*Masters in Practice: Rethinking Anger w/ Dr. Ray DiGigiuseppe

‼️Continuing Education Series‼️

Join us for our latest Masters in Practice episode featuring Ray DiGiuseppe, PhD, as he delves into his distinguished career and groundbreaking research on anger. Dr. DiGiuseppe shares his personal journey, from working with families of disruptive children, which ultimately led him to focus on understanding and managing anger. He sheds light on the lack of research in this area and advocates for improved assessment measures.  Explore the debate on whether anger is a primary or secondary emotion, along with strategies for effective anger management. Discover insights into the honor code's role in shaping attitudes towards anger and gain valuable tips for identifying dysfunctional beliefs related to anger. We hope you enjoy this Masters in Practice episode: Anger w/ Dr.  Ray DiGiuseppe 

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Transcript

Masters in Practice: Anger w/ Dr. Ray DiGigiuseppe
Everyone and welcome to the Psyched to Practice Podcast your one stop for practical and useful clinical information. Masterful insight from experts in the field and A Guide to Daily Living. I'm your host, Paul Wagner, and I'm actually not being joined by my co-host today, but thankfully we were able to find another way to join for today. And I had the pleasure to talk to Dr. Ray DiGigiuseppe. For those of you who aren't familiar with Dr. DiGigiuseppe's work. He's professor of psychology and chair of the Institutional Review Board at Saint John's University. He has an extensive history in terms of the research of anger and the identification of anger, diagnostic disorders, as well as a variety of psychological assessments, focusing on identifying anger through the anger disorder scales, as well as the anger regulation and expression scales. Additionally, he works on the development of the theory practice in empirical research, in support of rational mode of behavior therapy, as well as cognitive behavioral therapies, and has previously served as the Director of Professional Education at the Albert Alice Institute, where he's previously worked with Dr. Ellis himself. And I have to say, after being able to talk to Ray today, you know, the extensive background that he has really building the research on anger, really bringing it into the conversation to help support individuals who struggle with anger, especially dysfunctional anger. So Ray was really able to go in-depth on the research that he's done, as well as the vacuum of research. And thankfully, it sounds like we're kind of turning a corner here and starting to have, you know, more and more reliable data that we're able to pull from, you know, to support individuals that are currently going through their education program as well as the missions like Ray and I to really kind of help better serve these individuals. You're going to get one take away from me this time. But, you know, I think the entire episode could be a takeaway. You know, Dr. DiGigiuseppe is just absolutely brilliant. You know, one of the moments that really stood out in our conversation was when he was identifying and talking through the impact that anger has in terms of being an adaptive trait and working to identify at varying levels when anger becomes adaptive as well as maladaptive, and how we as clinicians can then use that recognition in helping to support anger as the approach emotion that it is an activating to improve communication and resolution, as well as this conversation surrounding, you know, bringing in stages of change. Again, I think I could go on with how just impressive he was in this episode, but please listen for yourself and enjoy this week's Master's and practice episode. Anger with Dr. Ray DiGigiuseppe. Well, Ray, thank you for come and join us on the site, the practice podcast. Really appreciate you taking the time here on a Thursday evening to sit down and talk about anger. Thank you. It's really a pleasure to be here. And I always like to talk about angry, all the anger, but I don't think I'm a very angry guy and that I must have gotten interested in this because of my own anger. I don't think I'm an angry guys, but I always kind of assumed that. Now we're here to prove them wrong. And here on the podcast, you know, when we're talking with individuals, we really like to take an opportunity really here what got them started in the field. And so kind of what was their story that brought them into psychology or into the mental health field? And what does that for you? What led you here? You know, it's probably a pretty typical story for people in our field. I really got involved with this because, you know, when I was a kid in high school, my father died and my mom was left with three kids. And I had this middle brother who was really a difficult kid. And I just remember my mom trying to go around getting mental health services for my brother. And, you know, when I talk about my story, I mean, I didn't think about it, but I can like well up and cry. It was like really a major event in my life. My mom couldn't find any place to get treatment for him. He was really kind of difficult. Probably had some attention deficit disorder, oppositional, defiant, this photo that caused him. Now, he was very lost after my dad died. And so I went to graduate school and I was kind of drawn to working with families with a difficult kid, you know, I guess I said, you know, like I couldn't help my mom, you know, giving them all this in the knee, but I was going to do that So I guess I always been on a little bit of a mission to help in and families of kids with disruptive behavior and probably really started from a, you know, a parent training model like with Chief. These are things to do. And I always think that's just a little funny part of the story. When I got my degree and I set up a private practice, I was really busy and I would get all these families that none of my peers wanted to deal with. You know, there's a kid who threw a gym in there and here's a kid who cursed his parents and the like. Nobody wanted to handle these disruptive kids. And I was always more than willing. It wasn't a financial payoff, although I wasn't my I wish I would have ended up with a practice that was pretty big because nobody really wanted to do that. So over the years I kind of got a little disappointed in the hair and training. It was really effective and I had a criticism of it. And like criticism was a parent training kind of a challenge that the parents just were ignorant. They just needed to learn these new skills, and if they learned these new skills, they were going to be okay. And what I realized, what these parents were just really emotionally upset, you know, I always said, boy, you got it wrong. You think you get crazy from your your your parents? I think you get crazy from your children. Nothing not going in the world gets you as sad as your children. And so the parents were desperate. They were angry. They were angry. 13. They were angry at the school. And I really started to deal with the emotions of the parent. And then I sort of started paying attention to the kids. And I realized that when we describe oppositional defiant disorder and, you know, intermittent explosive disorder, all the diagnoses are kind of affectless, like there's no emotion in them and that these kids really had strong emotions. And maybe it was a really disturbed emotion. Maybe it really was a not very frequent emotion and it was anger, but nobody was really kind of dealing with the anger. You know, maybe we deal with their anxiety. Maybe we were just assume that they had depression and nobody was really paying attention to that. So I spent a lot of time working with kids and a lot of time sort of thinking about their emotion. And the parents emotion only got me interested in anger as a sort of a bigger research topic. And working with Angry Adult occurred when I was in the Albert Ellis Institute. I always worked with Al Ellis at the Institute, and we were doing a lot of work with the place called the Viera Institute with ten pages of people with PTSD and, you know, trauma from being domestic violence or victims of crime, etc.. And we did that for a while. And eventually they said, you know. You're doing a good job. You're helping our clients with this problem who are victims. Would you point to any of the perpetrator? And nobody wanted to take the perpetrator, just like my early friends with the kids that nobody else wanted to treat. And at the time I was in a supervision group, I had checked the friend from central Connecticut State, Chris Eckhardt, who's now out of Purdue. Both of them went on to, you know, Chris Eckhart wanted to work with domestic violence and Chip has worked lots of people in the criminal justice system. And we're gonna work with these people that nobody else wanted to work with. And we're angry and aggressive and. I kind of thought that my experience with his brother was a natural. I was that was easy to do. And I remember the thing that got me interested in a research career. Chris Eckhart says to me one day, the the task really is on my case to give them diagnoses for this And I can find and diagnose this that I said, oh, let's think about that. And he says to me, You know, if you beat your wife once in a while, you meet the criteria for intermittent explosive disorder. But if you do it regularly, I'm not in this problem. And we went through the, you know, the DSM thinking that, you know, there really wasn't a place for diagnosing people with anger problem. Intermittent compulsive disorder had no affect. And, you know, like it was just impulsive behavior. You were really angry. You didn't fit. So I sort of got interested in researching this issue because I realized that we really didn't know a lot about anger and it wasn't there. And so chip to Frady and I sort of started together and we said, well, we wanted to write this book on understanding, anger, problem. And you know, back in the 1960s in back had this book on depression that was like the what summarize the scientific knowledge that we had on depression. And Chip and I said, we want to use that as a model. Like what's everything that we know about anger just like and wrote about everything about oppression and. And every time we would go and do a chapter, we realized, Oh, we really don't know much about that. I wanted to do I would like what research what is the research on clinical procedures worked and all that was. And so we stopped and we did a meta analysis, you know, like what are the best strategies to an instrument to assess anger? And there aren't really very good. They don't have enough to grant it, you know. So we designed one. And, and so every time we want to do a chapter of the book, we ended up realizing that we didn't know a whole lot of which honest and ended up doing a research project and eventually came out with the book and it was seven. Probably we should do a revision of that because there's a lot going on, but I think that we just realized how much we didn't know and how fascinating. Like, I mean, your beginning of your career really starting off with serving this underserved population that individuals didn't want to work with, you know, then moving on to the perpetrators that individuals didn't want to work with and then trying to give support. And there's not research because no one's wanted to work with these individuals for that much research. I mean, you know, a growing oracle from California, Irvine, was kind of a role model because he had done the one really good deal in the area and that the, you know, the Hunter group within the parent training or just the kids, you know, that was really very good for younger kids. And I remember I went to a conference I was actually presenting at this conference and I was on this panel with one of these big researchers in parent training. And he made the comment like, no, we've tended to drop the parents from the study who didn't follow through the parent training always shit. That's like all of my chi. They were like, Go on, mother. Those parents are so emotionally upset that that's exactly what he and I. Eventually we are. We developed this thing called the parent anger scale, which everyone fought with, like beach. And I still like every park when I sit there angry at our kids. Well, yes, they do, but it's a pretty, pretty good psychometric scale. I did that with Tami Delvecchio here, and Jon's right and wanted David over in Romania. So we had a good international thing on it. But parents really do get angry. And so I guess one of the things that I got sidetracked on is to do assessments because I really got interested in assessment research because I realized that A lot of the things that we want to measure to do good research on. We did have good measures of. But yeah, there was one when Chip and I did that, we developed a scale called the anger disorder scale. The most popular anger scale, of course, was the stacks, the Charlie Burger, who was a great man. And we used to spend a lot of time talking with him at conventions. But that's a test about normal anger, normally distributed, really didn't touch the dysfunctional nature of it. And so we tried to look at like what the anger, which is dysfunctional anger look like. And then there's a couple of interesting things that we found that were really surprising to us. First was we would take the anger scales that existed and try to take a subscale or an item and classify it. And we would do this in a systematic way. And we realized, you know, every scale has different content. Some people have anger out, which is physical. Some people have anger out with just physical aggression for people and some physically aggressive towards objects. And some people include anger out, which is verbal aggression. And some people have anger in and some don't. And so there was just a real unevenness. If you were reviewing the anger literature, you would find differences because people use different measures and the different measures have different content. And so that was really, I think, one of the major things that we found. I mean, I just can't help but like really at every turn having to start from ground zero and, you know, using what's been done beforehand, but needing to also break it down and coalesce it into something that's more consistent and structured that can be you know, it's improving that reliability and improving that validity aspect of it so that when we're measuring something, you know, we actually know what we're measuring and it's consistent across the board, really. Where's the prompt? You know, I think we had better measures of aggression, but not the emotion. It's like the emotion of anger was at and and it's not in DSM. There are no anger disorders in DSM. And Chip and I, you know, really advocated for that. And I remember a couple of people in the American Psychiatric Association told us we were really nutty, you know, and that's just never going to happen. And because anger is really not a disturbance, the anger is a symptom of other problem. I think think there were a couple of scientific issues that we ran across the first one, and it was this idea that anger is not a primary emotion, it's a secondary emotion. And whenever I do a lecture or something, I always say, someone's going to have a debate with me at the coffee break because they're going to say, well, behind anger is really anxiety, behind anger that is really killed by the anger of the jury. Shame. Anger is always a secondary emotion. And I remember kind of really we were writing the Understanding Anger Disorder book, and I had these this was before everything was very electronic. So I had these, you know, print copies of articles and I had to create one of them was articles written by psychologists to study the psychology of emotion, and the other was clinical hearing by clinicians. All of the clinicians said anger is not a set in that primary emotion. It's secondary. And all the psychology of emotion is sort of research theory people and the basic processes of emotions. So a lot of anger as a primary emotion. So right there we had this tremendous divide between what clinicians want and what scientific psychology thought. And I think that that still exists. I just responded to somebody about a week ago on Facebook that says Behind the anger, there's always all these other things I, I really had to disagree with. And now maybe you're right, but I, I disagree. But I think that was a really big issue. And we traced back know the truth seminal figures in abnormal psychology in the 20th century. You could say we're Sigmund Freud and big influence on everything. And the other was Emil Kraepelin, who wrote the first textbook, a psychiatry. And within a year of each other, they both and wrote that anger was part of mania. Mania was part of a depressive disorder. So therefore, anger really is a part of depression. And they both right there, they were separated geographically. The things were too close together for them to read each other and copy that. They probably weren't. But it's a great way to avoid both had this idea. And, you know, I think that there are some some relationship between depression and anger. And I don't think that, you know, one is the other. And I think that if you treat the depression, the anger doesn't go away and you treat the anger. The depression does so like and so we did that chip and I did this major review of what the literature says between anger and aggression. And the literature was really very bad. You know, like people would use a tape measure of one emotion and a trait measure of another emotion and all sorts of things. So I think that that was one of the major issues that we found there, that just the way people considered it. The other thing is. You know, I was always trained by Alice, who really loved the stoic philosophers. You know, there's always a famous quote by Epictetus. You know, people are not disturbed by things, but the views they said of them. And so, of course, when I was interested in anger, the first person I had to read was Seneca, that Roman stoic philosopher who's got a really great book on on anger. And, you know, it's like with all the debate that we're having now, go back to Seneca and how he he really set out really great things about anger. And there's some debate which I think are still going on, but the stoic philosophers are the people who probably wrote the most about anger and still there. You know, there's a movement of modern stoicism to try to make the philosophy more relevant to everyday life. And lots of people in that movement are into psychotherapy, but they're really still the best people to read on the ocean of control of your anger. And they start with Seneca, who really was rich. And Seneca really argued that anger is almost always dysfunctional. It doesn't really war, you know, it gets us in trouble. And other people say, well, you know, anger is an emotion. It's evolved that must have had some benefit to our species or wouldn't have evolved that there must be some adapt to that. So that's that's a debate that I think that goes on today. Is there adaptive anger? And as we were as I was getting ready for this book, you know, the Association for Behavioral Cognitive Therapies Convention is coming up. And I wanted to present that paper. We have been trying to do some research on whether there's adaptive anger that we've created this adaptive anger scale, a, whether you know. Seneca Right. Or the evolutionary theory, right? Yeah, we did. I did some data analysis the other day and we found that all the items that we had on adaptive anger, sort of fact, are analyzed quite within the two factors. One was a lot of people say my anger helped me grow because it tells me what I value, tells me what's important to me. And so people kind of think that their anger helped them identify their true values and the things that are important to them. And the other is like anger may help you solve a problem. And when we took this second one back, the score, you know, the anger, missile problems, we found that it was. Now, the more anger you had. It was a almost a perfect. You an inverted U-shaped curve. You know, some anger had to you get to the middle and then it really dropped off. So anger and me inactive. But once you reach a certain degree of intensity, it really is. And I think that's a pretty interesting finding because up until now, we haven't we have we don't even have measures of adaptive anger where we found like two or three other studies or some dissertation that was done in the course. The person didn't publish it. And and then there's another researcher who sort of put it in a discussion of a paper that, oh, these are some things that might be adaptive anger, but we may have some interesting idea. Yeah, the anger may work for you and anger may help, you know. So anger does get a bad rap. And you know, how fascinating the idea. And, you know, in in terms of practice, you know, I'm thinking of the different clients that I work with and, you know, when they are. I'm trying to think of like. When there is the presentation of anger, when they are, you know, they're getting heated, maybe they become more engaged. But. When it's taken too far that's when we're having to kind of would often it's because I hear how like it gets into that unproductive point and I'm curious when they're saying that in the data after it reaches that certain threshold. What are the different ways that the anger starts to become unproductive or almost maybe no longer an adaptive anger? Well, I think there's a couple interesting issues about this, going back to the ancient Greek fire. Now, if you go back. What I realized. Was that in reading about modern anger and modern anger measures. Nobody considered revenge. And if you go back and you read The Iliad and all those old stuff there, revenge is the key motive. There's a whole there's a whole series of ways that were done in the Middle Ages around the time they were called revenge strategy. You know, there are all these things. And Hamlet was considered the key piece of literature in that genre. We psychologists in. I think revenge and poor people in the literature department. Anger and revenge are. They almost go together. No, there is. There's a famous philosopher of her mouth and Nussbaum. And she says it's really not anger without revenge. And, you know, I read Nussbaum after rereading The Iliad, I said, where we psychologist, you know, like you want to learn about anger. Go to the classics department because we missed this entire issue. And I think that people still want revenge. And now they're not really focused on solving a problem. They're they're focused on hurting another person. And then that creates a cycle of things that go around, you know, like, I hurt you, you hurt me, then I hurt you more than you, and it distract you from any resolution. So this issue of revenge, our anger disorder scale, was really one of the first maybe the first anger scale to include a subscale, one of revenge. And how did we miss that? I mean, Homer wouldn't be so ashamed about, you know, not including it. But I think that that is one of the areas where it's dysfunctional. The other area that is dysfunctional is this is another problem that we discovered accidentally. You know, people think of anger as an impulsive emotion. Even the way it portrayed in DSM as intermittent explosive disorder is an impulsive border. And so we created our anger scale. And what we found was. I always put it this way. We did our theories of study to find out how people experience anger before we created the scale. And I remember one, I sort of got this idea I had given this questionnaire or an interview to this 14 year old adolescent girl. And one of the questions we asked is, when you get angry, how long does it last? I know. And so she says, Well, no, we're here for a day. Well, if you're having a motion that lasts for three or four days, this isn't an impulse problem. This is a rumination problem. And rumination was always considered to be an aspect of depression. And anger was supposed to be, you know, want me act real quickly. Right. And what we found was that rumination was really strongly endorsed by people that have anger problem. And that means so much sense to me afterwards because, you know, you have people like how long can you hold a grudge? Now we have a joke like, how do you know Italian Alzheimer? You forget everything but the grind. You can you can hold it along for a very long time. And I've always collected data on this. A client I have with the longest bridge was 40 years now. Wow. Yeah. So people can hold a grudge a very long time. That's the rumination problem. And then what we found was that rumination and impulsivity were kind of related. So, like, you ruminate, you know, one against you. You how do you do that? Manage. And after you're thinking about that for three or four days, then you want to break out and punch the person. So we really started to focus anger treatments on some things that weren't usually included. One of them was revenge, and the other one was rumination. Then Asoka Dyleski, around the same time created the anger, rumination, scale. Yeah. So we had some good karma, some confirmation of that idea. So it's not just an impulse. It's an impulse. Like you impulsively strike out at people after even thinking for days about how you want to punch them out now and how they were wrong jokes. And that was totally missing, I think, in the anger literature. And just think of anybody that, you know, that that, you know, like sort of marital relationship problems. Like how long can they hold a grudge against your spouse for not putting the dishes in the dishwasher the right way? You know, absolutely. You know, seemingly endless. And, you know, how interesting that the literature beforehand really only captured this snapshot of impulsivity. And we magnified this and we identified, you know, the impulse control management skills surrounding this. But really then not helping to support the underlying factors that led up so many years from about the mid 1970s Up until after 2000, the most referenced treatment for anger was Reign Nabokov's self instructional training approach, which was designed for treating the impulsivity. And, you know, I guess if somebody strikes out and they hit somebody, it's really, you know, you want to control that impulsivity, but you got to do something to calm them down so they're not ruminating or that to build up that, you know, intensity, to want to do it again. So I think that there were some things that we came across. The other thing that we we came across, as we noticed. Is that? Anger has often lead to aggression, but it doesn't always lead to aggression. And this is a problem that we really haven't resolved yet. Like, how many times do you get angry before you then go do something aggressive? Though I have like we have ten non-aggressive anger episodes before we had my arrest. One. And what we tend to do is identify people's anger by the dramatic nature of their aggression of where we started thing then ifthere is anybody but we kind of expanded on our enemies, asking people what they did, what they were angry. This sort of came from also some work by Jerry Diffenbaugh, who was one of my best anger researcher ever. Like he really had done a lot of great research and and Jerry found that people had more reaction. You anger than they did to any other emotion. If you go back into emotions theory, they say emotions evolve to trigger behaviors that can be adaptive. And, you know, you're anxious. You avoid if you're depressed, you know, you go in. But anger had the most different behaviors. And when you ask people, they engage in a whole lot of other aggressive behaviors that are beyond cursing, yelling, screaming, hitting, throwing, banging tables. There is acts of aggression. People don't really talk about passive aggression very much. It's, you know. But you know. That you can really hold somebody with passports. Absolutely. You know. And, you know, I think of all my teenage clients that, you know, that that that becomes a major talking point of, you know. Everything that someone didn't do that was so passive aggressive that, you know, carried this semblance of, you know, everything, you know that's their anger that that's why they're doing this. And yeah. So certainly it can play a role and have a have an impact for others. The other one that we found was what some other people have identified around the same time, which is this kind of social aggression. Like now I'm going to have a party invite everyone but you and I'm going to ask people to kind of ignore you. And one of the things that angry people do is they engage in conversations to encourage their friends and allies to boycott the people that they're angry about sort of develop now. So this kind of social aggression, which can be very hurtful to the person and but we don't really we only ask people how often they do that. So that was another thing. And another kind of aggression that we looked at was secret aggression. Again, anger and aggression. People always look at the dramatic and say yell and scream on the scanner. But, you know, maybe I break into your house and put a virus in your network and we never nail it. You know, what would happen, what happened? And so there's an idea of overt aggression, which is secretive, and you don't ever know who hurt you. So we kind of expanded the number of aggressive behaviors that people could do in the tradition of Jerry, Jeff and Bob or, you know, that that we really wanted to look at a wider variety of things that would get people to be upset. So I think that was a good thing that we'll look at a better sense of the different revenge strategies that people have. And certainly as you're sharing, especially that covert anger expression, I can't help but think about the onset of social media and the anonymity that can come along with that, which then, you know, maybe we then don't have to work as hard to suppress or to try to challenge that anger if it has an outlet that we feel that little maybe little to no repercussions for. But that could be an expression. And I think the people who do that overt aggression, they very much want to and very much enjoy seeing the other person. I think one of the one of the things we still need to research better is how to treat revenge, because you can say revenge may be a motive as part of your anger. You mentioned in talking that you work with some kids and you've probably seen this kid. Everybody's seen this kid who is angry at somebody. They tell you that they're going to get revenge, they're going to do something, that they're going to get caught. And you say, oh, you're going to get in big trouble if you do that. And the kid says, I don't care. You see, I just. I really like it. Okay, I'm going to do something to hold that by the person I'm angry at. I'm a yes in Kabul and get caught and I don't care. And I think that those kinds of cases always appear strange, almost psychotic. You're going to do something. And what we really missed was the idea that revenge is the reward on account. Now the bank is very powerful. There's there was a group in Switzerland that it means, you know, and crushing games for people. You know, they play like a prisoner's dilemma game and somebody hurt you and and just for the. And then they did this in a functional MRI on a unit so that they were taking pictures of the brain and just before the participants would do something to shock or hurt their opponent. The area of the brain itself. So I always say the big reinforcers in life are sex, drugs, rock and roll and revenge. You know, he feels good to people, and I don't think therapy's ever acknowledged that. You know, like, yeah, you're going to do this, but you really think it feels good. And is it really gonna. Is it going to be as good as you think it is? Is going to be as helpful as you think it is? And yet we don't really talk about that. But it really is a very powerful, positive reinforcement. And I'm curious, as you're putting it up there with sex, drugs and rock and roll, how each of those is has this level of satisfaction within the moment, but then how long that sense of satisfaction carries on. And I think. Traditionally, if I'm thinking of revenge, it's not as satisfying if we track it over time. However, there are some individuals that I've worked with or talked with that, you know, even years. Like in terms of the resentment, yeah, the expression of anger still has the level of satisfaction. There was a couple individuals I've worked with who have come out of prison and, you know, we talked about this and it's just like I felt good. I felt like I was seeing and I that that's what was going on because we have an acknowledged knowledge that really feels right to you that is like as good as an orgasm. You know, that's really and how the issue is, is that brief degree of dysfunction really worth. But and maybe we have those kinds of conversations about, as you just said, the enduring nature of the reward. What's the cost of that over time? And I think that we we can have those conversations and they're really important, but we've not focused on revenge as part of our traditional anger management treatment package. So I think that's one of the great difficulties that has been missing that we would add we would always our or we're bent. Jumping back just a few minutes, you brought up the social component and at once. Looking at the classics and the Iliad in know what lengths were gone through to raise this army or revenge you know in such a social way and how we can bring others into you know, into what like almost our anger can spark almost anger, a group anger and a sense of, you know, we we feel an injustice, we feel something. But then it's the act of the activation that anger can have to bring others together as well. Yeah, I think you're right. I think we we want to get revenge on other people. But, you know, they were Ben's focus has gotten us into a new area of mission. So now, since I've trained in Arabic and cognitive behavioral therapy, I've always been interesting on the missions that generate anger, stole philosophy and all that, and. I've always been concerned that I think many anger management treatment manuals. They take the punishment and distortions that were created for depression and anxiety and they take the irrational beliefs for present. And they they then apply them to anger. And I don't think I think that's why we don't get successful outcomes. And what we've noticed is this belief or this strategy that is really talked about more in social psychology. It's I referred to it as the honor code. Sometimes the code of honor and the code of honor is sort of written up. Probably the book that describes it best is a guy named Elijah Anderson who wrote about it in street gangs. No, but he was sort of writes about it in an office in our street bonds lets you know. And so the belief is among I if you disrespect me, I have to fight you not because I need to beat you up. But I might enjoy the revenge. But because other people are going to see that you disrespected me. And that sends a message that I'm vulnerable and I have to protect my reputation in the group. And so I'm going to fight you. And so there's a big literature of this in the social psychology, literature and notions of literature. And you have a major criticism of that literature because it makes it sound like a city or inner city youth setting with most or a lot of the literature goes up and says that's bounded by the Scots and Irish people who moved from the lowlands of Scotland and Ireland and Northern Ireland. And then, you know, they are all or another people who drew this code of honor with it and research and social psychology. We looked at it, we put it all in ways equal measure in this code of honor. And we developed this code of honor school, submitted it out for publication, and we were able to develop a really neat 15 items scale that were during the I I'm quite new and ballpark runs and without any disrespect to protect me my reputation a lot of people. A couple things that we found out as I tried to collect a large sample because people kind of identified with what it did with the poor one when I'm selling what now? And I probably quickly made up and down around and hardly knew how to tell you that the honor code gets more endorsement as you raise your income and after you go over a 150 grand, you really endorse it very highly. And I sort of have this worry that one about this guy who was a salesman, he sold these computer products now and some other salesperson in his company was trying to take credit for his sale at the commission, and he was the most aggressive son of a bitch I've ever dealt with. Nobody is this commissions. And so I think that this code of honor does exist. I think it's been played as being something that poor people do. But I found that to be the case. And doing a study right now where we think this may be the commission that I'm going to be able therapy needs to challenge the most. That it kind of it has more power to predict dysfunctional anger than any other of the beliefs like overgeneralization and frustration, tolerance. So so that's one of the things that we've been working on is like we can identify, like nonhuman, different partnerships and beliefs that people think are related to dysfunctional anger and they're not all always targeted and treatments or which ones seem to have the biggest bang for their buck or the most the. And so what we found is there was an attitude which very different backgrounds, the inflammatory label one unrelated to what I was just all you know other down like the movie with the person on the right is weird this utterly awful human being and but of course you don't call them an awful human being equal in an expletive deleted another is almost always per infinity. And with this, in the discussion of the worthlessness of that person, you're angry. That's really one of the and again other drowning is not focused in most CBT anger not but it's really up there that's the second one that comes across is attributions for hostile intent. I who did that to try to get even let me know that dogs and people have done that with kids and not really holds up as a very strong, clear, rational book, a belief that that's related to that work, that the jury's kind of out on self condemnation. Lots of psychotherapists believe that you're angry when you have self on the machine and or you know, there's a couple of studies that show it another type of balance. And we think that it's not that you think you're a worthless human being, but you you are upset that other people don't think you're as worthwhile as you think you are. I'm going to really think I'm great stuff. And you always think my hemorrhoids are value. And they got me on average, right? And so but that's. But then there's the honor code. And the honor code really seems to show a really strong affect. So we've developed this anger code scale, which we think therapist news. We've developed another way of measuring the anger code in a strategy where we compare it to other kinds of cognitions. And we're finding that the in that study, we're still collecting data on that, but that the anger that the honor code really is important are you mentioned earlier the idea of nations and I'm I spend on the book by a political scientist who identifies the honor code as being something that people have written about in wars all the way back for, you know, like, like the Hittites, you know, in the Egyptians. Like, you know, the Egyptians had to go pick the butts of those Hittites so that the Nubians wouldn't invade them. And they have no codes. Things seems to have this long history of just conflicts within individual people, but conflicts between nations. So I think that that's kind of an interesting finding. So we're trying to be a little bit more scientific and specific about the cognitions that channel, because it may not be the same cognition as you try to channel challenge with aggression. And the reason for that is, you know, there's there's this issue about anger. If you ask people to do a mood induction and you try to get them to feel guilty and anxious and depressed and floppy, you get really differences in which side of the brain they think saying when they express emotion, the negative emotions like anxiety guilt, they're all in the right side of the brain. Joy and happiness is on the left side. So people used to think it was negative or positive, but it ends up not to be that way. A truly of escape avoidance. Behavior is versus approach behaviors and anger is on the same side of the brain as joy. It is the only approach gradient, negative emotion, all other negative emotions. You want to avoid the stimulus that triggers it simple. When you're angry, you want to get in that person's face and tell them off. So it has a different anatomical place and it has a different function than all the negative emotions. Which is why I believe behind the anger, there's not always anxiety or maybe some co-morbidity. It really is physically different in the brain and it serves this very different approach function. So I think that that's why we want to study it somewhat separately. But maybe, maybe I should have said that in the beginning. And one of the reasons to do this, because angry people really do not want to give up. So we have one other we have an important clinical thing. So if you're a clinician and you have people with anger problems. Strongly influenced by the stages of change. People know all of the comments and the transcript. Now, the reason I'm influenced by them is because of my mother, who told me to go meet Carlo. We went there because our family's in the same small city in Italy at the same time. So. Wow. So my mother said, you better get better at Carlo because he's related to you. And he's a psychologist, too. So I started to think about the stages of change. Things actually occurred to me. And angry people are pre contemplating. They don't want to change, you know, lots of angry people who come to them. They always like ambivalent, like, you know, my right boy sent me. My romantic partner said, you better get help or I'm leaving you. That there's all these different reasons why people are wrong. But. They're always ambivalent. There's something about the anger that's reinforcing because of the revenge. There's something about it that is brooch that they want to have. And what we have found. And what they recommend is it? The first step of all treatment with angry people is to review the stage of change and why a change is good. What's the cost of remaining the same? What's the advantage of change? And I wouldn't even go so far as to say we review that with each new problem they bring up. No, it's just your tent session. They have a new promoter angry at somebody on the subway today. Well, what's the benefit of you to being with Subway? What's the benefit of it's a horseshoe. If you ruminate on the subway all week long and that's stages of change issue becomes really important, which because it provides the motivation for change, which I think angry people don't have on, they usually come what they do. It's very weak. And, you know, and that's fascinating. And there's actually a certain individual I can think of whom I would say, actually, we struggled to find a diagnosis there for him. And but anger was that primary reason and their because both boss and wife were saying, hey, we need you to make this change. And if we had explored a few different approaches, but when we started talking about the stages of change, that was something he was able to gravitate towards a little bit more so. And it just clicked in a different way where, you know, talking about, you know, some of the cognitive processing and reframing. Yeah, sure. And it was just this ambivalence. And, you know, so that the theoretical model that works best to start to treat anger comes from what's the whole the social problem solving approach. This is an approach that old street and this Zarella created up at Stony Brook in Long Island, New York. What that a whole group in Philadelphia at Harvard and Medical used to be in medical school, now part of Drexel University, Spivak and. Sure. And now that research is really led by the nation, you know, our peers in Asia. And they look at, you know, can you think of an alternative intervention? I've got to you and can you think of a consequences of your behavior? And if you go back 20, 30 years ago and on cares, then use this over this model to treat most aggressive oppositional kids and the skill that, you know, the naysayers, whether it's by sequential thinking, what's going to happen if I do this? But their focus on this is going to be fun. If I do this, I'm going to enjoy leading you. You know, I really want to hurt you and it's going to be fine rather than what's going to happen in the long run. So I think that while, you know, the treatment of behaviors, there would be a cognitive restructuring and I certainly want to be royal. Albert was influenced by Tim Beck. The social problem solving people in Philadelphia really hang on the first intervention because that's going to get you just see that it's not helpful for you and that's going to get you to see that there are alternative way for you to work and things to do. And and we would always do that to increase motivation and increase alternative thinking before we do any cognitive restructuring. Well, I certainly I'm going to be having some takeaways and going and delving into some of the research here a little bit after our conversation. But actually, there's something you had mentioned earlier. I wanted to circle back around to it. And it was the the standard distribution bell curve of adaptive noise for anger. And I'm curious about the front half, like when we're not having enough intensity and it's not that adaptive or doesn't play a role. And for those individuals that maybe it becomes either more suppressed or maybe their overall experience of anger just isn't as yeah, they don't have that as a significant like what what's the impact there which is in all of the literature in this that we discovered when we started through the to do this and that really came from all the sports psychology and sober dynamics. People warning you that you could have too little anger now and that as a result you were a doormat and you were afraid of change or you thought even you start doing it. And I think that that problem that's really happened. And so that the the intervention is to have people not to be afraid to speak their mind, not be afraid to ask for what they want and to give them assertiveness training. That's exactly where my thought, where the spectrum between passive and aggressive and moving on the issue. I think that the assertiveness issue is really important because I think people that have too much anger and have too little anger, both are very honest serve. So the people that you just mentioned, the people who have too little anger and they get walked on, they don't know how to say, please don't do that or No, you don't, and I want you to do that too, meaning where they have difficulty speaking. But the people who have too much anger seem to be equally an assertive vocal shout, but they won't say cheat. Well, I wish you wouldn't do that again. Yeah. So if you reduce, we want to get them to reduce their anger and aggression. It's almost like getting train. They're in a new way. So you would say, well. The relationship of anger to communication is an assertiveness at either end of the continuum, very low in anger and with a very hungry anger at that. So that whether you're treating the inner amount of anger or the excessive amount of anger, assertiveness training really needs to be up or part of your intervention. Otherwise, the person can't resolve any interpersonal conflict. They remain a doormat or they remain too aggressive. And, you know, going back along with that social model of treatment that you're talking about working to then identify what are the consequences that we're wanting to work towards rather than the satisfying experience of the act of aggression or anger itself. So we are sort of always pushing assertiveness training and you know, if you look at no one in that treatment. So I think is really the anger is marshaling. Lenihan So I gave the therapy spiel where the lines they have a lot of anger and they need to. And she's sort of incorporated and expanded one of the original assertiveness training exercises, More of Gallantry refers to a sort of Ms. training as the foregoing it and an empirically supported treatment. But it's not. What margin. Whenever I'm going to a place to talk they were workshop or I always ask like how many people here in the sort of this training in their courses in behavior therapy people under 50 never raise your hand. I would not raise my hand. They didn't learn. It's sort of like the forgotten intervention, and it really seems crucial here. And people have totally it's sort of dropped out of the textbooks and it's almost like we've gone to cognitive or we're so interested in looking at the art that we forget this basic communication skill where people are deficit. So we would always add. Going back to the model that you were sharing anger as an adaptive trait for or as. I hear how it then becomes this continuum for having our needs met through assertiveness and without anger. We then aren't, you know, maybe not activating or approaching many of those. It's some some allusion within the angry family. It may not be real anger, but it may be assertiveness or a desire is is maybe not up there, but maybe like if you think of that, there's a family of emotions that may be considered in the anger family. Some of them may be in rage. Some of them may be in bitter. Some of them may be assertive. Some of somebody may be reconciling. Some of them may be negotiating. The more ways you can conceptualize how you want to be, maybe the better off you are, right? Because otherwise you're maybe stuck with being a doormat or a stuck with being an enraged person. And I think that's sort of one of the issues. And I'm. I think that there's two other treatment issues that I think are really important for angry people. When you have angry clients. And the first is. This is why I think team does really well with angry people. And and that is angry anger doesn't get any empathy. I mean, there have been studies on this. You know, if you have a new client that comes in and they're angry, you say, you know, our only nuts like me work with them. You know, you have somebody at work who's really angry. You don't have support. They don't get support. And when the angry person sort of does have a legitimate gripe, it's somebody committed a transgression upon them. They usually nuke the other person or they go too far in their retaliation. And I've seen this happen like a thousand times is that the angry person will say, you know, I did this behavior. Yeah, I did that. But that's because this person is something to me first. And they everybody in the environment will say, but you should know that they knew you retaliated too strongly and they never get a validation. If somebody made a transgression against them. And so they are committed in convincing you and everybody else that somebody's screwing them over. And if you just say, Yeah, that really was bad, that they treated you that way, you can feel like, yeah, a lot of the defensive is. So I think that. Marsha does that really well. I think Al always did that, you know, because now if someone come into Ari and say, you know, no one doesn't respect me, I'm not going to challenge that belief. I'm going to say, yeah, you're probably right, they don't respect you. And and that really is that and that and that. Now how are we going to deal with the fact that they don't respect you're validating and so I think of the Ari between mode and the debate mode here is a validation with how. The angry person. So they don't have to convince you that there was a transgression again and that that's really important. The second issue related to that relationship issue. I've never written about this. I've only talked about it is I think that the the therapeutic alliance literature. My good friend, the Christian Moran, who writes about the therapeutic alliance. Well, in banks and all that, literature is really on them. Anxious and depressed people and angry people. Aggressive people. I think that there is a different element that needs to be added to the therapeutic alliance. And that has to do with our our attitudes. And if you are afraid of them. Your dad? I mean, do you know your effectiveness as a therapist? And, you know, angry people like to get revenge, but they also you like to use their anger to control up. And if you're intimidated and they know that you're just in this bad pathological interpersonal relationship. That's right. So I think it's really important not to be intimidated. Every year I run this anger group at the Albert Island Institute. Every Wednesday night, they write lists, and every year, six months, I take in a new trainee with the group of three. And I think they're the thing that they learn first. And the most helpful is not to be intimidated. Because if they're intimidated, they can't say anything. They're intimidated. Clients run all over them. If they can say, yeah, you're right, you know, you can validate. You have somebody that treat you badly. Now you're responsible for how you're going to react to that transgression. And without being afraid, you got a fighting chance. All right. So the the therapeutic alliance, I think, may be different. And, you know, going back to modeling that assertiveness in a sense, and demonstrating how to identify and work towards goals rather than, you know, the passiveness that can occur with the intimidation. Absolutely. Yeah. Yeah. So, you know, the client is using their anger to intimidate others and you get into that dynamic with them, you're just repeating the path of pathology relationships that they've already had. And you really want to do something different. Well, you know, I appreciate so much the artist Neal fascinating. And I find myself wanting to go and look into some of the literature and starting to treat people and working to become a better clinician, you know, to support those individuals. And also, I guess by proxy supporting those individuals that first sparked you in getting into the field in with of when individuals are struggling when there's no anger begets more anger in other individuals. How we can really help to support that and know navigating and making it more assertive rather than aggressive. Absolutely. We have the model. Yeah. We'll start pulling back here. And, you know, one part is that we are the Safe to practice podcast and would love to hear what keeps you motivated or what keep you psych practice. You know, I think I like when I work with angry people. And. They have positive relations. I get a lot of people referred to me through H.R. and their bosses when they have a good relationship at work. They know they're not going to get fired for their anger. They feel really good. I feel really good when somebody can take the worst time and not get into a fight. It's such a good feeling and. You know, Janet Wall used to say anger is not an aphrodisiac and anger really is just dropped to intimate romantic relationships and to parent child relationships. And you can really see that when people control their anger and learn to be assertive. The quality of their relationship lost some balance. And that really reinforced because they have a closeness to people that they haven't had before. So that's one of the things that I think hit me. Going in it. And certainly, you know, your work, it creates an opportunity for clinicians to do that. And so thank you for that. I thank you. One other thing we'd like to, uh, to ask about is if you could recommend one piece of content, so be that book, movie or TV show podcast music for those in the profession. What would it be? Well, you know, I was thinking about that. I always liked the movie Anger Management, although I still hear everybody used to say. And there's just one thing in that movie, Anger Management, where the Jack Nicholson character, who's the psychologist, is cheating. He has them on driving over the Queensboro Bridge, connecting Manhattan and me. And he's got a thing I feel pretty good from West Side Story and that you want to get people who are angry to do something totally silly and different from what they expect and if you can get them to do that. You got a fighting chance to not try to intimidate other people. If they can, you know, kind of laugh at themselves and learn to have a new thought. I think that that's really key. And that's the one that phased in my mind. Absolutely. Michelle, I'm going to have to go back and rewatching your movie, but I know keep an eye out for that scene again. And the last question we like to ask is if you could provide our listeners with three gems or takeaways that you've learned over your career, what would they be? I think the first one is. Be concerned about the emotion. A lot of times people are worried about the behavior and the aggression and they don't ever ask about how the person feels. And they're not just their behavior. They have feelings. If they want to change their behavior. But I think we have in this field, we have to little focus on emotion, whereas I think the rest of psychotherapy, we're always interested in how people feeling, but when they're angry and aggressive. We don't want to know how they're feeling, so we don't pay attention to their emotion. I think that, again, is. Important to validate transgression that the person has experienced, even though. They may have inflicted more harm on others that was inflicted on them, even though they may retaliate greater than what was done to them. Every angry person feels a bit. And if you don't sort of validate that they're just not paying attention to you, they're just going to turn you up or try to convince you. And I guess, third, I would stay in this sort of beginning of therapy. Don't be intimidated. L respect you if you are not intimidated. They're not crazy. They just got this bad habit of intimidating other people. And if you can't be intimidated, you're okay and you have a chance. So those are, I think, the things that would be most important for the therapeutic process. Three points. Sort of that unconditional positive regard. And, you know, really, Rogers wasn't crazy, you know, like e he could do it. And if you look at the number of psychotherapies you build on. Unconditional positive regard is an important thing may not be curative all on its own, but without it we're probably not going to get very far. And, you know, it's always fascinating. And I think in every conversation we have on the podcast, if there's a tether to this and it's the idea of the relationship that heals. And, you know, even in here, you know, we need to create that relationship that says, I respect you, I hear you, I validate you. So let's get together and actually do some of that work. Right. Yeah. And so you're not shocked and surprised and angry at the people. They're they're they're used to shocking people and they shock you. And they're really going to try to shock you know, I have this collection of stories of like, revenge stories. Like in my group, people, like, try to say, like, who's done the most offensive revenge. They're really funny and they're really dramatic and they're really effective. And they think, I'm going to think really awful about them when they tell me this. But, okay, I can understand how you want to do that. Yeah, yeah, yeah. And and they don't have to do it. I understand that you want to do it. And so there's that, there's an old psychodynamic article on the therapeutic relationship with arrested. Yeah. That, that you want to validate and reflect that desire but not the behavior. I understand that you want to do that, that, that and yeah, I can understand you're not the only one who may want to do that. So I think that we want to do that. Absolutely. Well, and, you know, thank you so much for taking the time to sit down and talk about anger. And I say personally, I've taken away so much. And, you know, my co-host, Dr. Ray Christner, isn't able to join us, but I'm sure he's going to thoroughly enjoy listening through and just really appreciate having you on the podcast, you know? And with that, we. Is there any area or. You know, if our listeners are interested in learning more about what's going on, whether that's new research or just things that you really think that they would value or they would benefit from listening to. Where should our listeners look to hear what's going on for you? I guess maybe I'm going to have to put this podcast on my own website because I've done a really bad job promoting the kind of things that I'm doing. But I'm going to create a web page and or go to the Albert Ellis Institute. I have a thing there on Anger and I'll post things there. We have a number of new measures. You know, we have the code of honor scale that I spoke about and the anger, cognitions. You know, we've created this thing called the romantic partner anger scale, which is really, really kind of interesting, you know, to be able to we can share that with people because you get the most angry at the people you love. We've also created another new instrument, the in psychology, psychotherapy research is really big on wrongs, you know, rooting out and monitoring scales. And I realized that most of the related the anger and aggression, the items are just sugar first. And I've given them to clients who are angry and don't show any improvement because it's just many items. So we created the animals, you know. Q is like a famous album questionnaire by Mike Lambert, and we have the anger management outcome questionnaire, the 25 items. We have data on a thousand people have pretty good norms on it. And it asks about how angry been in the last few months. So people want a copy of the know more than one share. Okay. Well, certainly. Thank you and I appreciate that. Hoping our audience takes an opportunity to go into, you know, just putting out good information and improving the understanding, but also the support that we can give individuals struggling with some dysfunctional anger. Thank you. And with that, if you're interested in hearing more and staying up to date with what's going on for the Sector Practice podcast, you can visit our website at WW dot site to practice dot com or follow us on all major social media by searching sector practice. We'll be back in two weeks, but until then, you will stay safe. The information contained in this podcast and on the site. The practice website is intended for informational and educational purposes only. Nothing in this podcast or on the website is intended to be a substitute for professional, psychological, psychiatric, educational or medical advice, diagnosis or treatment. Please note that no professional patient relationship is formed here, and similarly, no supervisory or consultative relationship is formed between the host guest and listeners of this podcast. If you need the qualified advice of a mental health professional or practitioner, please contact services in your area. Similarly, if you need supervision on clinical matters, please locate a supervisor with experience to fit your professional needs.