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Cognitive and Behavioral Practice 18 (2011) 241–250

www.elsevier.com/locate/cabp

The Application of Acceptance and Commitment Therapy to Problem Anger

Georg H. Eifert, Chapman University

John P. Forsyth, University at Albany, State University of New York

The goal of this paper is to familiarize clinicians with the use of Acceptance and Commitment Therapy (ACT) for problem anger by
describing the application of ACT to a case of a 45-year-old man struggling with anger. ACT is an approach and set of intervention
technologies that support acceptance and mindfulness processes linked with commitment and behavior change processes. Here, we
outline an ACT model of problem anger, extend that analysis to a clinical case, and illustrate ACT intervention strategies and
assessment considerations. As will be seen, ACT teaches individuals to “act on life, not an anger” by choosing and committing to live
consistently with personal values rather than acting on anger feelings and associated behavioral impulses.

metaphorical, experiential, and behavior change tech-

ANGER emotion, and although
is a ubiquitous it is often
and particularly easy to spot, it is
destructive nologies to undermine processes that support narrowing
much harder to define in scientific terms. The process of of behavioral options, while creating broader and more
anger can be ignited by a number of events, typically flexible patterns of behavior that help clients move in
starting with the experience of emotional hurt and the direction of chosen life goals (Forsyth & Eifert,
discomfort, and quickly followed by judgment and 2008; Luoma, Hayes, & Walser, 2007).
blame directed at self or others. This process can set Before we move on, we wish to acknowledge that our
into motion a wide range of behavioral predispositions to
analysis of Mr. P is limited to the case description as
act. Problem anger, as we see it, is this predisposition
presented, and is arguably speculative. Nonetheless, we
manifesting in anger behavior, and where the conse-
hope that some of what you are about to read may be
quences of that behavior are damaging to self and others.
helpful in illustrating ACT as applied to problem anger
Our intention here is to lay out a conceptualization (see Eifert, McKay, & Forsyth, 2006).
of problem anger based on Acceptance and Commit-
ment Therapy (or ACT, said as one word; Hayes,
Stroshal, & Wilson, 1999), and then to apply that ACT Model of Problem Anger
analysis to the case of Mr. P (Santanello, 2011). ACT, as All human beings carry the capacity to experience and
many readers know, is a newer behavior therapy, built express anger. Yet, if you look past the experience of
upon a technical account and model of human anger and the associated urge to act, you will often find a
suffering and its alleviation. The model explains how vulnerable human being who is hurting in some way
individuals get entangled in language and verbal- (Hanh, 2001; McKay, Rogers, & McKay, 2003). Indeed,
symbolic behavior processes that trap them in a struggle there is ample evidence linking emotional and physical
with thoughts and emotions they experience as aversive pain (including loss) with anger (Berkowitz, 1993; Smith
(Hayes, Barnes-Holmes, & Roche, 2001). ACT has two & Gallo, 1999). One approach is to address the pain
major goals: (a) acceptance of unwanted thoughts and directly and its functional relationship with anger
feelings whose occurrence or disappearance clients behavior. Another tactic is to target the anger itself, and
often cannot control, and (b) commitment and action the often-destructive consequences of anger manifest in
toward living a life consistent with a client's values. ACT anger behavior. There are whole industries built around
involves both acceptance and change, and uses several managing anger, the feeling, and its outward expression.
Yet, unless we can address processes that transform pain
(physical or emotional) into anger, we may never get the
kind of durable solution to problem anger that we seek,
and truly address the main social ills that seem to flow
1077-7229/10/241–250$1.00/0
© 2010 Association for Behavioral and Cognitive Therapies.
from anger behavior.
Published by Elsevier Ltd. All rights reserved.
242 Eifert & Forsyth

Anger typically occurs in an interpersonal context and Cognitive Fusion and Defusion
stems from at least four related sources (Eifert et al., Conscious or automatic thought, usually in the form of
2006): (a) thoughts, typically of judging or blaming, evaluative judgment and blame, can transform pain into
suggesting that other people (or the self) have violated full-blown anger. Within ACT, the form or frequency of
or failed to meet personal needs, or firmly held ideas such thoughts tends to be less important than the fact that
about right and wrong, rules about conduct, and so on; people frequently buy into them and do what they seem
(b) strong belief in these thoughts, which are held as to demand, even when doing so is largely unhelpful.
literally true, such that judgment and blame are treated Cognitive fusion is a term used within ACT to describe the
as properties or qualities of self and other behavior (e.g., tendency for humans to get caught up in the content of
“that bastard screwed me over” is not simply a thought, what they are thinking and to take their thoughts literally,
but “bastard” and “screwed over” are seen as qualities of believing that these thoughts accurately describe how
the person and their actions and intentions); (c) strongly things are rather than seeing them as what they are: just
believed-in thoughts catalyze unpleasant emotional thoughts. More technically, cognitive fusion refers to the
responses, from feelings of hurt, fear, anxiety, tension, dominance of automatic and derived stimulus functions
shame and guilt, and ultimately anger and rage; and (d) entailed in language over more direct and experiential
strong urges or impulses to resolve the welling discom- functions with the end result that “literal evaluative
fort are translated into actions, namely efforts to right strategies dominate in the regulation of human behavior,
the presumed injustice by struggling to control other even when less literal and less judgmental strategies would
people, particularly their behavior, in order to have one's be more effective” (Hayes, 2004, p. 13).
needs met.
For instance, if someone said the word lemon, it is
With problem anger, the terminal point in this likely that you could see it in your mind's eye and perhaps
sequence is often anger behavior, and this behavior experience some of its tart properties. Yet, thinking lemon
tends to create more problems than it solves. Anger does not make you a lemon, right? You are not that
behavior is also largely ineffective in the long-term as a thought. This point is often lost on people struggling with
means to reduce or eliminate painful anger-feelings and anger, including other related forms of emotional and
associated feelings of hurt, shame, and guilt. Such psychological pain (e.g., guilt, shame, stress, anxiety). The
behavior does tend to get in the way of the life people thought “you hurt me” is not just a thought like “this is a
want, and imperils or destroys relationships. It may also lemon” for someone who is struggling with anger. It is an
adversely affect work, health, and well-being, and reduce unacceptable thought, linked with unpleasant feelings
overall enjoyment of life (McKay et al., 2003; Suarez, (e.g., hurt, embarrassment, and shame), other thoughts
Lewis, & Kuhn, 2002). such as intention (e.g., “she meant to hurt me”) and
judgment (“that's not right”), and one's sense of self (e.g.,
From an ACT point of view, anger is a natural
consequence of six related processes that can lead to a “I am inadequate, weak, or stupid”), and thus appears to
narrowing of behavioral options or, in ACT terms, demand some action.
“psychological inflexibility.” This is defined as “the Judgment here appears to be a quality of the pain and
inability to modulate behavior in response to how useful its source. What we often overlook is that this process of
it is––changing behavior when change is needed and evaluating is not a property of what is being evaluated––
persisting when persistence is needed––so as to accom- although to the person who is doing the evaluating it
plish value-guided ends” (Hayes & Strosahl, 2004, p. 25). appears to be so. Ramnerö and Törneke (2008) provide
We briefly describe each of the six processes below, and the example of a woman who states that her “anxiety is
then apply them to Mr. P's case. We will also describe unbearable.” She sees the unbearability as a characteristic
how they link up with ACT targets for change that of her anxiety, not as the result of her own relational
promote psychological flexibility, which is the ability to responding. In fact, human beings can evaluate just about
contact the present moment more fully and to either anything in innumerable ways, and yet fail to see that this
change or persist with goal-directed behavior when process is arbitrary (i.e., largely shaped by social
doing so serves to accomplish desired ends (Hayes & convention) and not a property of nature (e.g., a rose is
Strosahl, 2004, p. 5). As we do that, it is important to be a rose, whether you call it stupid, beautiful, ugly, precious,
appropriat ely cautious. Despite a growing literature dumb). When a person is hurting and adds layers of
supporting the operation of each of the six processes judgment and blame, it does little to ameliorate the hurt,
across various forms of human suffering (see Hayes, but only shifts responsibility for the hurt to another
2008; Hayes et al., 2006), there is relatively little work person (“you did this to me”), and with that shift the
linking these processes directly to problem anger and its hurting person becomes a victim. The important skill to
treatment. We hope that this case series may advance learn here is to learn to recognize the evaluations that
and encourage that kind of work. our mind constantly comes up with and, based on past
 ACT on Life, Not on Anger 243

experience, decide when acting on these evaluations is personal narratives and stories, noticing that their story
likely to be helpful and when it is not. about themselves is different from the person doing the
Cognitive fusion is neither bad nor good. It is a natural noticing. For instance, just as you can notice and observe
byproduct of language processes. The critical question is objects in the world around you, you can also just notice
whether it is helpful or not in a particular situation. With and observe thoughts, sensations, urges. This may involve
problem anger, fusion with pain plus judgmental evalu- learning to notice that the stories clients tell about
ation more or less goes on unchecked, and the result in themselves (e.g., “I inherited depression from my
cases of problem anger is often this: the initial experience mother” or “I've always been hot-headed”) are just one
of hurt morphs and transforms into anger and a of several possible stories that could be told, that such
narrowing of behavioral options in the form of what stories can be held lightly and looked at in terms of how
seems like inevitable and justifiable anger behavior. they function, and more important, that attachment to
one or more particular stories may not be working well.
ACT employs several defusion exercises to weaken
cognitive fusion where it is unhelpful. Such exercises, of
which mindfulness may be a part, help clients let go of the
idea that one's thoughts are valid descriptions and Experiential Avoidance Versus Acceptance
explanations of one's experiences. Instead, clients gain Anger can serve as a powerful means to avoid
perspective to see their thoughts as only thoughts. Another emotional and psychological pain. The emotion of
way to conceptualize this is in terms of the distinction anger can quickly mask psychological hurt and pain and
between self-as-content (I am my thoughts) and self-as- redirect attention away from the self and toward other
process (I am having the thought that…). Self-as-content people who are seemingly responsible for the hurt. With
tends to emerge from cognitive fusion, whereas self-as- this shift may come a sense of power and control. This
process denotes a more defused and flexible stance. shift also can keep people from recognizing and dealing
with their pain, while fostering ruminative thinking about
how one might get back at the people who seemingly
Attachment to the Conceptualized Self Versus triggered the hurt and anger to begin with. Language and
Self-as-Context cognition make it possible for pain linked with anger to
generalize to many life areas, which is part of the reason
This is another form of cognitive fusion because it is why anger can be so destructive, and at the same time, so
fusion with one's self-concept (the stories we tell about difficult to avoid.
ourselves). People become invested in how they perceive
(conceptualize) themselves. In short, people literally Experiential avoidance is a term used within ACT to
believe their own stories about who they are, even when describe rigid and inflexible efforts to escape from or avoid
doing so results in significant harm. The truth of the stories unpleasant private events—thoughts, emotions, and bodily
is irrelevant because the stories are accepted as true. sensations—and the circumstances that might occasion
Attachment to the conceptualized self results in rigid them (Hayes et al., 1999; Hayes, Wilson, Gifford, Follette, &
behaviors aimed at validating or defending one's stories, Strosahl, 1996). It also involves attempts to change the
which contributes to psychological inflexibility. With form or frequency of these events to make them less
anger, this can manifest as attachment to being right, painful, even when doing so results in significant harm
being loved, looking smart, not making mistakes, having (e.g., substance abuse, physical violence). Such attempts,
one's needs met regularly, or ideas about fairness, justice, often in the form of direct change efforts, require
and how people ought to be treated. It can also manifest considerable effort, typically do not work in the long-
as holding on to personal narratives or stories about one's term to avert pain and reduce anger, and end up causing
life, including relations between the past and the present more suffering and damaging relationships (Tangney,
and the present and the future (“I've always been a loose Wagner, Hill-Barlow, Marschall, & Gramzow, 1996).
cannon”). Anything that may threaten the conceptualized
self, in turn, is a likely trigger and target for anger There are many ways that one can avoid painful
behavior. A rigid attachment to the conceptualized self emotional and psychological triggers for anger, including
may manifest in many ways (e.g., defensive resistance and the discomfort associated with anger itself. For instance,
excessive reasons and justifications for behavior, thoughts, attributing blame and responsibility for one's pain to
and feelings; ways of speaking that link the self with someone else is a powerful strategy to avoid taking
evaluative labels or with the past; rigid rules of conduct). responsibility for the hurt and the pain one is experienc-
ing in the moment. Even when these attributions are
correct, their long-term effects are often deleterious; the
Detachment from the conceptualized self requires
critical issue here, as with cognitive fusion, is to help
cognitive defusion, a process of distancing oneself from clients explore whether such strategies have worked in the
specific thoughts to gain psychological flexibility. Clients long run in terms of producing the desired outcome, or
are encouraged to step back from and observe their
244 Eifert & Forsyth

whether such strategies have not worked, leaving clients Unclear Values
feeling like their life has been reduced to the size of a
The dominance of language and cognition, coupled
postage stamp.
with significant pain, self-defense, and avoidance, can
Acceptance literally means to take what is offered, and greatly interfere with a good quality of life in domains
entails (a) remaining in contact with painful experiences such as relationships, intimacy, family, work, recreation,
(b) without attempting to alter their form or frequency health, or spirituality. Within ACT, anger is a problem
and (c) persisting in actions that are consistent with one's precisely because anger behavior dominates over other
personal values. As such, acceptance-based strategies behaviors in life domains that are important to the client.
oppose experiential avoidance while offering something Pain, anger, and anger behavior become so central, that
new. Such acceptance fosters new and more flexible ways clients often lose sight of their values, or what is really
of relating to painful or uncomfortable emotional and important to them.
psychological experiences. The effectiveness of accep-
tance strategies has been demonstrated in the treatment A central aim of ACT is to help clients clarify their
of such diverse problems as chronic pain, anxiety values and then find ways to more fully enact them. Values
disorders, self-injurious behaviors, and smoking (for a provide direction for action. They are enacted in patterns
comprehensive review, see Hayes et al., 2006). of action designed to reach specific goals. Values can be
likened to a lighthouse or compass that shows clients the
direction they want to move in. Goals are specific concrete
waypoints on the map, places they plan to visit as they
Disconnection From the Present Moment move in the direction of their values. Goals involve actions
Behavior therapists have traditionally adopted a here- people can put on a list, complete, and then tick off.
and-now focus with their clients precisely because the Values, on the other hand, cannot be attained or
present is where problems manifest and are amenable to completed––they are ongoing commitments that are
change. The present is also the place where we can act to reflected in moment-to-moment actions. We cannot ever
make a difference in our lives. Anger can undermine
contact with the present, which then becomes a place “finish” a value (Dahl & Lundgren, 2006). For instance, if
dominated by anger-related private and public behavior, a client values intimacy, there are many ways in which that
and for many people these behaviors are hurtful obstacles value can be enacted, and one could create a list of goals
to creating a meaningful life. and then check them off when completed. Yet, the value
of intimate connection with other human beings is not
If clients are fused with their private events, they are something that one can finish or check off; there is always
“living in their heads” and are not in contact with what is more than can be done.
going on in their life in the present, moment-to-moment.
Thus, the critical question is whether actions are
Not only is their focus on their inner world, it is also
moving a client toward or away from what they care
located in the past or future, remembering and antici-
deeply about, or want to be about as a human being.
pating painful events, ruminating about past wrongs,
Without having clear values, clients find it difficult to act.
imagining retribution to the wrong-doers, or pondering
They feel “stuck,” and their behavior becomes habitual
how to get back or get even in the future.
and automatic, which is itself a common feature of
The antidote to such disconnection is mindful contact problem anger and a form of psychological inflexibility.
with the present moment. In its most basic form, One of the goals of ACT is to help clients focus on their
mindfulness is about focusing our attention on the values and clarify them so that they can direct their
present moment and making direct contact with our behavior toward actions that foster what matters in their
present experiences, with acceptance and without de- lives. One could start this process in treatment by
fense, and with as little judgment as possible (Kabat-Zinn, exploring a client's response to the following question:
1994). The functions of mindfulness within ACT are to If anger weren't such a problem for you (or “if we could
foster defusion, to help clients become observers rather make anger just disappear”), then you'd be doing what?
than responders to their experience, and to foster greater
tolerance of and kindness towards the experience of
unwanted cognitions and emotions. Another important Inaction With Respect to Values
function of mindfulness is to promote greater contact
with present contingencies that may be more useful in Inaction with respect to values is a clear indication of
shaping and guiding behavior. A variety of strategies are psychological inflexibility (Luoma et al., 2007). Inaction
used within ACT to foster mindfulness, both in session comes from different sources, including being unclear
and outside of session, and we will describe one of them about one's values. It also is a by-product of experiential
later in the section on intervention strategies for problem avoidance in which clients are so consumed with
anger. defending themselves from painful experiences that
they cannot act, or act in ways that are damaging to
 ACT on Life, Not on Anger 245

them and what they truly care about. Or, if they do act, the stress and discomfort Mr. P experiences, rather than
their actions are likely to be ineffective or maladaptive him taking responsibility for how he responds to his
and exacerbate their problem. A major goal of ACT is to thoughts, feelings, and emotions. Fusion with judgmental
get clients to act, but in ways that are in the service of their thoughts about the “nagging” girl-friend, “idiot drivers,”
values—in other words, value-guided action as opposed to and his “blaming” and “misunderstanding” former
anger-guided behavior. therapist all lead to one basic conclusion: other people
are at fault. Believing (“buying into”)theseanger-
Case Conceptualization
triggering thoughts are the psychological equivalent of
An ACT Approach to Problem Anger pouring gasoline on a fire to put it out. The illusion that
From the case description of Mr. P, one could extract the mind creates here is that nagging and idiot are
properties of people, when they are nothing more than
behaviors that fit each of the six processes that are
thoughts. Mr. P also appears fused with the thought that
believed to promote psychological inflexibility. In fact, a
he is basically powerless and at the mercy of his anger, and
useful exercise here would be to go back to the case
thus is more or less a victim of idiots, nags, jerks, and other
description and see if you can identify each of the six
wrongdoers in his life.
processes, or at least some of them before reading on.
Here, we will provide a brief outline of how we
Mr. P seems to be fused with his sense of self too,
conceptualize Mr. P's problems from an ACT perspective.
describing himself as someone that is “difficult to handle”
An ACT case conceptualization tends to be functional and as a person that others are intolerant of. The story is
and focuses on the six processes described earlier. Mr. P that others need to change, not me, and it is they (not
seems to have a long history of learning that the me) who have the problems: “I am not a jerk like other
expression of anger behavior is normal and adaptive. people; others ought to know that, including knowing
Thus, it is likely that he has learned, directly or indirectly, what I want, need, and desire.” And, it is important to be
that anger behavior is associated with positive conse- strong, with anger behavior being a reasonable way to
quences, whereas the expression of a range of normal show that. He also appears entangled in a victim story, and
human emotions (e.g., sadness and fear) was often met is afraid of opening up, being vulnerable, and taking
with punishing consequences. It also seems that his anger responsibility for his behavior. Facing these issues
is precipitated by events that evoke other unpleasant squarely would likely be difficult for Mr. P, not simply
emotions, and thus one might expect that Mr. P will be because it would hurt facing his unpleasant feelings, but
more prone to experience and express anger when also because he may need to face the social and other
feeling various forms of discomfort (e.g., stress). costs caused by his choices and anger behavior.

Being punished for the healthy expression of emotion, In terms of values, it seems that Mr. P has not given
in turn, likely shaped the use of various emotion much thought to what he wants his life to be about as
regulation strategies to avoid punishing consequences indicated by his somewhat ambivalent response to his
(i.e., early history of reinforcement for experiential expectations for treatment, namely, “I guess I'd like to
avoidance), with anger expression being linked with enjoy my life more.” What does seem clear is that Mr. P's
short-term reinforcing consequences. Anger is a powerful anger behavior has resulted in negative consequences
emotion that can quickly overshadow other forms of pain across several life that are important to him, namely
and discomfort, and thus can function as a form of career (e.g., loss of several jobs for aggressive and violent
experiential avoidance. Mr. P appears to engage in anger behavior), his relationships with his former wife and now
behavior when pain threatens to overwhelm him. He then with his current girlfriend (e.g., using verbal aggression to
engages in blame and external attributions of responsi-
bility as reasons for action or inaction (e.g., not taking “punish” his girlfriend when he is upset by her actions)
responsibility for making changes in therapy), and thus and his children, his health (e.g., anger and blame
avoids personal responsibility for his choices and actions destroyed opportunities to benefit from his prior efforts
(e.g., being verbally aggressive toward others). Collective- in psychotherapy), and more generally other people. The
ly, these actions may function to reduce the hurt and triggers here appear to be forms of discomfort, including
discomfort he experiences prior to anger episodes. reading intention into the actions of other people (e.g.,
being misunderstood or snubbed, others speaking to him
in a demeaning way, judgment that others would betray
Moving beyond this basic history, there is evidence for
him). Being unwilling to express his thoughts and feelings
fusion, the conflation of thoughts with reality—in several (remember history of punishment for doing so), coupled
parts of the case description. For instance, he seems to with failure of others to meet his expectations, set the
firmly believe the story that “he does not have an anger stage for a struggle.
problem” and that “external stressors are the real
problem.” Holding on to this story leads to a shift, In sum, the case description conveys a fairly rigid and
where other events and people are held responsible for
inflexible behavior repertoire dominated by anger
246 Eifert & Forsyth

behavior, which is largely under aversive control. Behavior the likelihood of relapse when such strategies fail to
under aversive control tends to result in a narrowing of work as intended.
behavioral options: “High levels of avoidance patterns We have summarized an ACT approach to problem
tend to increasingly narrow the repertoire of behaviors in anger as teaching individuals to act on life, not an anger
which an individual engages and often create secondary (Eifert et al., 2006). One of the main goals of treatment is
problems in an individual's life” (Jacobson, Martell, & to target unsuccessful efforts to control and get rid of
Dimidjian, 2001, p. 259). From an ACT perspective, this aversive anger-related thoughts and feelings by acting on
narrowing of behavioral options is the heart of psycho- them. For this reason, it is essential that Mr. P first
logical inflexibility, and is created and maintained by the experience the personal, social, and other costs associated
six interrelated processes that we outlined earlier. We with acting on anger feelings. He also needs to learn to
recommend that a clinician evaluate whether these ACT- distinguish what is difficult to control (experiencing
relevant processes are present in a given case and how anger feelings) and what he can control (his actions––
they operate functionally in the context of anger
behavior. The challenge for the therapist is to help the what he does with his hands, feet, and mouth). Although
client establish other, more flexible and viable options for it is difficult, and at times impossible, to control intense
behaving. This is accomplished by targeting processes that feelings, thoughts, memories, images, sensations, and
maintain psychological inflexibility and by modeling and impulses (Abramowitz, Tolin, & Street, 2001; Petrie,
supporting alternative processes that encourage psycho- Booth, & Pennebaker, 1998; Salkovskis & Reynolds,
logical flexibility. 1994; Trinder & Salkovskis, 1994; Wenzlaff & Wegner,
2000), he can learn to control and change how he
responds to discomfort, including anger-related feelings
The remainder of this paper focuses on some ACT
and impulses. He also needs to learn to recognize
intervention strategies that may be used to undermine evaluations that his mind const antly comes up with
psychological inflexibility in cases of problem anger. An (“idiot driver,”“she wants to hurt me”) as thoughts that
ACT approach to problem anger builds on the basic he can have without needing to respond to them or do
ideas that although it may seem that anger behavior is an what they implicitly or explicitly seem to tell him to do.
inevitable (even justifiable) consequence of anger
feelings, this need not be the case: People can learn to
One important therapeutic goal is to help Mr. P to stop
respond differently to the hurt and discomfort they
trying to get rid of or keep anger-related thoughts and
experience when anger ignites and still choose to act in
feelings down when they arise. Instead, he can learn how
ways that uphold their values. This is why early on it is
to change his relationship with, and response to, such
critical to help clients learn to distinguish between anger
uncomfortable and painful aspects of his history. To get
“the feeling” and anger “the behavior.” As will be seen, there, he needs to learn how to acknowledge angry
fostering psychological flexibility means increasing be- thoughts instead of believing in and acting on them. To
havioral options by learning to mindfully contact and accomplish this, an ACT therapist would likely employ
accept distressing thoughts and feelings, learning to experiential exercises, metaphors, and imagery to contact
disentangle from one's evaluative mind, and engage in the unworkability and costs of coping and other anger
behaviors that are consistent with chosen values. management strategies, and that he can make a different
choice: He can choose to leave them alone and simply
experience them as thoughts or feelings. Most impor-
tantly, these experiential exercises can show him that he
General Therapeutic Strategy and Goals: ACT on Life, does not have to act on his anger-related thoughts and
Not on Anger feelings––they need not drive what he does. For instance,
One of the core skills to be learned in ACT is how to as much as he may feel like tailgating another motorist
recognize and refrain from self-perpetuating and self- who drives “too slowly”, he can instead learn to notice and
defeating emotional, cognitive, and behavioral avoid- watch his anger feelings and resentful thoughts and not do
ance routines. Learning acceptance, mindfulness, and what they tell them to do.
other defusion skills undermines excessive and rigid
emotion regulation (Blackledge & Hayes, 2001) while It will be important earlyin treatment for Mr. P to learn
fostering actions that are in the service of living a values-
that such changes are not desirable simply for social or
oriented life instead of living a symptom-free life
moral reasons, but if enacted, such changes may help him
(meaning less angry). Thus, ACT is different from
live the life he wants to live without letting anger get in the
what many clients and therapists typically expect must be
way. Recall that a central aim of ACT is to promote
done to solve anger problems. ACT is not about helping
psychological flexibility, or the ability to live in the present
clients to control or manage anger. Such strategies may
moment more fully and with less avoidance and defense
prolong clients' struggle for effective anger control as a
so that “individuals can change or persist in behavior when
prerequisite for effective action, and may even increase
doing so serves valued ends” (Hayes et al., 2006, p. 7, italics
 ACT on Life, Not on Anger 247

added). To this end, ACT would teach Mr. P to notice and terms of strained relationships with his children and
acknowledge his anger-related thoughts and feelings, to difficulty maintaining employment that are likely to be
respond less literally to his anger-related thoughts by elucidated in this exercise. A related assessment work-
decreasing their believability, and to commit to and sheet is designed to help Mr. P look back at his past
pursue life goals important to him. As clients are guided attempts to manage and control anger and examine what
in learning these skills, we also nurture the development triggers his anger feelings. At the surface, these triggers
of compassion for themselves and others. The goal is for are often people and situations, but most importantly are
clients to rediscover what truly matters, to focus on what also internal triggers such as feelings of being frustrated,
they want their life to stand for, and then to act in ways threatened, hurt, ashamed, and guilty. For each trigger,
that move them forward in their lives. This process may Mr. P would write down his coping strategies (what he
mean bringing anger or other unwanted thoughts and actually did) and the outcome of his actions.
feelings “along for the ride.”
The goal of these exercises is not to make Mr. P feel
The actual delivery of ACT is more akin to a fluid hopeless. Rather, creative hopelessness is about letting
dance around several core processes rather than a linear Mr. P experience that his former strategies and solutions
progression. This is consistent with the view that ACT is a to manage his anger are hopeless in that they have not
functional approach, not merely a therapy or collection of worked and have only damaged important personal and
treatment technologies. It builds on a model with several professional relationships in his life. This process is
interrelated treatment targets that are continually revis- creative and empowering because it makes space for
ited throughout therapy (Hayes et al., 2006). For instance, him to act in a different way that is more consistent with
cognitive fusion is addressed with mindfulness and other what he really cares about.
defusion strategies that also help reduce believability of
thoughts and attachment to stories about the self, the
past, or future. Experiential avoidance is weakened by Letting Go of the Struggle––Learning Where Control Is Helpful
providing clients with skills to stay with unwanted Mr. P stated that he believes he has no control over his
cognitions and emotions rather than attempting to anger or his tendency to become aggressive. It is therefore
move away from them. Remaining open and sensitive to important for Mr. P to learn to distinguish what is difficult
the present moment is directly fostered with mindfulness to control (his anger feelings and thoughts) from what he
exercises. Committing to and engaging in value-guided can learn to control (his behavior). The notion of not
action is facilitated by letting go of old attachments and doing what anger feelings strongly suggest and letting go
not getting entangled with thoughts that are not helpful of the struggle with anger thoughts and feelings is
and constructive in guiding an individual toward the life counterintuitive and likely to be quite alien to Mr. P.
they want to live. Again, rather than trying to convince Mr. P, the therapist
can employ a number of metaphors and exercises that will
help Mr. P experience that he has more control over his
What this means is that concepts, metaphors, and actions than over his thoughts and feelings. The tug-of-war
exercises introduced early on may be revisited again at exercise has been used extensively (e.g., Eifert et al., 2006;
any time they seem relevant. This is consistent with ACT as Forsyth & Eifert, 2008; Hayes et al., 1999) to let clients
a principle-guided approach, where the focus is on experience what it feels like to let go of the struggle with
changing the function of internal experiences rather unwanted thoughts and feelings.
than their content or absence and presence (Forsyth &
Eifert, 1996).
This metaphor could be introduced in the context of
exploring Mr. P's struggle to “get even” with people who
annoy him. The therapist could gently suggest that this
Specific Assessment and Intervention Techniques
war sounds like a fight with an anger monster and could
Creative Hopelessness: Assessing the Costs of Anger ask Mr. P if he is willing to see how this might play out in
One of the first steps in treatment is for the therapist the room. The therapist would then play the role of the
and Mr. P to explore his former solutions to problems, anger monster in a tug of war with Mr. P using an actual a
with an eye on how well they have worked both in the rope (about 3 to 4 feet long). Both therapist and Mr. P
short and long term, and whether they are workable at all. would take the rope and start pulling. To enhance the
Using a worksheet (Eifert et al., 2006), Mr. P would be exercise, the therapist may bring important life areas into
encouraged to explore the costs of anger behavior in key the room, and particularly areas where anger feelings
life domains such as interpersonal relationships, career, tend to occur and lead to destructive behavior that gets in
health,andself-concept.ThegoalistoletMr.P the way of value-guided action.
experience how much responding to anger feelings with
anger behavior has cost him in the various areas of his life. As the tug of war unfolds, Mr. P would notice that
The case description already alludes to significant costs in efforts to pull harder result in the monster pulling
harder right back. Acting out this exercise will let Mr. P
248 Eifert & Forsyth

physically experience how much energy and focus it from what he cannot control in his life, and to identify
takes to keep his anger in check. We have found that where he has choices.
almost all clients will grab the rope with both of their For example, Mr. P cannot do much about the rage
hands when the therapist hands it to them. This is a very arising in his body or the vengeful thoughts popping into
graphic illustration of how the struggle can leave our his mind when other motorists “drive like idiots.” Yet, he
hands tied up in the fight and no longer free to do has options when it comes to how he responds to them
anything else. and what he does with them. The purpose of these and
The key element of the exercise is to let clients related exercises is to set the stage for gradually replacing
old, habitual, automatic ways of behaving (such as blowing
experience that they have a choice: One choice is to
up) with intentional, new, flexible ways of behaving that
continue to fight, another is to drop the rope. The choice
he can consciously choose. By practicing mindfulness and
is not whether the anger monster (e.g., intense feelings)
other defusion exercises, he can learn over time to simply
shows up or not, but whether to pick up the rope or not.
watch his feelings and thoughts, recognize them as
Once Mr. P drops the rope, he can experience the
feelings and thoughts, and absolutely not do as they say.
difference this action makes and what he gains from it. At
Learning to recognize and stay with unwanted feelings
that point, the therapist can point out in a very concrete
when he has them is an important first step toward
fashion what Mr. P cannot control (i.e., presence,
learning not to respond with anger behavior because of
intensity, quality of painful thoughts and feelings) and
anger feelings.
what he can control, which is what he does with his hands,
feet, and mouth. Incidentally, therapists need not worry
about ending up in a fight with their clients. We have
found that clients fully recognize and stay within the Facing Anger and Hurt With Compassion
playful boundaries of the exercise. Behind many episodes of anger is unresolved and
often hidden pain and hurt. To let Mr. P experience his
hurt and emotional pain and provide him with an
Approaching Anger With Mindful Acceptance and opportunity to learn to stay with these experiences, the
Gentle Awareness therapist may conduct a number of “anger exposure”
This step introduces Mr. P to acceptance and exercises. These exercises would first be practiced in
mindfulness as a skillful way of approaching his anger session and at home, so that he can apply the skills later in
experiences and his life. Accepting anger involves situations where his anger gets triggered. The long-term
recognizing and staying with unpleasant thoughts and goal is to develop willingness to be in contact with his
feelings—making space for them—without acting on anger and not act on it. These exercises involve asking Mr.
them. It is not about agreeing or disagreeing with them, P to imagine recent episodes of anger and get in touch
nor does it mean giving in, or giving up. For Mr. P, it with all the evaluative thoughts, emotions, sensations, and
means to simply learn to notice any feelings of rage, urges he experiences in those situations. The goal of these
blame, guilt, shame, or inadequacy without arguing with exercises is (a) to learn to recognize and acknowledge
or trying to replace them. In short, to observe anger- anger, rage, fear, guilt, rejection, and hurt when he feels
related thoughts and feelings without getting caught up in them; (b) develop the courage to do nothing and just sit
evaluation or judgment and without holding onto, getting with his anger feelings and thoughts with increasing
rid of, suppressing, or otherwise changing what he degrees of kindness and compassion; and (c) develop an
experiences. observer's perspective with his anger experience. Watch-
ing, without judging, his feelings will allow him to
The goal is for Mr. P to learn an observer perspective in disentangle himself from what his body and mind are
relation to his anger-related feelings and thoughts. A doing and give him the control to act in ways that matter
variety of closed eyes exercises, described elsewhere to him.
(Eifert et al., 2006), are used to develop this skill. Another
option is to adapt a more generic exercise, such as the Anger needs an enemy to exist and grow (Ellis & Robb,
Acceptance of Thoughts and Feelings exercise (Eifert & 1994). Meeting anger with compassion and forgiveness
Forsyth, 2005), by including thoughts and sensations leaves anger with no room to grow. Developing compas-
related to anger. This is a 12-minute closed eyes exercise sion is incorporated in anger exposure exercises by
that he would be asked to practice once a day. The adding imagery components that foster (a) acknowledg-
exercise encourages willingness to experience unpleasant ing his hurt and pain as it is, without judgment or denial;
thoughts and feelings that are difficult for the client and (b) softening to his experience using his wise mind
provides him with a tool for doing so. The larger goal is to (McKay, Wood, & Brantley, 2007) while inviting healing
undermine any tendency to react to anger-related and change; (c) extending compassion to his experience
thoughts and sensations with anger behavior. The second and that of others; and (d) letting go and moving on––
goal is to help Mr. P differentiate what he can control
releasing the grudges, resentment, and pain, and then
250 ACT onEifert
Life, Not
& Forsyth
on Anger 249

moving
ACT treatment.
forward in Moreover,
his life in“acceptance”
directions hedid wants
not to
appear
go. Hayes, S. C.,that
programs Strosahl, K. D., &used
are widely Wilson, K. G. (1999).
in behavior Acceptance
therapy can and
Thus,
to mediate
compassion
reductionsentails
in frequency
both engaging of problematic
in acts of anger be a Commitment
useful tool Therapy:
to guideAntherapists
experiential approach to behavior change. New
in this process (Hopko,
York: Guilford Press.
kindness
behaviors. toward
However,
oneselfthoseandreceiving
other peoplethe ACT (e.g.,interven-
extend- Lejuez,
Hayes, S. Ruggiero,
C., Strosahl,& K. Eifert, 2003;
D., Wilson, Jacobson
K. G., et T.,
Bissett, R. al.,Pistorello,
2001). J.,
ing
tionforgiveness;
did show a small,
engaging butin
significant
friendly behavior)
increase inand a Toarmino,
The D., Polusny,
therapist would alsoM. A., Dykstra,ongoing
provide T. A., Batten, S. V., Bergan,
feedback
mindful
acceptanceresponse
(assessed
to one's
withownthe Acceptance
private events and(anger
Action J., Stewart, S. H., Zvolensky, M. J., Eifert, G. H., Bond, F. W.,
and work with
thoughts
Questionnaire;
and feelings).
Hayes et al., 2004), while controls showed Forsyth, J. P.,him to setM.,realistic
Karekla, goals
& McCurry, and(2004).
S. M. criteria,
Measuring
monitor progress,
experiential and brainstorm
avoidance: A preliminary solutions to move
test of a working withThe
model.
a nonsignificant deterioration. anger-related
Psychologicalbarriers
Record,rather than trying to overcome or
54, 553–578.
Initially, Mr. P will likely ask, “Why should I have
Hayes, S. C.,them.
eliminate Wilson,HeK.can
G., doGifford,
this E.
byV., Follette, V. M., &angry
acknowledging Strosahl, K.
compassion
Though this and study
forgive is XYZ?
small, and
I wassuffers
hurt so from
badlyall that
the the (1996). Emotional avoidance and behavioral disorders: A
other guy deserves
limitations of a modestto beclinical
hurt too.” Here,
trial, it is itnonetheless
will be feelings that may accompany him along the way
functional dimensional approach to diagnosis and treatment.
and
important
encouraging to point out thatthat
in showing compassion
problematic does not behavior
anger mean approach
Journalthem with mindful
of Consulting awareness.
and Clinical It may
Psychology, also
64, 1152–1168.
condoning or tolerating
can be addressed using behaviors
ACT without thatnecessarily
damage him or
changing require
Hopko, D. taking a hard
R., Lejuez, lookRuggiero,
C. W., at where K. anger behavior
J., & Eifert, would
G. H. (2003).
keep him in an abusive
the dispositional situation.
experience He can
of anger. still protect
Larger clinical take Behavioral
him and where heaswants
activation to gofor
a treatment instead.
depression: Procedures,
principles, and progress. Clinical Psychology Review, 23, 699–717.
himself andnot
trials have others from conducted
yet been harm and danger.
and areItneeded.
is, however, Jacobson, N. action
S., Martell, C. R., responsibility––or
& Dimidjian, S. (2001).being Behavioral
Taking is about re-
better for him to do so without harboring ill will toward activation treatment for depression: Returning to contextual
sponse-able: using his hands, feet, and mouth for the
those people. Holding onReferences to his anger, even when he does roots. Clinical Psychology: Science and Practice, 8, 255–270.
purposes
Kabat-Zinn,ofJ. living
(199 4).the life heyou
Wherever wants to live.
go, there Response-ability
you are: Mindfulness
not act on it, keeps him feeling tense and unhappy. It may
Abramowitz, J. S., room
Tolin, D. is a choice
meditationhe inhas: Whenlife.
everyday heNewfeelsYork:
anger, he can (a) make a
Hyperion.
also give anger to F., & Street,
spill G. P.affect
over and (2001).important
Paradoxical
Luoma, J.
effects of thought suppression: A meta-analysis of controlled choice toB., Hayes, S.
respond withC., & Walser,
anger R. D. (2007).
behavior, Learning
or (b) he canACT: feelAn
partsstudies.
of hisClinical
life (e.g.,
Psychology Review, 21, 683–703. children)
work, relationship with his
angerAcceptance
and respond and Commitment Therapy skills-training manual for
in ways that are compassionate, caring,
that
Berkowitz, L. (1993). Painabout.
he seems to care Learning
and aggression: compassion
Some findings andand therapists. Oakland, CA: New Harbinger.
genuine,
McKay, M.,open, honest,
Rogers, P. D., & and respectful––ways
McKay, J. (2003). When that angerwill
hurts, 2nd ed.
forgiveness is difficult.
implications. MotivationWe andhave therefore
Emotion, developed
17, 277–293.
Blackledge, J. T., & Hayes, S. C. can
(2001). Emotion regulation help Oakland,
move him CA:in Newdirections
Harbingerhe want his life to go.
Publications.
specific exercises that they repeatedly practice inat McKay, M., Wood, J. C., & Brantley, J. (2007). The Dialectical Behavior
Acceptance and Commitment Therapy. JCLP/Insession: Psychotherapy
homein to help clients
Practice, develop such skills (Eifert et al.,
57,243–255. Therapy Skills Workbook. Oakland, CA: New Harbinger.
2006,
Dahl, J.,ch. 9; Forsyth
& Lundgren, T. & Eifert,
(2006). 2008,
Living ch. your
beyond 17).pain. Oakland, CA: Petrie, K., Booth, R., & Pennebaker, J. (1998). The immunological
New Harbinger Publications. Empirical Support
effects of thought suppression. Journal of Personality and Social
Ellis, A., & Robb, H. (1994). Acceptance in rational-emotive therapy. In Psychology, 75, 1264–1272.
S. C. Hayes, ThereJ.,are
Ramnerö, a number
& Törneke, N. of rigorous
(2008). The ABCsclinical trialsbehavior.
of human and case
Choosing New N. S. Jacobson, V. M. Follette, & M. J. Dougher (Eds.),
Directions Oakland, CA: New
Acceptance and change: Content and context in psychotherapy studies showing that Harbinger.
ACT is effective for a wide range of
This
(pp. step is about
91–102). Reno, Mr. P choosing a direction for his life.
NV: Context. Saavedra, K. (2007). Toward a New Acceptance and Commitment Therapy
clinical problems (Hayes, 2008; Hayes et al., 2006). There
Much ofH.,
Eifert, G. his&life has been
Forsyth, spent Acceptance
J. P. (2005). on “getting andeven” with Therapy
Commitment (ACT) treatment of problematic anger for low income minorities in
is also research
substance evidence
abuse recovery:that ACT outcomes
A randomized controlledare mediated
experiment of an eight-
for anxiety
others, disorders: Aeffects
with disastrous practitioner's
on thetreatment
qualityguide to using
of his life.
mindfulness, acceptance, and value-guided behavior change strategies. by relevant clinical act
week group-based processes
protocol.such as acceptance,
Unpublished dissertation,defusion,
Wright
This important step is about helping him discover what is Institute Graduate
and engagement School of Psychology,behavior
in life-goal-directed Berkeley, (for
CA.
Oakland, CA: New Harbinger.
truly
Eifert,important
G. H., McKay, to him
M., &and thenJ.making
Forsyth, P. (2006).a ACT
choice thatnoton
on life is atanger: Salkovskis, P.,see
summaries, & Reynolds,
Hayes, 2008; M. (1994).
Hayes Thought suppression
et al., 2006). In anda
the heart
The new of Acceptance
an ACT approach:
and Commitment choosing to act
Therapy on life, anger.
for problem not smoking cessation. Behaviour Research and Therapy, 32, 193–201.
related vein, Hayes, Levin, Yadavaia, and Vilardaga (2007)
on anger.
Oakland, TheCA: goal
NewisHarbinger.
to affirm value-guided living as an Santanello, A. P. (2011). A composite case study of an individual with
Forsyth, J. P., & Eifert, G. H. (1996). The language of feeling and the anger as a presenting problem. Cognitive and Behavioral Practice, 18,
alternative agenda to an anger-driven life. To this end, were209–211.
able to show that pre-to-post changes in ACT
feeling of anxiety: Contributions of the behaviorisms toward
Mr. P will be asked to complete several experiential
understanding the function-altering effects of language. The
processes
Smith, T. W.,accounted
& Gallo, L.for nearly
(1999). 50%and
Hostility of the pre- to
cardiovascular
exercises and worksheets
Psychological Record, 46, to help him explore core values
607–649. follow-up changes
reactivity in outcome
during marital produced
interaction. by ACT.
Psychosomatic Medicine, 61,
in his life
Forsyth, and
J. P., then derive
& Eifert, moreThe
G. H. (2008). specific goals and
Mindfulness thatAcceptance
could 436–445.
Thus far, however, there is only one study that has
lead Workbook
him in the fordirection
Anxiety: Atoward
Guide tothose
Breaking Free from Anxiety, Phobias, Suarez, E. C., Lewis, J. G., & Kuhn, C. (2002). The relation of
values.
and Worry with Acceptance and Commitment Therapy. Oakland, CA: directly evaluated
aggression, an
hostility, ACT
and approach
anger to to problem anger.
lipopolysaccharide-stimulated
New Harbinger. Based on necrosis
tumor the treatment program
factor (TNF) summarized
by blood monocytes fromin this
normal
Hanh, T. Action
N. (2001). Anger: Wisdom for cooling the flames. New York: men.
article Brain. et
(Eifert Behavior, and Immunity,
al., 2006), Saavedra16,(2007)675–684. has con-
Taking and Moving With Barriers Tangney, J. P., Wagner, P. E., Hill-Barlow, D., Marschall, D. E., &
Riverhead Books, Penguin Putnam. ducted a randomized wait-list controlled trial of an 8-
ThisS.step
Hayes, focuses
C. (2004). on helping
Acceptance Mr. P engage
and Commitment in value-
Therapy, Relational Gramzow, R. (1996). Relation of shame and guilt to constructive
guidedFrameaction andand
Theory, staying
the third committed to suchand
wave of behavioral action in the
cognitive
week, group-based
versus destructive ACTresponsesprotocol
to angerfor the the
across treatment
lifespan. ofJournal of
therapies. Behavior Therapy, 35, 639–666.
face of inevitable anger-related setbacks and other problematic
Personality anger. The
and Social sample
Psychology, was70,comprised
797–809. of low-
Hayes, S. C. (2008). Climbing our hills: A beginning conversation on Trinder, H.,
income & Salkovskis,
adults P. (1994).
self-identified asPersonally relevant intrusions
ethnic minorities and
barriers. This step is about taking charge of what he can
the comparison of ACT and traditional CBT. Clinical Psychology: outside the laboratory: Long- term suppression increases intru-
control and change what he can change. The major goal receiving
sion. substance
Behaviour abuse
Research recovery
and Therapy, treatment
32, 833–842. at a local,
Science & Practice Review, 15, 286–295.
here
Hayes,is S.
toC.,continue to create
Barnes-Holmes, D., broader
& Roche, and more(2001).
B. (Eds.). flexibleRelational
publicly
Wenzlaff, funded community
R., & Wegner, D. (2000). clinic.
Thought Ofsuppression.
this cohort, In 11
S. T.were
Fiske
Frame Theory: A Post Skinnerian account
patterns of relating with the people, situations, and of human language and randomized to
(Ed.), Annual waitlist
review ofand 15 to
psychology the ACT
(Vol. intervention.
51, pp. 59–91). Palo Alto,
cognition. New York: Kluwer Academic/ Plenum. CA: showed
Results Annual Reviews.
relatively large (medium to large) effect
internal stimuli that trigger anger thoughts and feelings.
Hayes, S. C., Levin, M., Yadavaia, J. E., & Vilardaga, R. V. (2007, size (d = 0.76), indicating an important impact of ACT
ThisNovember).
part of treatment
ACT: Model makes extensive
and processes of use of behavioral
change. Paper Address correspondence to Dr. Georg H. Eifert, Department of
activation
presented methods to assist for
at the Association Mr.Behavioral
P in doing and what matters
Cognitive
over
Psychology, Chapman University, Results
problematic behaviors. were Dr.,
One University particularly
Orange, CA
most to him.
Therapies, Philadelphia, PA. impressive
92866; e-mail: for high anger
geifert@sbcglobal.net.clients at baseline, with a 50%
Hayes, S. C., Luoma, J. B., Bond, F. W., Masuda, A., & Lillis, J. (2006). reduction in frequency of problematic behaviors over the
Acceptance and Commitment Therapy:
The therapist would help Mr. P implement meaningful Model, processes and course of the intervention.
outcomes. Behaviour Research and Therapy, 44,1–25. Received: March 28, 2009
activities
Hayes, S. C., that would move
& Strosahl, him toward
K. D. (2004). reaching
A practical guide toselected
acceptance and Accepted: April 2, 2010
goalscommitment
by helping him develop
therapy. New York: a Springer
specificScience
plan of& action
BusinessforMedia. The treatment
Available did not2010
online 20 October impact trait anger, nor did
each week and identifying sequences of actions that need trait anger mediate reductions in anger-associated
to be taken to achieve goals. Behavioral activation problematic behaviors resulting from the group-based