Cogn itive Therapy and Research ‚ Vol. 22 ‚ No. 1‚ 1998 ‚ pp.

63-74

Cogn itive-Behavioral Th erapy in the Treatm ent of

An ger: A Meta-Analysis
Rich ard Beck1 an d Eph rem Fernan dez1 ‚2

Anger has com e to be recognized as a significan t social problem worthy of clin ical
attention an d systematic research. In the last two decades ‚ cognitive-behavioral therapy
(CBT) has emerged as the m ost com m on approach to an ger m anagement. The overall
efficacy of this treatm ent has not been ascertain ed ‚ and therefore‚ it was decided to
con du ct a m eta-an alysis of this literature. Based on 50 studies in corporatin g 1‚640
subjects‚ it was fou nd that CBT produ ced a gran d m ean weighted effect size of .70 ‚
indicatin g that the average CBT recipient was better off than 76% of un treated subjects
in terms of anger reduction . This effect was statistically significant ‚ robust‚ and relatively
hom ogen eou s across studies. These fin dings represent a quan titative integration of 20
years of research into a coherent pictu re of the efficacy of CBT for anger m an agement.
The results also serve as an im petu s for con tinu ed research on the treatm ent of anger.
KEY WORDS: anger; cognitive-behavioral therapy; me ta-analysis.

INTRODUCTION

With viole nt crime rising among adole scents ‚ wide spread familial abuse ‚ con-
tinuing racial discord ‚ and recent acts of te rrorism ‚ attention has turne d to ange r
as a major proble m in human re lations (Koop & Lundbe rg ‚ 1992; Novello ‚ Shosky ‚
& Froehlke ‚ 1992) . Yet ange r disorde rs have bee n ne glected in diagnostic classifi-
cations and treatme nt programs (Eckhardt & Deffe nbache r‚ 1995; Kassinove &
Sukhodolsky ‚ 1995) . Incre asing re fe re nce s to ange r appe ar in PSYCINFO and othe r
database s‚ and practitione rs are increasingly cognizant of the ramifications of ange r
in their clients (Abikoff & Kle in ‚ 1992; Fernande z & Turk‚ 1993 ‚ 1995; Koop &
Lundbe rg‚ 1992) ‚ but little is known about how best to treat ange r disorde rs.
In a surve y of the lite rature on ange r‚ it was found that the vast majority of
ange r tre atment outcome studie s had utilize d a cognitive -behavioral approach. The
pre sent study there fore e valuate d the e fficacy of cognitive -behavioral the rapy ( CBT)
1
Methodist University‚ Dallas‚ Te xas 75275.
Southern
Address all correspondence to Ephrem Fe rnandez ‚ Ph.D.‚ Departme nt of Psychology‚ Southern
2

Methodist University‚ Dallas‚ Texas 75275-0442.

63

0147-5916/98/0200-0063$15.00/0 Ó 1998 Plenum Publishing Corporation

64 Beck and Fern an dez

in the tre atment of ange r. Instead of a narrative re view‚ a meta-analysis was con-
ducte d to quantitative ly inte grate the re sults of individual studie s e mploying CBT
for ange r control.

Cogn itive-Beh avior al Th erap y Applied to Anger

Cognitive -be havioral therapy draws upon the rich traditions of be havior modi-
fication and rational-e motive or cognitive the rapy (Me ichenbaum ‚ 1976) ‚ paying at-
tention to social cognition (Dodge ‚ 1993) as well as individual constructions of
reality (Mahone y‚ 1993) . It may combine a varie ty of technique s such as relaxation ‚
cognitive re structuring ‚ proble m-solving ‚ and stress inoculation ‚ but rathe r than be-
ing a mere form of technical e cle ctism ‚ it is theore tically unifie d by principle s of
le arning theory and information processing. This approach has elicite d much inter-
est in the treatme nt of affe ctive disorde rs such as anxie ty and depression as re ve aled
in recent meta-analyse s by Dobson (1989) and Van Balkom (1994) . The status of
CBT for ange r‚ however‚ re mains uncle ar.
Yet the last 20 ye ars has see n an accumulation of research on the e fficacy of
cognitive -behavioral the rapy in the tre atment of ange r proble ms. This re search has
focused pre dominantly on Novaco ’s (1975) adaptation of Me iche nbaum ’s stre ss in-
oculation training (SIT) initially develope d for the tre atment of anxie ty (Me ichen-
baum ‚ 1975). Using a coping skills approach ‚ stre ss inoculation inte rve ntions are
typically structure d into three phase s: cognitive pre paration ‚ skill acquisition ‚ and
application training. During this performance -base d intervention ‚ the client is e x-
posed to cognitive reframing ‚ re laxation training ‚ image ry‚ modeling ‚ and role-play-
ing to e nhance ability to cope with proble m situations.
In SIT for ange r proble ms‚ clie nts initially identify situational “ trigge rs” which
pre cipitate the onset of the ange r re sponse . Afte r ide ntifying environme ntal cue s‚
the y re hearse self-state ments intende d to re frame the situation and facilitate healthy
response s (example s of cognitive self-state ments include : “ Relax‚ don ’t take things
so personally ” or “ I can handle this. It isn ’t important enough to blow up over
this ” ). The se cond phase of tre atment require s the acquisition of re laxation skills.
The cognitive se lf-state ments can the n be couple d with relaxation as clie nts attempt ‚
afte r e xposure to the trigge r‚ to mentally and physically soothe themselve s. Finally ‚
in the rehe arsal phase ‚ clie nts are expose d to ange r-provoking situations during the
session utilizing image ry or role-plays. The y practice the cognitive and relaxation
te chnique s until the mental and physical re sponse s can be achie ve d automatically
and on cue . This basic outline of SIT can also be supple mented with alte rnative
te chnique s such as proble m-solving ‚ conflict manage ment ‚ and social skills training
as in the social cognitive model of Lochman and colle ague s (Lochman & Lenhart ‚
1993) .
The purpose of the present study was to e valuate the overall e ffective ne ss of
such cognitive -be havioral treatme nts for ange r by using the methodology of meta-
analysis. This e ntaile d computing various summary statistics of the stre ngth of treat-
ment e ffect‚ as well as infe rential tests of the specific re se arch hypothe sis that CBT
statistically significantly re duce s ange r. Finally ‚ the se re sults were conve rted into
CBT for An ger 65

measure s of practical significance . This is particularly informative in the curre nt

climate of manage d health care where there is a pre mium on time-limite d inter-
ve ntions like CBT and growing demands for e mpirical evide nce to support the
choice of tre atments. This quantitative synthe sis of the lite rature will also familiarize
reade rs with the main parame ters of rese arch on this topic and gene rate consid-
erations for furthe r rese arch in this area.

Meta-An alys is

Me ta-analysis is a quantitative procedure for evaluating tre atment effe ctiveness

by the calculation of e ffect size s (Fernande z & Boyle ‚ 1996; Glass ‚ McGaw‚ &
Smith ‚ 1981; Rosenthal ‚ 1991). The e ffect size e xpre sse s the magnitude of difference
betwee n tre ated and untre ate d subje cts. Because e ffect size is e xpre sse d in standard
deviation units ‚ it e nable s comparisons among studie s and the computation of sum-
mary statistics such as the grand ave rage effe ct size ‚ an inde x of overall effe ctiveness
for the tre atment. Despite its advantage s over narrative and quasistatistical methods
of re view (Fe rnande z & Turk‚ 1989) ‚ meta-analysis has raised certain concerns which
call for spe cific solutions (Fernande z & Boyle ‚ 1996) . For e xample ‚ it has bee n ar-
gue d that effe ct sizes obtaine d from studie s of varying quality may not be directly
comparable ; conse que ntly‚ it is now customary to weight e ffects sizes‚ typically ac-
cording to obje ctive crite ria such as sample size ( which de te rmine s statistical
powe r). Concern has also be en raised about possible inflation in effe ct sizes due
to sampling only publishe d studie s which are more like ly to re port significant re sults
than are non-publishe d studie s (the file-drawe r proble m); this can be counte racted
to some extent by including unpublishe d studie s and also by conducting te sts of
robustne ss that provide a margin of tolerance for null results (Rosenthal ‚ 1995) .
To date ‚ the only docume nted attempt to meta-analyze studie s of ange r man-
age ment was done by Tafrate (1995) . Howe ve r‚ this revie w has certain methodo-
logical limitations. First‚ stringe nt inclusion criteria restricte d the numbe r of CBT
studie s re viewed to only nine . This small numbe r of studie s is unre pre sentative of
the last 20 years of rese arch on CBT. Tafrate confine d his survey to adult sample s
of mostly colle ge stude nts. No doubt ‚ stude nts have ange r proble ms too‚ but the
ne gle ct of nume rous studie s of CBT for oppositional childre n and adole scents
(populations of primary conce rn) is proble matic. Only three of the studie s revie wed
by Tafrate were base d on clinical sample s‚ thus placing limits on the ecological sig-
nificance of results. Unpublishe d results were ignore d ‚ and due to the small numbe r
of studie s actually re viewed‚ the conclusions re ache d were probably susceptible to
sampling bias. Finally ‚ Tafrate ne glected tests of homoge neity‚ te sts of significance
or tests of robustne ss‚ or weighing of effe ct size s based on any of the design feature s
of the studie s; as e mphasize d earlie r‚ the se statistics have now become standard
practice in meta-analytic revie ws‚ and they can significantly affe ct the conclusions
reached.
To improve upon Tafrate ’s (1995) initial revie w‚ the pre se nt study e xpande d
inclusion criteria ‚ incorporate d unpublishe d studie s‚ and weighte d all e ffect size s.
As de taile d below‚ the scope of the revie w was broade ned to incorporate dive rse
66 Beck and Fern an dez

sample s re ceiving a combination of cognitive and be havioral technique s. In this way‚

more than five time s the numbe r of CBT studie s re viewed by Tafrate were meta-
analyze d here .

METHOD

Inclu sion Criteria

A compute r se arch of PSYCINFO and Dissertation Abstracts International from

1970 to 1995 was conducte d. Using keywords such as an ger control ‚ anger treatm ent‚
and an ger m an agem ent and cross-re fe re nce s among article s‚ a total of 58 re levant
studie s of CBT were identifie d. Eight of these were single -case or small-sample
studie s (n < 4) and hence were e xclude d. The final sample consiste d of 50 no-
mothetic studie s incorporating a total of 1640 subje cts. All studie s provide d data
on at le ast one ange r-relate d depe nde nt variable .
In te rms of the inde pende nt variable ‚ only cognitive -behavioral tre atments for
ange r were se lected. Studie s using pu rely cognitive or behavioral interventions alone
were not include d ‚ nor were treatme nts aimed sole ly at re laxation. Typically ‚ the
study include d was one in which some form of cognitive reappraisal or re structuring
was com bined with some technique of promoting relaxation. The sample s were
pre dominantly clinical such as prison inmate s‚ abusive pare nts ‚ abusive spouse s‚ ju-
ve nile de linque nts ‚ adole scents in re side ntial treatme nt‚ childre n with aggre ssive
classroom behavior ‚ and mentally handicappe d clie nts ‚ but also include d colle ge
stude nts with re porte d ange r proble ms.
Thirty-five studie s use d self-reporte d ange r as a de pe nde nt variable . Effe ct
sizes for 28 of the 35 studie s were calculate d e xclusive ly from se lf re ports of ange r.
The re maining se ven studie s combine d depe nde nt measure s of ange r and aggre s-
sion into e ffe ct size e stimate s. Fifte e n studie s of school childre n and adole scents
in place ment (eithe r re side ntial or de tention facility) re fe rred to ange r but only
re porte d be havioral ratings of aggre ssion. Since aggre ssive be havior has be en the
focus in CBT inte rve ntions for childre n and adole scents ‚ aggre ssion ratings se rve d
as the de pe nde nt variable for the se studie s. For younge r populations ‚ measure s of
se lf-re porte d ange r are not always fe asible and behavioral ratings of aggre ssion
be come a valid alte rnative ‚ just as se lf-re ports of depre ssion and anxie ty in childre n
may be le ss acce ssible than the behaviors corre sponding to the se mood distur-
bance s.

Calcu lation of Effect Sizes

Glass ’s d (e ffect size) was calculate d for each study whe re means and standard
deviations were available for treatme nt and control groups (Glass e t al.‚ 1981). For
studie s utilizing single group ‚ pre- ve rsus postte st de signs ‚ and any othe r studie s
not reporting means and standard deviations ‚ e ffect size was e stimate d from t- and
F-value s. Whe re multiple depende nt variable s were reporte d ‚ e ffect sizes were av-
CBT for An ger 67

erage d across variable s to yield one e ffect size per study‚ thus minimizing nonin-
depende nce in the data.
Adopting proce dures recommende d by Rosenthal (1991) ‚ e ach effe ct size was
weighte d by sample size ‚ and ave rage d to yield a grand weighte d mean d base d on
50 studie s. Weighting e ffect size s by sample size is an unbiase d and obje ctive pro-
cedure for assigning different weights to studie s that vary in statistical powe r. The
grand weighte d mean d was tested for significance (d compare d to zero) using a
one -sample t-test‚ and 95% confide nce inte rvals were calculate d. A chi square was
also calculate d to te st for heteroge ne ity of variance within the se t of e ffect size s.
The heteroge ne ity te st is the basis for a de cision on whe ther or not to search for
mode rator variable s; in case of significant heteroge ne ity‚ it would be ne cessary to
disaggre gate the e ffect sizes according to the variable s influe ncing e ffect size. Fi-
nally‚ to addre ss the file-drawe r proble m a fail-safe N‚ as re commende d by Rosen-
thal ( 1991) ‚ was calculate d to test for robustne ss. A robust finding indicate s that
the probability of a Type I e rror arising from unpublishe d ‚ nonsignificant re sults ‚
is ne gligible . As strongly recomme nde d by Rosenthal (1995) ‚ a Binomial e ffect size
display (BESD) was also constructe d to provide a more concrete impre ssion of the
relative outcome s in tre atment and control groups.

RESULTS

A total of 50 effe ct size s was obtaine d for the 50 studie s (Table I). O f the se ‚
40 utilize d control groups while 10 use d single -group ‚ repe ated-measure s de signs.
The sample size and de sign feature s for each study are also tabulate d.
As summarize d in Table II‚ the effe ct size s range d from ¯0.32 to 1.57 ‚ SD =
0.43. With only one e xce ption ‚ all effe ct size s were positive in value . The grand
mean unwe ighte d d was 0.81. The grand mean weighte d effe ct size was 0.70. This
differe d significantly from zero‚ t (49) = 13.28 ‚ p < .0001. The 95% confide nce in-
te rvals for the mean unweighte d e ffect size range d from 0.69 to 0.93. A ste m and
le af plot is shown in Table III to display batche s of e ffect sizes. As can be see n ‚
the effe ct sizes approximate d a normal distribution. Most of the e ffect sizes were
betwee n 0.5 and 0.99 ‚ and six e ffect sizes reache d about 1.2 ‚ thus making this the
mode . A notable outlie r was the one negative value in the data set.
Since any effe ct size is a standard de viation unit (z-score ) ‚ it can be conve rted
into a pe rcentile by asce rtaining the area unde r the normal curve that is bounde d
betwee n that z-score and the tail e nd of the curve . Thus ‚ the grand weighte d mean
effe ct size of 0.70 corresponds to an are a unde r the curve of 0.5 + 0.258 ‚ which
in turn means that the average subje ct in the CBT treatme nt condition fared be tter
than 76% of those not receiving CBT.
To furthe r illustrate the practical importance of these re sults ‚ a binomial e ffect
size display was adde d ( Table V I). This first e ntaile d conve rsion of the grand
weighte d mean d to r‚ which turne d out to be 0.33; as note d in the table ‚ half the
value of r was the n adde d or subtracte d from 0.5 ‚ revealing that subje cts re ceiving
CBT e xpe rienced a 67% treatme nt succe ss rate whe re as control subje cts had only
a 33% succe ss rate .
68 Beck and Fern an dez

Table I. Effect Sizes and Sample Sizes for Individual Studies of CBT on Anger a
Study Sample DV De sign N d
Acton & During ( 1992) Abusive pare nts SR PP 29 0.85
Barth ‚ Blythe ‚ Schinke ‚ & Schilling Abusive pare nts SR TC 20 1.09
(1983)
Benson ‚ Rice ‚ & Miranti ( 1986) MR individuals SR ‚ BR PP 54 0.40
Boswell (1984) School children SR TC 30 -0.32
Cain (1987) Adult volunteers SR TC 62 0.83
Dangle ‚ Deschner ‚ & Rasp ( 1989) Clinical adolesce nts BR PP 12 0.92
Deffe nbache r‚ Story‚ Stark ‚ Hogg ‚ & College students SR TC 32 1.04
Brandon (1987)
Deffe nbache r‚ Story‚ Brandon ‚ Hogg ‚ College students SR TC 30 1.27
& Hazaleus (1988)
Deffe nbache r‚ McNamara ‚ Stark ‚ & College students SR TC 32 0.59
Sabadell (1990a)
Deffe nbache r‚ McNamara ‚ Stark ‚ & College students SR TC 29 0.45
Sabadell (1990b)
Deffe nbache r & Stark ( 1992) College students SR TC 36 1.43
Deffe nbache r‚ Thwaite s‚ Wallace ‚ & College students SR TC 94 0.82
Oetting (1994)
Deffe nbache r‚ Lynch ‚ Oetting‚ & School children SR TC 80 1.32
Kemper ( 1996)
Deschne r & McNeil (1986) Abusive spouses SR ‚ BR PP 47 0.32
Faulkne r‚ Stoltenbe rg ‚ Cogen ‚ Nolde r‚ Abusive spouses SR ‚ BR PP 32 1.57
& Shooter (1992)
Feindle r‚ Ecton ‚ Kingsle y‚ & Dubey Clinical adolesce nts BR TC 21 1.16
(1986)
Feindle r‚ Marriott‚ & Iwata (1984) Adolescent (school) BR TC 36 0.68
Gaertner ( 1984) Inmates SR TC 19 1.33
Glick & Goldstein ( 1987) Juvenile delinquents BR TC 111 0.72
Hinshaw ‚ Henke r‚ & Whalen ( 1984) School children BR TC 22 1.29
Jackson ( 1992) Clinical adolesce nts SR TC 40 0.32
Ke nnedy ( 1992) Inmates SR ‚ BR PP 37 1.29
Larson (1991) School children SR TC 37 0.21
Lochman (1985) School children BR TC 80 0.38
Lochman ‚ Burch ‚ Curry‚ & Lampron School children BR TC 76 0.28
(1984)
Lochman & Curry ( 1986) School children BR PP 20 0.36
Lochman ‚ Lampron ‚ Gemmer ‚ School children BR TC 32 0.24
Harris ‚ & Wyckoff (1989)
Lochman ‚ Ne lson‚ & Sims ( 1981) School children BR PP 12 0.65
Macphe rson ( 1986) Inmates SR TC 21 1.28
Mandel ( 1991) Adolescent volunteers SR ‚ BR TC 26 0.53
McDougall ‚ Boddis‚ Dawson ‚ & Juvenile delinquents BR TC 18 0.64
Haye s ( 1990)
Moon & Eisler (1983) College students SR ‚ BR TC 20 1.52
Moore & Shannon (1993) Clinical adolesce nts SR TC 42 0.22
Napolitano (1992) Inmates SR TC 75 0.68
Novaco ( 1975) College and adult SR ‚ BR PP 17 1.03
Olson (1987) Clinical adult SR TC 83 0.76
Omizo ‚ He rshberger ‚ & Omizo (1988) School children BR TC 24 0.84
Pascucci (1991) Clinical adolesce nts BR TC 28 0.56
Rhoades (1988) Forensic in-patients SR TC 21 0.91
Rokach ( 1987) Inmates SR TC 95 0.69
Rose ngren (1987) Adolescent volunteers SR TC 13 1.00
Saylor ‚ Benson ‚ & Einhaus (1985) Clinical adolesce nts SR TC 14 1.13
Schlichter & Horan (1981) Juvenile delinquents SR TC 19 1.20
Shivrattan ( 1988) Juvenile delinquents BR TC 28 0.22
Smith & Beckner (1993) Inmates SR PP 18 0.55
Steele (1991) Juvenile delinquents BR TC 19 0.57
CBT for An ger 69

Table I. (continued )
Study Sample DV Design N d
Stermac (1986) Forensic patie nts SR TC 40 1.31
Whiteman ‚ Fanshel ‚ & Grundy Abusive parents SR TC 24 1.52
(1987)
Wilcox & Dowrick (1992) Clinical adolescents SR PP 10 1.20
Wu (1990) Divorced women SR TC 26 0.49
a
CBT = Cognitive-behavioral therapy; DV = de pendent variable; N = sample size; d = effect size; SR
= self-reported anger ‚ BR = behavioral ratings of anger/aggre ssion‚ TC = treatment ve rsus control
de sign ‚ PP = pre/postdesign.

Table II. Meta-Analytic Summary Statistics for Studies of CBT on Ange ra

Total N = 1‚640 subjects

Grand weighte d mean d: 0.70
95% confidence intervals for unweighted d: 0.69 to 0.93
d compare d with zero: t (49) = 13.28 ‚ p < .0001
Heteroge neity of ds: c (49) = 61.71 ‚ p > .10
2

Fail-safe N: 790; crite rion = 225

a
CBT = cognitive -behavioral therapy.

Table III. Stem and Le af Display of Effect Sizes from

Studies of CBT on Ange ra
Fre quency Stem Leaf

1.00 ¯0. 3
12.00 0. 222223333444
18.00 0. 555556666677888899
16.00 1. 0000112222223334
3.00 1. 555

Range = ¯0.32 to 1.57

Mean (unweighted) d = 0.81
Standard deviation = 0.43
Median = 1.75
Mode = 1.2
a
CBT = cognitive behavioral therapy; Each stem which
represents the first digit of an effect size is attache d to
several leave s‚ each denoting the first decimal place of
an effect size .

The fail-safe N of 790 was well above the minimal criterion of 225 ‚ indicating
a robust finding. The te st of he teroge neity reve ale d a c 2 (49) = 61.71 ‚ p > .10. This
indicate s homoge ne ity of e ffect size value s‚ and the refore ‚ no ne ed to se arch for
mode rator variable s.
70 Beck and Fern an dez

Table IV. Binomial Effect Size Display of Treatment

(CBT) Versus No Treatment of Anger a
Condition Success Failure å
Treatment 67 33 100
Control 33 67 100
å 100 100 200
a
CBT = cognitive -behavioral therapy. The numbers are in
pe rcentages. To obtain them ‚ d must first be converted to r
(cf. Rosenthal ‚ 1991) ‚ which is halved and then added to or
subtracted from 0.5 (depe nding on the condition) ‚ before
multiplication by 100.

DISCUSSION

Effectiven ess of Cogn itive-Beh avior Th erap y in th e Treatm ent of An ger

Re se arche rs have incre asingly focuse d the ir atte ntion on CB T as a tre at-
me nt for ange r disorde rs. O ve r the past 20 ye ars ‚ many individua l studie s have
sugge ste d that CBT is an e ffe ctive ‚ time -limite d tre atme nt of ange r proble ms.
O ur m e ta-analysis of 50 nom othe tic studie s of 1 ‚640 subje cts re ve ale d a
we ighte d me an e ffe ct size of 0.70 ‚ sugge stive of mod e rate tre atme nt gains.
Since this is in standar d de viation units ‚ it can be infe rre d that the ave rage
subje ct in the CBT condition was be tte r off than 76% of control subje cts. More -
ove r‚ this e ffe ct was signific antly diffe re nt from what would be e xpe cted unde r
chance . The grand e ffe ct size was also robust e nough to be unaffe cted by un-
publishe d null re sults ‚ and it was re lative ly homoge ne ous across studie s. Since
the populat ions inve stigate d consiste d large ly of abusive pare nts or spouse s ‚
viole nt and re sistant juve nile offe nde rs ‚ inmate s in de te ntion facilitie s ‚ and ag-
gre ssive school childre n ‚ it is appare nt that CBT has ge ne ral utility in the clini-
cal manage me nt of ange r.
The se findings imply that the appare nt popularity of CBT in the treatme nt of
ange r is justifie d by its e ffectivene ss in achie ving the de sire d treatme nt goals. The
results are congrue nt with othe r meta-analyse s docume nting the effe ctiveness of
CBT in the tre atme nt of othe r affe ctive disturbance s‚ in particular ‚ de pre ssion
(Dobson ‚ 1989) and anxie ty (Van Balkom e t al. ‚ 1994) .
At the same time ‚ it may be note d that the grand weighte d e ffect size of 0.70
in this revie w is smalle r than Tafrate ’s ( 1995) reporte d effe ct size of 1.00 for CBT
studie s (which were labe le d as “ multicompone nt” ); this is probably because the lat-
te r consiste d of only nine publishe d studie s‚ none of which were weighte d according
to statistical power. O n the othe r hand ‚ by sampling unpublishe d results ‚ revie wing
studie s with clinical populations ‚ and weighing effe ct sizes by sample size ‚ the pre-
sent study may have produce d a slight deflation of effe ct size ‚ but one that is prob-
ably more reliable .
CBT for An ger 71

Fu ture Con sid eration s

This study was an attempt to summarize and docume nt the progre ss made
ove r the last two decades of rese arch on CBT for ange r tre atment rese arch. The
clinical implications of the meta-analysis are e ncouraging. Clinicians treating clie nts
with ange r control proble ms can now substantiate the ir choice of CBT in the treat-
ment of ange r‚ and expe ct at least mode rate improve ments in the ir clie nts. More-
ove r‚ the pre sent findings may se rve as a benchmark against which to evaluate othe r
psychological and pharmacological treatme nts for ange r. O utcome efficacy aside ‚
future re search might also addre ss the cost-e ffectivene ss of the se treatme nts ‚ an
issue of growing interest in the curre nt era of manage d care.
New variations of CBT might also be explore d. Deffe nbache r and colle ague s
have alre ady take n a step in this dire ction with the developme nt of a package calle d
“ cognitive relaxation. ” O n the othe r hand ‚ Lochman and colle ague s have empha-
sized training pe ople in e ncoding of social stimuli and proble m-solving within a
social context. With additional studie s in these areas‚ it is forsee able that the most
active ingre die nts of CBT may be ide ntifie d and integrate d to produce an e ven
more e ffective regimen for managing ange r.
Anothe r viable frontie r of re search might be client variable s relate d to treat-
ment outcome . These may center around se lf-e fficacy‚ locus of control ‚ impulsivity
versus refle ctivity‚ and a host of traits predisposing individuals to respond to treat-
ment in se le ct ways. Clarification of these variable s may enable the careful matching
of clie nts to spe cific treatme nt re gime ns.
Finally‚ ecological validity re mains a goal for most tre atment outcome research.
In ange r manage ment ‚ well-controlle d laboratory studie s have re ve aled e ncouraging
tre atment e ffects. But the generalizability of these findings to various clinical and
multicultural populations ofte n nee ds to be establishe d. Ultimate ly‚ the ability to
pre dict and control ange r as it occurs spontane ously in differe nt groups of pe ople
within the ir own naturalistic se ttings is a challe nge worth addre ssing.

REFERENCES

Reference s marke d with an asterisk indicate studies included in the me ta-analysis.

Abikoff‚ H.‚ & Klein ‚ R. G. (1992) . Attention-deficit hype ractivity and conduct disorder: Comorbidity
and implications for tre atment. Journal of Consulting and Clinical Psychology‚ 60 ‚ 881-892.
*Actor ‚ R. G.‚ & During‚ S. M.‚ (1992) . Pre liminary results of aggression manageme nt training for ag-
gressive pare nts. Journal of Interpersonal Violence. 7‚ 410-417.
*Barth ‚ R. P.‚ Blythe ‚ B. J.‚ Schinke ‚ S. P.‚ & Schilling R. F. (1983). Self-control training with maltreating
parents. Child Welfare. 62 ‚ 313-324.
*Benson ‚ B. A.‚ Rice ‚ C. J.‚ & Miranti ‚ S. V. (1986) . Effects of anger manageme nt training with mentally
re tarde d adults in group tre atment. Journal of Counseling and Clinical Psychology‚ 54 ‚ 728-729.
*Boswell ‚ J. W. ( 1984) . Effects of a multimodal counse ling program and of a cognitive -behavioral coun-
seling program on the ange r management skills of pre-adolesce nt boys within an eleme ntary school
setting (Doctoral dissertation‚ Pennsylvania State Unive rsity‚ 1984). Dissertation Abstracts Interna-
tional‚ 45 ‚ 372.
*Cain ‚ J. A. (1987) . Anger control: A comparison of cognitive-behavioral and relaxation training‚ with
post-treatment follow-up (Doctoral dissertation‚ United States International University‚ 1987). Dis-
sertation Abstracts International ‚ 48 ‚ 1804-1805.
72 Beck and Fern an dez

*Dangle ‚ R. F.‚ De schner ‚ J. P.‚ & Rasp ‚ R. R. (1989) . Anger control training for adolesce nts in reside ntial
treatment. Behavior Modification ‚ 13 ‚ 447-458.
Deffe nbache r‚ J. L. (1995) . Ideal treatme nt package for adults with anger disorders. In H. Kassinove
(Ed.) ‚ Anger disorders: Definition ‚ diagnosis ‚ and treatm ent (pp 151-172) . Washington DC: Taylor &
Francis.
*Deffenbacher ‚ J. L.‚ Story‚ D. A.‚ Stark ‚ R. S.‚ Hogg ‚ J. A.‚ & Brandon ‚ A. D. (1987). Cognitive-re-
laxation and social skills interventions in the treatme nt of anger. Journal of Coun seling Psychology‚
34 ‚ 171-176.
*Deffenbacher ‚ J. L.‚ Story‚ D. A.‚ Brandon ‚ A. D.‚ Hogg ‚ J. A.‚ & Hazaleus ‚ S. L. (1988). Cognitive
and cognitive-relaxation treatments of ange r. Cogn itive Therapy and Research ‚ 12 ‚ 167-184.
*Deffenbacher ‚ J. L.‚ Lynch R. S.‚ Oetting‚ E. R.‚ and Ke mper ‚ C. C. (1996). Anger re duction in early
adolescents. Journal of Coun seling Psychology‚ 43 ‚ 149-157.
*Deffenbacher ‚ J. L.‚ McNamara ‚ K.‚ Stark‚ R. S.‚ & Sabadell ‚ P. M. (1990a) . A comparison of cogni-
tive -behavioral and process-oriented group counseling for ge neral ange r reduction. Journal of Coun-
seling and Developm ent‚ 69 ‚ 167-172.
*Deffenbacher ‚ J. L.‚ McNamara ‚ K.‚ Stark‚ R. S.‚ & Sabadell ‚ P. M. ( 1990b). A combination of cognitive ‚
re laxation ‚ and be havioral coping skills in the reduction of gene ral ange r. Journal of College Student
Developm ent‚ 31 ‚ 351-358.
*Deffenbacher ‚ J. L.‚ & Stark‚ R. S. (1992) . Relaxation and cognitive-relaxation tre atments of general
ange r. Journal of Counselin g Psychology‚ 39 ‚ 158-167.
*Deffenbacher ‚ J. L.‚ Thwaites‚ G. A.‚ Wallace ‚ T. L.‚ & Oe tting‚ E. R. (1994) . Social skills and cogni-
tive -re laxation approaches to general anger. Journal of Coun seling Psychology‚ 41 ‚ 386-396.
*Deschner ‚ J. P.‚ & McNe il‚ J. S. (1986) . Results of anger control training for batte ring couples. Journal
of Fam ily Violence ‚ 1‚ 111-120.
Dobson ‚ K. S. (1989). A me ta-analysis of the efficacy of cognitive therapy for depression. Journal of
Consulting and Clinical Psvchology‚ 57 ‚ 414-419.
Dodge ‚ K. A. (1993) . Social cognitive mechanisms in the developme nt of conduct disorder and depres-
sion. Annual Review of Psvchology‚ 44 ‚ 559-584.
Eckhardt ‚ C. l.‚ & Deffenbacher ‚ J. L. (1995) . Diagnosis of anger disorders. In H. Kassinove (Ed.) ‚
Anger disorders: Definition ‚ diagnosis ‚ and treatm ent (pp 27-48) . Washington DC: Taylor & Francis.
*Faulkner ‚ K. ‚ Stoltenberg‚ C. D.‚ Cogen ‚ R.‚ Nolder ‚ M.‚ & Shooter‚ E. ( 1992) . Cognitive-behavioral
group treatment for male spouse abusers. Journal of Fam ily Violence ‚ 7‚ 37-55.
*Fe indler‚ E. L.‚ Ecton ‚ R. B.‚ Kingsley‚ D.‚ & Dubey‚ D.R. (1986) . Group anger control training for
institutionalized psychiatric male adolesce nts. Behavior Therapy‚ 17 ‚ 109-123.
*Fe indler‚ E. L.‚ Marriott ‚ S. A.‚ & Iwata ‚ M. (1984) . Group anger-control training for junior high school
delinquents. Cognitive Therapy and Research ‚ 8 ‚ 299-311.
Fernandez ‚ E.‚ & Boyle ‚ G.J. (1996). Meta-analytic proce dure and interpretation of treatment outcome
and test validity for the practitioner psychologist. In M. Smith & V. Sutherland (Eds.) ‚ International
review of professional issues in selection and assessm ent (Vol. 2 ‚ pp. 109-125). Chichester ‚ UK: Wiley.
Fernandez ‚ E.‚ & Turk‚ D. C. (1989) . The utility of cognitive coping strategie s for altering pain percep-
tion: A meta-analysis. Pain ‚ 38 ‚ 123-135.
Fernandez ‚ E.‚ & Turk‚ D. C. (1993) . Anger in chronic pain patients: A neglected target of attention.
American Pain Society Bulletin ‚ 3‚ 5-7.
Fernandez ‚ E. ‚ & Turk‚ D. C. (1995) . The scope and significance of anger in the expe rience of chronic
pain. Pain ‚ 61 ‚ 165-175.
*Gaertner ‚ G. P. ( 1984) . A component analysis of stress inoculation training for the de velopment of
ange r management skills in adult male offenders (Doctoral dissertation‚ Pennsylvania State Univer-
sity‚ 1983) . Dissertation Abstracts International ‚ 44 ‚ 2359.
Glass‚ G. V.‚ McGaw ‚ B.‚ & Smith‚ M. L. ( 1981) . Meta-analvsis in social research. Beverly Hills‚ CA:
Sage.
*Glick‚ B.‚ & Goldstein ‚ A. P. (1987) . Aggression replaceme nt training. Journal of Counseling and De-
velopm ent‚ 65 ‚ 356-362.
*Hinshaw‚ S. P.‚ He nker ‚ B.‚ & Whalen ‚ C. K. ( 1984) . Self-control in hyperactive boys in ange r-inducing
situations: Effe cts of cognitive-behavioral training and of methylphenidate . Jou rnal of Abnorm al
Child Psychology‚ 12 ‚ 55-77.
*Jackson ‚ N. C. (1992). Anger control training for adolescents in acute inpatient psychiatric treatment
(Doctoral dissertation‚ Mississippi State University‚ 1991). Dissertation Abstracts International ‚ 53 ‚
407.
Kassinove ‚ H.‚ & Sukhodolsky‚ D. G. (1995) . Ange r disorders: Basic science and practice issues. In H.
Kassinove (Ed.) ‚ Anger disorders: Definition ‚ diagnosis ‚ and treatm ent (pp. 1-26) . Washington DC:
Taylor & Francis.
CBT for An ger 73

*Kennedy ‚ S. M. ( 1992) . Anger manage ment training with adult prisoners (Doctoral dissertation‚ Uni-
versity of Ottawa‚ 1990) . Dissertation Abstracts International ‚ 52 ‚ 6087.
Koop ‚ C. E.‚ & Lundberg‚ G. D. ‚ ( 1992) . Violence in America: A public health emergenc y. Journal of
the American Medical Association ‚ 267 ‚ 3075-3076.
*Larson ‚ J. D. ( 1991) . The e ffects of a cognitive-behavioral anger-control interve ntion on the be havior
of at risk middle school students (Doctoral dissertation‚ Marque tte University‚ 1990) . Dissertation
Abstracts International ‚ 52 ‚ 117.
*Lochman ‚ J. E. (1985) . Effe cts of different treatme nt lengths in cognitive-behavioral interventions with
aggressive boys. Child Psychiatry and Hum an Developm ent‚ 16 ‚ 45-56.
*Lochman ‚ J. E. ‚ Lampron ‚ L. B.‚ Ge mmer ‚ T. C.‚ Harris ‚ S. T.‚ & Wyckoff ‚ G. M. (1989) . Teacher
consultation and cognitive-behavioral interventions with aggressive boys. Psychology in the Schools ‚
26 ‚ 179-188.
*Lochman ‚ J. E. ‚ Burch ‚ P. R.‚ Curry‚ J. F.‚ & Lampron ‚ L. B. ( 1984) . Treatme nt and ge neralization
effe cts of cognitive-behavioral and goal-se tting interve ntions with aggressive boys. Journal of Con-
sulting and Clinical Psychology‚ 52 ‚ 915-916.
*Lochman ‚ J. E. ‚ & Curry‚ J. F. ( 1986) . Effe cts of social problem-solving training and self-instruction
training with aggressive boys. Journal of Clinical Child Psychology‚ 15 ‚ 159-164.
Lochman ‚ J. E.‚ & Lenhart ‚ L. A. ( 1993) . Anger coping intervention for aggre ssive children: conce ptual
models and outcome effects. Clinical Psychology Review‚ 13 ‚ 785-805.
*Lochman ‚ J. E. ‚ Nelson ‚ W. M.‚ & Sims ‚ J. P. (1981) . A cognitive-be havioral program for use with
aggressive children. Journal of Clinical Child Psychology‚ 10 ‚ 146-148.
*Macpherson ‚ S. L. (1986) . An investigation of the compone nts of anger management as applied to an
incarcerated population (Doctoral dissertation‚ Pennsylvania State University‚ 1986). Dissertation Ab-
stracts In ternational ‚ 47 ‚ 1731.
Mahoney‚ M. (1993) . Theoretical developme nts in the cognitive psychotherapie s. Journal of Consulting
and Clinical Psychology‚ 61 ‚ 187-193.
*Mande l‚ S. M. ( 1991) . Cognitive behavioral anger control training with aggre ssive adolescent male s in
a spe cial education high school (Doctoral dissertation‚ Temple University‚ 1991) . Dissertation Ab-
stracts In ternational ‚ 52 ‚ 2471.
*McDougall ‚ C.‚ Boddis‚ S.‚ Dawson ‚ K. ‚ & Hayes ‚ R. (1990). De velopments in anger control training.
Issues in Criminological and Legal Psychology‚ 15 ‚ 39-44.
Me iche nbaum ‚ D. H. (1975) . Stress inoculation training. New York: Pe rgamon Press.
Me iche nbaum ‚ D. H. ( 1976) . A cognitive-behavior modification approach. In M. Hersen & A. Bellack
(Eds.) ‚ Behavioral assessm ent: A practical handbook. New York: Pergamon Press.
*Moon ‚ J. R.‚ & Eisler ‚ R. M. (1983). Ange r control: An expe rimental comparison of three behavioral
treatments. Behavior Therapy‚ 14 ‚ 493-505.
*Moore ‚ K. J.‚ & Shannon ‚ K. K.‚ (1993). The de velopment of supe rstitious be liefs in the effectiveness
of treatment of anger: Evidence for the importance of e xperime ntal program evaluation in applied
settings. Behavioral Residen tial Treatm ent‚ 8 ‚ 147-161.
*Napolitano ‚ S. ( 1992) . Evaluation of prison anger control training (PACT): A group tre atment program
for incarcerated murderers and violent offenders (Doctoral dissertation‚ California School of Pro-
fessional Psychology‚ 1991) . Dissertation Abstracts International ‚ 53 ‚ 1071.
*Novaco ‚ R. W. ( 1975) . Anger control: The developm ent and evaluation of an experim ental treatm ent. Lex-
ington‚ MA: D.C. Health.
Nove llo‚ A.‚ Shosky‚ S.‚ & Froe hlke ‚ R. ( 1992) . From the Surgeon General ‚ U.S. Public Health Service:
A medical response to violence. Journal of the Am erican Medical Association ‚ 267 ‚ 3007.
*O lson‚ M. L. (1987). The effect of a cognitive-be havioral anger manage ment program on hostility among
clinically anger clients (Doctoral dissertation ‚ Weste rn Conservative Baptist Seminary‚ 1986). Dis-
sertation Abstracts International ‚ 48 ‚ 885.
*O mizo ‚ M. M.‚ Hershbe rger ‚ J. M.‚ & Omizo ‚ S. A. (1988) . Teaching children to cope with anger.
Elem entary School G uidance and Counselin g‚ 22 ‚ 241-245.
*Pascucci ‚ N. J. (1991) . The efficacy of ange r control training in reducing chronic aggre ssive be havior
among emotionally disturbed/learning disabled African-American male pre-adole scents and adoles-
cents (Doctoral dissertation‚ St. John ’s Unive rsity‚ 1991) . Dissertation Abstracts International ‚ 51 ‚
3678.
*Rhoade s‚ G. F. (1988) . The e ffects of stre ss inoculation and relative dogmatism upon anger management
with forensic inpatients (Doctoral dissertation ‚ Weste rn Conservative Baptist Seminary‚ 1982) . Dis-
sertation Abstracts International ‚ 48 ‚ 3694.
*Rokach ‚ A. (1987) . Ange r and aggre ssion control training: Replacing attack with interaction. Psycho-
therapy‚ 24 ‚ 353-362.
74 Beck and Fern an dez

*Rosengre n‚ D. B. (1987) . The program of anger control (PACT): An intervention for angry adolescents
(Doctoral dissertation ‚ University of Montana‚ 1986). Dissertation Abstracts In ternational ‚ 48 ‚ 1819.
Rose nthal‚ R. (1991) . Meta-analytic procedures for social research ‚ Ne wbury Park‚ CA: Sage.
Rose nthal‚ R. (1995) . Writing meta-analytic reviews. Psychological Bulletin ‚ 118 ‚ 183-192.
*Saylor ‚ C. F.‚ Benson ‚ B.‚ & Einhaus‚ L. (1985). Evaluation of an ange r manageme nt program for
aggressive boys in inpatient treatment. Journal of Child and Adolescent Psychotherapy‚ 2‚ 5-15.
*Schlichter ‚ J. K.‚ & Horan ‚ J. J. ( 1981) . Effe cts of stress inoculation on the anger and aggression man-
agement skills of institutionalized juve nile delinquents. Cogn itive Therapy and Research ‚ 5 ‚ 359-365.
*Shivrattan ‚ J. L. (1988). Social interactional training and incarcerated juve nile de linquents. Canadian
Journal of Criminology‚ 30 ‚ 145-163.
*Smith ‚ L.‚ & Beckne r‚ B. M. (1993). An anger manageme nt workshop for inmates in a medium security
facility. Journal of Offender Rehabilitation ‚ 19 ‚ 103-111.
*Stee le ‚ H. V. (1991). Social skills and anger control training with juvenile ‚ mentally retarded felony
offenders (Doctoral dissertation‚ University of South Florida‚ 1990) . Dissertation Abstracts Interna-
tional‚ 51 ‚ 5593.
*Stermac ‚ L. E. (1986) . Anger control treatment for forensic patients. Journal of In terpersonal Violence ‚
1‚ 446-457.
Tafrate ‚ R. C. (1995) . Evaluation of treatme nt strategies for adult ange r disorders. In H. Kassinove
(Ed.) ‚ Anger disorders: Definition ‚ diagnosis ‚ and treatm ent (pp 109-130) . Washington ‚ DC: Taylor &
Francis.
Van Balkom ‚ A. J. L. M.‚ van Oppen ‚ P.‚ Vermeulen ‚ A. W. A.‚ van Dyck ‚ R.‚ Nauta ‚ M. C. E.‚ & Vorst‚
H. C. M. (1994). A meta-analysis on the tre atment of obse ssive compulsive disorder: A comparison
of antidepressants ‚ behavior‚ and cognitive therapy. Clinical Psychology Review‚ 14 ‚ 359-381.
*Whiteman ‚ M.‚ Fanshel ‚ D. ‚ & Grundy‚ J. F. (1987) . Cognitive-behavioral interventions aimed at anger
of parents at risk of child abuse. Social Work ‚ 32 ‚ 469-474.
*Wilcox‚ D.‚ & Dowrick‚ P. W. ( 1992) . Anger manage ment with adolescents. Residential Treatm ent for
Children and Youth ‚ 9 ‚ 29-39.
*Wu ‚ S. F. ( 1990) . The e fficacy of cognitive-be havioral interventions in facilitating griefwork‚ decre asing
attachment ‚ and anger management : A comparative study of post-divorce adjustme nt groups (Doc-
toral dissertation ‚ University of South Florida‚ 1989) . Dissertation Abstracts International ‚ 51 ‚ 2080.