Stress inoculation therapy for anger

Cognitive
Behavior
Technique #16

Stress inoculation for Anger

Compiled by Jerome R. Gardner
2000 – First Edition

The enclosed techniques and procedures were developed with materials from a workbook of cognitive behavior techniques titled “Thoughts & Feelings and written by Matthew McKay, Martha Davis, and Patrick Fanning. The workbook was published by New Harbinger Publications, Inc in 1997.

Technique #16 Stress Inoculation for Anger

Clinical Prompt

Step 1. Mastering Relaxation Skills: Don’t proceed past Step 3 in this technique until the child has learned these skills.

Step 2. Developing an Anger Hierarchy

• draft highest anger & lowest anger
• fill in the middle gradients
• finalize the ranking on the Anger Hierarchy Form

Step 3. Developing Coping Thoughts

• identify ‘trigger’ thoughts
• separate blame and ‘broken rules’
• develop two coping thoughts for each situation on anger hierarchy
• see Suggested Anger Coping Thoughts
• fill out Anger Hierarchy Worksheet

Step 4. Applying Anger-Coping Skills

• get relaxed
• visualize first/next situation
• start to cope
• rate the anger
• alternate relaxation and scenes

Step 5. Practice In Vivo

• anticipate

Special Considerations:

• incomplete relaxation
• visualization difficulty
• try Technique #17 – ‘Covert Modeling’

Forms & Charts

Anger Hierarchy Worksheet CBT#16-001
Suggested Anger Coping Thoughts CBT#16-002
Technique #16 Stress Inoculation for Anger

Download Available | CMBT 16 Supplemental Docs

Introduction

Anger is one of the most devastating and physically harmful emotions. Stress inoculation training was extended to the management of anger by Raymond Novaco in 1975. In his book Anger Control: The Development and Evaluation Of an Experimental Treatment, Novaco says, “Anger is fomented, maintained, and influenced by the self-statements that are made in provocative situations.” He makes a strong case for the proposition that the source of all anger is what you think about a situation.

Provocations don’t make you angry; hurtful, attacking statements don’t make you angry; stressful and overwhelming situations do not make you angry. What turns painful and stressful situations into anger are trigger thoughts.

Trigger thoughts:

1. blame others for deliberately, needlessly causing you pain, and
2. see others as breaking rules of appropriate or reasonable behavior.

If you decide that people are deliberately harming or attacking you, that you are a victim of their unreasonable behavior, then your trigger thoughts act like a match to gasoline.

A person is not helpless when provocations occur. Anger is not automatic. Stress inoculation teaches you how to relax away your physical tension while developing effective coping thoughts to replace the old anger triggers.

There are five steps in stress inoculation for anger control:

1. mastering relaxation skills,
2. developing an anger hierarchy,
3. developing coping thoughts for items in your hierarchy,
4. applying anger-coping skills during visualized hierarchy scenes, and
5. practicing anger-coping skills in real life.

Symptom Effectiveness

Both Raymond Novaco and Jerry Deffenbacher (1987) have demonstrated in numerous studies the effectiveness of stress inoculation for anger control. Hazaleus and Deffenbacher (1986) have shown that relaxation skills, combined with coping thoughts, provide an effective anger management technique.

Time for Mastery

Developing the key relaxation skills for stress inoculation will take from two to four weeks. Once the relaxation skills are in place, you could have the child successfully complete a visualized anger hierarchy in a week or less.

Applying the new coping skills to real-life anger provocations takes longer. You’ll need to have the child take advantage of spontaneous situations when they arise, using them as a laboratory to experiment with relaxation skills and coping thoughts. Real-life anger management may require two to six months of hard work before the new skills become automatic and can be used reliably whenever the child is provoked.

Instructions

Step 1: Mastering Relaxation Skills

The child will need to master the four skills of Technique #04 “Relaxation”: Progressive muscle relaxation, relaxation without tension, cue-controlled relaxation, and special-place visualization. Don’t proceed past Step 3 in this technique until the child has learned and practiced each of these procedures.

Step 2: Developing an Anger Hierarchy

Have the child get a blank piece of paper and begin writing down as many anger situations as s/he can think of. Have him/her think of the full range of provocations, from minor irritations to things that make him/her blow his/her top. This list should include at least twenty-five or thirty situations. If s/he can’t think of that many, try breaking some of the anger episodes into steps – how things escalated between the child and the other participant(s).

Once the list is complete, have the child write at the top of a fresh piece of paper the least anger evoking item on the list. At the bottom of the page, have the child write the item that makes him/her angriest.

Fill In the Middle Scenes

Now it’s time to select from six to eighteen items of graduated intensity that can fill in between the lowest and highest anger scenes. The child can use the list developed in Step 2, or even come up with some new items, to build the hierarchy.

Once you believe that the child has enough items, you can direct him/her to go through the scenes in the hierarchy to make sure that the increments of anger between each item are approximately equal throughout. If some increments are larger than others, s/he may need to fill in these “holes” with additional scenes. Keep working on it until the steps of the hierarchy are close to even.

Finalizing the Hierarchy

Once the child has ranked his/her hierarchy items from 1 (lowest anger item) to X (highest anger item), photocopy the Anger Hierarchy Worksheet [CBT#16-001] and have him/her fill in the items s/he has developed.

Step 3: Developing Coping Thoughts

You should have the child develop two or more coping thoughts as s/he gets ready to visualize each new scene in the hierarchy. Briefly have the child visualize the scene, making it as real as possible. Encourage the child to notice what s/he sees, hears, and even feels physically Now have him/her listen to the trigger thoughts.

Ask: Are you blaming the other person or people involved for deliberately harming or hurting you? Do you see their behavior as wrong and bad, as violating basic rules of conduct?

If the trigger thoughts fall into the category of blame, here are some suggested coping responses to help the child control his/her anger:

• I may not like it, but they’re doing the best they can.
• I’m not helpless – I can take care of myself in this situation.
• Blaming just upsets me there’s no point in getting mad. Don’t assume the worst or jump to conclusions.
• I don’t like what they’re doing, but I can cope with it.

If the triggers fall into the “broken rules” category, where the provocative party seems to be violating standards of reasonable behavior, some of the following coping thoughts may be helpful:

• Forget shoulds – they only upset me.
• People do what they want to do, not what I think they should do.
• No one is right, no one is wrong. We just have different needs.
• People change only when they want to.
• No one’s bad; people do the best they can.

Some of the best coping thoughts simply remind you not to get upset. They affirm that you can stay calm and relaxed in the face of irritation. See Suggested Anger Coping Thoughts [CBT#16-002]. If none of the coping thoughts from these lists feels right to the child, s/he can make his/her own. Or s/he can combine elements from different coping thoughts into something that feels more useful. Some of the best coping thoughts involve a specific plan for handling a situation: stating your wants clearly, saying no, finding an alternative way to meet your needs, and so on. A good plan in a problematic situation can make a person feel less helpless. And when you experience yourself having more control, you often feel less angry.

Now it’s time for the child to distill the two or three best coping thoughts for the first scene in your hierarchy. S/he will write them in the space provided on the Anger Hierarchy Worksheet [CBT#16-001]. S/he will do the identical process for each succeeding scene you come to.

Step 4: Applying Anger-Coping Skills

Here’s the sequence for using stress inoculation in anger control1

A. Take ten to fifteen minutes to get relaxed.

Have the child go through progressive muscle relaxation, cue-controlled relaxation (which includes deep breathing), and a special-place visualization to feel calm and safe.Then have him/her briefly review the coping statements for the first (or next) scene.

B. Visualize the first (or next) item of your hierarchy.

Have the child try to bring the scene alive. See the situation, hear what’s going on, feel the growing tension on a physical level. Remind the child to listen for his/her trigger thoughts, the unfairness, the wrongness, the outrageousness of the offense. When s/he really feels the anger, go on to Step C.

C. Start to cope.

Once the child has the visualized scene clear in his/her mind, s/he should immediately begin relaxing and using coping thoughts. It’s recommended that s/he use cue-controlled relaxation during hierarchy scenes because this is the quickest stress-reduction strategy. All s/he has to do is take a few deep breaths and use your cue word or phrase.

As the child copes physically using cued relaxation, have him/her try to recall the designed coping thoughts. Have the child say them to him/her self while continuing to visualize the scene. Keep the child coping and visualizing the provocative situation for about sixty seconds.

D. Rate the anger.

Using a ten-point scale ranging from 0 (no anger) all the way to 10 (the worst rage s/he has ever felt), have the child rate the anger s/he experienced in the scene just before s/he shuts it off. If the anger is rated 1 or 0, you can relax and move on to the next scene. If the anger is 2 or above, have the child go through the relaxation sequence and then revisit the same scene.

This is a good time for the child to spend a moment evaluating the coping thoughts. If any have proved ineffective, have the child stop using them. If none of them works, go back to the general list of coping responses and experiment with one or two others. If you’ve been using suggested coping thoughts from the lists and they haven’t worked, perhaps you and the child can write a few of your own coping thoughts. The ones the child develops his/herself are likely to be a better fit for you.

E. Always do deep relaxation between scenes.

Typically, the child might use cue-controlled relaxation and spend time calming him/herself in a special place. If a particular anger scene is really upsetting, or the child is having difficulty reducing his/her anger during a scene, you might suggest that s/he do progressive muscle relaxation or relaxation without tension before re-entering the scene.

Have the child continue visualizing and coping with scenes until you have finished the highest-ranked item in the hierarchy. Best results come from daily practice. The first practice session should last fifteen to twenty minutes. Later you can extend stress inoculation sessions to as much as thirty minutes. The main limiting factor is fatigue. If the child is getting tired and having difficulty visualizing a scene, it’s best to postpone practice until s/he is more alert.

Expect the child to master from one to three hierarchy items during each practice session. Always go back to the last scene successfully completed when starting a new practice session. This helps the child consolidate gains before facing more anger-evoking items.

Step 5: Practicing Anger-Coping Skills in Real Life

Since anger situations tend to be spontaneous, it’s hard to schedule real-life practice for new anger skills. If the hierarchy includes items that occur frequently or predictably, the child will find many opportunities to practice. The key to real-life practice of relaxation and anger-coping thoughts is to recognize the first signs of anger. The earlier the child intervenes with cue-controlled relaxation and some helpful coping thoughts, the more likely s/he is to maintain control.

If the child is entering a situation where s/he [or you] can predict a likely anger response, s/he should prepare the coping thoughts in advance and commit to using cue-controlled relaxation at the first touch of anger. By now, with all your practice in the hierarchy scenes, cue-controlled relaxation has hopefully become “overlearned.” It should be getting easier and easier to do, more and more automatic. If the child has difficulty remembering to use relaxation and coping thoughts during a particular provocative situation, have him/her visualize the scene and practice coping later (using the same procedure as when you worked the hierarchy). Extra practice with an imagined or remembered scene can make the child more prepared and better able to remember to use these skills when it next shows up in real life.

Special Considerations

If the child experiences difficulties in practicing stress inoculation, they are likely to be in common problem areas:

1. Incomplete Relaxation. If the child can’t relax at the beginning of a session, have them try to imagine lying on a soft lawn on a calm summer day, watching clouds slowly floating by. Or imagine watching leaves float by on a broad, slow river. Each cloud or leaf takes some of the muscular tension away with it.

You may also want them to record the relaxation routine on tape and play it at the beginning of each session or scene.

2. Visualization Difficulty. If the child finds that the scenes seem flat, unreal, and unevocative of the distress they would feel in real-life scenes, they probably have trouble visualizing things clearly. To strengthen the powers of imagination, ask the child questions of all the senses to make the scenes real:

Sight: What colors are there in the scene? What colors are the walls, the landscape, people’s clothes, cars, furnishings? Is the light bright or dim? What details are there—books on the table, pets, chairs, rugs? What pictures are on the walls? What words can you read on signs?

Sound: What are the tones of voices? Are there plane or traffic noises, dogs barking or music playing in the background? Is there wind in the trees? Can you hear your own voice?

Touch: Reach out and feel things—are they rough or smooth? hard or soft? rounded or flat? What’s the weather like? Are you hot or cold? Do you itch, sweat, have to sneeze? What are you wearing? How does it feel against your skin?

Smell: Can you smell dinner cooking? flowers? tobacco smoke? sewage? perfume or aftershave? chemicals? decay? pine trees?

Taste: Are you eating food or drinking water? Are the tastes sweet? sour? salty? bitter? It also helps to go to the real setting of one of your scenes. Then you can gather images and impressions, and practice remembering details. Close your eyes and try to see the scene, then open your eyes and notice what you missed. Close your eyes and try again. Describe the scene out loud to yourself. Open your eyes and see what you missed this time, and what you changed in your mind. Close your eyes and describe the scene again, adding the sounds and textures and smells and temperatures. Keep this up until you have a vivid sense picture of the scene

If the child repeatedly struggles with an anger-provoking situation that involves a familiar sequence of responses (i.e., fights in school about spouse, about homework or chores), you may want to try Technique #17 “Covert Modeling.” This is an excellent technique to help a child develop and rehearse new behavior patterns.