Anger Management: Cognitive Therapy Interventions

On the last track, we discussed anger and depression.  The key points are intrapersonal dynamics and the vicious cycle of anger and depression.

On this track, we will discuss the Ventilation Trap.  Two ideas we will consider are continued anger and acknowledging hostility. 

Ventilation Trap - Two Ideas

#1 Continued Anger
As you know, there is little evidence that uncontrolled anger ventilation helps anger management clients to avoid their feelings of depression, guilt, or anxiety.  Clearly clients who negatively express anger may feel better momentarily, but, in the long run, only contribute to their own continued anger.  Thus by expressing anger but continuing to feel angry creates a Ventilation Trap for themselves.  

For example, Tom, age 42, was court-ordered to attend anger management sessions.  Tom stated, "I think that if I get mad, I should let it out.  So, if someone gets under my skin, I tell them off.  If someone really ticks me off, I go into a rage."  I asked Tom why he felt uncontrolled ventilation was the key to anger management.  Tom felt that the best way to deal with anger was openly and forcefully, because it made him feel better.  Also, he stated, "Telling people off is a good way to avoid ulcers." 

Four Questions Regarding Unrealistic Expectations

I asked Tom four questions regarding unrealistic expectations.  As I list the four questions, decide if they apply to a client you may be treating.

a. Do you often feel that circumstances beyond your control have deprived you of the good things in life?
b. Do you feel upset because life seems complicated and unfair for you while other people have it so easy?
c. Do you attribute much of your present unhappiness to mistakes your parents made?
d. Do you believe a person’s happiness and success in life depends on luck or connections?

I felt Tom’s positive answers to these questions indicated he held unreasonable expectations regarding life.  As a result, Tom had created a self-fulfilling prophecy of continued anger and created a ventilation trap for himself.  Are you treating a client like Tom who is caught in a Ventilation Trap?

#2 Acknowledging Hostility
In addition to continued anger, the second idea in avoiding the Ventilation Trap is acknowledging hostility. For Tom, his instantaneous anger was not an effective way for him to cope with his feelings.  However, acknowledging hostility was an effective way of coping with his feelings.  I asked Tom to give me an example of a recent confrontation in which he became hostile. 

Tom stated, "I was at the gas station yesterday waiting in line at the pump.  Some guy was fumbling with the pump like he’d never seen one before.  I yelled, ‘Hey, jerk!  What the hell do you think you’re doing?  Are you stupid?  Get it together or get out of my way!’  The moron just looked at me blankly and kept on screwing around with the pump!  I was about to get out of my car when the attendant showed up and helped the guy figure it out!" 

I asked Tom how long he was sitting there being angry with the man at the pump before the attendant arrived.  Tom stated, "About five or ten minutes.  Then it took another five or ten minutes for him to finish pumping and pay.  By the time I got to the pump, I’d wasted almost half an hour because of this prick." 

Cognitive Behavior Therapy Technique: The Four Question Challenge
To help Tom learn to acknowledge his hostility and get out of his Ventilation Trap of continued anger, I helped him implement the Four Question Challenge. 

a. The first question in the challenge is ‘What am I feeling?’  I stated, "Tom, when you feel the first hint of irritation, stop and ask yourself  ‘What am I feeling?’  For instance, what were you feeling when you first became irritated at the pump yesterday."  Tom stated, "I started feeling late, then annoyed and frustrated." 

b. The second question is ‘Why am I feeling this way?’  As you probably know, this is the stage where the client has the opportunity to acknowledge hostility.  When I asked Tom why he felt annoyed and frustrated at the pump, he stated, "I felt annoyed because that idiot was taking so much time." 

c. The third question in the Four Question Challenge is ‘What can I do about it?’  I explained to Tom that he could have assessed his options.  Tom stated, "You mean like helping the guy out instead of yelling at him?"  Would you agree that at this point Tom was beginning to see the difference between acknowledging hostility and engaging in hostility?  In addition to ‘What am I feeling?’,  ‘Why am I feeling this way?’  and  ‘What can I do about it?’, the fourth question is ‘What am I going to do about it?’  

d. The fourth question asks the client to make a decision.  After Tom analyzed his options, he decided which option would benefit him the most without harming others.  Tom stated, "I guess if I had helped the guy, I could have beaten my anger and saved some time." 

CBT 6-Step Systematic Desensitization Technique
Another CBT technique I used with Tom to help him acknowledge hostility in addition to the Four Question Challeng was the Systematic Desensitization technique. 

First, I asked Tom to make a list of five anger-provoking situations.  Tom chose stupid people as his hierarchy topic. 
Second, I gave Tom a stack of 3 by 5 cards on which to write ten to fifteen situations based on dealing with stupid people.  One of Tom’s situations included the guy at the pump. 
Third, Tom arranged the cards in order regarding the intensity of his anger as he focused on each situation. 
Fourth, I asked Tom to visualize each situation and state the degree of anger he felt during each situation.  Once Tom had arranged the situations regarding dealing stupid people from least to most anger-provoking, I asked him to relax using the Breathe Deeply technique from track 7.  Fifth, I asked Tom to select a positive mental image.  Tom stated, "When I was a kid, my mom took me to a park with a creek flowing through it.  It’s the most relaxing place I can think of."  Sixth, Tom visualized the mildest situation, which was stupid people on television, until he became angry.  At that point, he replaced that visualization with a positive mental image of the park from his youth. 

I asked Tom to continue this exercise until he could visualize all of the situations in his hierarchy without becoming angry. 

Do you have a Tom that you could use the CBT Four Question Challenge or Systematic Desensitization techniques with?  You might consider replaying this track and making notes on these techniques to implement with your client caught in a Ventilation Trap for your next session.

On this track, we discussed The Ventilation Trap.  Two ideas we discussed were continued anger and acknowledging hostility.

Peer-Reviewed Journal Article References:
Baer, R. A., & Sauer, S. E. (2011). Relationships between depressive rumination, anger rumination, and borderline personality features.Personality Disorders: Theory, Research, and Treatment, 2(2), 142–150.

Christ, N. M., Contractor, A. A., Wang, X., & Elhai, J. D. (2020). The mediating effect of rumination between posttraumatic stress disorder symptoms and anger reactions. Psychological Trauma: Theory, Research, Practice, and Policy. Advance online publication. 

Peters, J. R., Geiger, P. J., Smart, L. M., & Baer, R. A. (2014). Shame and borderline personality features: The potential mediating role of anger and anger rumination. Personality Disorders: Theory, Research, and Treatment, 5(1), 1–9.

Online Continuing Education QUESTION 14
What are two ideas concerning The Ventilation Trap? To select and enter your answer go to CEU Test.

This CD set has covered such topics as the five methods for handling anger, how feeling controlled causes anger, five myths that perpetuate anger, how other emotions create anger, intentions of anger displays, children and anger, rationalizations that perpetuate anger, assertiveness training, being accountable, combating trigger thoughts, alternatives to anger, positive response, the relationship between anger and depression, and the ventilation trap.

I hope you have found the information to be both practical and beneficial. We appreciate that you've chosen the Healthcare Training Institute at homestudycredit.com as a means for receiving your continuing education credit.

Other Home Study Courses we offer include: Treating Teen Self Mutilation; Treating Post Holiday Let-Down and Depression; Living with Secrets: Treating Childhood Sexual Trauma; Interventions for Anxiety Disorders with Children and Adults; and Balancing the Power Dynamic in the Therapeutic Relationship.