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patient who is extremely paranoid, enhance connectedness
with the uncooperative patient, and make an informed
determination of suitability for cognitive therapy. She also
addresses how therapists' beliefs and prejudicescan impede
the therapeutic alliance. Nelson concludes this section with
a discussion of homework assignments, stating, “Most peo-
ple with psychosis are not good at completing formal
homework.”This conclusion may stem from her work with
more severely affected inpatients, although it has been the
experienceof other cognitive therapists working in this area
that patients with psychosis routinely complete homework
as an integral component of their treatment (e.g., Rector,
2007). Notwithstanding, Nelson provides helpful sugges-
tions for setting, reviewing, and providing feedback around
homework.
The next two sections, comprising 200 pages of text,
focus exclusively on the step-by-step components of
assessing, formulating, and treating delusions and
voices. The level of detail and sophistication of this
section is truly remarkable and perhaps unparalleled in
the literature. Topics covered include: information
gathering during the assessment phase and the devel-
opment of a case conceptualization; factors involved in
the decision to share or not to share the conceptualiza-
tion with the patient; factors involved in the decision of
whether to attempt to modify the delusional belief
entirely or just partially; consideration of when and how
to introduce alternative beliefs; and a thorough overview
of cognitive and behavioral strategies to reduce the
intensity and inflexibility of the delusional belief and
enhance the acceptance of alternative, less distressing
beliefs with the use of familiar techniques. Similarly,
following guidelines on the assessment of voices,
practical coping strategies are covered including the
use of earplugs and Walkmans, etc. Next, following the
pioneering work of Kingdon and Turkington (2005),
the goals and strategies associated with normalizing
voices for the patient are outlined. Further, detailed
instruction is provided regarding how and when to
modify the secondary beliefs about the nature and
origin of the voices, and beliefs about the power and
authority of the voices. Finally, this section concludes
with an overview of the assessment and treatment of the
special problem of command hallucinations. These
sections are replete with superb clinical material high-
lighting not just the idealized delivery of specific
interventions but detailing the nuances of the difficul-
ties that can and do often emerge, as well as how to
negotiate these potential setbacks so the patient remains
actively engaged in treatment. The final sections of the
book cover aspects related to helping the patient
maintain gains over the long term, using cognitive
therapy strategies to enhance medication adherence,
and relapse prevention strategies.
While we will await Hazel Nelson's coverage of other
symptoms of psychosis that cognitive therapy has been
shown to effectively treat such as negative symptoms,
social functioning, and comorbid disorders, this volume is
essential reading for any therapist wishing to better
understand and treat delusions and voices. Beyond its
specific focus on psychosis, Nelson demonstrates the
multiple entry points into creating a “kink in the chain”of
firmly held beliefs, which is undoubtedly helpful to any
therapist grappling with the familiar problem of over-
valued ideation.
References
American Psychiatric Association (2004). Treating schizophrenia: A quick
reference guide. Arlington: American Psychiatric Association.
Lehman, A. F., & Steinwachs, D. M. (1998). Translating research into
practice: The schizophrenia patient outcomes research team
(PORT) treatment recommendations. SchizophreniaBulletin,24,1–10.
Kingdon, D. G., & Turkington, D. (2005). Cognitive therapy of
schizophrenia. New York: Guilford Press.
National Institute for Clinical Excellence. (2003). Schizophrenia: Core
interventions in the treatment and management of schizophrenia in
primary and secondary care. London: National Institute for Clinical
Excellence.
Rector, N. A. (2007). Homework use in cognitive therapy for psychosis:
A case formulation approach. Cognitive and Behavioral Practice,14,
303–316.
Address correspondence to Neil A. Rector, Centre for Addiction
and Mental Health, 250 College Street,Toronto,Ontario,Canada
M5T 1R8; e-mail: neil_rector@camh.net.
R. DiGiuseppe, &
R.C. Tafrate (2007)
Understanding Anger Disorders
New York: Oxford University Press
Reviewed by Denis G. Sukhodolsky
Yale University, School of Medicine
ANGER is a commonly felt emotion. On average, healthy
participants of psychological studies report getting
angry once or twice per week. These anger experiences
may last from several minutes to a few hours and are often
triggered during interactions with friends or family mem-
bers. Usually these common episodes of anger are conclu-
ded with the discussion and resolution of the issue that
caused the anger experience in the first place. In contrast
to a common prototype of yelling or hitting when angry,
anger is often expressed through calm discussion that
leads to problem solving and positive outcomes. Of course,
excessive anger may lead to a variety of harmful outcomes,
including health problems and personal maladjustments.
Furthermore, most psychiatric disorders are associated
with increased likelihood of difficulties with anger
224 Book Reviews
Author's personal copy
experience and expression, which makes the topic of
anger of particular relevance for clinical psychologists and
other mental health professionals.
Many brilliant minds—Aristotle, Darwin, and Freud, to
name a few—have commented on the nature of anger and
its place in human psychology. However, it is during the
past two decades that considerable advances have been
made in experimental anger research; this research both
expanded our understanding of the phenomenology of
anger and provided tools for its assessment and treatment.
After a comprehensive review of historical perspectives,
current theories, and empirical research on anger, Ray
DiGiuseppe and Chip Tafrate make a compelling case that
anger can be conceptualized as “a possible form of psycho-
pathology in its own right and not just a symptom of other
disorders”(p. xii). Their 418-page book consists of 20
chapters that are divided into six parts: theoretical back-
ground, anger and aggression, models of anger, anger and
cooccurring psychiatric conditions, diagnosis of anger dis-
orders, and treatment.
Several important findings in the field of anger research
have been consistently replicated. For example, the facial
expressions of anger are universally recognized, and
excessive and chronic anger has been found to be a risk
factor in cardiovascular disease. However, a number of
fundamental areas, such as the primacy of thought or affect
in anger experience and the association of anger with
aggression, continue to be actively debated. Even an agreed-
upon definition of anger remains elusive; it has been
referred to as a social role, a perception of blameworthiness,
and a blueprint for aggression. The first third of the book
(Chapters 1 to 6) contains an exhaustive review of these
debated issues and provides objective and concise conclu-
sions. Of particular note is a systematic review of studies on
triggers, cognitive appraisals, and expression of anger.
Chapters 7 and 8 are dedicated to the behavioral and
cognitive models of anger as well as supportive empirical
research. These sections of the book provide a critical
introduction to the exploration of anger in clinical contexts.
Anger and irritability appear as symptoms or diagnostic
features of several psychiatric disorders, most notably
oppositional-defiant disorder and intermittent explosive
disorder. Three chapters of the book are dedicated to the
co-occurrence of anger with psychiatric disorders.
Indeed, this is an important area of research and practice
since even in most impairing disorders, such as autism,
schizophrenia, and dementias, excessive and inappropri-
ate anger could be contributing to impairment above and
beyond the core symptoms. Furthermore, patients with a
variety of psychiatric diagnoses, including PTSD and
substance-use disorders, may receive anger management
as part of their treatment-as-usual. Finally, there are active
programs of clinical research dedicated to manifestations
of anger within particular disorders, such as “anger
attacks”in major depression. At the same time, DiGiu-
seppe and Tafrate lead their readers to appreciate the
enormity of research that is yet to be done and to ask
questions that should be addressed in this research. For
example, are the phenomenology and causes of anger the
same or different in different psychiatric disorders? Could
the same psychological treatments or at least treatment
principles be applied to anger across different diagnostic
categories?
It is pointed out throughout the book that the current
diagnostic system does not address anger consistently or
systematically and that angry clients most often receive the
diagnosis of intermittent explosive disorder. In Chapters
12 through 15, DiGiuseppe and Tafrate review literature
on the detrimental correlates of anger and propose a set of
criteria for anger disorders. Some of the noteworthy
correlates of excessive anger include risk of cardiovascular
disorders, domestic violence, occupational un-
derachievement, and reckless driving. Furthermore, if
anger contributes to aggressive behavior, it can also lead to
physical injury and property damage. The extent to which
anger interferes with an individual’s life and functioning
and causes harm is proposed as a primary determining
factor of whether an anger disorder may be present.
Frequency, intensity, and duration of anger episodes
constitute other characteristics that should be used to
determine whether or not anger is dysfunctional. Based on
extensive literature review as well as on their own data, the
authors propose 12 criteria for an “anger regulation-
expression disorder,”which are divided into “angry affect”
and “aggressive/expressive behaviors”categories, with at
least two affective and one behavioral characteristic re-
quired for the diagnosis. It is noted that these criteria per-
mit a more refined classification of individuals with anger
problems, particularly those who fall within the category of
angry affect without serious physical aggression.
The last part of the book is dedicated to interventions,
including an overview of treatment effectiveness as well as
guidelines for comprehensive psychosocial treatment. It is
noted that a more detailed treatment manual was not in-
cluded with this book because the goal of creating a treat-
ment manual was accomplished earlier by Kassinove and
Tafrate in their Anger Management treatment manual
(2002) and video program instructional guide for practi-
tioners (2006). Overall, a combination of cognitive and
behavioral interventions is recommended for the treat-
ment of dysfunctional anger. A strong case is made for
using exposure-based interventions, behavioral treat-
ments that are among the most effective for a variety of
anxiety disorders, with patients whose anger reactions
become strongly associated with particular stimuli, such as
verbal provocation. The goals of behavioral intervention
are to reduce the intensity of anger arousal and to avoid
the overlearned automatic response. At the same time, the
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authors advise the practitioners against moving into
change strategies too quickly and suggest that a good
starting point involves using empathy, alliance building,
and even motivational interviewing techniques.
In conclusion, this book provides a very much needed
platform for conceptualization, research, and treatment
of anger. Overall, Understanding Anger Disorders is a valuable
resource for readers interested in understanding anger
and applying this understanding either in their research,
teaching, or clinical work.
References
Kassinove, H., & Tafrate, R. C. (2002). Anger management: The complete
treatment guidebook for practitioners. Atascadero, CA: Impact
Publishers.
Kassinove, H., & Tafrate, R. C. (2006). Anger management: The complete
practitioner’s guidebook for the treatment of anger [DVD video
demonstrations].Atascadero, CA: Impact Publishers.
Address correspondence to Denis G. Sukhodolsky, Ph.D., Yale
University School of Medicine, Child Study Center, 230 S. Frontage
Road, New Haven, CT 06520; e-mail: denis.suk hodolsky@yale.edu.
226 Book Reviews
