Anger is a common and often problematic feature for many trauma survivors, yet it receives little systematic attention in research or clinical practice.
What we know about anger generally is that it is a normal emotion, an understandable reaction to certain circumstances, and a mobilising, adaptive and appropriate approach to overcoming obstacles to facilitate goal attainment. It is a multifaceted experience comprised of cognitive, emotional, behavioural and physiological components that reinforce each other.
While anger is a normal emotion it can be considered problematic when it occurs with a frequency, intensity, or duration that causes significant distress and interferes with relationships and day-to-day functioning. Problematic anger can also be associated with aggression and violence, posing risks to the safety of others and indeed the self.
There is now mounting research evidence for the prominence of problematic anger in trauma survivors in terms of its prevalence, role in the development of disorder, relationship to aggression and violence, and interference in the effectiveness of treatment for posttraumatic stress disorder (PTSD).
Problematic anger has been identified as common across a broad range of trauma survivors, including survivors of large-scale disasters and sexual assault, adult survivors of childhood interpersonal trauma, and veterans and emergency service personnel exposed to trauma.
A program of research conducted following the Victorian Black Saturday bushfires of 2009 showed that problem anger was reported at more than twice the rate in high bushfire-affected areas compared to less affected areas. Disturbingly, four times as many women from more affected areas reported experiencing violence following the fires.
Longitudinal studies of police and military personnel across the US, UK, Israel and Australia demonstrate that early anger predicts subsequent development of disorder. Indeed, the more a person perceives their anger as ‘helpful’ in coping with stress and threat following trauma, the greater the potential for it to become an ongoing problem-solving tool and a contributor to the development of subsequent disorder.
Despite the significant impacts of anger for patients with a trauma history, both on daily functioning and in the development of disorder, we know that in clinical practice anger is rarely assessed. While in research, assessment is often inconsistent, with confusion between the measures for anger, hostility and aggression.
The STAXI is considered the gold standard measure for anger, however, it is lengthy, often too lengthy for use in clinical practice or research protocols.
The Dimensions of Anger Reactions 5 (DAR-5) scale as a brief five-item measure is simple to use in clinical practice. It has been implemented by large clinical and research programs in the UK, US and Australia. Its five items measure anger frequency, intensity, duration, aggressive intent, and the impact of anger on social functioning.
In terms of treatments, there are now a small number of studies demonstrating the effectiveness of anger-focussed cognitive behavioural therapy, targeting anger-specific cognitive themes, short-circuit strategies to ensure safety of self and others, the costs and benefits of anger, and coping-focussed exposure to anger provoking cues (both imaginal and in vivo). PTSD-specific anger programs have also been piloted and show promise.
Advances in anger-focussed e-health applications can also be very useful not only as adjunctive supports to treatment but also as low intensity self-management interventions where anger presents as an early sign.
For researchers in this space, there is much work to be done in enhancing anger interventions and treatments, developing new ones, and ensuring that anger measurement is included in studies.
In the consulting room, clinicians should consistently consider anger in clients’ presentations, and assess and treat as needed.
This is a summary of an invited presentation given by Professor David Forbes, Director of Phoenix Australia, at the ISTSS 35th Annual Meeting in Boston in November 2019.