear is that Mr. P'sanger behavior has resulted in negative consequencesacross several life that are important to him, namelycareer (e.g., loss of several jobs for aggressive and violentbehavior), his relationships with his former wife and nowwith his current girlfriend (e.g., using verbal aggression to“punish” his girlfriend when he is upset by her actions)and his children, his health (e.g., anger and blamedestroyed opportunities to benefit from his prior effortsin psychotherapy), and more generally other people. Thetriggers here appear to be forms of discomfort, includingreading intention into the actions of other people (e.g.,being misunderstood or snubbed, others speaking to himin a demeaning way, judgment that others would betrayhim). Being unwilling to express his thoughts and feelings(remember history of punishment for doing so), coupledwith failure of others to meet his expectations, set thestage for a struggle.

In sum, the case description conveys a fairly rigid andinflexible behavior repertoire dominated by anger


behavior, which is largely under aversive control. Behaviorunder aversive control tends to result in a narrowing ofbehavioral options: “High levels of avoidance patternstend to increasingly narrow the repertoire of behaviors inwhich an individual engages and often create secondaryproblems in an individual's life” (Jacobson, Martell, &Dimidjian, 2001, p. 259). From an ACT perspective, thisnarrowing of behavioral options is the heart of psycho-logical inflexibility, and is created and maintained by thesix interrelated processes that we outlined earlier. Werecommend that a clinician evaluate whether these ACT-relevant processes are present in a given case and howthey operate functionally in the context of angerbehavior. The challenge for the therapist is to help theclient establish other, more flexible and viable options forbehaving. This is accomplished by targeting processes thatmaintain psychological inflexibility and by modeling andsupporting alternative processes that encourage psycho-logical flexibility.

The remainder of this paper focuses on some ACTintervention strategies that may be used to underminepsychological inflexibility in cases of problem anger. AnACT approach to problem anger builds on the basicideas that although it may seem that anger behavior is aninevitable (even justifiable) consequence of angerfeelings, this need not be the case: People can learn torespond differently to the hurt and discomfort theyexperience when anger ignites and still choose to act inways that uphold their values. This is why early on it iscritical to help clients learn to distinguish between anger“the feeling” and anger “the behavior.” As will be seen,fostering psychological flexibility means increasing be-havioral options by learning to mindfully contact andaccept distressing thoughts and feelings, learning todisentangle from one's evaluative mind, and engage inbehaviors that are consistent with chosen values.

General Therapeutic Strategy and Goals: ACT on Life,

Not on Anger

One of the core skills to be learned in ACT is how torecognize and refrain from self-perpetuating and self-defeating emotional, cognitive, and behavioral avoid-ance routines. Learning acceptance, mindfulness, andother defusion skills undermines excessive and rigidemotion regulation (Blackledge & Hayes, 2001) whilefostering actions that are in the service of living a values-oriented life instead of living a symptom-free life(meaning less angry). Thus, ACT is different fromwhat many clients and therapists typically expect must bedone to solve anger problems. ACT is not about helpingclients to control or manage anger. Such strategies mayprolong clients' struggle for effective anger control as aprerequisite for effective action, and may even increase

the likelihood of relapse when such strategies fail towork as intended.

We have summarized an ACT approach to problemanger as teaching individuals to act on life, not an anger(Eifert et al., 2006). One of the main goals of treatment isto target unsuccessful efforts to control and get rid ofaversive anger-related thoughts and feelings by acting onthem. For this reason, it is essential that Mr. P firstexperience the personal, social, and other costs associatedwith acting on anger feelings. He also needs to learn todistinguish what is difficult to control (experiencinganger feelings) and what he can control (his actions––what he does with his hands, feet, and mouth). Althoughit is difficult, and at times impossible, to control intensefeelings, thoughts, memories, images, sensations, andimpulses (Abramowitz, Tolin, & Street, 2001; Petrie,Booth, & Pennebaker, 1998; Salkovskis & Reynolds,1994; Trinder & Salkovskis, 1994; Wenzlaff & Wegner,2000), he can learn to control and change how heresponds to discomfort, including anger-related feelingsand impulses. He also needs to learn to recognizeevaluations that his mind constantly comes up with(“idiot driver,” “she wants to hurt me”) as thoughts thathe can have without needing to respond to them or dowhat they implicitly or explicitly seem to tell him to do.

One important therapeutic goal is to help Mr. P to stoptrying to get rid of or keep anger-related thoughts andfeelings down when they arise. Instead, he can learn howto change his relationship with, and response to, suchuncomfortable and painful aspects of his history. To getthere, he needs to learn how to acknowledge angrythoughts instead of believing in and acting on them. Toaccomplish this, an ACT therapist would likely employexperiential exercises, metaphors, and imagery to contactthe unworkability and costs of coping and other angermanagement strategies, and that he can make a differentchoice: He can choose to leave them alone and simplyexperience them as thoughts or feelings. Most impor-tantly, these experiential exercises can show him that hedoes not have to act on his anger-related thoughts andfeelings––they need not drive what he does. For instance,as much as he may feel like tailgating another motoristwho drives “too slowly”, he can instead learn to notice andwatch his anger feelings and resentful thoughts and not dowhat they tell them to do.

It will be important early in treatment for Mr. P to learnthat such changes are not desirable simply for social ormoral reasons, but if enacted, such changes may help himlive the life he wants to live without letting anger get in theway. Recall that a central aim of ACT is to promotepsychological flexibility, or the ability to live in the presentmoment more fully and with less avoidance and defenseso that “individuals can change or persist in behavior whendoing so serves valued ends” (Hayes et al., 2006, p. 7, italics


added). To this end, ACT would teach Mr. P to notice andacknowledge his anger-related thoughts and feelings, torespond less literally to his anger-related thoughts bydecreasing their believability, and to commit to andpursue life goals important to him. As clients are guidedin learning these skills, we also nurture the developmentof compassion for themselves and others. The goal is forclients to rediscover what truly matters, to focus on whatthey want their life to stand for, and then to act in waysthat move them forward in their lives. This process maymean bringing anger or other unwanted thoughts andfeelings “along for the ride.”

The actual delivery of ACT is more akin to a fluiddance around several core processes rather than a linearprogression. This is consistent with the view that ACT is afunctional approach, not merely a therapy or collection oftreatment technologies. It builds on a model with severalinterrelated treatment targets that are continually revis-ited throughout therapy (Hayes et al., 2006). For instance,cognitive fusion is addressed with mindfulness and otherdefusion strategies that also help reduce believability ofthoughts and attachment to stories about the self, thepast, or future. Experiential avoidance is weakened byproviding clients with skills to stay with unwantedcognitions and emotions rather than attempting tomove away from them. Remaining open and sensitive tothe present moment is directly fostered with mindfulnessexercises. Committing to and engaging in value-guidedaction is facilitated by letting go of old attachments andnot getting entangled with thoughts that are not helpfuland constructive in guiding an individual toward the lifethey want to live.

What this means is that concepts, metaphors, andexercises introduced early on may be revisited again atany time they seem relevant. This is consistent with ACT asa principle-guided approach, where the focus is onchanging the function of internal experiences ratherthan their content or absence and presence (Forsyth &Eifert, 1996).

Specific Assessment and Intervention Techniques

Creative Hopelessness: Assessing the Costs of AngerOne of the first steps in treatment is for the therapist

and Mr. P to explore his former solutions to problems,with an eye on how well they have worked both in theshort and long term, and whether they are workable at all.Using a worksheet (Eifert et al., 2006), Mr. P would beencouraged to explore the costs of anger behavior in keylife domains such as interpersonal relationships, career,health, and self-concept. The goal is to let Mr. Pexperience how much responding to anger feelings withanger behavior has cost him in the various areas of his life.The case description already alludes to significant costs in

terms of strained relationships with his children anddifficulty maintaining employment that are likely to beelucidated in this exercise. A related assessment work-sheet is designed to help Mr. P look back at his pastattempts to manage and control anger and examine whattriggers his anger feelings. At the surface, these triggersare often people and situations, but most importantly arealso internal triggers such as feelings of being frustrated,threatened, hurt, ashamed, and guilty. For each trigger,Mr. P would write down his coping strategies (what heactually did) and the outcome of his actions.

The goal of these exercises is not to make Mr. P feelhopeless. Rather, creative hopelessness is about lettingMr. P experience that his former strategies and solutionsto manage his anger are hopeless in that they have notworked and have only damaged important personal andprofessional relationships in his life. This process iscreative and empowering because it makes space forhim to act in a different way that is more consistent withwhat he really cares about.

Letting Go of the Struggle––Learning Where Control Is HelpfulMr. P stated that he believes he has no control over his

anger or his tendency to become aggressive. It is thereforeimportant for Mr. P to learn to distinguish what is difficultto control (his anger feelings and thoughts) from what hecan learn to control (his behavior). The notion of notdoing what anger feelings strongly suggest and letting goof the struggle with anger thoughts and feelings iscounterintuitive and likely to be quite alien to Mr. P.Again, rather than trying to convince Mr. P, the therapistcan employ a number of metaphors and exercises that willhelp Mr. P experience that he has more control over hisactions than over his thoughts and feelings. The tug-of-warexercise has been used extensively (e.g., Eifert et al., 2006;Forsyth & Eifert, 2008; Hayes et al., 1999) to let clientsexperience what it feels like to let go of the struggle withunwanted thoughts and feelings.

This metaphor could be introduced in the context ofexploring Mr. P's struggle to “get even” with people whoannoy him. The therapist could gently suggest that thiswar sounds like a fight with an anger monster and couldask Mr. P if he is willing to see how this might play out inthe room. The therapist would then play the role of theanger monster in a tug of war with Mr. P using an actual arope (about 3 to 4 feet long). Both therapist and Mr. Pwould take the rope and start pulling. To enhance theexercise, the therapist may bring important life areas intothe room, and particularly areas where anger feelingstend to occur and lead to destructive behavior that gets inthe way of value-guided action.

As the tug of war unfolds, Mr. P would notice thatefforts to pull harder result in the monster pullingharder right back. Acting out this exercise will let Mr. P


physically experience how much energy and focus ittakes to keep his anger in check. We have found thatalmost all clients will grab the rope with both of theirhands when the therapist hands it to them. This is a verygraphic illustration of how the struggle can leave ourhands tied up in the fight and no longer free to doanything else.

The key element of the exercise is to let clientsexperience that they have a choice: One choice is tocontinue to fight, another is to drop the rope. The choiceis not whether the anger monster (e.g., intense feelings)shows up or not, but whether to pick up the rope or not.Once Mr. P drops the rope, he can experience thedifference this action makes and what he gains from it. Atthat point, the therapist can point out in a very concretefashion what Mr. P cannot control (i.e., presence,intensity, quality of painful thoughts and feelings) andwhat he can control, which is what he does with his hands,feet, and mouth. Incidentally, therapists need not worryabout ending up in a fight with their clients. We havefound that clients fully recognize and stay within theplayful boundaries of the exercise.

Approaching Anger With Mindful Acceptance andGentle Awareness

This step introduces Mr. P to acceptance andmindfulness as a skillful way of approaching his angerexperiences and his life. Accepting anger involvesrecognizing and staying with unpleasant thoughts andfeelings—making space for them—without acting onthem. It is not about agreeing or disagreeing with them,nor does it mean giving in, or giving up. For Mr. P, itmeans to simply learn to notice any feelings of rage,blame, guilt, shame, or inadequacy without arguing withor trying to replace them. In short, to observe anger-related thoughts and feelings without getting caught up inevaluation or judgment and without holding onto, gettingrid of, suppressing, or otherwise changing what heexperiences.

The goal is for Mr. P to learn an observer perspective inrelation to his anger-related feelings and thoughts. Avariety of closed eyes exercises, described elsewhere(Eifert et al., 2006), are used to develop this skill. Anotheroption is to adapt a more generic exercise, such as theAcceptance of Thoughts and Feelings exercise (Eifert &Forsyth, 2005), by including thoughts and sensationsrelated to anger. This is a 12-minute closed eyes exercisethat he would be asked to practice once a day. Theexercise encourages willingness to experience unpleasantthoughts and feelings that are difficult for the client andprovides him with a tool for doing so. The larger goal is toundermine any tendency to react to anger-relatedthoughts and sensations with anger behavior. The secondgoal is to help Mr. P differentiate what he can control

from what he cannot control in his life, and to identifywhere he has choices.

For example, Mr. P cannot do much about the ragearising in his body or the vengeful thoughts popping intohis mind when other motorists “drive like idiots.” Yet, hehas options when it comes to how he responds to themand what he does with them. The purpose of these andrelated exercises is to set the stage for gradually replacingold, habitual, automatic ways of behaving (such as blowingup) with intentional, new, flexible ways of behaving thathe can consciously choose. By practicing mindfulness andother defusion exercises, he can learn over time to simplywatch his feelings and thoughts, recognize them asfeelings and thoughts, and absolutely not do as they say.Learning to recognize and stay with unwanted feelingswhen he has them is an important first step towardlearning not to respond with anger behavior because ofanger feelings.

Facing Anger and Hurt With CompassionBehind many episodes of anger is unresolved and

often hidden pain and hurt. To let Mr. P experience hishurt and emotional pain and provide him with anopportunity to learn to stay with these experiences, thetherapist may conduct a number of “anger exposure”exercises. These exercises would first be practiced insession and at home, so that he can apply the skills later insituations where his anger gets triggered. The long-termgoal is to develop willingness to be in contact with hisanger and not act on it. These exercises involve asking Mr.P to imagine recent episodes of anger and get in touchwith all the evaluative thoughts, emotions, sensations, andurges he experiences in those situations. The goal of theseexercises is (a) to learn to recognize and acknowledgeanger, rage, fear, guilt, rejection, and hurt when he feelsthem; (b) develop the courage to do nothing and just sitwith his anger feelings and thoughts with increasingdegrees of kindness and compassion; and (c) develop anobserver's perspective with his anger experience. Watch-ing, without judging, his feelings will allow him todisentangle himself from what his body and mind aredoing and give him the control to act in ways that matterto him.

Anger needs an enemy to exist and grow (Ellis & Robb,1994). Meeting anger with compassion and forgivenessleaves anger with no room to grow. Developing compas-sion is incorporated in anger exposure exercises byadding imagery components that foster (a) acknowledg-ing his hurt and pain as it is, without judgment or denial;(b) softening to his experience using his wise mind(McKay, Wood, & Brantley, 2007) while inviting healingand change; (c) extending compassion to his experienceand that of others; and (d) letting go and moving on––releasing the grudges, resentment, and pain, and then


moving forward in his life in directions he wants to go.Thus, compassion entails both engaging in acts ofkindness toward oneself and other people (e.g., extend-ing forgiveness; engaging in friendly behavior) and amindful response to one's own private events (angerthoughts and feelings).

Initially, Mr. P will likely ask, “Why should I havecompassion and forgive XYZ? I was hurt so badly that theother guy deserves to be hurt too.” Here, it will beimportant to point out that compassion does not meancondoning or tolerating behaviors that damage him orkeep him in an abusive situation. He can still protecthimself and others from harm and danger. It is, however,better for him to do so without harboring ill will towardthose people. Holding on to his anger, even when he doesnot act on it, keeps him feeling tense and unhappy. It mayalso give anger room to spill over and affect importantparts of his life (e.g., work, relationship with his children)that he seems to care about. Learning compassion andforgiveness is difficult. We have therefore developedspecific exercises that they can repeatedly practice athome to help clients develop such skills (Eifert et al.,2006, ch. 9; Forsyth & Eifert, 2008, ch. 17).

Choosing New DirectionsThis step is about Mr. P choosing a direction for his life.

Much of his life has been spent on “getting even” withothers, with disastrous effects on the quality of his life.This important step is about helping him discover what istruly important to him and then making a choice that is atthe heart of an ACT approach: choosing to act on life, noton anger. The goal is to affirm value-guided living as analternative agenda to an anger-driven life. To this end,Mr. P will be asked to complete several experientialexercises and worksheets to help him explore core valuesin his life and then derive more specific goals that couldlead him in the direction toward those values.

Taking Action and Moving With BarriersThis step focuses on helping Mr. P engage in value-

guided action and staying committed to such action in theface of inevitable anger-related setbacks and otherbarriers. This step is about taking charge of what he cancontrol and change what he can change. The major goalhere is to continue to create broader and more flexiblepatterns of relating with the people, situations, andinternal stimuli that trigger anger thoughts and feelings.This part of treatment makes extensive use of behavioralactivation methods to assist Mr. P in doing what mattersmost to him.

The therapist would help Mr. P implement meaningfulactivities that would move him toward reaching selectedgoals by helping him develop a specific plan of action foreach week and identifying sequences of actions that needto be taken to achieve goals. Behavioral activation

programs that are widely used in behavior therapy canbe a useful tool to guide therapists in this process (Hopko,Lejuez, Ruggiero, & Eifert, 2003; Jacobson et al., 2001).

The therapist would also provide ongoing feedbackand work with him to set realistic goals and criteria,monitor progress, and brainstorm solutions to move withanger-related barriers rather than trying to overcome oreliminate them. He can do this by acknowledging angryfeelings that may accompany him along the way andapproach them with mindful awareness. It may alsorequire taking a hard look at where anger behavior wouldtake him and where he wants to go instead.

Taking action is about responsibility––or being re-sponse-able: using his hands, feet, and mouth for thepurposes of living the life he wants to live. Response-abilityis a choice he has: When he feels anger, he can (a) make achoice to respond with anger behavior, or (b) he can feelanger and respond in ways that are compassionate, caring,genuine, open, honest, and respectful––ways that willhelp move him in directions he want his life to go.

Empirical Support

There are a number of rigorous clinical trials and casestudies showing that ACT is effective for a wide range ofclinical problems (Hayes, 2008; Hayes et al., 2006). Thereis also research evidence that ACT outcomes are mediatedby relevant clinical processes such as acceptance, defusion,and engagement in life-goal-directed behavior (forsummaries, see Hayes, 2008; Hayes et al., 2006). In arelated vein, Hayes, Levin, Yadavaia, and Vilardaga (2007)were able to show that pre-to-post changes in ACTprocesses accounted for nearly 50% of the pre- tofollow-up changes in outcome produced by ACT.

Thus far, however, there is only one study that hasdirectly evaluated an ACT approach to problem anger.Based on the treatment program summarized in thisarticle (Eifert et al., 2006), Saavedra (2007) has con-ducted a randomized wait-list controlled trial of an 8-week, group-based ACT protocol for the treatment ofproblematic anger. The sample was comprised of low-income adults self-identified as ethnic minorities andreceiving substance abuse recovery treatment at a local,publicly funded community clinic. Of this cohort, 11 wererandomized to waitlist and 15 to the ACT intervention.Results showed relatively large (medium to large) effectsize (d=0.76), indicating an important impact of ACTover problematic behaviors. Results were particularlyimpressive for high anger clients at baseline, with a 50%reduction in frequency of problematic behaviors over thecourse of the intervention.

The treatment did not impact trait anger, nor didtrait anger mediate reductions in anger-associatedproblematic behaviors resulting from the group-based


ACT treatment. Moreover, “acceptance” did not appearto mediate reductions in frequency of problematic angerbehaviors. However, those receiving the ACT interven-tion did show a small, but significant increase inacceptance (assessed with the Acceptance and ActionQuestionnaire; Hayes et al., 2004), while controls showeda nonsignificant deterioration.

Though this study is small, and suffers from all thelimitations of a modest clinical trial, it is nonethelessencouraging in showing that problematic anger behaviorcan be addressed using ACT without necessarily changingthe dispositional experience of anger. Larger clinicaltrials have not yet been conducted and are needed.

References

Abramowitz, J. S., Tolin, D. F., & Street, G. P. (2001). Paradoxicaleffects of thought suppression: A meta-analysis of controlledstudies. Clinical Psychology Review, 21, 683–703.

Berkowitz, L. (1993). Pain and aggression: Some findings andimplications. Motivation and Emotion, 17, 277–293.

Blackledge, J. T., & Hayes, S. C. (2001). Emotion regulation inAcceptance andCommitmentTherapy. JCLP/In session: Psychotherapyin Practice, 57, 243–255.

Dahl, J., & Lundgren, T. (2006). Living beyond your pain. Oakland, CA:New Harbinger Publications.

Ellis, A., & Robb, H. (1994). Acceptance in rational-emotive therapy. InS. C. Hayes, N. S. Jacobson, V. M. Follette, & M. J. Dougher (Eds.),Acceptance and change: Content and context in psychotherapy(pp. 91–102). Reno, NV: Context.

Eifert, G. H., & Forsyth, J. P. (2005). Acceptance and Commitment Therapyfor anxiety disorders: A practitioner's treatment guide to usingmindfulness, acceptance, and value-guided behavior change strategies.Oakland, CA: New Harbinger.

Eifert, G. H., McKay, M., & Forsyth, J. P. (2006). ACT on life not on anger:The new Acceptance and Commitment Therapy for problem anger.Oakland, CA: New Harbinger.

Forsyth, J. P., & Eifert, G. H. (1996). The language of feeling and thefeeling of anxiety: Contributions of the behaviorisms towardunderstanding the function-altering effects of language. ThePsychological Record, 46, 607–649.

Forsyth, J. P., & Eifert, G. H. (2008). The Mindfulness and AcceptanceWorkbook for Anxiety: A Guide to Breaking Free from Anxiety, Phobias,and Worry with Acceptance and Commitment Therapy. Oakland, CA:New Harbinger.

Hanh, T. N. (2001). Anger: Wisdom for cooling the flames. New York:Riverhead Books, Penguin Putnam.

Hayes, S. C. (2004). Acceptance and Commitment Therapy, RelationalFrame Theory, and the third wave of behavioral and cognitivetherapies. Behavior Therapy, 35, 639–666.

Hayes, S. C. (2008). Climbing our hills: A beginning conversation onthe comparison of ACT and traditional CBT. Clinical Psychology:Science & Practice Review, 15, 286–295.

Hayes, S. C., Barnes-Holmes, D., & Roche, B. (Eds.). (2001). RelationalFrame Theory: A Post Skinnerian account of human language andcognition. New York: Kluwer Academic/ Plenum.

Hayes, S. C., Levin, M., Yadavaia, J. E., & Vilardaga, R. V. (2007,November). ACT: Model and processes of change. Paperpresented at the Association for Behavioral and CognitiveTherapies, Philadelphia, PA.

Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006).Acceptance and Commitment Therapy: Model, processes andoutcomes. Behaviour Research and Therapy, 44, 1–25.

Hayes, S. C., & Strosahl, K. D. (2004). A practical guide to acceptance andcommitment therapy. New York: Springer Science & Business Media.

Hayes, S. C., Strosahl, K. D., & Wilson, K. G. (1999). Acceptance andCommitment Therapy: An experiential approach to behavior change. NewYork: Guilford Press.

Hayes, S. C., Strosahl, K. D., Wilson, K. G., Bissett, R. T., Pistorello, J.,Toarmino, D., Polusny, M. A., Dykstra, T. A., Batten, S. V., Bergan,J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W.,Forsyth, J. P., Karekla, M., & McCurry, S. M. (2004). Measuringexperiential avoidance: A preliminary test of a working model. ThePsychological Record, 54, 553–578.

Hayes, S. C., Wilson, K. G., Gifford, E. V., Follette, V. M., & Strosahl, K.(1996). Emotional avoidance and behavioral disorders: Afunctional dimensional approach to diagnosis and treatment.Journal of Consulting and Clinical Psychology, 64, 1152–1168.

Hopko, D. R., Lejuez, C. W., Ruggiero, K. J., & Eifert, G. H. (2003).Behavioral activation as a treatment for depression: Procedures,principles, and progress. Clinical Psychology Review, 23, 699–717.

Jacobson, N. S., Martell, C. R., & Dimidjian, S. (2001). Behavioralactivation treatment for depression: Returning to contextualroots. Clinical Psychology: Science and Practice, 8, 255–270.

Kabat-Zinn, J. (1994). Wherever you go, there you are: Mindfulnessmeditation in everyday life. New York: Hyperion.

Luoma, J. B., Hayes, S. C., & Walser, R. D. (2007). Learning ACT: AnAcceptance and Commitment Therapy skills-training manual fortherapists. Oakland, CA: New Harbinger.

McKay, M., Rogers, P. D., & McKay, J. (2003).When anger hurts, 2nd ed.Oakland, CA: New Harbinger Publications.

McKay, M., Wood, J. C., & Brantley, J. (2007). The Dialectical BehaviorTherapy Skills Workbook. Oakland, CA: New Harbinger.

Petrie, K., Booth, R., & Pennebaker, J. (1998). The immunologicaleffects of thought suppression. Journal of Personality and SocialPsychology, 75, 1264–1272.

Ramnerö, J., & Törneke, N. (2008). The ABCs of human behavior.Oakland, CA: New Harbinger.

Saavedra, K. (2007). Toward a New Acceptance and Commitment Therapy(ACT) treatment of problematic anger for low income minorities insubstance abuse recovery: A randomized controlled experiment of an eight-week group-based act protocol. Unpublished dissertation, WrightInstitute Graduate School of Psychology, Berkeley, CA.

Salkovskis, P., & Reynolds, M. (1994). Thought suppression andsmoking cessation. Behaviour Research and Therapy, 32, 193–201.

Santanello, A. P. (2011). A composite case study of an individual withanger as a presenting problem. Cognitive and Behavioral Practice, 18,209–211.

Smith, T. W., & Gallo, L. (1999). Hostility and cardiovascularreactivity during marital interaction. Psychosomatic Medicine, 61,436–445.

Suarez, E. C., Lewis, J. G., & Kuhn, C. (2002). The relation ofaggression, hostility, and anger to lipopolysaccharide-stimulatedtumor necrosis factor (TNF) by blood monocytes from normalmen. Brain. Behavior, and Immunity, 16, 675–684.

Tangney, J. P., Wagner, P. E., Hill-Barlow, D., Marschall, D. E., &Gramzow, R. (1996). Relation of shame and guilt to constructiveversus destructive responses to anger across the lifespan. Journal ofPersonality and Social Psychology, 70, 797–809.

Trinder, H., & Salkovskis, P. (1994). Personally relevant intrusionsoutside the laboratory: Long- term suppression increases intru-sion. Behaviour Research and Therapy, 32, 833–842.

Wenzlaff, R., & Wegner, D. (2000). Thought suppression. In S. T. Fiske(Ed.), Annual review of psychology (Vol. 51, pp. 59–91). Palo Alto,CA: Annual Reviews.

Address correspondence to Dr. Georg H. Eifert, Department ofPsychology, Chapman University, One University Dr., Orange, CA92866; e-mail: [email protected].

Received: March 28, 2009Accepted: April 2, 2010Available online 20 October 2010

mailto:[email protected]

Documents

The Application of Acceptance and Commitment Therapy to Problem Anger