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APA Psychotherapy Training Videos are intended solely for educational purposes for mental health professionals. Viewers are expected to treat confidential material found herein according to strict professional guidelines. Unauthorized viewing is prohibited.
Table of Contents
Introduction One of the most challenging moments in psychotherapy is grappling with expressions of overt anger toward the therapist. Survey results and personal accounts consistently reveal its difficulty for seasoned and neophyte clinicians alike. In two separate surveys of psychologists' perceptions of stressful client behavior (Deutsch, 1984; Farber, 1983), for example, aggression and hostility directed toward the therapist emerged as the second most stressful behavior, second only to suicidal statements. In a survey of experienced and inexperienced psychiatrists (Plutchik, Conte, & Karasu, 1994), as another example, criticism of the therapy and the therapist surfaced as one of four major categories of critical incidents defined by the behavior of patients who create special difficulties for psychotherapists. Such criticism was rated as both an important and a frequent incident in psychological treatment. In fact, over 80% of psychotherapists acknowledge feeling afraid or angry when a client is verbally abusive toward them (Pope & Tabachnick, 1993). Our own clinical practices, teaching experiences, and survey findings confirm that patient expression of anger toward the psychotherapist is a stressful and prevalent phenomenon in the course of psychological treatment. In developing the American Psychological Association (APA) Psychotherapy Video Series, we initiated numerous discussions and conducted a small survey of fellow clinicians (n = 28) to determine which in-therapy incidents they would most like to observe on video for the purposes of clinical training and continuing education. Clinicians of various disciplines and orientations rated "expresses anger toward the therapist" among the most instructive incidents. Responding skillfully to a patient's anger thus constitutes a major technical and interpersonal hurdle for psychotherapists. Trained to foster empathic communication within a helping context, practitioners are frequently ill-prepared to handle verbal assaults directed at them or their interventions. The predictable repercussion oft times is therapist defensiveness, evasiveness, rebuttal, or counter-anger, rather than a facilitative transaction. Explicit modeling and training in reacting therapeutically to anger is quite rare. Trainees are routinely advised to listen attentively, to avoid counterattacking, and to "address" patient anger. However, it is unclear how to concretize this generic advice in the absence of specific examples of therapists actually responding to patient anger in unrehearsed sessions of psychotherapy. This stimulus training tape, created from the APA Psychotherapy Video Series, demonstrates how seven psychologists handle patient anger in session. The vignettes are drawn from videotaped sessions in which professional actors adept at improvisation portrayed actual clients in unscripted and spontaneous exchanges that included expressing anger toward their respective therapists at some point in the sessions. In selecting the vignettes, variety was sought in both the type of psychotherapist and the type of patient anger. The psychotherapists vary in gender, age, and theoretical orientation. Similarly, the clients manifest anger in several ways: as generalized displeasure with the treatment, as hostility obliquely directed at the therapist, and as criticism of a particular event or intervention in the session. Of course, the psychotherapist's method of responding to the anger is specific to the context of that session and the dynamics of that patient, and these vignettes may not represent how the psychotherapist would respond to an expression of anger in another session or from another patient. The seven vignettes, between 3 and 6 minutes in length, were selected to show the content and process of the client's expression of anger, the therapist's initial responses, and some of the ensuing transaction. To illustrate a variety of therapist responses and keep the tape to an appropriate length for training purposes, we limited the amount of dialogue following the anger expression. Responding Therapeutically to Patient Anger demonstrates an assortment of skilled responses to anger expressed by patients in psychotherapy. The goal is to assist you in identifying and acquiring the technical and interpersonal skills that best suit you and (most important) that best suit your patients. We hope to stimulate constructive dialogue and critical reflection on patient anger, your response, and therapeutic interventions. Purpose The developers of the APA Psychotherapy Video Series have prepared this guide as an aid in using and learning from the video. The sections below contain suggested training applications for the video, synopses with pertinent information on each of the seven vignettes, general questions that can be asked following each vignette, and observations and reflections gleaned in developing the video, and related resources. Each of the vignette synopses contains a biographical sketch of the psychologist, background information on the patient, and the session context leading to the expression of anger. Suggested Training Applications The video vignettes that comprise Responding Therapeutically to Anger offer training and other applications that psychotherapists may find useful in their practice, teaching, and research. This video may be used to demonstrate various ways in which anger is expressed and ways in which it may be interpreted. Before using the video in the classroom, instructors should prepare students to understand the varied meanings of anger. Anger may represent displaced hostility, diffuse affect, situational stress, attention getting, defensive strategy, or any number of other intentions. Viewers should keep in mind that expression of affect may be misinterpreted, as when behavior actually represents an interaction style characterized by strong emotion. In other words, anger may be intended by the patient or may be misinterpreted by the therapist. One possible use of this video is in a course or class discussion focusing on anger. The video shows expressions of anger in interpersonal situations that can also occur outside the therapeutic context. Although brief and relating to specific content, the seven vignettes contain expressions of emotion that can serve as useful examples for demonstration and teaching. They could also be used as stimuli for research on reactions to anger or interpretations of angry outbursts. These vignettes also provide an opportunity for studying observers' reactions to expressions of anger. The video can help therapists appreciate the countertransferential feelings aroused by anger directed at them. Anger is one of the earliest threats to a sense of self. Therapists' own initial experiences with and reactions to anger may shape much of how they are able to deal with strong emotional responses. Natural reactions to aggressive anger are feeling hurt, attacked, or misunderstood; defending oneself; and retreating into self-blame. Many therapists—indeed, many people—were taught as children to respond "in kind" to anger, and it is common to react negatively to anyone who may threaten or challenge. None of these "natural" responses to anger are typically therapeutic, although some clinicians espouse reacting "honestly" as a way to demonstrate their humanness. When therapists decide to respond in a so-called natural manner to anger, they must be fully aware of the clinical implications of that reaction to the therapeutic relationship and treatment process. Escalation of anger seldom leads to deeper insights, new skills, or conflict resolution. Reciprocated anger usually begets emotional conflicts; these may be common in peer, sibling, and couple relationships, but they are seldom—if ever—helpful in psychotherapy. The video is primarily intended to model several methods of responding therapeutically to patient anger. In an instructional context, the teacher or viewer can pause the tape after each vignette to examine the interaction and the implication of the therapist's response. The viewer or instructor can ask (and answer) several of the queries presented in the Questions to Consider Following Each Vignette section that follows. Other important teaching applications include considering the advantages and disadvantages of the therapist's response, thinking aloud about the specific types of clients and situations for which certain responses are indicated, and generating alternative responses. Another useful approach is to make process observations and notes on these interpersonal transactions. This method allows the viewer to track the affect-laden interaction and to infer some causal connection between the therapist's and the patient's responses. What happened when the therapist provided an empathic reflection or an interpretative observation? Where did that lead the patient? How did the patient, in return, influence or lead the therapist? Such exercises model and encourage a process analysis of psychotherapy in general, and of critical incidents in particular. Vignette Synopses Vignette 1. Dr. Lillian Comas-Díaz with Sam Lillian Comas-Díaz, PhD, is executive director of the Transcultural Mental Health Institute in Washington, DC, where she also maintains a private practice. Dr. Comas-Díaz has published extensively on the topics of ethnocultural mental health, gender, and ethnic factors in psychotherapy. Her most recent book is Women of Color: Integrating Ethnic and Gender Identities Into Psychotherapy (1994). Sam is a 32-year-old, single Caucasian man who earned a master of arts degree. He was divorced 3 years ago (married a total of 4 years). Sam works as a sound engineer at a network radio station. Sam's parents died when he was 12. Although he remembers his biological parents, he views the aunt and uncle who brought him up as his parents. Sam has one younger sister and three male cousins he views as brothers. Session context leading to the expression of anger: In the previous session, Sam agreed with his psychologist that depression, boredom, infidelity, and a slow descent into self-destruction were problems he would like to confront. However, he was uncertain whether his use of drugs and alcohol constituted a serious problem. He declined a referral to Alcoholics Anonymous or Rational Recovery, but he did agree to remain abstinent for another month (bringing the total to 2 months) to determine how alcohol and cocaine abuse affects his mood. This vignette begins early in the fourth session, after an exchange of greetings and general questions about how the week went. Vignette 2. Dr. John C. Norcross with Celeste John C. Norcross, PhD, is professor and former chair of psychology at the University of Scranton, a clinical psychologist in part-time independent practice, and an authority on psychotherapy integration and prescriptive treatments. He is the author of more than 100 scholarly articles and 10 books. Dr. Norcross most recently coedited the Handbook of Psychotherapy Integration (with M. R. Goldfried; 1992). Celeste is a 29-year-old, single Caucasian/Hispanic woman who earned a bachelor of arts degree. She is employed as a feature writer for Vanity Parade. Both of her parents are living; she has a sister (32) and a brother (26). Session context leading to the expression of anger: In her two previous sessions, Celeste expressed strong ambivalence toward being in psychotherapy but agreed to try it on a weekly basis. In negotiating the clinical contract, Celeste and her psychologist agreed to work on understanding and managing Celeste's anger. In the third session, where the vignette occurs, Celeste and Dr. Norcross are continuing to review her repeated outbursts of anger and rage, and the subsequent problems that these incidents have created: losing a potential promotion, destroying another's property, and graduating late from college. Vignette 3. Dr. Donald K. Freedheim with Dorothy Donald K. Freedheim, PhD, is an associate professor of psychology at Case Western Reserve University and has been a psychologist in part-time practice for more than 30 years. Dr. Freedheim edited the American Psychological Association Division 29 (Psychotherapy) journal, Psychotherapy, for 10 years, and was the principal editor of the volume History of Psychotherapy: A Century of Change (1992) for the 100th anniversary of the American Psychological Association. Dorothy is a 58-year-old Caucasian woman who earned a master of science in computer science and works as a computer consultant. Dorothy was widowed 3 years ago (at age 55); she had been married 35 years. Both Dorothy's parents are dead. She has one older sister and two children: a son, Adam (37); and a daughter, Ann (32). Session context leading to the expression of anger: In the previous three sessions, Dorothy related that she has been "in a slump" for almost 2 months, unable to sleep, with swings in her mood from feeling agitated to feeling hopeless. To help her understand the role of her husband's death in her present situation, Dr. Freedheim had asked Dorothy to prepare for this session by gathering memorabilia of her husband—pictures, letters, and so forth—and reviewing them over the week. This vignette opens at the beginning of the fourth session, when Dr. Freedheim asks Dorothy how the previous week was. Vignette 4. Dr. Jacqueline B. Persons with Lisa Jacqueline B. Persons, PhD, is a psychologist in private practice in Oakland, California, and an associate clinical professor in the Department of Psychiatry at the University of California, San Francisco, where she provides clinical and research training to postdoctoral psychologists and psychiatric residents. Dr. Persons is the author of Cognitive Therapy in Practice: A Case Formulation Approach (1989). Lisa is a 29-year-old, single Caucasian woman who earned a master of arts in public relations. She works as a public relations manager. Both her parents are living, and she has one older sister. Session context leading to the expression of anger: In the previous (third) session, Lisa reported that she had not had much anxiety because she had been avoiding speaking situations whenever possible. Dr. Persons focused on the importance of exposure, and Lisa agreed that she would need to begin approaching feared situations and not avoiding them. To begin the process, Dr. Persons suggested that she develop a hierarchy of feared speaking situations. As a homework assignment between the third and fourth session, Lisa agreed to chat informally with colleagues before each regular business meeting during the week, speaking for at least 2 minutes each time. The vignette opens with Lisa reporting to Dr. Persons on the homework assignment. Vignette 5. Dr. Marvin R. Goldfried with Janet Marvin R. Goldfried, PhD, is a professor of psychology and psychiatry at State University of New York at Stony Brook and maintains a limited practice of psychotherapy in New York City. Cofounder of the Society for the Exploration of Psychotherapy Integration, Dr. Goldfried's most recent book is From Cognitive–Behavior Therapy to Psychotherapy Integration: An Evolving View (1995). Janet is a 31-year-old, divorced Caucasian woman who attended college for three semesters and graduated from secretarial school. She works as a legal secretary. Janet's mother (60) is living; her father died 17 years ago at age 43. Janet has no siblings. Session context leading to the expression of anger: In the previous session, Janet clearly prioritized her therapy goals: improving her relationship with her boyfriend, Larry; eventual resolution of her interpersonal problems at work; and a better long-term relationship with her mother, if possible. During this fourth session, Dr. Goldfried and Janet have looked at Janet's internal conflicts by engaging in the two-chair dialogue, and Dr. Goldfried has tape-recorded and played back Janet's behavioral rehearsal with her boyfriend. The vignette opens as Dr. Goldfried and Janet are considering the next steps in her treatment. Vignette 6. Dr. Florence W. Kaslow with Alan Florence W. Kaslow, PhD, is in independent practice in West Palm Beach, where she is also Director of the Florida Couples and Family Institute. Recipient of numerous awards from the American Psychological Association and the American Association of Marriage and Family Therapy, Dr. Kaslow is author or editor of more than 115 articles and 13 books. Her most recent book is Handbook of Relational Diagnosis and Dysfunctional Family Patterns (1996), a volume in a new series she is editing, the Wiley Series in Couples and Family Dynamics and Treatment. Alan is a 54-year-old, married Caucasian man who holds a master's degree in economics. He is a CPA and the CEO of an accounting firm that he founded 15 years ago. Alan has been married for more than 30 years to Joyce; they have two children, Julie (28, engaged to be married, a CPA in Alan's company) and Jon (20, single, a student). Session context leading to the expression of anger: In the two previous sessions, Alan and Dr. Kaslow explored a series of possible interventions both at the business, which was the site of recent dissension, and with other family members. These possibilities included meeting with Alan's wife, meeting with his daughter and future son-in-law, meeting with his daughter, and meeting with top executives at the firm. Alan was to be present during all these meetings. This vignette opens with Dr. Kaslow greeting Alan as the session begins. Vignette 7. Dr. Laura S. Brown with Ellen Laura S. Brown, PhD, is in independent practice as a psychotherapist and forensic psychologist in Seattle, Washington, and is a clinical professor in psychology at the University of Washington. The recipient of numerous awards from the Association for Women in Psychology and the American Psychological Association, Dr. Brown is author, most recently, of Subversive Dialogues: Theory of Feminist Therapy (1994). Ellen is a 34-year-old, single Caucasian woman who spent 3 years in a bachelor of fine arts program studying painting. She occasionally works in an art-related job. Her parents are living and divorced; she has a brother (32). Session context leading to the expression of anger: Six months ago, Ellen was arrested for grand larceny and possession of narcotics. For the drug charges, she was remanded by the court to see a psychologist. During the previous (second) session, Ellen and Dr. Brown discussed the pros and cons of Ellen's possible attendance at a Narcotics Anonymous (NA) meeting. Dr. Brown asked Ellen to observe whether, between Sessions 2 and 3, she chose to go or not to go to an NA meeting and to pay careful attention to the way in which she engaged in the decision-making process, with particular attention to whom she gave authority in her decision to go or not to go. The vignette begins with an opening question from Dr. Brown. Questions to Consider Following Each Vignette
Observations and Reflections Having prepared the clients–actors for the demonstration sessions and observed the original sessions, the video series developers are able to offer some integrative reflections on responding therapeutically to patient anger. Analysis of the videotaped transactions suggests several consensual, perhaps oversimplified, dos and don'ts for psychotherapists confronted with overt patient anger. Neither originality nor exhaustiveness is claimed for the following list; rather, it represents transtheoretical convergence in how these seven psychologists handled the situation. Therapist Dos and Don'ts
Typical Therapist Interventions There are recurring commonalities in the types of interventions that these psychotherapists used in the video vignettes. Following are several of these typical interventions framed in descriptive, theoretically neutral language. The therapist
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