Systematic desensitization of an anger response

Bchav. lies. k Therapy, 1971. Vol. 9, pp. 273 to 280. Pergamon

SYSTEMATIC DAVID

Press.

DESENSITIZATION

Printed

in England

OF AN ANGER

RESPONSE

C. RIMM,*JOANNEC. DEGROOT,PARTHENABOORD,JULIA HEIMANand PAUL v. DILLOW Arizona State University, Tempe, Arizona, U.S.A. (Received 16 March 1971)

Summary-Systematic desensitization was used in an attempt to reduce anger felt in driving situations. Thirty subjects were randomly assigned to one of three conditions: Desensitization, Placebo and NonTreated Controls. The Desensitization subjects received standard systematic desensitization with muscle relaxation as the countercondition, while Placebo subjects were given an interview dealing with the physiological and psychological aspects of anger. The response measures were subjective anger ratings (SAS), GSR and heart rate. For both SAS and GSR, the Desensitization group showed a significantly greater reduction than did either of the other two groups. These differences were maintained at a 2-week followup. Implications for the Wolpian reciprocal inhibition model are discussed. SINCE its inception, systematic desensitization as an efl’ective procedure for overcoming maladaptive anxiety has received massive empirical support. The results of a very large number of reported case histories (Paul, 1969a) strongly suggest that desensitization reduces avoidance behavior and subjective discomfort, and several well-controlled analogue studies (Paul, 1969b) provide substantial support for the view that the specific procedures outlined by Wolpe (1958) do lead to a lasting reduction in both avoidance behavior and self-ratings of fear. It is reasonable to conclude that while the method is not 100 per cent successful, any well-delineated fear reaction (i.e. with the target stimuli well specified) may be eliminated or reduced with a rather high probability. Wolpe (1958) holds the view that malaptive behavior, in very considerable measure, has as its substrate, anxiety. Since the goal of systematic desensitization is the elimination of anxiety, the method should then be applicable to a wide variety of so-called neurotic behavior, and a review of the literature suggests this is so (Paul, 1969a; Bandura, 1969). However, there are classes of behavior, such as sex and aggression, which are driven by, or at least correlated with, types of internal arousal which, typically are not labelled by the individual as “anxiety.” In the case of sexual deviance (Marks and Gelder, 1967; Feldman and MacCulloch, 1964) and inappropriate aggression (Agras, 1967), some researchers have remained within a counterconditioning paradigm, pairing aversive stimulation with real or symbolic stimuli which in the past have given rise to these types of inappropriate behavior. Presumably part of the reason these sensitization methods have been successful is that anxiety has been conditioned to the stimuli which had in the past given rise to sexual arousal or anger, and anxiety is antithetical to these emotional responses. With respect to the relationship between anger and anxiety, Wolpe (1969, page 62) cites Simonov who provided what Wolpe considers to be “ . . . . unequivocal evidence of the existence of separate and reciprocally inhibitory centres for anger and anxiety in the midbrain.” *Requests for reprints should be sent to David C. Rimm, Dept. University, Carbondale. Illinois 62901.

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In the present in?,estigation, a counterconditioning procedure e.mplo!,in~ stand,rrd desensitization rather than sensitization was used in an attcr.lpt to r.educr anger. Thu,. the competing response was deep muscle relaxation. The rationaic. more intuiti\c than theoretical, was that deep muscle relaxation could successfully compete u ith anger arousal as well as fear arousal. This is counter to what would seem to follow from a strict adhercnc: to the Wolpian model of reciprocal inhibition which assunes that both anger (\\hrch IS behaviorally manifested in aggression or assertivfeness) and muscle relaxation are associated with predominance of parasympathetic (as opposed to s~~mpnthetic) ner\ 011s acti\ it!. so that relaxation should not reciprocally inhibit anger. MET HOD SubjectA.

Subjects were selected on the basis of t!leir indication that the!. become uncomfortnbi~ or inappropriately angry while operating an automobile (e.g. when being depri\,ed of the right of way; having to stop for an excessive number of lights). The anger might hn\c obvious manifestations (swearing at another driver out loud: “tailgating:” driving 31 excessive speeds) or it might be entirely subjecti\,e. i.e. only manifested in feelings of discomfort. This particular response class was chosen because it is fairly widespread among y’oung male drivers, it is not difficult to persuade members of this population to admit to this type of anger and finally it seems to represent a class of anger relatively free of underlying conflict or ambivalence (in contrast, for instance, to anger felt towards authority figures or members of the opposite sex). All subjects were male introductory psychology students fulfilling a course requirement who placed their names on a sign-up sheet which asked only for individuals who experienced inappropriate or distressing anger while operating an automobile. During the first experimental session, each subject was asked to recall three or four pastexperiences in which he had become angry while driving and then he was asked to recall three or four comparable fear experiences. He was asked whether lte could discriminate the subjective emotional states associated with these two classes of experiences. Any subject indicating difficulty making this discrimination was excluded from further participation. Of the 30 subjects selected in this manner, 10 were randomly assigned to one of three treatment conditions: Desensitization; Placebo; Non-Treated Control. Procedure Session I (nil suhjecrs). During the first session each subject was requested to provide certain minimal biographical information (including whether he had previously received professional treatment for problems related to anger). He then participated in the angerfear discrimination test described above. Each subject capable of the discrimination was tlten given a set of fifteen 3 in. by 5 in. blank cards, with the instructions to describe on each card in vivid and specific detail a different driving experience which typically gave rise to uncomfortable or inappropriate anger. He was instructed to return the following week (Session II) with the cards completed. Session II (hierarchlz constrxtion and pre-test--all mhjects). This session was devoted to hierarchy construction. This was accomplished by first having each subject rank his 15 cards in order of increasing anger associated with each. The experimenter then selected 9 from the I5 c;trds. eliminating those cards lacking in detail or depicting situations already handled in previous cards. In addition, the experimenter and subject eliminated cards such

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that the final 9 to be used in the remainder of the experiment would roughly approximate an interval scale of subjective anger. Following this, the subject filled out two additional cards, one for an experience which he considered affectively neutral and the second for an experience which he felt was pleasant. The nine hierarchy cards were again given to the subject who was asked to rank them on a five-point scale (no anger to extreme anger) as a final check. If the ordering resulting from this procedure was inconsistent with the original ordering, the procedure was repeated until two successive perfectly correlated ranhings occurred. Immediately following the completion of the hierarchy, the subject was taken to a different room where he was administered the pre-test by a different experimenter. During the pre-test, the subject was seated in a comfortable armchair and electrodes for monitoring GSR and heart rate were attached, feeding into a Gelson MSP-polygraph recorder. He was then asked to close his eyes and relax. About ihree min later a buzzer was sounded for four set and the consequent GSR deflection was adjusted to two cm for all subjects. Heart rate deflection was also calibrated at this time. One min later the subject was presented the previously selected neutral scene and asked to rate its vividness or clarity on a seven-point scale (one signifying “nothing” and serer~ signifying “real life” clarity) and the rating was recorded. Following th.is, the subject was told he was to imagine a series of scenes and to indicate the anger he experienced ona seven-pointscale (e.g. one meant “no anger at all,” three meant “mild anger,“fifive meant “great anger”, and seven meant “rage”). The nine hierarchy scenes were presented in alternation with the neutral scene in one of two preselected but random orders, bvith half the subjects in each treatment condition receiving one of the orders and the remainder the other. Each of the scenes was read by the experimenter and within two set after the reading the subject gave his anger rating. Thirty set later the next scene was read to the subject, and this was continued until all nine hierarchial scenes had been presented (and the neutral scene presented nine times). Throughout the pre-test, GSR and heart rate were continuously monitored. Session III (&sensitizntion). For subjects in the desensitization group the third session began with 20 min of deep muscle relaxation (Wolpe and Lazarus, 1966) followed by a desensitization procedure in which, starting with the scene associated with the least anger, scenes were presented for 10 sec. If no anger was indicated (i.e. the subject did not raise his finger) to the first presentation of the first scene, the item \vas again presented for IO set after a 30 set pause. If once again anger was not indicated, the next item in the hierarchy was presented following a 60 set delay. For both 30- and 60-set intervals, the subject was instructed to imagiile the neutral scene. If during the first presentation of a given hierarchy item anger was indicated, the subject was immediately shifted to the neutral scene and given relaxation suggestions. Sixty set later the scene was presented again. If no anger was signaled, the experimenter went on to the next hierarchy item. If anger was again signaled (which was rather uncommon), the experimenter either returned to the previous item, presented additional relaxation suggestions, presentedthe previouslyselected pleasants item, or read the hierarchy item more slowly. The particular strategy selected was at the exHowever, as the perimenter’s discretion, and initially was little more than guesswork. experimenter and subject progressed through the hierarchy, the strategy chosen was the one which appeared to work best for the given subject. This session was continued until all nine hierarchy items were completed. Following this the subject was given the post-test. Placebo. Each subject in the Placebo condition was yoked to a desensitization subject with respect to total Session III participation time (excluding the time required for the post-test). The Placebo treatment consisted of the experimenter giving the subject

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a standardized series of 16 questions relating to his overall experiencies with an_eer ce.g. “describe any physical symptoms which you experience when you are angry :” “Rate your degree of anger in the following situations: (not related to driving).” The subject responded orally with the experimenter recording his answers. The verbal interchange uas unstructured to the extent that the experimenter was free to ask the subject to elaborate on his answers. This allowed the experimenter to ensure that the total contact time with the subject was equal to the total treatment time for the corresponding desensitization subject. Immediately following the interview the subject received the post-test. Non-treated controls. The subjects in this group simply received the post-test. Folio w-up Approximately two weeks after Session identical to the pre- and post-test.

III, the subject

returned

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RESULTS Selflratings Each subject was exposed to nine hierarchy items and nine neutral item presentations. His Subjective Anger Score (SAS) was the sum of his individual ratings for each of the hierarchy items (with a minimum possible total of 9 x 1 or 9 and a maximum of 9 x 7 or 63). An SAS was similarly calculated for the neutral item presentations. The pre-test results were as follows. As anticipated for the neutral item, a large majority of subjects receivedSAS totals of 9(three subjects in the Placebo group, two subjects in the Desensitization Group, and two in the Control Group had scores exceeding 9, with the maximum being 21). In these cases, almost without exception, the subject would spontaneously verbalize that the anger reported to the neutral item was a residual from the previous hierarchy item. The SAS means for the hierarchy items for the Desensitization, Placebo and Control groups were, respectively, 39.7, 42.5 and 39.2 [F (2,27)=0*36, ns]. For the post-test, every subject obtained an SAS of 9 for the neutral item. An SAS change score (pre-test minus post-test) for the hierarchy items was calculated for each subject, and the mean change score for the Desensitization, Placebo and Control groups was, respectively, 14.0, I.7 and 3.8. An analysis of variance revealed a significant treatment effect [F (2,27)=6*38, p
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standard clinical measure of this ability is some sort of subjective rating, which is expected to correlate withtherapeutic success. In the presentinvestigation for each test (pre-, post- and follow-up) the subject was asked to rate the clarity of the neutral scene. For the Desensitization subjects, the product-moment correlation between the averages of these three ratings and improvement observed during the post test (i.e. the SAS change score) was O-458. The corresponding correlations obtained for the Placebo and Non-Treated Controls were -0.326 and -0.351, respectively. The fact that none of the correlations was significantly different from zero is probably attributable, in part, to the very small number of degrees of freedom (8) in each case. The similarity in correlationsfor the Placebo and Controlsubjects suggested combining them into a single group, and the correlation between these two measures for the combined group was -0.350, which did not differ significantly from that obtained for the Desensitization subjects (z= 1.92, p
GSR For each subject an average GSR deflection was calculated for each of the hierarchy items and each of the neutral item presentations. The averages for each item were based on five equally spaced readings over an eight second interval. the center of which coincided with the completion of the description of the item by the experimenter. The sums of these averages were then obtained for the 9 hierarchy items and the 9 neutral item presentations, and the difference between the sum for the hierarchy items and the neutral sum was determined. This difference score seemed a more approriate measure of responsiveness to hierarchy items since it took into account the subject’s response to the neutral items which varied considerably from testing session to testing session. Subjects did in fact show greater reactivity to hierachy items than to neutral items during the pre-test [t (29d’)= 1.621, although the difference was not quite significant. However, significant neutral versus hierarchy differences were obtained for the Placebos and Controls combined for the posttest [t (19#)=3*02, p O*Ol] tending to provide additional support for the validity of the response measure. For the pre-test the mean difference scores for the Desensitization, Placebo and Control groups were. respectively, 12.52, 2.54 and 4.03. The large differences among these means tends to be misleading, since negative difference scores were not uncommon, and in fact the groups did not differ significantly [F (2,27)=0.61, ns]. For the post-test, the comparable means were 3.49, 24.09 and 6.85. For each subject the post-test difference score was subtracted from the pre-test difference score, and the means for this measure for the Desensitization, Placebo and Control groups were, respectively, 9.03, -21.55 and -2.89 [F (2,27)= 3.24, p ~0.05, w* = 13.02 per cent]. Since a positive score indicates that the subject is, on the average, showing less responsiveness to hierarchy items (relative to neutral items) on the post-test than on the pre-test, these results tend to support those obtained for the self-rating measure. A SchefE analysis revealed a significant difference between the Desensitization and Placebo groups. For the follow-up, means for the difference scores for the Desensitization, Placebo and Control groups were, respectively, 3.80, 29.40 and 8.80. The means of the difference of differences (pre-test minus follow-up) were 12.15, -26.88, and -4.77 [F (2,27)=4.02, pc:O-05, MI*= 16.78 per cent]. Again, these results tended to parallel the self-rating results. The Scheffi analysis revealed a significant difference between the Desensitization and Placebo groups. The product-moment correlations between rated clarity of the neutral scene and improvement observed during the post-test (i.e. pre-testdiffrence minuspost-test difference) were as follows: Desensitization group, -0-003; Placebo group, +0*559, Control, +O- 138.

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While none of these correlations differ sig:iticantly from zero. they pro\.ide a littlc corrobcration for the relationships obtained between clarity of imagery and improvement as measured by self-rating. Heart rate

For each subject an average heart rate was calculated for each hierarch>, item and each neutral itempresentation. These averages were based upon readings coinciding in time with the GSR readings and, as with th: GSR measures, they were summed o\‘cr hierarch!, and neutral items and the difference between the sum for hierarchlr items and neutral items \vas determined. For the pre-test, the means for the difference scores for the Desensitization. Placebo and Control groups were respectively 16.30, 9.75 and 1.06 [F (2.27)=@97. ns]. As before, subjects as a whole showed greater reacti\,ity to hierarchy items than to nelltral items during the pretest [t (29#)=2*65, ,~<0*Of]. At post-test. the comparable means (Desensitization, Placebo and Controls, respecti\,cly) here 13.75. 17.56 and 19.30. The means for the difference of the differences (i.e. pre- minus post-) were 2.62. -7. I6 and -15.23 As with the GSR measure, the more positive the score, the greater the treatment effect. so that in accord with the GSR and self-rating results the subjects showing the greatest average change in the therapeutic direction belonged to the Desensitization group. The differences however, did not approach significance [F (2.27)=@6’i]. For the follow-up. the means of the difference of the differences were: Desensitization, 7.23: Placebo. -5.39: Controls, l-82 [F (2,27)=0+32]. Thus, contrary to the results obtained with the self-rating and GSR measures, significant treatment effects were not obtained for the heart rate measure either at post-test or at follow-up. The failure to obtain significant differences for the heart rate measure is somewhat puzzling since subjects did show a significantly greater heart rate when imagining the hierarchy scene that when imaging the neutral scene, One possible scarce of error is unreliability of the response measure employed and for the Placebo and Controls the correlation between the pre-test differences score (responsitivity to heirarchy items minus responsitivity to neutral item) and post-test difference score was 0.092. Since subjects in neither group underwent any treatment which would be expected to have any \‘ery strong effect, this correlation may be interpreted as a test-retest reliability coefficient and as such is low in the extreme. The corresponding correlation coefficient for the GSR measure was 0.545 @<0*02), which, while not especially high when viewed as a reliability coef%cient. is sufficiently high to allow one to use this measure to validate an experimental effect. The authors’ intention had been to obtain the subjects’ self-report of ho!v much anger he experienced while driving during the post-test to folio\+-up period. Through an oversight this data was not collected. In an effort to remedy this, while at tile same time increasing the follow-up period, about three months later the subjects \\ere contacted by mail and asked to indicate the degree to which they had experienced anger while driving after as well as prior to their participation in the experiment. They were to rate their feelings on seven point scales with “7” indicating maximum anger. Of the 30 original participants, 14 responded (five Desensitization subjects, five Placebo and four Controls.) The mean changes in self-ratings (pre-experimentel minus post-experimental) were. Desensitization. 1.0, Placebo, I.6 and Controls, 1.5. Unfortunately, the five Desensitization subjects who responded showed somwhat less mean improvement on the in ~itm measure of self-rating than those Desensitization subjects not responding (11.2 vs. 16*8), whereas the five Placebo subjects responding showed considerably more improvement on the in vitro measure than those not responding (3.6 vs. -0.20) and the same held true for the Controls (7.25 vs.

SYSTEMATIC

1.17). Thus, the sample clearly biased. Therefore,

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of subjects responding to the retrospective questionnaire was there seems to be little basis for viewing this as a valid measure. DISCUSSiON

The present experiment provides in viro evidence that standard desensitization procedure may be useful in connection with inappropriate or maladaptive anger. No objective assessment of in viva anger while driving was attempted, although one might have driven with thesubject and asked him how he felt, observed his demeanor, or even provided physiological monitoring. On the assumption that anger increases the probability of recklessness while driving, one could use the number of moving violations the subject received as a criterion measure although the period of assessment would have to be long. The positive relationship found only for the Desensitization group between improvement as measured by self-ratings of anger and self-rated ability to imagine the neutral scene is consistant with the traditional view (Wolpe, 1958) that progress in desensitization requires that the subject be able to imagine scenes clearly. However, the failure to corroborate this relationship when the measure of progress involved the GSR requires that any statement relating visual imagery ability to improvement in desensitization be of a rather tentative nature. Since as the present study suggested, one can desensitize anger using relaxation as the counterconditioned response the Wolpian model which tends to view these responses as psychophysiologically conlpulible is not applicable. On the other hand, it is well known that fear and anger have some common physiological correlates (Ax, 1953) and to the extent that one can use relaxation to reduce one or more of the physiological components of fear, one should similarly be able to reduce those same components when present in a state of anger. This second position is essentially atheoretical. Another interpretation which is consistent witb the Wolpian view is that subjects learn to generate anger as a consequence, initially, of being fearful in such situations, That is, when a subject is driving, the actions of another driver might initiate a fear response, which serves as a cue for the self-generation of anger. If such is the case, it might be argued that one can successfully treat anger using desensitization because anger is typically initiated by fear, and it is the,feor response which is being removed so that the self-generation of anger is no longer necessary. Why individuals would tend to make themselves angry in response to the experience of fear is not entirely clear, although in the case of males in our culture it might be argued that, within limits, the expression of anger is more acceptable than the expression of fear. REFERENCES AGRASW. S. (1967) Behavior therapy in the management of chronic schizophrenia. Am. J. Psychint. 124, 240-243. Ax A. F. (1953) The physiological differentiation between fear and anger in humans. Psychosom. Med. 15,433-44:. A. (1969)

Principles of’ Behavior Midifiration. Holt, Rinehart & Winston, New York. FFI.DMANM. P. and MACCLJLLOCH M. J. (1964) A systematic approach to the treatment of homosexuality by conditioned aversion. Preliminary report. Am. J. Psychiat. 121, 167-171. MARKS I. M. and GELDERM. G. (1967) Transvestism and fetishism: Clinical and psychological changes during faradic aversion. Br. J. Psychiat. 119, 71 l-730. PAUL G. L. (1969a) Outcome of systematic desensitization. I: Background procedures and uncontrolled reports of individual treatment. In Behavior Therapy: Appraisal and Status (Ed. C. M. FRANKS), pp. 63-104. McGraw-Hill, New York. BANDURA

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D.

C. RIMhI,

PAUL G. L. (1969b)

J. C. DEGROOT,

P. BOORD,

J. HEIMAh

iid

P. \‘. DILLO\\’

Outcome of systematic desensitization. II: Controlled investigations of Individual treatment, technique variations, and current status. In Behavior Thcrupv: Appraisd and Smrrrs (Ed. C. M. FRANKS), pp. 105-159. McGraw-Hill, New York. WOLPE J. (1958) fsych0rherap.v by Reriprocal Inhibition. Stanford University Press, Stanford. WOLPE J. and LAZARUS A. A. (1966) Behavior Therapy Techniques. Pergamon Press, New York. WOLPE J. (1969) The Prncrice o.f Behavior Therupr. Pergamon Press, New York.