Drexel University Online - March and May

Anger and Autism Spectrum Disorders: A Clinician’s Perspective

Psychology defines anger as a complex psychological phenomenon, a syndrome consisting of emotions, related thoughts, physiological reactions, and behavioral scripts or action tendencies that define the way in which the person acts when angry (e.g. Berkowitz & Harmon-Jones, 2004; Deffenbacher, 1999; Kassinove & Sukhodolsky, 1995). Anger is commonly and frequently experienced (Averill, 1983), and it has an adaptive value: It signifies lack of satisfaction with the current state of affairs and could mobilize a person to take steps to change this situation. It is the poor regulation of anger that often leads to problematic outcomes, could cause an individual’s and family’s distress, and calls for treatment.

People with autism spectrum disorders (ASD) have more reasons than the average person to feel angry. In addition to typical triggers of anger, such as feeling provoked or intentionally mistreated by someone, they often struggle with communication and processing problems, sensory overload, transition difficulties, social rejection, difficulty meeting expectations in school, at work, and in their families (Gaus, 2007), all contributing to frustration and angry feelings. A recent study by Samson, Huber, and Gross (2012) indicates that people with Asperger’s syndrome and high functioning autism report higher level of negative affect (defined as feeling nervous and upset) and more difficulty identifying, describing, and regulating their emotions than typically developed individuals do. Other studies (e.g. Fitzgerald & Bellgrove, 2006; Hill, Berthoz, & Frith, 2004; Konstantareas & Stewart, 2006) and clinical experiences confirm these results.

Clinicians often see individuals with ASD referred for counseling to improve frustration tolerance and anger management. The referral sources usually expect that through participation in individual counseling or an anger management group, the person will learn how to control his or her outward expressions of anger and better manage frustration. However, this can be particularly challenging when a person with ASD is not able to make use of therapy sessions, for example, because he or she does not have sufficient verbal and processing abilities or refuses to participate in sessions. Even when a person is able and willing to verbalize his or her experiences and work with a therapist on coping strategies, there is a limit as to how much can be done by focusing on the individual. People typically experience anger in a situational context, mostly in relation to others (Buckley, Winkel, & Leary, 2004). In my experience, conceptualizing anger as related to an issue that exists in a person’s environment, and work with a system in which the person with ASD functions, in addition to individual or group counseling, brings faster and more lasting results.

Work on Coping Strategies

As previously stated, anger consists of emotions, related thoughts, physiological reactions, and behavioral scripts. According to Berkowitz and Harmon-Jones’s model (2004), all those components are interconnected: Activation of one of them affects the other parts. For example, physical discomfort could increase physiological arousal and evoke angry feelings and thoughts, which may or may not be related to the discomfort. On the other hand, decrease in activation of one of the components affects the other parts as well. For example, relaxation, which brings down the physiological arousal typical for anger experience, reduces the intensity of angry feelings and decreases angry thoughts.

The interconnectedness of anger components has a great impact on the therapist’s ability to help people with ASD to manage anger. The therapist has a choice to work on physiological reactions, thoughts, feelings, or behavioral scripts, and she can tailor work on coping strategies to the needs of a person that he/she serves. It is difficult to treat people who cannot verbalize their thoughts and feelings, but they can benefit from relaxation strategies (Taylor & Novaco, 2005). Their angry feelings can also be decreased by introducing the opposite emotion (as suggested by Dialectical Behavioral Therapy, Linehan, 1993). For example, they can engage in an activity that makes them feel good or happy, such as watching a comedy show or playing with pets, to decrease their frustration. These simple techniques could be used preventively, to reduce overall stress level, or as coping strategies. It cannot be expected, however, that all people on the spectrum will use these strategies without being reminded or encouraged. That is why work with the person’s support team is crucial.

One anger management strategy is to identify angry thoughts and challenge them. This work is possible with some people with ASD and not possible with others. Cognitions that evoke anger include blaming and labeling others and deeming their behavior to be wrong and intentional. For example, a person with Asperger’s syndrome who is sensitive to the smell of cigarette smoke, becomes outraged around smokers. He says to me that he thinks that smokers are “a menace to the society” and that they “always blow smoke in my face, to spite me and to make me sick.” Cognitive therapy could be used to help this individual identify and challenge his unhelpful thinking styles, such as black and white thinking, labeling, mind reading, or over-generalizing. It is also helpful to ask a person who is angry at smokers to think about someone they like and respect who also happens to smoke. This technique introduces an element of complexity to the black and white thinking of people on the spectrum and helps to decrease their anger with behaviors or attributes of others.

People with ASD have difficulty seeing situations from the perspective of others. My patients with Asperger’s often say, “I don’t know how people operate.” This limited ability to understand what is going on with others, what do they think, and how do they feel, causes a great deal of misunderstanding of the motivation or intentions of others. Interpersonal situations become, therefore, ambiguous and easy to misinterpret. Difficulty reading social cues adds to the confusion and frustration that many people with ASD experience when interacting with others. Anger management with people with ASD needs to focus on improving their perspective-taking and challenging errors that they make while attempting to read minds of others.

There are many other coping strategies that could be used to help people with ASD manage their anger and use its energizing aspect to their advantage. These include assertiveness and problem-solving, strategies that are crucial in modifying anger-evoking situations. Again, working with the system in which the person exists could increase a person’s chances to use these skills effectively.

Situation Modification

Any work on behavior modification starts with an assessment. In anger management, anger logs are used to identify situations that anger the person (anger triggers), and specifics of the person’s response. Completing anger logs is often difficult for people with ASD and typically staff or family members assist in compiling them. The logs provide information which is used to determine situational and behavioral patterns of anger.

Once the conditions related to the person’s anger are identified, work on changing them could start. Counseling could help a person with ASD to find a solution that would modify the situation in order to remove the anger trigger and to advocate for the change needed to stop feeling angry. This aspect of anger management is crucial; It would be unwise to expect any person just to adjust to the existing situation and suppress or otherwise control those angry feelings if the situation continues to trigger that anger. It would also be unwise to expect that all situations could be changed, but many of them need to change in order to prevent triggering the person’s anger. Unfortunately, change is difficult. Many people with ASD can and do advocate for their needs, but many of them also state that caregivers or other authorities dismiss their best efforts to resolve their anger triggers and that they eventually either give up or act out because others “don’t listen.” Therefore, the clinical work is more useful when anger is conceptualized as resulting from an issue that exists in the system, not necessarily within the individual, and work includes a system, such as a family, program, or residence.

Conclusion

Both coping strategies and situation modification are needed when helping people with ASD to manage anger. Special considerations need to be given to the unique characteristics of people on the spectrum and anger management techniques that are used with the general population need to be modified to utilize strengths and address difficulties related to those characteristics.

 

Grazyna Kusmierska is a psychologist at Premier HealthCare, a health care practice serving people with intellectual and developmental disabilities and their families throughout New York City. For more information about psychological and other services available through Premier HealthCare, visit YAI.org or call 212-273-6182.

References

Averill, J. R. (1983). Studies on anger and aggression: Implications for theories of emotions. American Psychologist, 38, 1145-1160.

 

Berkowitz, L., & Harmon-Jones, E. (2004). Towards an understanding of the determinants of anger. Emotion, 4, 104-130.

 

Buckley, K. E., Winkel, R. E., & Leary, M. R. (2004). Reactions of acceptance and rejection: Effects of level and sequence of relational evaluation. Journal of Experimental Social Psychology, 40, 14-28.

 

Deffenbacher, J. L. (1999). Cognitive-behavioral conceptualization and treatment of anger. Journal of Clinical Psychology, 55,295-309.

 

Fitzgerrald, M., & Bellgrove, M. A. (2006). The overlap between alexithymia and Asperger’s syndrome. Journal of Autism and Developmental Disorders, 36, 573-557.

 

Gaus, V. L. (2007). Cognitive-behavioral therapy for adult Asperger syndrome. New York, USA: The Guilford Press.

 

Hill, E., Berthoz, S., & Frith, U. (2004). Cognitive processing of own emotions in individuals with autistic spectrum disorder and in their relatives. Journal of Autism and Developmental Disorders, 34, 229-235.

 

Kassinove, H., & Sukhodolsky, D. G. (1995). Anger disorders: Basic science and practice issues. In: H. Kassinove (Ed.). Anger Disorders: Definition, Diagnosis, and Treatment (pp. 27-48. Washington, DC: Taylor & Francis.

 

Konstantareas, M. M., & Stewart, K. (2006). Affect regulation and temperament in children with autism spectrum disorder. Journal of Autism and Developmental Disorders, 36, 143-154.

 

Linehan, M. M. (1993). Cognitive-behavioral treatment of Borderline Personality Disorder. New York, USA: The Guilford Press.

 

Samson, A. C., Huber, O., & Gross, J. J. (2012). Emotion regulation in Asperger’s syndrome and high-functioning autism. Emotion, 12, 659-665.

 

Taylor, J. L., & Novaco, R. W. (2005). Anger Treatment for People with Developmental Disabilities. Chichester, England: John Wiley & Sons, Ltd.